Anxiety disorders are highly prevalent and result in a substantial negative impact on quality of life, psychosocial functioning, and physical health (Comer et al., Reference Comer, Blanco, Hasin, Liu, Grant, Turner and Olfson2011; Hendriks et al., Reference Hendriks, Spijker, Licht, Hardeveld, de Graaf, Batelaan and Beekman2016). At some point in their lives, most individuals affected by an anxiety disorder will come into contact with a treatment provider as a result of their condition (Wang, Angermeyer, et al., Reference Wang, Angermeyer, Borges, Bruffaerts, Chiu, De Girolamo and Kessler2007). As a result, understanding the most effective methods for treating anxiety disorders is paramount. This chapter first provides an overview of the different forms of treatment for anxiety disorders, including traditional cognitive behavioral therapy, acceptance and mindfulness-based treatments, relaxation, pharmacotherapy, and psychodynamic therapy, as well as the evidence for the efficacy of each treatment. Next, this chapter reviews the various treatment components that make up evidence-based treatments for anxiety disorders, with an emphasis on the treatment targets and interventions with transdiagnostic relevance. These treatment components include psychoeducation, exposure, cognitive restructuring, mindfulness, and relaxation. The chapter concludes by highlighting important future directions for reducing the enormous burden to society caused by anxiety disorders.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is considered the gold standard of treatment for adult anxiety disorders (NICE, 2011). CBT consists of a class of scientifically informed interventions that view emotional disorders as persisting due to dysfunctional beliefs and maladaptive behavioral patterns (Hofmann, Asmundson, & Beck, Reference Hofmann, Asmundson and Beck2013). In the case of anxiety disorders specifically, these unhelpful beliefs are related to overestimating the likelihood of negative outcomes, and a perceived inability to cope with anxiety-inducing situations. Such perceptions result in patterns of behavioral and cognitive avoidance, which often become habit and reinforce maladaptive beliefs about threat. Treatment with CBT addresses maladaptive cognitions through cognitive restructuring, which involves identifying automatic thinking patterns and developing more useful or realistic alternative interpretations. Behavioral factors contributing to the maintenance of anxiety, on other hand, are targeted by the use of exposure exercises, which involve systematically confronting anxiety-inducing situations in order to learn that feared outcomes are unlikely to occur. More detailed descriptions of these and other common CBT techniques used in CBT are provided later in the chapter.
Evidence for the efficacy of CBT comes from a number of clinical trials that have shown CBT to be associated with a reduction in anxiety symptoms (Butler et al., Reference Butler, Chapman, Forman and Beck2006; Hofmann, Asnaani, Vonk, Sawyer, & Fang, Reference Hofmann, Asnaani, Vonk, Sawyer and Fang2012). Specifically, meta-analyses have shown CBT to result in superior outcomes compared to various control conditions for social anxiety disorder (SAD) (Mayo-Wilston et al., Reference Mayo-Wilson, Dias, Mavranezouli, Kew, Clark, Ades and Pilling2014), generalized anxiety disorder (GAD) (Cuijpers et al., Reference Cuijpers, Sijbrandij, Koole, Huibers, Berking and Andersson2014), panic disorder (PD) (Pompoli et al., Reference Pompoli, Furukawa, Imai, Tajika, Efthimiou and Salanti2016), and specific phobias (Wolitzky-Taylor, Horowitz, Powers, & Telch, Reference Wolitzky-Taylor, Horowitz, Powers and Telch2008), as well as other fear-based disorders like obsessive-compulsive disorder (OCD) (Olatunji et al., Reference Olatunji, Davis, Powers and Smits2013) and posttraumatic stress disorder (PTSD) (Bisson et al., Reference Bisson, Roberts, Andrew, Cooper and Lewis2013). Recent meta-analyses have also examined the effect of CBT across multiple types of anxiety disorders, and demonstrated superiority in comparison to waitlist controls (Bandelow et al., Reference Bandelow, Reitt, Röver, Michaelis, Görlich and Wedekind2015) and treatment as usual (Watts et al., Reference Watts, Turnell, Kladnitski, Newby and Andrews2015). To date, perhaps the most rigorous evaluation of the efficacy of CBT comes from a meta-analysis by Hofmann and Smits (Reference Hofmann and Smits2008), which compared the effect of CBT to psychological or pharmacological placebo in 27 randomized controlled trials (RCTs) of CBT for SAD, PTSD, PD, acute stress disorder, OCD, and GAD. Using placebo-controlled trials in this instance is important for understanding the specific effect of CBT (as opposed to treatment generally), as such a comparison condition better controls for the effects of patient expectations and the therapeutic relationship on treatment outcome. Findings revealed CBT interventions to be superior to psychological and pharmacological placebo conditions, with controlled effect sizes for continuous measures of anxiety symptoms in the medium to large range. Furthermore, patients completing CBT were more than four times more likely to be treatment responders than those completing placebo treatment. A recent extension and update of this study essentially replicated these findings (Carpenter et al., 2018).
Given the high rates of comorbidity with depression among anxious populations (Goldberg, Krueger, Andrews, & Hobbs, Reference Goldberg, Krueger, Andrews and Hobbs2009; Kaufman & Charney, Reference Kaufman and Charney2000), depressive symptoms are often evaluated as outcome measures in CBT treatment studies for anxiety disorders. Cuijpers and colleagues (Reference Cuijpers, Cristea, Weitz, Gentili and Berking2016) conducted a meta-analysis on 46 clinical trials of CBT for anxiety disorders and found that CBT was associated with moderate to large effects on symptoms of depression. The effect sizes were comparable to direct treatment for major depressive disorder (MDD). Researchers have also examined the effects of CBT for anxiety disorders on other symptoms not directly targeted in treatment, such as quality of life. Hofmann, Wu, and Boettcher (Reference Hofmann, Wu and Boettcher2014) conducted a meta-analysis examining the effect of CBT for anxiety disorders on self-reported quality of life, which captures outcomes such as patients’ subjective view of their life circumstances, overall mental and physical health, social and family relationships, and functioning at work and at home. Pooling together the results from 44 studies, CBT significantly outperformed control conditions, with a controlled effect size in the moderate range.
One of the most frequently noted criticisms of the extant literature on CBT is the generalizability of CBT trials (e.g., Westen & Morrison, Reference Westen and Morrison2001). Specifically, critics question whether the effects of CBT delivered by expert therapists in highly controlled clinical trials extend to treatment delivered by community providers with more complex and diverse patients seen in routine clinical practice. In response to such a critique, Hans and Hiller (Reference Hans and Hiller2013) conducted a meta-analysis of nonrandomized effectiveness studies for adult anxiety disorders and found that CBT was widely effective in routine clinical settings; both disorder-specific symptoms as well as general anxiety and depression showed improvement at the conclusion of treatment as well as at 12-month follow-up visits. Notably, however, 63% of the studies included were conducted with completer-only samples and 30% of studies did not report participant dropout rates. Similarly, only a minority (24%) of the placebo-controlled RCTs in Hofmann and Smits (Reference Hofmann and Smits2008) used intent-to-treat analyses. This represents an important limitation of CBT, as studies with completer-only samples are at risk of producing inflated effect sizes due to the possibility of nonresponding patients who systematically discontinued treatment prior to completion.
In addition, not all patients respond favorably to CBT, with response rates estimated at 60–70% (Loerinc et al., Reference Loerinc, Meuret, Twohig, Rosenfield, Bluett and Craske2015), and more data on long-term outcomes are needed (Hans & Hiller, Reference Hans and Hiller2013). Furthermore, on average approximately 27% of CBT patients in routine clinical practice drop out before the conclusion of their treatment (van Ingen, Freiheit, & Vye, Reference van Ingen, Freiheit and Vye2009). Nonetheless, extant literature shows that response rates for CBT are higher and dropout rates are no different than comparison treatments (Hofmann & Smits, Reference Hofmann and Smits2008). In addition, the evidence base supporting the efficacy of CBT far outpaces that of any other treatment approach, thus making it the treatment of choice for anxiety disorders.
Treatment formats in CBT.
Although CBT was originally developed as an individual, face-to-face therapy, it has also been successfully delivered in group settings, through computerized programs, and in self-help formats. Having a variety of formats through which CBT can be delivered is important because access to a particular form of treatment may be limited by geographic or financial barriers, and because individual preferences and feelings of stigma may make one form more desirable over another for individuals considering treatment. Patient preference as well as levels of disorder severity should be taken into consideration as therapists consider variations of CBT that best suit patients’ needs.
