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Article

Jonathan S. Gooblar and Sherry A. Beaudreau

Anxiety disorders are among the most prevalent and understudied mental health problems in late life. Specific phobia, social anxiety disorder, and generalized anxiety disorder are the most prevalent anxiety disorders in older adults among the 11 disorders identified by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Anxiety disorders lead to significant functional burdens and interface with physical health problems and cognitive impairment, concerns frequently experienced in adults over age 65. Additional contextual factors should be considered when assessing and treating late-life anxiety, including the effects of polypharmacy, other mental health conditions, role changes, and societal attitudes toward aging. The relationship between anxiety and physical health problems in older adults can be causal or contextual, and can involve poorer estimates of subjective health and lower ratings of functioning. These factors present unique challenges to the detection, conceptualization, and treatment of late-life anxiety, including the tendency for older adults to focus on somatic symptoms and the potential for long-term behaviors that can mask distress such as substance use. Researchers are increasingly incorporating a gerodiversity framework to understand the contributions of cultural, individual, and other group differences that may affect the presentation of anxiety symptoms and disorders. Older adults in general are less likely to be treated for anxiety disorders, and intersecting individual and group differences likely further affect how anxiety disorders are perceived by healthcare providers. Cognitive behavioral therapy and its variants have the most empirical support for treatment. Newer evidence lends support to acceptance and commitment therapy and problem-solving therapy, which tend to address some of the contextual factors that may be important in treatment.

Article

A historically popular research topic in exercise psychology has been the examination of the exercise-anxiety relationship, with an ever-growing literature exploring the link between exercise and anxiety. In addition to its potential for preventing anxiety and anxiety disorders, an increasing number of studies have examined the utility of physical activity and exercise interventions for the treatment of elevated anxiety and clinical anxiety disorders. A National Institute of Mental Health “state-of-the-art workshop” in 1984 was the first significant call put forth that understanding the anxiety-reducing potential of exercise was important and required further investigation. Since the publication of the evidence that came out of that NIMH workshop in Morgan and Goldston’s 1987 book, “Exercise and Mental Health,” a great deal more has been learned yet key aspects of the relationship between exercise and anxiety remain unknown. There is a great deal of work that remains to make good on the “potential efficacy of exercise.”

Article

Jutta Lindert

People who are forcibly displaced are forced to flee by serious threats to fundamental human rights, caused by factors such as persecution, armed conflict, and indiscriminate violence. Contemporary drivers of forced displacement are increasingly complex and interrelated. They include population growth, food insecurity, and water scarcity, at times compounded and multiplied by the effects of climate change. A refugee is someone who fled his or her home and country owing to “a well-founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group, or political opinion,” according to the United Nations 1951 Refugee Convention. Internally displaced persons (IDPs) are people who have not crossed an international border but were forced to move to a different region than the one they call home within their own country. People who cannot return home without serious risk to their human rights have specific needs. Forced displacement, both within a country and to other countries, is a major life event that abruptly changes environmental living conditions, such as social networks, language, and cultural environment of the displaced populations. The changes in environmental living conditions and disruptions in life challenge both the individual and the families of the displaced persons. Both types of forced displacement challenge adaptational mechanisms of individuals and families. Accordingly, the challenges can contribute to changes in mental health and mental disorders. However, estimates of mental health, mental disorders, and mental health determinants vary across and between forcibly displaced persons. This heterogeneity in estimates is associated with differences between refugee groups and with methodological difficulties in assessing refugees’ mental health. Instruments to assess mental health need to be culture-grounded and gender-sensitive to capture the scope and extent of refugees’ mental health and mental disorders. Based on reliable and valid instrument needs for assessing mental health and mental disorders, determinants can be identified and intervention can be developed and evaluated.

