Hartford Hospital

David F. Tolin

Anxiety-related disorders include specific phobia, social anxiety, generalized anxiety, panic, agoraphobia, obsessive-compulsive, and posttraumatic stress disorders. These conditions are highly common, with an estimated cost to society in excess of $42 billion in 1990, the last time such an analysis was conducted, and substantial reductions in health-related quality of life. Fortunately, effective treatments are available. Cognitive-behavioral therapy (CBT) is an evidence-based, time-limited, and action-oriented psychological treatment. Some of the most commonly used strategies for treating anxiety-related disorders include: (a) exposure, in which patients are asked to gradually approach feared and avoided stimuli; (b) cognitive restructuring, in which faulty beliefs are challenged and the patient is encouraged to consider new perspectives, and (c) relaxation, which involves muscle or breathing-related strategies aimed at reducing autonomic arousal.

Exposure is a mainstay of CBT for anxiety-related disorders. In this procedure, patients are assisted to gradually reduce avoidant behavior and confront feared situations, activities, or people.  For example, a patient with a phobia of dogs might be instructed to be in a room with a small dog first, then to pet the dog, and work up to being in contact with larger dogs. This process can be duplicated across anxiety-related disorders. For example, an individual with panic disorder might deliberately provoke feared physical sensations by hyperventilating, spinning, or running in place (a process termed interoceptive exposure). A patient with social phobia might be instructed to interact with others and even make small blunders while doing so. A patient with obsessive-compulsive disorder and contamination fears might be instructed to touch progressively dirtier objects while refraining from handwashing (a process termed exposure and response prevention). A patient with post-traumatic stress disorder might deliberately recall a traumatic event they have been trying to keep out of awareness (a process termed imaginal exposure). 

Cognitive restructuring aims to identify and correct maladaptive or erroneous beliefs.  Although exposure can and does address many of these beliefs (e.g., touching a dirty object helps correct the belief ‘I will get sick and die’), it may be advantageous to address these beliefs more directly at times.  Some strategies for cognitive restructuring include: (a) examining the evidence, in which patients evaluate the available evidence that supports or refutes their belief; (b) considering alternatives, in which patients consider other ways they could evaluate a troublesome situation, and (c) conducting behavioral experiments, in which the patient and therapist construct an experiment to test whether the belief is true. 

Cognitive restructuring aims to identify and correct maladaptive or erroneous beliefs. Although exposure can and does address many of these beliefs (e.g., touching a dirty object helps correct the belief ‘I will get sick and die’), it may be advantageous to address these beliefs more directly at times. Some strategies for cognitive restructuring include: (a) examining the evidence, in which patients evaluate the available evidence that supports or refutes their belief; (b) considering alternatives, in which patients consider other ways they could evaluate a troublesome situation, and (c) conducting behavioral experiments, in which the patient and therapist construct an experiment to test whether the belief is true. For example, a patient with social phobia might hold the belief, “If I go to the party, I’ll just embarrass myself and no one will want to talk to me.” The therapist might encourage the patient to examine the evidence for and against that belief; for example, what evidence tells you that you will embarrass yourself and no one will want to talk to you? On the other hand, what evidence might suggest that you will not embarrass yourself and that people might actually like talking to you? The therapist could encourage the patient to consider alternatives, for example, by asking the patient what someone else in this situation might think. Finally, the therapist and patient could treat this belief as a hypothesis, rather than a fact, and test its accuracy by going to the party and observing one’s behavior and that of others.

Relaxation is neither necessary nor helpful for all patients with anxiety-related disorders, though it has its place in CBT, particularly in the treatment of generalized anxiety disorder, which is characterized by chronic physiological arousal. Progressive muscle relaxation is the most well-studied relaxation strategy. In this exercise, the therapist instructs the patient to tense, and then relax, muscles of their body until a state of physiological and mental relaxation is achieved. The patient might then be instructed to practice this relaxation exercise at home, first under routine conditions and eventually working up to using relaxation as an active coping strategy when feeling acutely anxious. Breathing training can also be used as a relaxation strategy. Contrary to popular belief that deep cleansing breaths are helpful, the purpose of breathing training is actually to reduce hyperventilation. As such, the therapist helps the patient decrease the rate of oxygen intake by inhaling slowly (e.g., 4 seconds) through the nose and exhaling slowly (e.g., 6 seconds) through the mouth.

Well-controlled research points to the efficacy of CBT for anxiety-related disorders, with a medium to large effect over placebo. However, it is also noted that the remission rate for CBT for anxiety disorders—the likelihood that a treated patient will no longer have an anxiety disorder at the end of treatment—is only around 50%, suggesting a need for further treatment refinement.