Group CBT.
Group therapy has the potential to yield benefits such as normalizing symptomology, providing patients with the opportunity to give and receive support from others, and allowing the influence of successful behavior from group members who are doing well to spread to other members of the group (Wersebe, Sijbrandij, & Cuijpers, Reference Wersebe, Sijbrandij and Cuijpers2013). Additionally, group treatments are more time- and cost-effective. The most obvious beneficiaries of group CBT are socially anxious patients, as the group format provides a unique opportunity to encounter feared settings and become more comfortable with social interaction during therapy. However, research on group CBT presents mixed results across disorders. Studies have shown group CBT to be effective compared to waitlist or placebo for SAD and OCD (Marchand et al., Reference Marchand, Roberge, Primiano and Germain2009; Mörtberg et al., Reference Mörtberg, Karlsson, Fyring and Sundin2006; Wersebe et al., Reference Wersebe, Sijbrandij and Cuijpers2013), and comparable to individual CBT for PD (Jónsson et al., Reference Jónsson, Hougaard and Bennedsen2011). A significant number of studies have also shown that group CBT is less effective than individual CBT for GAD and SAD (Covin et al., Reference Covin, Ouimet, Seeds and Dozois2008; Hedman et al., Reference Hedman, Mörtberg, Hesser, Clark, Lekander, Andersson and Ljótsson2013; Mayo-Wilson et al., Reference Mayo-Wilson, Dias, Mavranezouli, Kew, Clark, Ades and Pilling2014; Stangier et al., Reference Stangier, Heidenreich, Peitz, Lauterbach and Clark2003), likely because therapists cannot provide the same attention to address patients’ individual issues. It is also important to note that group and individual CBT can be used together; patients may benefit from beginning treatment in a group format and then progressing into individual therapy to allow for increased therapist guidance and individualized exercises (Hofmann et al., Reference Hofmann, Asmundson and Beck2013).
Computerized CBT.
Computer-based CBT (cCBT) for anxiety disorders has received a recent surge of exploration, as it has the potential to increase accessibility of treatment and reduce costs. A recent meta-analysis of RCTs comparing cCBT to wait-list, in-person CBT, and Internet control for the treatment of anxiety disorders found cCBT superior to wait-list and equivalent to in-person CBT (Adelman, Panza, Bartley, Bontempo, & Bloch, Reference Adelman, Panza, Bartley, Bontempo and Bloch2014). An important issue with cCBT, however, is whether some level of remote therapist support is necessary. A meta-analysis by Spek and colleagues (Reference Spek, Cuijpers, Nyklíček, Riper, Keyzer and Pop2007) found that interventions that included therapist support yielded a large effect size, whereas those that did not yielded only a small effect size (Spek et al., Reference Spek, Cuijpers, Nyklíček, Riper, Keyzer and Pop2007). In contrast to this finding, however, is a study by Berger and colleagues (Reference Berger, Caspar, Richardson, Kneubühler, Sutter and Andersson2011) that compared three arms of Internet-based treatment for SAD with varying levels of therapist support. The study found no significant difference between groups. Also of note, the age of participants has the potential to moderate the effect of cCBT such that older adults may benefit less from digital intervention due to generational differences in comfort with technology (Barak et al., Reference Barak, Hen, Boniel-Nissim and Shapira2008; Grist & Cavanaugh, Reference Grist and Cavanagh2013). The implementation of cCBT is relatively new, and more research is necessary to evaluate the impact of therapist support and other potential moderators of treatment success.
“Third Wave” Therapies
Over the past three decades, researchers have expanded upon CBT for anxiety disorders to include mindfulness and acceptance-based treatments. Some refer to this class of therapy as the “third wave” of CBT, as such treatment approaches focus not just on the content of one’s thoughts but also on one’s relationship to them (Hayes, Reference Hayes2004). Accordingly, third wave therapies rely on treatment strategies such as mindfulness, acceptance, cognitive defusion, experiential learning, and contextual change motivated by the focus on clients’ values and life goals (Hayes, Reference Hayes2004). The most popular adaptations of this approach are acceptance and commitment therapy (ACT) and mindfulness-based therapies (mindfulness-based cognitive therapy [MBCT] and mindfulness-based stress reduction [MBSR]). Of note, some have argued against the notion of these treatments forming a “new wave,” citing that ACT and mindfulness-based therapies are more similar to than different from traditional CBT (Hofmann, Reference Hofmann2008a; Hofmann & Asmundson, Reference Hofmann and Asmundson2008). Nonetheless, such authors acknowledge that these treatment approaches have brought about meaningful changes and advancements in the treatment of anxiety (Hayes & Hofmann, Reference Hayes and Hofmann2017). Brief overviews and supporting evidences of these therapeutic approaches are provided in what follows.
Acceptance and commitment therapy (ACT).
ACT is based on the notion that the goal of treatment is not to decrease anxiety, but rather to promote psychological flexibility and enable patients to live in accordance with their values, regardless of their subjective anxiety (Hayes, Pistorello, & Levin, Reference Hayes, Pistorello and Levin2012). Accordingly, ACT does not attempt to identify and correct cognitive distortions or directly regulate physiological sensations like traditional CBT. It instead employs an acceptance-based approach using techniques such as mindfulness, cognitive defusion, and self-as-context to change a patient’s relationship with anxiety (Hayes, Luoma, Bond, Masuda, & Lillis, Reference Hayes, Luoma, Bond, Masuda and Lillis2006). For instance, a common ACT technique involves responding to anxious thoughts or feelings by saying “I am having the thought/feeling of anxiety,” in order to create distance from the lived experience of anxiety. ACT still relies on exposure techniques, but exposure is viewed as an opportunity to practice behaving in accordance with one’s goals or values, rather than an exercise designed to reduce anxiety.
A number of meta-analyses of RCTs have shown ACT to be superior to control conditions (Hayes et al., Reference Hayes, Luoma, Bond, Masuda and Lillis2006; Powers, Vörding, & Emmelkamp, Reference Powers, Vörding and Emmelkamp2009), and some indicate that ACT is as effective as established treatments (Bluett, Homan, Morrison, Levin, & Twohig, Reference Bluett, Homan, Morrison, Levin and Twohig2014). In one of the few direct comparisons of ACT and traditional CBT, Arch and colleagues (Reference Arch, Eifert, Davies, Vilardaga, Rose and Craske2012) found the two treatments to be equally efficacious for a sample of patients with mixed anxiety disorders, including PD with or without agoraphobia, specific phobia, SAD, and GAD. However, findings did indicate greater improvements in quality of life in the CBT condition, while ACT led to superior outcomes on measures of psychological flexibility. In addition, CBT was found to be superior to ACT among patients with moderate levels of anxiety sensitivity, whereas ACT outperformed CBT among patients with comorbid mood disorders (Wolitzky-Taylor, Arch, Rosenfield, & Craske, Reference Wolitzky-Taylor, Arch, Rosenfield and Craske2012). Although existing research does not suggest differential efficacy between ACT and traditional CBT for anxiety disorders, the potential to personalize treatment based on individual characteristics is a promising future direction for research and practice. Additionally, some researchers have suggested that the integration of ACT techniques in CBT protocols (Bluett et al., Reference Bluett, Homan, Morrison, Levin and Twohig2014) holds particular promise.
Mindfulness-based therapies.
Another group of therapies that emerged as part of the “third wave” is rooted in the ancient Buddhist practice of mindfulness. Mindfulness refers to the process of adopting a nonjudgmental awareness of present experience, including one’s sensations, thoughts, bodily states, consciousness, and environment (Kabat-Zinn, Reference Kabat-Zinn2003). MBCT (Segal, Williams, & Teasdale, Reference Segal, Williams and Teasdale2002) and MBSR (Kabat-Zinn, Reference Kabat-Zinn1982) integrate mindfulness practices with elements of traditional CBT, and are based on the idea that taking a more accepting and less judgmental stance toward one’s negative emotions can lessen their hold on day-to-day experiences.