Article

Gretchen N. Neigh, Mandakh Bekhbat, and Sydney A. Rowson

Bidirectional interactions between the immune system and central nervous system have been acknowledged for centuries. Over the past 100 years, pioneering studies in both animal models and humans have delineated the behavioral consequences of neuroimmune activation, including the different facets of sickness behavior. Rodent studies have uncovered multiple neural pathways and mechanisms that mediate anorexia, fever, sleep alterations, and social withdrawal following immune activation. Furthermore, work conducted in human patients receiving interferon treatment has elucidated some of the mechanisms underlying immune-induced behavioral changes such as malaise, depressive symptoms, and cognitive deficits. These findings have provided the foundation for development of treatment interventions for conditions in which dysfunction of immune-brain interactions leads to behavioral pathology. Rodent models of neuroimmune activation frequently utilize endotoxins and cytokines to directly stimulate the immune system. In the absence of pathogen-induced inflammation, a variety of environmental stressors, including psychosocial stressors, also lead to neuroimmune alterations and concurrent behavioral changes. These behavioral alterations can be assessed using a battery of behavioral paradigms while distinguishing acute sickness behavior from the type of behavioral outcome being assessed. Animal studies have also been useful in delineating the role of microglia, the neuroendocrine system, neurotransmitters, and neurotrophins in mediating the behavioral implications of altered neuroimmune activity. Furthermore, the timing and duration of neuroimmune challenge as well as the sex of the organism can impact the behavioral manifestations of altered neuroimmune activity. Finally, neuroimmune modulation through pharmacological or psychosocial approaches has potential for modulating behavior.

Article

Joan N. Vickers and A. Mark Williams

Considerable debate has arisen about whether brain activity in elite athletes is characterized by an overall quieting, or neural efficiency in brain processes, or whether elite performance is characterized by activation of two simultaneous networks. One network exercises cognitive control using increased theta activation of premotor and cingulate gyrus, whereas the second reduces alpha activation in an inhibitory network that prevents the intrusion of debilitating thoughts emanating from the temporal lobe and other areas. Also, there is controversy about how a long-duration “quiet eye” (QE) can fit within a single efficient neural system, or whether a dual system where both increased cognitive control and reduced inhibitory processes has advantages. The literature on neural efficiency, the QE, and theta cognitive control, suggest that a long-duration QE promotes both an increase in theta band activation of the medial prefrontal cortex and anterior cingulate and reduced activation and inhibition of the temporal regions during high-pressure situations when a high level of focused, cognitive control is essential.

Article

People not only want to be safe from natural hazards; they also want to feel they are safe. Sometimes these two desires pull in different directions, and when they do, this slows the journey to greater physical adaptation and resilience. All people want to feel safe—especially in their own homes. In fact, although not always a place of actual safety, in many cultures “home” is nonetheless idealized as a place of security and repose. The feeling of having a safe home is one part of what is termed ontological security: freedom from existential doubts and the ability to believe that life will continue in much the same way as it always has, without threat to familiar assumptions about time, space, identity, and well-being. By threatening our homes, floods, earthquakes, and similar events disrupt ontological security: they destroy the possessions that support our sense of who we are; they fracture the social structures that provide us with everyday needs such as friendship, play, and affection; they disrupt the routines that give our lives a sense of predictability; and they challenge the myth of our immortality. Such events, therefore, not only cause physical injury and loss; by damaging ontological security, they also cause emotional distress and jeopardize long-term mental health. However, ontological security is undermined not only by the occurrence of hazard events but also by their anticipation. This affects people’s willingness to take steps that would reduce hazard vulnerability. Those who are confident that they can eliminate their exposure to a hazard will usually do so. More commonly, however, the available options come with uncertainty and social/psychological risks: often, the available options only reduce vulnerability, and sometimes people doubt the effectiveness of these options or their ability to choose and implement appropriate measures. In these circumstances, the risk to ontological security that is implied by action can have greater influence than the potential benefits. For example, although installing a floodgate might reduce a business’s flood vulnerability, the business owner might feel that its presence would act as an everyday reminder that the business, and the income derived from it, are not secure. Similarly, bolting furniture to the walls of a home might reduce injuries in the next earthquake, but householders might also anticipate that it would remind them that there is a continual threat to their home. Both of these circumstances describe situations in which the anticipation of future feelings can tap into less conscious anxieties about ontological security. The manner in which people anticipate impacts on ontological security has several implications for preparedness. For example, it suggests that hazard warnings will be counterproductive if they are not accompanied by suggestions of easy, reliable ways of eliminating risk. It also suggests that adaptation measures should be designed not to enhance awareness of the hazard.