A number of studies have shown that MBTs result in moderate reductions in anxiety symptoms associated with medical illnesses or other psychiatric disorders (Hofmann, Sawyer, Witt, & Oh, Reference Hofmann, Sawyer, Witt and Oh2010). A growing number of clinical trials have also looked directly at MBTs for individuals with anxiety disorders. Two trials showed that a meditation-based stress reduction program (Lee et al., Reference Lee, Ahn, Lee, Choi, Yook and Suh2007) and MBCT (Kim et al., Reference Kim, Lee, Choi, Suh, Kim, Kim and Song2009) for patients with GAD and PD led to greater reductions in anxiety symptoms than an anxiety education control condition. A later study demonstrated MBSR to lead to significant reductions in anxiety symptoms among patients with GAD. However, MBSR was not significantly different from a stress management education condition (Hoge et al., Reference Hoge, Bui, Marques, Metcalf, Morris, Robinaugh and Simon2013). Another treatment study indicated that MBSR benefited patients with SAD, but was not as effective as group CBT (Koszycki, Benger, Shlik, & Bradwejn, Reference Koszycki, Benger, Shlik and Bradwejn2007). Lastly, a study on veterans with mixed anxiety disorders showed equivalent outcomes of MBSR and CBT on principal disorder severity at post-treatment and follow-up (Arch, Ayers et al., Reference Arch and Ayers2013). However, CBT outperformed MBSR on anxious arousal outcomes, while MBSR led to greater reductions in worry and comorbid emotional disorders than traditional CBT. In an interesting parallel with the moderator analysis of ACT vs. CBT by Wolitzky-Taylor and colleagues (Reference Wolitzky-Taylor, Arch, Rosenfield and Craske2012), MBSR outperformed CBT among those with moderate to severe depressive symptoms (Arch & Ayers, Reference Arch and Ayers2013). Taken together, the results of MBTs for the treatment of anxiety are encouraging, though studies showing equivalent outcomes to active controls (Hoge et al., Reference Hoge, Bui, Marques, Metcalf, Morris, Robinaugh and Simon2013) or inferior outcomes to CBT (Koszycki et al., Reference Koszycki, Benger, Shlik and Bradwejn2007) suggest further investigation and treatment development may be warranted.
Other Treatment Approaches
Pharmacotherapy.
Psychopharmacological approaches have been widely employed in the treatment of adult anxiety disorders. Based on research examining efficacy, side-effects, and the frequency of harmful interactions with other medications, the World Federation of Societies of Biological Psychiatry reported selective serotonin reuptake inhibitors (SSRIs) as the first-line pharmacological treatment for anxiety disorders. Other medications recommended for the treatment of anxiety include serotonin-noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), benzodiazepines, monoamine oxidase inhibitors (MAOIs), and the calcium channel modulator pregabalin (Bandelow et al., Reference Bandelow, Zohar, Hollander, Kasper, Möller and Vega2008). Of note, clinical guidelines warn that benzodiazepines should be used sparingly and with significant caution, as tolerance and dependence can arise as a result of the immediate and temporary anxiety relief they provide (NICE, 2014).
Regarding all medication classes, research has shown that a significant number of patients do not respond to psychopharmacological interventions or do not experience complete remission of symptoms (Farach et al., Reference Farach, Pruitt, Jun, Jerud, Zoellner and Roy-Byrne2012; Pollack, Otto et al., Reference Pollack, Otto, Roy-Byrne, Coplan, Rothbaum, Simon and Gorman2008). For instance, between one-third and one-half of patients treated with an antidepressant for anxiety experience a relapse of symptoms (Pollack et al., Reference Pollack, Otto, Roy-Byrne, Coplan, Rothbaum, Simon and Gorman2008). Researchers attribute the problem to the limited amount of long-term efficacy combined with the increasing number of drug classes available to treat anxiety disorders. Furthermore, clinicians often change medication, combine medication, or alter dosing without evidence-based guidance (Farach et al., Reference Farach, Pruitt, Jun, Jerud, Zoellner and Roy-Byrne2012). Therefore, future research is necessary to inform optimal selection and sequencing of existing treatments.
Several studies have directly compared the effects of pharmacological treatment to CBT for anxiety disorders, finding superiority of CBT (Roshanaei-Moghaddam et al., Reference Roshanaei‐Moghaddam, Pauly, Atkins, Baldwin, Stein and Roy‐Byrne2011) or equality of efficacy (Bandelow et al., Reference Bandelow, Zohar, Hollander, Kasper, Möller and Vega2008). Cuijpers and colleagues (Reference Cuijpers, Berking, Andersson, Quigley, Kleiboer and Dobson2013) conducted a meta-analysis of direct comparisons between antidepressants and psychotherapy for the treatment of depressive and anxiety disorders, finding little to no difference between psychotherapies and pharmacotherapies, with the exception of TCAs and nondirective supportive counseling, which were less efficacious than comparative treatments (SSRIs, monoamine oxidase inhibitors, CBT, interpersonal psychotherapy, problem-solving therapy, psychodynamic psychotherapy, and others). In addition, Bandelow and colleagues (Reference Bandelow, Reitt, Röver, Michaelis, Görlich and Wedekind2015) conducted a meta-analysis on all psychopharmacological treatments that had demonstrated efficacy in an RCT and were licensed in at least one country, and compared their effects to placebo and available psychological treatments for the treatment of PD, GAD, and SAD. SSRIs, SNRIs, and pregabalin yielded the largest effect sizes among the medications, while individual CBT yielded the largest effect size among the psychological treatments. On the whole, pharmacotherapy had higher effect sizes than psychological therapies when grouped together, and symptom improvement occurred faster with psychopharmacological treatments. However, note that symptom improvement has been shown to be maintained after the termination of CBT, whereas symptoms often return after the termination of medication (Otto, Smits, & Reese, Reference Otto, Smits and Reese2005).
Pharmacotherapy in combination with psychotherapy has produced mixed results in the literature (Farach et al., Reference Farach, Pruitt, Jun, Jerud, Zoellner and Roy-Byrne2012; Otto, Smits, & Reese, Reference Otto, Smits and Reese2005). With the exception of PD and GAD, studies on combined pharmacological and psychological treatments have not shown superiority of combined treatment to either treatment alone (Bandelow et al., Reference Bandelow, Zohar, Hollander, Kasper, Möller and Vega2008; Cuijpers et al., Reference Cuijpers, Sijbrandij, Koole, Huibers, Berking and Andersson2014; Hofmann, Sawyer, Korte, & Smits, Reference Hofmann, Sawyer, Korte and Smits2009). When pursuing a combination of treatment, one must also consider the potential increase in time and resources required of patients.
Cognitive enhancers.
Aside from the psychopharmacological medications described earlier, a number of recent studies have explored the use of medications referred to as cognitive enhancers, which target the learning processes thought to be central to effective psychotherapy for anxiety disorders. Of these medications D-cycloserine (DCS), a partial agonist at the glycine recognition site of the glutamatergic NMDA receptor, has received the most attention for its potential to enhance extinction learning processes in the context of exposure therapy (Hofmann, Reference Hofmann2014). Meta-analytic research has shown DCS to accelerate the effect of exposure therapy compared to placebo (Mataix-Cols et al., Reference Mataix-Cols, Fernández de la Cruz, Monzani, Rosenfield, Andersson, Pé`rez-Vigil and Rück2017; Rodrigues et al., Reference Rodrigues, Figueira, Lopes, Gonçalves, Mendlowicz, Coutinho and Ventura2014), but not all studies have resulted in positive effects (e.g., Hofmann et al., Reference Hofmann, Asmundson and Beck2013). Hofmann’s (Reference Hofmann2014) review of the clinical studies concluded that inconsistencies in the literature are largely accounted for by failure to consider both dosing and dose timing of DCS. For instance, studies have shown that patients’ level of fear at the end of their exposure exercise predicts the overall effect of DCS administration (Smits et al., 2013a; Smits et al., 2013b). DCS augmented the effect of exposure sessions when self-reported fear levels at the end of the exposure were low, whereas it had the opposite effect if end fear levels were high. More research is under way to investigate whether selective administration of DCS following exposures with low end fear levels can maximize the benefits of the medication (Hofmann et al., Reference Hofmann, Carpenter, Otto, Rosenfield, Smits and Pollack2015).
Psychodynamic therapy.
Psychodynamic therapy is also widely practiced for the treatment of anxiety disorders. Varying significantly from the cognitive-behavioral orientation, the psychodynamic approach attempts to uncover patients’ unconscious processes through fostering insight into the origins of one’s emotions, thoughts, and conflicts within current relationships (Gabbard, Reference Gabbard2004). In order to achieve this understanding, emphasis is placed on the way in which patients’ conflicts play out in the patient–therapist relationship. A growing number of clinical trials have investigated the efficacy of psychodynamic therapy for PD and SAD, some of which have compared psychodynamic therapy to CBT. For PD, the two treatments were found to be equivalent in a randomized controlled trial by Leichsenring and colleagues (Reference Leichsenring, Salzer, Jaeger, Kächele, Kreische, Leweke and Leibing2009), and in an effectiveness study by Beutel and colleagues (Reference Beutel, Scheurich, Knebel, Michal, Wiltink, Graf-Morgenstern and Subic-Wrana2013). However, these results are of questionable validity given some significant methodological limitations (Hofmann, Reference Hofmann2016a, Reference Hofmann2016b), as described later in this chapter. More recently, panic-focused psychodynamic psychotherapy was compared with CBT and applied relaxation (AR) (Milrod et al., Reference Milrod, Chambless, Gallop, Busch, Schwalberg, McCarthy, Gross, Sharpless, Leon and Barber2015). Results were complicated by site differences, such that no differences between treatments were seen in reductions in panic symptoms at one site, whereas another site showed greater effects of CBT. For SAD, psychodynamic treatment was found to be superior to a credible placebo control in one randomized trial (Knijnik, Kapczinski, Chachamovich, Margis, & Eizirik, Reference Knijnik, Kapczinski, Chachamovich, Margis and Eizirik2004). In another study comparing psychodynamic therapy with CBT, the two treatments led to equivalent response rates, but CBT was associated with higher rates of remission and greater reductions on measures of social phobia and interpersonal problems (Leichsenring et al., Reference Leichsenring, Salzer, Beutel, Herpertz, Hiller, Hoyer and Leibing2013).
While these results suggest that psychodynamic therapy may be an efficacious treatment for SAD and PD, such an approach does not consistently produce equivalent results to CBT. Furthermore, the empirical and theoretical basis of psychodynamic therapy has been criticized. In reviewing a meta-analysis that suggested psychodynamic treatment was as efficacious as other established treatments (Leichsenring et al., Reference Leichsenring, Luyten, Hilsenroth, Abbass, Barber and Steinert2015), Hofmann (Reference Hofmann2016a) found substantial risk of bias in a large number of the studies included. Furthermore, research validating the conceptual basis and proposed mechanisms of change in psychodynamic therapy is lacking (Hofmann, Reference Hofmann2016b), which is an important aspect of establishing an evidence-based treatment.
Applied relaxation.
Applied relaxation (AR) is another long-standing technique that was first used to treat PD and phobias and was later applied treat GAD (Hayes-Skelton, Roemer, Orsillo, & Borkovec, Reference Hayes-Skelton, Roemer, Orsillo and Borkovec2013). AR aims to teach patients how to decrease muscle tension through relaxation in order to counteract high levels of anxiety (Öst, Reference Öst1987). Early studies with PD patients compared AR to cognitive therapy, wait-list, and active controls, and found AR as or more effective than controls (Öst, Reference Öst1988) and equivalent to cognitive therapy (Öst & Westling, Reference Öst and Westling1995; Öst, Westling, & Hellström, Reference Öst, Westling and Hellström1993) in reducing symptoms up to 15 months after termination of treatment. However, another study found that CBT was superior to AR in reducing panic frequency and symptom severity (Arntz & van den Hout, Reference Arntz and van den Hout1996). For GAD, AR has been found to be comparable to CBT (Dugas et al., Reference Dugas, Brillon, Savard, Turcotte, Gaudet, Ladouceur and Gervais2010) as either a stand-alone treatment or in combination with cognitive therapy. Dugas and colleagues (Reference Dugas, Brillon, Savard, Turcotte, Gaudet, Ladouceur and Gervais2010) compared a 12-week protocol of AR alone to CBT and found equivalence of efficacy in the short term (12 weeks) and long term (6-, 12-, and 24-month follow-ups) on five out of six outcomes. However, CBT produced significantly greater symptom improvement immediately after treatment termination. Other trials (Hayes-Skelton, Roemer, & Orsillo, Reference Hayes-Skelton, Roemer and Orsillo2013; Hoyer et al., Reference Hoyer, Beesdo, Gloster, Runge, Höfler and Becker2009; Wells et al., Reference Wells, Welford, King, Papageorgiou, Wisely and Mendel2010) have elucidated AR’s optimal benefit for GAD in combination with other evidence-based treatment. Therefore, AR is no longer commonly employed as a stand-alone treatment, but rather as a helpful additive to CBT.
Treatment Components
While anxiety can manifest in a wide variety of symptoms across different disorders, the basic components of evidence-based treatments tend to be quite similar regardless of the specific clinical presentation. This is appropriate, given the research showing that anxiety disorders have a number of shared underlying mechanisms, including neuroticism (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, Reference Barlow, Sauer-Zavala, Carl, Bullis and Ellard2014), intolerance of uncertainty (McEvoy & Mahoney, Reference McEvoy and Mahoney2012), anxiety sensitivity (Boswell et al., Reference Boswell, Farchione, Sauer-Zavala, Murray, Fortune and Barlow2013), distress tolerance (Leyro, Zvolensky, & Bernstein), perfectionism (Egan, Wade & Shafran, Reference Egan, Wade and Shafran2011), and experiential avoidance (Chawla & Ostafin, Reference Chawla and Ostafin2007), among others. The components of anxiety treatments thus tend to target one or more of these shared mechanisms, with potential adjustments in the delivery of such treatments components based on an individual’s clinical presentation. The next section of this chapter reviews the procedures involved in such treatment components, the theoretical and empirical basis for their use, and issues related to maximizing their effectiveness.
Psychoeducation
Treatment for anxiety normally begins with at least one to two sessions of psychoeducation about the nature of anxiety, including how it develops, how it is maintained, and how it is effectively treated. Although the details covered by these early sessions may vary, in one form or another, patients are typically introduced to the idea that anxiety consists of thoughts, physical sensations, and behaviors (or behavioral urges) that occur in response to anticipated danger or other negative consequences. Patients are taught that anxiety is not inherently problematic, but rather it is a universally experienced emotion that serves the essential function of helping to prepare us for potential threats. Individuals with anxiety disorders, however, have an overly sensitive alarm system that causes them to respond to potentially threatening situations in an exaggerated manner. Patients learn that such exaggerated threat responses become particularly problematic when they lead to patterns of avoidance behavior, one of the most prominent factors in maintaining anxiety (Krypotos, Effting, Kindt, & Beckers, Reference Krypotos, Effting, Kindt and Beckers2015). Patients are encouraged to see that despite the temporary relief resulting from avoidance, such behavior reinforces the notion that danger is present in the first place, and prevents them from developing more realistic appraisals about the likelihood of their feared consequences actually occurring.
Presenting psychoeducational material in this way serves several important functions. First, breaking anxiety down in to its constituent parts (thoughts, physical sensations, behaviors) provides patients the language to understand and describe their experience of anxiety, and helps them see how the different components of anxiety reinforce one another (e.g., anxious thinking becomes more intense when one’s heart is racing). Daily self-monitoring of anxiety, which is typically assigned as homework during psychoeducation sessions, can help to bolster a patient’s awareness of his or her emotions from this perspective. Second, teaching patients that anxiety serves an adaptive function normalizes the experience of anxiety and helps patients more accurately understand the nature of their problem: feeling anxiety is not inherently bad, but problems arise as a result of attempts to avoid anxiety-inducing situations. Third, discussing the way in which avoidance maintains anxiety helps establish a credible rationale for conducting exposures, a treatment component for which patient buy-in and expectation of success are particularly important (Price & Anderson, Reference Price and Anderson2012; Taylor, Reference Taylor2003).
Little research has been conducted on the specific impact of psychoeducation on symptom change in anxiety, or on issues like how much psychoeducation is necessary or what material needs to be covered. However, treatments consisting purely of psychoeducation have been shown to have small effects on symptom improvements in psychological distress (Donker, Griffiths, Cuijpers, & Christensen, Reference Donker, Griffiths, Cuijpers and Christensen2009), and some evidence suggests that the administration of a psychoeducation module within a larger treatment can lead to changes in beliefs about emotions and other treatment-relevant skills (Sauer-Zavala et al., Reference Sauer-Zavala, Cassiello-Robbins, Conklin, Bullis, Thompson-Hollands and Kennedy2017). Furthermore, a substantial portion of patients receiving anxiety treatment sees meaningful symptom improvements in the first two to four sessions, before additional treatment ingredients have been introduced (Crits-Cristoph et al., Reference Crits-Christoph, Connolly, Gallop, Barber, Tu and Gladis2001; Westra, Dozois, & Marcus, Reference Westra, Dozois and Marcus2007). Such findings lend credence to the idea that psychoeducation can have an impact on symptoms by itself.