Article

Jennifer Mitzen and Kyle Larson

In the early 21st century, a stream of international relations (IR) scholarship has emerged that interprets states’ foreign policy processes, decisions, and international outcomes through the lens of a distinctive type of security, ontological as opposed to “physical” or “material” security. It is a concept that helps us think about how the ability to make choices and take action depends critically on our sense of self, which is itself produced in our actions, albeit often at the level of routines and background narratives. Bringing ontological security into the study of foreign policy in some cases points to different explanations for choices, while in others it adds causal depth and generates new implications. This article reviews the literature that treats foreign policy as an outgrowth of the pursuit of a multifaceted understanding of security, ontological and physical, and raises questions for further research.

Article

Despite high rates of mental illnesses, older adults face multiple barriers in accessing mental health care. Primary care clinics, and home- and community-based senior-serving agencies are settings where older adults routinely receive medical care and social services. Therefore, integration of mental health care with existing service delivery systems can improve access to mental health services and reduce the unmet mental health needs of seniors. Evidence suggests that with innovative components mental health provided in collaboration with primary care providers with or without co-location within primary care clinics can improve depression and anxiety. Home-based models for depression care are also effective, but more research is needed in examining home-based approaches in late-life anxiety treatment. It is noteworthy that integrative models are particularly helpful in expanding the reach in underserved communities: elders from minority and low-income backgrounds and homebound seniors.

Article

The majority of anxiety disorders emerge during childhood and adolescence, a developmental period characterized by dynamic changes in frontolimbic circuitry. Frontolimbic circuitry plays a key role in fear learning and has been a focus of recent efforts to understand the neurobiological correlates of anxiety disorders across development. Although less is known about the neurobiological underpinnings of anxiety disorders in youth than in adults, studies of pediatric anxiety have revealed alterations in both the structure and function of frontolimbic circuitry. The amygdala, prefrontal cortex (PFC), anterior cingulate cortex (ACC), and hippocampus contribute to fear conditioning and extinction, and interactions between these regions have been implicated in anxiety during development. Specifically, children and adolescents with anxiety disorders show altered amygdala volumes and exhibit heightened amygdala activation in response to neutral and fearful stimuli, with the magnitude of signal change in amygdala reactivity corresponding to the severity of symptomatology. Abnormalities in the PFC and ACC and their connections with the amygdala may reflect weakened top-down control or compensatory efforts to regulate heightened amygdala reactivity associated with anxiety. Taken together, alterations in frontolimbic connectivity are likely to play a central role in the etiology and maintenance of anxiety disorders. Future studies should aim to translate the emerging understanding of the neurobiological bases of pediatric anxiety disorders to optimize clinical interventions for youth.

Article

Stephen M. Croucher

Despite rises in immigration and attempts to manage immigration, anti-immigrant threat and prejudice remains a major concern at the individual and societal levels, and often surfaces as a key political, economic, and social issue. Research shows anti-immigrant prejudice is widepread. One of the explanatory factors for widespread anti-immigrant attitudes is threat perception. Attitudes towards immigrants and immigration have become less positive amidst the outbreak of the current refugee crises in Europe. This can lead to many anti-immigration demonstrations and to anti-immigration sentiment. Many nonimmigrants worry about the economic burden immigrants pose to society and the potential danger immigrants represent to the dominant culture and society. Overall, research shows that believing people from other cultures are a threat to one’s own culture and survival leads to prejudice and discrimination. Stephan and Stephan’s integrated threat theory (ITT) offers an explanation to these feelings of threat. ITT proposes that prejudice and negative attitudes towards immigrants and out-groups is explained by four types of threats: realistic threat, symbolic threat, negative stereotype, and intergroup anxiety. Realistic threats are to the physical well-being and the economic and political power of the in-group; symbolic threats arise due to cultural differences in values, morals, and worldview of the out-group; negative stereotypes arise from negative stereotypes the in-group has about the out-group; and intergroup anxiety refers to anxiety the in-group experiences in the process of interaction with members of the out-group, especially when both groups have had a history of antagonism.

Article

Michael A. Hogg and Sucharita Belavadi

The subjective state of uncertainty can be understood as deriving from reduced predictability of and control over events and the world around us. There are different ways to conceptualize the nature of uncertainty, its antecedents and predictors, and the strategies that individuals use to manage & reduce uncertainty within communication science and social psychology. Prominent theories of uncertainty within communication—uncertainty reduction theory, anxiety/uncertainty management theory, and approaches to uncertainty management—focus on states of uncertainty and lowered predictability within the context of interactive communication with others. In these theories, communication with others plays a central role in the production, maintenance, and management of uncertainty. These three communication-based approaches also differ in the ways in which they conceptualize uncertainty and its management in communicative contexts. Uncertainty reduction theory treats uncertainty as an aversive state that individuals always aim to reduce. In contrast, although anxiety/uncertainty management theory and approaches to uncertainty management discuss uncertainty as an aversive state, they also provide for conditions under which uncertainty might be a desired state. Within social psychology, the construct of uncertainty has received different treatments. Some approaches have conceptualized the extent of uncertainty experienced and tolerated by individuals as an enduring individual difference or a personality attribute. Social psychologists have also conceptualized uncertainty as an aspect of a person’s identity and self-concept. For instance, uncertainty-identity theory explains uncertainty as a context-invoked aversive state associated with lowered perceived predictability of self and others—uncertainty about who one is, how one should behave, and how one will be treated by others. The theory argues that individuals are motivated to reduce such uncertainty by seeking group memberships, as groups provide a framework for self-definition that helps manage self-conceptual uncertainty.

Article

Aaron L. Slusher and Edmund O. Acevedo

Physical activity is essential for optimal human functioning. However, the emergence of modern lifestyle conveniences has contributed to the increased prevalence of sedentary behavior. As a result, the psychobiological nature of physical activity and the positive impact of physical activity on body and brain communication has prompted investigators to utilize a breadth of research strategies and techniques to identify physical activity regimes, associated mental health benefits, and the plausible mechanisms that explain the mental health adaptations. Furthermore, investigators have provided evidence supporting a number of mechanisms that at least partially explain the psychological adaptations to acute (a single bout) and chronic (long-term) physical activity intervention. Through these efforts, the observed efficacy of physical activity as a potential therapeutic intervention strategy to ameliorate the most prevalent mental disorders (i.e., anxiety, depression, bipolar disorder, and schizophrenia), and to enhance mental illness-related and age-related impairments of cognitive function has received some attention in the literature and will likely lead to clarity and confidence for clinical use.

Article

Progressive neurological disorders are incurable disorders with gradual deterioration and impacting patients for life. Two common progressive neurological disorders found in late life are Parkinson’s disease (PD) and motor neuron disease (MND). Psychological complications such as depression and anxiety are prevalent in people living with PD and MND, yet they are underdiagnosed and poorly treated. PD is classified a Movement Disorder and predominantly characterized by motor symptoms such as tremor, bradykinesia, gait problems and postural instability; however, neuropsychiatric complications such as anxiety and depression are common and contribute poorly to quality of life, even more so than motor disability. The average prevalence of depression in PD suggest 35% and anxiety in PD reports 31%. Depression and anxiety often coexist. Symptoms of depression and anxiety overlap with symptoms of PD, making it difficult to recognize. In PD, daily fluctuations in anxiety and mood disturbances are observed with clear synchronized relationships to wearing off of PD medication in some individuals. Such unique characteristics must be addressed when treating PD depression and anxiety. There is an increase in the evidence base for psychotherapeutic approaches such as cognitive behavior therapy to treat depression and anxiety in PD. Motor neuron disease (MND) is classified a neuromuscular disease and is characterized by progressive degeneration of upper and lower motor neurons is the primary characteristic of MND. The most common form of MND is Amyotrophic lateral sclerosis (ALS) and the terms ALS and MND are simultaneously used in the literature. Given the short life expectancy (average 4 years), rapid deterioration, paralysis, nonmotor dysfunctions, and resulting incapacity, psychological factors clearly play a major role in MND. Depression and suicide are common psychological concerns in persons with MND. While there is an ALS-specific instrument to assess depression, evaluation of anxiety is poorly studied; although emerging studies suggesting that anxiety is highly prevalent in MND. Unfortunately, there is no substantial evidence-base for the treatment of anxiety and depression in MND. Caregivers play a major role in the management of progressive neurological diseases. Therefore, evaluating caregiver burden and caregiver psychological health are essential to improve quality of care provided to the patient, as well as to improve quality of life for carers. In progressive neurological diseases, caregiving is often provided by family members and spouses, with professional care at advanced disease. Psychological interventions for PD carers addressing unique characteristics of PD and care needs is required. Heterogeneous clinical features, rapid functional decline, and short trajectory of MND suggest a multidisciplinary framework of carer services including psychological interventions to mitigate MND. A Supportive Care Needs Framework has been recently proposed encompassing practical, informational, social, psychological, physical, emotional, and spiritual needs of both MND patients and carers.