Exposure
Exposure techniques consist of patients deliberately and repeatedly confronting feared situations while refraining from engaging in avoidance behaviors. These techniques are an essential part of most anxiety treatments, and have been widely demonstrated to be effective even in the absence of other treatment components (Ougrin, Reference Ougrin2011). Such success comes from the numerous underlying mechanisms of anxiety disorders that exposure targets. For one, successful exposure exercises cause changes in patients’ exaggerated beliefs about the possibility of threat by teaching them that their feared consequences are unlikely to occur. For instance, a socially anxious patient might think that he or she will stumble over his or her words and sound completely incoherent when giving a presentation in front of a group. By actually giving the presentation, the patient can learn that his or her speech is much more fluent and coherent than he or she expected, a realization that is often assisted by the use of confederate feedback or videotape review. Patients may also have expectations about the persistence of anxiety in such an exposure situation, believing that their anxiety will only decline if they leave the situation. Through exposure patients can learn that if they persist in the situation for long enough, for instance giving a presentation for 10–15 minutes rather than getting it over as quickly as possible, their anxiety goes down and their expectations about the persistence of heightened anxiety are disconfirmed.
Exposures can also target biased beliefs about the cost of potential negative events by creating a situation in which the feared situation actually occurs. This can be an important element of treatment because even if a patient comes to realize that the probability of a negative outcome is low, his or her anxiety may be maintained if the consequences of that negative event are perceived as disastrous (Foa, Huppert, & Cahill, Reference Foa, Huppert, Cahill and Rothbaum2006). For instance, the thought of giving a stumbling and incoherent speech may seem unacceptable to a socially anxious patient, and therefore will cause the patient to become highly anxious even though he or she has never given the type of speech he or she is afraid of. The negative consequences of such an occurrence, however, could be tested through a social mishap exposure in which the patient intentionally stumbles over his or her words and says things that do not make sense (Fang, Sawyer, Asnaani, & Hofmann, Reference Fang, Sawyer, Asnaani and Hofmann2013). The patient may feel as if they appeared completely incompetent and ridiculous, but through feedback from audience members can learn that stumbling over words made them look less ridiculous than they thought. Or even more powerfully, the patient might get no feedback from the audience, and instead reflect on the long-term significance of the anxiety or other negative consequences they are experiencing in the moment. A therapist might ask, for instance, “Do you think the audience members will be thinking about how you made an incoherent speech later tonight?” or “How much will you care about your speech a week, month or year from now?” Concretely considering such possibilities after the exposure, as well as reflecting back at a later time point on how much they continue to be concerned about their behavior during the exposure, can help patients realize that their concerns are exaggerated, leading to a long-term reduction in anxiety.
Another important outcome of exposure exercises is that patients have the opportunity to learn that they can function in the context of high levels of anxiety. The socially anxious patient might feel as if he or she won’t be able to speak properly on account of anxiety, or a patient with a driving phobia might feel like he or she is incapable of competently driving a car because of panic symptoms. These concerns are almost always exaggerated, however, and the experience of realizing this tends to leads to a greater sense of self-efficacy regarding one’s ability to cope with intense anxiety (Fentz et al., Reference Fentz, Hoffart, Jensen, Arendt, O’Toole, Rosenberg and Hougaard2013). This process of learning to cope with strong anxiety symptoms is also assisted through instructing patients to focus their attention on the task at hand during an exposure (e.g., driving), rather than on the internal experience of anxiety, as such an attentional shift can reduce the intensity and interference of anxiety symptoms (Mörtberg, Hoffart, Boecking, & Clark, Reference Mörtberg, Hoffart, Boecking and Clark2015; Wells & Papageorgiou, Reference Wells and Papageorgiou1998).
Variants of exposure.
While exposure is frequently conducted by having patients confront feared situational stimuli in vivo, several variants of exposure provide clinicians more flexibility in the types of fears that can be effectively targeted. One such variation is interoceptive exposure, which involves intentionally eliciting the physical symptoms associated with an anxiety response such as shortness of breath, a racing heart, or dizziness. For many patients, such interoceptive sensations have become associated with negative emotional experiences because of the strong physical sensations that occur during periods of anxiety, and therefore become feared stimuli in their own right (Barlow, Reference Barlow1988). Similar to situational exposure, repeated confrontation of such fears without avoidance provides the opportunity for patients to learn that such physical sensations are not in fact dangerous. While originally developed to treat the sensitivity to physical anxiety symptoms present in PD, a growing understanding that anxiety sensitivity is present transdiagnostically has led to greater utilization of interoceptive exposure in the treatment of a variety of anxiety disorders (Boettcher, Brake, & Barlow, Reference Boettcher, Brake and Barlow2016). Interoceptive exposures can also be used in combination with situational exposures (e.g., hyperventilating before delivering a speech) in order to optimize the feared consequences an exposure can test. Common techniques used for interoceptive exposure include running in place or up stairs, straw-breathing, spinning in a circle, muscle tensing, and head-shaking. Of note, significant intra-individual variability is seen in the distress resulting from different procedures (Lee et al., Reference Lee, Noda, Nakano, Ogawa, Kinoshita, Funayama and Furukawa2006), so clinicians may need to try a number of different techniques before identifying an effective exposure.
Another variant of exposure involves playing out a feared situation in one’s imagination, a procedure that is useful when the feared situation is something that is difficult or unethical to actually create. Such imaginal exposure is used frequently to retell the narrative of a trauma in PTSD, and also can be utilized to play out a feared catastrophic scenario about the future in OCD and GAD. The rationale behind such a technique is that in imagination patients are able to confront fearful thoughts and accompanying physical sensations that tend to be avoided through cognitive strategies like worry or through overt avoidance behavior. After repeated exposure to such imagined worst-case scenarios, patients’ emotional distress tends to decline as they realize that such emotions by themselves cannot do any real harm, and/or by seeing they could cope with the feared scenario better than they originally thought (Hoyer & Beesdo-Baum, Reference Hoyer, Beesdo-Baum, Neudeck and Wittchen2012). For instance, an individual who has intense worry about the status of his or her relationship would vividly imagine a scene in which his or her significant other breaks off the relationship. Through repeated imagination of this scene, the accompanying emotions would tend to decline as the individual realizes the scene is just an image and is not actually harmful, and that he or she could cope with such an occurrence even though it would be difficult.
Maximizing the effects of exposure.
While exposure has been practiced as a treatment for anxiety disorders for at least 50 years (e.g., Wolpe, Reference Wolpe1968), recent research has illuminated a number of insights about the mechanisms of exposure that can help maximize its efficacy. One issue that has garnered significant attention in the literature is the extent to which reduction in fear levels during exposure matters for subsequent improvement in anxiety symptoms. While habituation to a feared situation during the course of an exposure can appear to suggest therapeutic learning, there is limited evidence demonstrating that fear reduction during exposures is a meaningful predictor of treatment outcome (Asnaani, McLean, & Foa, Reference Asnaani, McLean and Foa2016; Craske et al., Reference Craske, Kircanski, Zelikowsky, Mystkowski, Chowdhury and Baker2008). Research has shown that extinction learning, the purported mechanism of exposure therapy, does not rely on processes of habituation, but rather leads to the formation of a new safety memory that overrides the original fear response (Bouton, Reference Bouton2002). This means that exposures ought to be designed in ways that maximize the formation of this new safety memory, as well as a patient’s ability to retrieve this memory in future situations (Craske, Treanor, Conway, Zbozinek, & Vervliet, Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014).
One of the primary ways in which such inhibitory learning can be facilitated is through maximizing violations of patient’s expectations. Hofmann (Reference Hofmann2008b) argues that even though exposure is a behavioral technique, its effects are cognitively mediated by changes in one’s beliefs about the likelihood and cost of harm. Thus having patients explicitly describe their expectations about what will happen when they confront their feared situation is helpful for highlighting the extent to which such expectations are inaccurate. The learning that occurs from having such expectations violated will then be reinforced if upon completion of the exposure, patients review the discrepancy between their predicted outcomes and what actually occurred (Rescorla & Wagner, Reference Rescorla, Wagner and Prokasy1972). Exposures can also be designed to continue until patients no longer believe that their feared outcome will occur. Deacon and colleagues (Reference Deacon, Farrell, Kemp, Dixon, Sy, Zhang and McGrath2013) demonstrated this in a treatment study for PD in which patients persisted with repeated interoceptive exposures consisting of hyperventilation until they rated that there was less than a 5% chance that their most feared outcome (e.g., “I will run out of air” or “I will pass out”) would occur. Results showed that such an intensive form of interoceptive exposure was more effective in reducing panic symptoms than treatment using a prespecified (lower) number of exposures, and that these effects were accounted for by greater reductions in negative outcome expectancies and fear tolerance. Such a result highlights the benefits of focusing on expectancy violation as a means of changing beliefs and forming safety memories during exposure.
In addition to expectancy violations, therapists need to create exposure exercises with substantial variability in the situations and contexts used in order to enhance the strength and retrievability of the safety memories formed during exposure. As mentioned previously, extinction learning inhibits rather than eliminates fear memories, meaning that fear is highly susceptible to renewal when patients are presented with a slightly different stimulus than previously encountered during an exposure (Vervliet, Vansteenwegen, Baeyens, Hermans, & Eelen, Reference Vervliet, Vansteenwegen, Baeyens, Hermans and Eelen2005), or the same feared situation but in a different context (Mineka, Mystkowski, Hladek, & Rodriguez, Reference Mineka, Mystkowski, Hladek and Rodriguez1999). Accordingly, varying the location of exposure training has been shown to lead to reduced anxiety symptoms at long-term follow-up (Vansteenwegen, Vervliet, Hermans, Thewissen, & Eelen, Reference Vansteenwegen, Vervliet, Hermans, Thewissen and Eelen2007) and reduced renewal of fear during exposure in a novel context (Bandarian-Balooch, Neumann, & Boschen, Reference Bandarian-Balooch, Neumann and Boschen2015; Shiban, Pauli, & Mühlberger, Reference Shiban, Pauli and Mühlberger2013) compared to exposure training in the same location. In addition, using varying exposure stimuli has been shown to eliminate return of fear in response to the presentation of novel feared stimuli (Rowe & Craske, Reference Rowe and Craske1998). Interestingly, greater variability in minute-to-minute subjective fear during an exposure task has also been shown to predict superior treatment outcomes (Culver, Stoyanova, & Craske, Reference Culver, Stoyanova and Craske2012; Kircanski et al., Reference Kircanski, Mortazavi, Castriotta, Baker, Mystkowski, Yi and Craske.2012), suggesting that emotional state can also serve as a context with which safety becomes associated. Together these results show that varying the features of exposures throughout the course of treatment is important to ensure that safety learning is not just associated with the specific experience of a successful exposure, but can generalize across situations.
Safety behaviors in exposure.
Another important issue in the administration of effective exposure therapy is the elimination of safety behaviors, or actions meant to minimize, prevent, or avoid feared outcomes in an anxiety-inducing situation. For instance, a patient with PD and agoraphobia may be willing to enter a crowd, but only if accompanied by a close partner whose presence will diminish the patient’s anxiety response. As reviewed in Blakey and Abramowitz (Reference Blakey and Abramowitz2016), safety behaviors can interfere with exposure therapy in a number of ways, as well as generally maintain clinical levels of anxiety. For one, safety behaviors can lead to misattributions of safety, as patients associate the absence of an expected aversive outcome to the presence of the safety signal (e.g., a partner in a crowd), instead of learning that such a situation is not actually as dangerous as originally believed (Salkovskis, Reference Salkovskis1991). Relatedly, safety behaviors disrupt therapeutic information processing by suggesting that safe situations are in fact dangerous (Gangemi, Mancini, & van den Hout, Reference Gangemi, Mancini and van den Hout2012; van den Hout et al., Reference van den Hout, Gangemi, Mancini, Engelhard, Rijkeboer, van Dams and Klugkist2014), and by increasing attentional resources toward threatening stimuli (Stewart, Westra, Thompson, & Conrad, Reference Stewart, Westra, Thompson and Conrad2000) and away from disconfirmatory information (Sloan & Telch, Reference Sloan and Telch2002). Furthermore, the use of safety behaviors during exposure may reinforce the notion that anxiety is intolerable and something to be minimized. This is contraindicated given that one of the mechanisms theorized to be responsible for improvement from exposure is greater distress tolerance (Craske et al., Reference Craske, Kircanski, Zelikowsky, Mystkowski, Chowdhury and Baker2008).
Despite the strong theoretical rationale for the deleterious effects of safety behaviors, there is mixed evidence on the extent to which the use of safety behaviors negatively impacts treatment outcome. In fact, some research suggests that permitting the use of safety behaviors can increase the acceptability of exposure therapy (Levy, Senn, & Radomsky, Reference Levy, Senn and Radomsky2014; Milosevic & Radomsky, Reference Milosevic and Radomsky2013) and enable greater approach behavior during the course of exposure (Goetz & Lee, Reference Goetz and Lee2015; Levy & Radomsky, Reference Levy and Radomsky2014). Furthermore, a meta-analysis of 20 studies by Meulders, van Daele, Volders, and Vlaeyen (Reference Meulders, Van Daele, Volders and Vlaeyen2016) found only a borderline significant (p = 0.08) advantage of self-reported fear after exposure without safety behaviors compared to baseline behavior, and no significant advantage of baseline exposure behavior compared to exposure in which participants were explicitly instructed to engage in safety behaviors. Of note, the authors point out that because safety behaviors tend to reduce exposure-related distress, post-intervention fear levels may not capture the negative impact of safety behaviors on therapeutic learning as well as follow-up assessments, and data on follow-up symptom outcomes in the studies in the meta-analysis were lacking.
Nonetheless, a separate meta-analysis by Podină, Koster, Philippot, Dethier, and David (Reference Podină, Koster, Philippot, Dethier and David2013) showed that distraction during exposure, which can be conceptualized as a safety behavior, led to superior effects on behavioral approach tasks at both post-intervention and follow-up assessments points when compared to attention-focused exposure. This finding also extended to self-reported distress ratings among studies with multiple exposure sessions, and that used interactive distractions (i.e., patient–therapist communication about non-fear-related topics). Regarding the results of both Podina et al. (Reference Podină, Koster, Philippot, Dethier and David2013) and Meulders et al. (Reference Meulders, Van Daele, Volders and Vlaeyen2016), it should be noted that safety behaviors might have been found to be helpful or at least not harmful because they enhanced self-efficacy or a patient’s ability to meet goals for an exposure, but could still have harmful effects if symptom reduction is attributed to the use of the safety behavior. Furthermore, the gradual elimination of safety behaviors can also lead to an enhanced self-efficacy, while also fostering greater therapeutic learning through continued expectancy violations. Accordingly, a sizable number of studies have shown that the gradual elimination of safety behaviors (in contrast to strict prevention) leads to enhanced outcomes compared to continued safety behavior use (see Telch & Lancaster, Reference Telch, Lancaster, Neudeck and Wittchen2012). Clinically, it is typically recommended (e.g., Blakey & Abramowitz, Reference Blakey and Abramowitz2016; Telch & Lancaster, Reference Telch, Lancaster, Neudeck and Wittchen2012) that therapists carefully monitor safety behaviors, permit them early in treatment only to the extent to which it is necessary to facilitate treatment acceptability, enable greater approach to feared situations and foster self-efficacy, and then work with patients to fade such behaviors as treatment progresses.
Cognitive Restructuring
Cognitive restructuring is a core technique of anxiety treatment that consists of identifying unhelpful thinking patterns and developing more realistic alternative ways of viewing situations. The technique is typically introduced by demonstrating how almost all situations are somewhat ambiguous, with a variety of plausible interpretations that can be made based off whatever information is present. For instance, if a patient notices that a friend walks by him or her without acknowledgment, this could be interpreted as happening because the friend simply did not notice the patient, or as an intentional slight because they do not like him or her. Patients are encouraged to see how these different interpretations can lead to substantially different emotional reactions, and how it is not the event itself but one’s appraisal of it that leads to anxiety or other negative emotions. In the prior example, interpreting the friend’s lack of acknowledgment as a slight might lead a patient to feel anxious about the status of the friendship, whereas a neutral interpretation about the friend’s intentions might not lead to an emotional reaction at all. Patients are also taught that individuals tend to develop patterns of interpretation based on their affective state, past experiences, and core beliefs about themselves and the outside world. Someone who has a high degree of interpersonal sensitivity and frequently worries about social rejection, for example, would readily appraise the ambiguous situation as indicative of rejection.