Article

Intergroup anxiety is a form of restlessness and negative feeling caused by communicating with someone with a different social and cultural identity. Just like any other form of anxiety, intergroup anxiety has negative consequences, such as disability in social interactions, weak cognitive performance, and even life consequences. Intergroup anxiety is the result of fear of being disapproved, embarrassed, and rejected across different racial, ethnic, religious, and social groups’ interactions. Theoretically, intergroup anxiety is influenced by the previous experiences one has had with the members of other groups, one’s knowledge of other groups, and the situation in which one interacts with other groups. Intergroup anxiety has behavioral, cognitive, and affective consequences. There are different theories of communication that explain the nature and function of intergroup anxiety. Uncertainty reduction theory, for example, defines anxiety as a result of uncertainty and asserts that to maintain communication, parties should decrease their uncertainty and consequently their anxiety. Anxiety/uncertainty management theory focuses on anxiety and argues that to have effective communication the level of intergroup anxiety should be managed between a minimum and a maximum threshold. A decrease in anxiety and uncertainty is also essential to intercultural adaptation. Different factors can increase the amount of anxiety in intergroup contexts, namely ethnocentrism, prejudice, and discrimination. These factors are related to individuals’ feeling of threat due to one or some of the following: intergroup conflict, unequal group status, in-group identification, knowledge of out-group, and intergroup contact. To settle intergroup conflicts individuals are advised to establish more high-quality intergroup contacts and to change the way they make distinctions among various groups. Quality intergroup contact can be reached through strategies such as establishing cross-cultural friendships and intergroup disclosure. One form of intergroup anxiety is intercultural communication apprehension, which is the apprehension individuals feel due to real or imagined intercultural communication. Intercultural communication apprehension is positively correlated with uncertainty and ethnocentrism, and negatively correlated with intercultural willingness to communicate.

Article

Performance psychology addresses issues of optimal performance across a wide range of fields. Optimal performance can be enhanced via psychological methods; psychology also addresses the mental barriers and detriments to performance. One major performance arena is the performing arts. The performing arts include music, dance, and theatre arts. In some instances, people are performing live in front of an audience; in other situations, their performance is prepared for a future audience (e.g., movie, TV, or video). A number of psychological aspects need to be addressed to produce optimal performance: flawless performance, optimal arousal, focus maintenance, competition and perfectionism, and artistic expression. Much of the knowledge concerning the enhancement of performance is derived from the field of sport psychology. Some common concerns include the management of performance arousal, developmental issues in relation to early training, injury recovery, and transitions within or out of the performance arena. Although many concerns and expectations are similar with regard to the end “product” of excellent performance, there are also vast differences in such aspects as the culture of the performing arts, historical roots, purpose of the activity, resources and supports, and the place of the particular performance arena within the larger culture. Both research and practice opportunities are increasingly of interest to academicians, practitioners, and performing artists themselves.

Article

One of the most frequently evoked emotions on a daily basis is anger. Regardless of time and context, anger is a central emotion of action and motivation. Closely related with a number of high arousal negative emotions, such as hatred, disgust, feelings of revenge, and contempt, anger stands out among all with its neural and appraisal foundations and attitudinal and behavioral consequences. More importantly, anger differs from anxiety in essential aspects that place the two emotions in different dimensions. So far, various studies have demonstrated the potential consequences of anger (and its distinct nature from anxiety) across an array of domains including risk assessments, policy preferences, information processing and motivated biases, political participation, social media engagement, group relations and ethnocentrism, intractable conflicts and conflict resolution, and vote behavior. Some others have treated anger as a mediator or a moderator between prior attitudes and beliefs, with evidence on how it could alter primary associations. It is thus relevant to begin with the overview of the theoretical debates and matters of conceptualization, followed by a discussion of how anger differs from anxiety. In pursuit of these foundations, contemporary research tackles the domains where anger plays a critical role in exploration of early 21st-century phenomena such as the populist surge, growing polarization, and disconnected networks across distinct contexts.