Bringing these patterns of interpretation to awareness is the first step toward cognitive restructuring, and is often assisted by the identification of certain “thinking traps,” or errors in logical reasoning that lead to unrealistic or unhelpful interpretations. As discussed previously, for anxiety patients these thinking traps tend to be related to either an overestimation of the likelihood of danger or the cost of danger. To help combat such thinking traps, therapists engage in Socratic questioning that guides a patient’s awareness toward alternative information they are not considering in making their evaluation of danger (Beck & Emery, Reference Beck and Emery1985). For instance, to combat a patient’s anxiety that something terrible has happened to his wife after she did not answer a phone call, the therapist might explore with the patient what evidence there is that something terrible has happened, what the probability of such an occurrence actually is, and whether the negative prediction the patient is making is driven by his intense emotions rather than the facts. Such questioning can also be used to combat cost overestimation. For example, with a patient who is intensely anxious about being late, a therapist might explore what concretely is likely to happen as a result of being late, would she be able to be cope with such an outcome, and whether she has been late in the past and whether it was as bad as she feared. The ultimate goal is for patients to be able to engage in such cognitive restructuring processes independently, allowing them to be more flexible in their interpretation of anxiety-inducing situations.
Experimental evidence has shown cognitive restructuring to lead to an immediate reduction of anxiety responses (Hofmann, Heering, Sawyer, & Asnaani, Reference Hofmann, Heering, Sawyer and Asnaani2009), even for conditioned fears (Shurick et al., Reference Shurick, Hamilton, Harris, Roy, Gross and Phelps2012). Furthermore, therapies using cognitive restructuring techniques without explicit use of exposure exercises have been shown to be highly efficacious, and generally lead to equivalent outcomes as exposure-based therapy (Ougrin, Reference Ougrin2011). In spite of such evidence, some question whether the inclusion of cognitive techniques in the treatment of anxiety is necessary, citing evidence that addition of cognitive restructuring to exposure techniques does not improve treatment outcome beyond standard exposure therapy (Longmore & Worrell, Reference Longmore and Worrell2007). In addition, some argue that engaging in cognitive restructuring to combat probability or cost overestimation prior to or during exposure actually takes away from the effects of exposure because it reduces expectancy violations (Craske et al., Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014).
Despite these critiques, cognitive techniques clearly have an important place in anxiety treatment. For one, using cognitive restructuring after an exposure exercise can be effective in combating any negative interpretations of exposure outcomes that patients may have (Hofmann & Otto, Reference Hofmann and Otto2008). For instance, patients with social anxiety often ruminate after a social interaction on mistakes they might have made or the way they were perceived, even when such an interaction is framed as an exposure. In response, a therapist might help the patient reframe what happened by asking him or her how likely it is that the person the patient interacted with is still thinking about the interaction, and how much the patient will care about the way he or she acted a day, a week, or even a year later. By helping a patient reframe the outcome in this way, cognitive restructuring can help to reinforce or enhance the discrepancy between a patient’s expectations and reality, rather than reducing expectancy violations. This may be particularly important given the evidence that some individuals with anxiety disorders demonstrate deficits in extinction learning, which can be overcome by the use of cognitive reappraisal strategies (Blechert et al., Reference Blechert, Wilhelm, Williams, Braams, Jou and Gross2015).
Another important use of cognitive restructuring in the treatment of anxiety can be to address metacognitions. Metacognitive processes involve the appraisal and monitoring of one’s thinking, as well as attempt’s to control mental activity. Maladaptive metacognitive beliefs have been implicated in the development and maintenance of anxiety disorders, particularly GAD (Wells, Reference Wells2000). These beliefs often present as beliefs that worry or anxiety is uncontrollable and harmful. Paradoxically, patients also often believe that the experience of anxiety is necessary as a means of preparation for potentially negative events. To combat such harmful metacognitive beliefs, cognitive restructuring techniques can be used to highlight instances of the patient’s experience in which he or she was able to control anxiety, for example, or to evaluate counterevidence for beliefs about the positive impact of worry (Wells, Reference Wells2007). Of note, such a cognitive approach often does include what are referred to as behavioral experiments, in which patients “test out” their beliefs in the form of exposures or other behavioral exercises, effectively representing a blend of behavioral and cognitive techniques. Numerous studies have demonstrated the efficacy of targeting meta-cognitive beliefs in the treatment of anxiety disorders (Normann, Emmerik, & Morina, Reference Normann, Emmerik and Morina2014).
Mindfulness
Mindfulness has become an increasingly common strategy for addressing anxiety, often in conjunction with other treatment components. Mindfulness training begins by teaching patients how to direct their attention to the present moment rather than thinking about the past or future, since past- and future-oriented thinking often leads to worry or rumination among individuals prone to anxiety (Roemer & Orsillo, Reference Roemer and Orsillo2002). The breath is often used as an anchor for present moment awareness, as it is always present, but any observable sensation (e.g., a sight, sound, or physical sensation) can be attended to as a way of reorienting to the present. Typically therapists will guide patients through brief meditations in which patients are given an opportunity to focus on particular sensations like the breath, one’s body, a piece of music, or even food (e.g., the raisin exercise, in which patients mindfully observe the sensations associated with eating a raisin).
In addition to present moment awareness, mindfulness training involves teaching patients to develop an attitude of acceptance and nonjudgment. Such an attitude is important because judging situations or experiences (e.g., anxiety) as unwanted or unacceptable can exacerbate their negative impact and lead to maladaptive attempts to control one’s emotions. This is often demonstrated by the white bear experiment, in which patients are asked to think of anything except a white bear for 30 seconds. Inevitably, this leads to frequent thoughts about a white bear, and this is used as an example of how attempts to suppress anxious thoughts or feelings can actually make them worse. In order to help foster an attitude of nonjudgment, patients are taught to simply describe things they notice, including thoughts or sensations related to anxiety. If they notice judgments, the idea is to simply notice that they are judging and label it as such (e.g., “I am having the thought that this situation is unpleasant and notice an urge to escape”). Typically the practice of present moment awareness and nonjudgment starts with more benign, non-emotional situations to help patients master the technique, before applying it to situations in which stronger emotions are present. As patients build more proficiency with this skill, they begin to realize how an attitude of acceptance can actually decrease the intensity of anxiety and increase their ability to engage in goal-directed action.
Research on acceptance and mindfulness in experimental settings has consistently demonstrated that such techniques are effective in helping to regulate emotions (Kohl, Rief, & Glombiewski, Reference Kohl, Rief and Glombiewski2012), and effects are as strong as cognitive reappraisal (Hofmann et al., Reference Hofmann, Sawyer, Korte and Smits2009). Furthermore, improvements in mindfulness skills during treatment have been shown to account for improvement in symptoms of anxiety and other psychological symptoms (Visted, Vøllestad, Nielsen, & Nielsen, Reference Visted, Vøllestad, Nielsen and Nielsen2014). While research on the mechanisms through which mindfulness has its effects is still emerging, empirical evidence and theoretical work suggest that processes of attention regulation, reappraisal, exposure, change in self-perspective, and self-compassion each play a role (Hölzel et al., Reference Hölzel, Lazar, Gard, Schuman-Olivier, Vago and Ott2011). Of note, the processes understood to underlie mindfulness have been referred to using a wide variety of terms, including decentering, metacognitive awareness, cognitive distancing, re-perceiving, and cognitive defusion, among others (Bernstein et al., Reference Bernstein, Hadash, Lichtash, Tanay, Shepherd and Fresco2015). Further work is needed to clarify the extent to which these processes are distinct, and the exact role they play in reducing symptoms of anxiety.