Article

The effects of uncertainty and anxiety are profiled in association with intercultural communication and the initiation and development of intercultural relationships. Uncertainty is cognitive and refers to what one knows about another and one’s level of predictability about another. Anxiety is the affective equivalent of uncertainty and refers to the level of discomfort associated with interacting with a stranger. Two major theories are associated with this process, including uncertainty reduction theory and anxiety/uncertainty management theory. Other communicative factors also affect uncertainty and anxiety reduction and management during intercultural communication.

Article

DeMond M. Grant and Evan J. White

Cognitive control is the ability to direct attention and cognitive resources toward achieving one’s goals. However, research indicates that anxiety biases multiple cognitive processes, including cognitive control. This occurs in part because anxiety leads to excessive processing of threatening stimuli at the expense of ongoing activities. This enhanced processing of threat interferes with several cognitive processes, which includes how individuals view and respond to their environment. Specifically, research indicates that anxious individuals devote their attention toward threat when considering both early, automatic processes and later, sustained attention. In addition, anxiety has negative effects on working memory, which involves the ability to hold and manipulate information in one’s consciousness. Anxiety has been found to decrease the resources necessary for effective working memory performance, as well as increase the likelihood of negative information entering working memory. Finally, anxiety is characterized by focusing excessive attention on mistakes, and there is also a reduction in the cognitive control resources necessary to correct behavior. Enhancing our knowledge of how anxiety affects cognitive control has broad implications for understanding the development of anxiety disorders, as well as emerging treatments for these conditions.

Article

Hee Yun Lee, William Hasenbein, and Priscilla Gibson

As the older adult population continues to grow at a rapid rate, with an estimated 2.1 billion older adults in 2050, social welfare researchers are determined to fill the shortage of gerontological social workers and structural lag to best serve the baby boomers who are expected to need different services than previous generations. Mental illness impacts over 20% of older adults in the world and the United States. The major mental health issues in older adults include depression, anxiety, loneliness, and social isolation. Depression is considered one of the most common mental health issues among this population; however, the prevalence could be underestimated due to older adults linking relevant symptoms to other causes, such as old age, instead of as possible depression. Like depression, anxiety symptoms are often mistaken as results of aging. It is also difficult for providers to diagnose anxiety in this population due to anxiety frequently being coupled with other illnesses and the psychological stress that comes with old age. Because the presence of loneliness or social isolation can manifest depression and anxiety symptoms in older adults, it is also difficult to separate these two issues. With the anticipated increase of the older adult population within the next few years, measurement tools have been created to assess depression and anxiety specifically for older adults. In addition to adapting assessment tools, interventions tailored to older adults are essential to ensure treatment coherence, even though medications are the go-to treatment option.

Article

Simona C. Kaplan, Michaela B. Swee, and Richard G. Heimberg

Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations. Multiple psychological interventions have been developed to treat SAD. The most widely studied of these interventions stem from cognitive-behavioral, acceptance-based, interpersonal, and psychodynamic conceptualizations of SAD. In cognitive-behavioral therapy (CBT), patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs. Mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Interpersonal psychotherapy links SAD to interpersonal problem areas and aims to reduce symptoms by targeting interpersonal difficulties. Psychodynamic psychotherapy for SAD focuses on identifying unresolved conflicts that lead to SAD symptoms, fostering insight and expressiveness, and forming a secure helping alliance. Generally, CBT is the most well-studied of the psychological treatments for SAD, and research demonstrates greater reductions in social anxiety than pill placebo and waitlist controls. Results from randomized controlled trials (RCTs) suggest that mindfulness—and acceptance-based therapies may be as efficacious as CBT, although the body of research remains small; four of five RCTs comparing these approaches to CBT found no differences. RCTs comparing CBT to IPT suggest that CBT is the more efficacious treatment. Two RCTs comparing CBT to psychodynamic psychotherapy suggest that psychodynamic psychotherapy may have efficacy similar to CBT, but that it takes longer to achieve similar outcomes. RCTs examining CBT and pharmacotherapy suggest that the medications phenelzine and clonazepam are as efficacious as CBT for treating SAD and are faster acting, but that patients receiving these medications may be more likely to relapse after treatment is discontinued than patients who received CBT. Research generally does not indicate added benefit of combining psychotherapy with pharmacotherapy above each monotherapy alone, although this body of research is quite variable. Effectiveness studies indicate that CBT is equally effective in community clinics and controlled research trials, but studies of this nature are lacking for other psychological approaches.