Relaxation
Relaxation is not typically considered a core element of evidence-based anxiety treatments. This is because emphasizing relaxation as a primary way to combat anxiety can send the message to patients that anxiety sensations are dangerous and need to be avoided or controlled, which is at odds with the cognitive and behavioral principles central to effective treatment. Nonetheless, relaxation techniques can serve a purpose as an easily taught and used coping tool for experiences of high distress. For instance, high levels of distress are known to interfere with the cognitive regulation of emotion (Raio, Orederu, & Palazzolo, Reference Raio, Orederu, Palazzolo, Shurick and Phelps2013), and thus the use of a brief relaxation technique can help downregulate a person’s anxiety enough that they may be able to more effectively reappraise an anxiety-inducing situation.
One of the most common and easily implemented relaxation techniques is breathing retraining. Typically when individuals are anxious, they take short, quick breaths akin to hyperventilation that exacerbate the anxiety response by signaling a sympathetic nervous system response. In breathing retraining, patients are taught to take slow, full breaths, filling their diaphragm with air so that their body reaches a more balanced level of oxygen and carbon dioxide, thereby triggering a relaxation response (Hazlett-Stevens & Craske, Reference Hazlett-Stevens, Craske, O’Donohue and Fisher2009). A related technique mentioned previously as part of applied relaxation treatments is progressive muscle relaxation (PMR). In PMR, patients engage in diaphragmatic breathing while simultaneously tensing (during inhalation) and then relaxing (during exhalation) distinct muscle groups. This process of intentionally tensing and then relaxing muscles is meant to highlight the contrast between tension and relaxation for patients, leading to an enhanced relaxation response. Finally, mental imagery can be an effective relaxation technique. Patients imagine a scene in which they feel totally and completely relaxed, and vividly try to imagine as many sensory details as possible so that they can be present in the scene more fully. As patients continue practicing such an imagery exercise, they tend to become more skilled at fully immersing themselves in the scene, and imagining the scene can quickly produce a sensation of relaxation.
Transdiagnostic Approaches
Given the substantial amount of comorbidity across anxiety disorders and other forms of psychopathology (Brown & Barlow, Reference Brown and Barlow2009), developing treatments that can target shared underlying processes across diagnostic categories is highly important. Fortunately, the treatment components reviewed in this chapter are applicable to any variety of anxiety disorder(s), as well as many other emotional disorders. Based on these treatment components and our growing understanding of the shared mechanisms of anxiety disorders, a number of formalized transdiagnostic treatments have been developed and empirically tested in the past decade. For instance, Barlow and colleagues (Reference Barlow, Farchione, Fairholme, Ellard, Boisseau, Allen and May2010) developed the Unified Protocol, which consists of four core modules designed to target core aspects of emotional disorders: increasing emotional awareness, facilitating flexibility in appraisals, identifying and preventing behavioral and emotional avoidance, and situational and interoceptive exposure to emotion cues.
Evidence for such transdiagnostic approaches has been steadily emerging. Both the Unified Protocol (Barlow et al., Reference Barlow, Farchione, Bullis, Gallagher, Murray-Latin, Sauer-Zavala and Cassiello-Robbins2017) and another group transdiagnostic treatment tested by Norton and Barrera (Reference Norton and Barrera2012) have shown equivalent efficacy for a mixed anxiety disorders sample to gold-standard single-diagnosis protocols. This is important because transdiagnostic treatments are argued to be useful from an efficiency standpoint, such that therapists seeing patients with a wide variety of presentations only need to learn a single protocol (Wilamowska et al., Reference Wilamowska, Thompson‐Hollands, Fairholme, Ellard, Farchione and Barlow2010). With evidence suggesting that a transdiagnostic protocol is equally effective to matching patients with a single diagnosis treatment, such efficiency can be achieved without sacrificing efficacy.
In addition to broad-based transdiagnostic treatments, a number of interventions designed to target a specific facet underlying anxiety disorders have been tested in recent years. For instance, different mechanism-specific treatments have been shown to work effectively on reducing anxiety sensitivity (Keough & Schmidt, Reference Keough and Schmidt2012; Olthuis, Watt, Mackinnon, & Stewart, Reference Olthuis, Watt, Mackinnon and Stewart2014), distress tolerance (Macatee & Cougle, Reference Macatee and Cougle2015), perfectionism (Rozental et al., Reference Rozental, Shafran, Wade, Egan, Nordgren, Carlbring and Trosell2017), and intolerance of uncertainty (Oglesby, Allan, & Schmidt, Reference Oglesby, Allan and Schmidt2017). Such treatments are particularly important because they present the opportunity to personalize treatment based on particular facets underlying an individual’s anxiety, rather than a diagnosis based purely on symptom presentation. Also of note, several of these interventions (Macatee & Cougle, Reference Macatee and Cougle2015; Olthuis et al., Reference Olthuis, Watt, Mackinnon and Stewart2014) were delivered remotely through the telephone or a computer program, which has important implications for dissemination and increasing access to treatment.
Conclusions and Future Directions
While anxiety is a highly prevalent and debilitating disorder, work over the past several decades has led to a number of treatments that can effectively decrease anxiety symptoms, as well as lead to improvements in other areas like depression and quality of life. First and foremost of these is CBT, a scientifically grounded intervention consisting of exposure and cognitive restructuring techniques that help patients more effectively respond to their anxiety. Building upon traditional CBT, the field has seen the development of mindfulness- and acceptance-based treatments that provide additional tools for patients and alternative approaches for therapists treating anxiety disorders. While the quantity of evidence supporting such approaches has not reached that of traditional CBT, they have nonetheless moved the field forward. Of particular promise is the potential for matching patients to a particular treatment that is likely to be most effective for address their specific presentation.
Although CBT is effective, there is certainly room for improvement in both response and retention rates. Two promising directions for addressing this need for improvement are personalized medicine and the development of treatments that target underlying mechanisms of anxiety disorders rather than broad symptom presentations. We anticipate that the field will continue moving away from techniques for specific DSM-defined syndromes, and toward empirically supported process-based therapies that focus on relevant treatment mechanisms linked to theory (Hayes & Hofmann, Reference Hayes and Hofmann2017; Hofmann & Hayes, 2018). The approach of the National Institute of Mental Health’s Research Domain Criteria (RDoC), which is a framework for understanding mental disorders rooted in dysfunctional brain circuitry, brought about a much-needed discussion about the limits and problems of the existing DSM classification system. However, we do not believe that including biological aspects will be sufficient or necessary to develop an improved psychiatric classification system. Instead, we believe that the time is ripe to move beyond a simplistic latent disease model toward a system that takes an evidence-based and person-centered approach to linking treatment techniques to underlying processes related to mental and behavioral health.
Beyond maximizing the efficacy of anxiety treatment, two additional areas of work need to be addressed to reduce the impact that anxiety disorders have on the population. The first is prevention. Treating an anxiety disorder that has already developed is likely to be much more cost- and time-intensive than providing individuals with the tools to more effectively deal with their emotions before an anxiety disorder develops. Research on prevention programs for anxiety disorders has been growing, particularly with children and adolescents, but effect sizes for measures of anxiety symptoms compared to control conditions tend to be small, and results from long-term follow-up show more variable efficacy (Fisak, Richard, & Mann, Reference Fisak, Richard and Mann2011). Generally research and development of depression prevention programs has outpaced targeted anxiety prevention, and few studies have examined the effect of such prevention programs on incidence rates of anxiety disorders after a long-term follow-up period (Stockings et al., Reference Stockings, Degenhardt, Dobbins, Lee, Erskine, Whiteford and Patton2016). Nonetheless, some progress has been made. A recent study by Topper, Watkins, Ehmmelkamp, and Ehring (Reference Topper, Emmelkamp, Watkins and Ehring2017) tested a six-week cognitive behavioral prevention training in both an online and group format for adolescents and young adults with high levels of repetitive negative thinking. Results showed that one year after the study, the training was associated with either an 18.0% (group intervention) or 16.0% (online intervention) prevalence of GAD, compared to 42.2% for a wait-list control. Further high-quality studies targeting other processes underlying anxiety are needed to continue the advancement of prevention efforts.
A second important area in need of further research is the dissemination of evidence-based treatments for anxiety disorders. In spite of the strong evidence base for CBT, most individuals seeking treatment for anxiety in community settings receive medication or non-CBT psychotherapy (Wolitzky-Taylor, Zimmerman, Arch, De Guzman, & Lagmasino, Reference Wolitzky-Taylor, Zimmermann, Arch, De Guzman and Lagomasino2015), severely limiting the benefit that can be achieved. The barriers to effectively disseminating and implementing evidence-based treatments are substantial, and include factors such as a lack of training opportunities for practitioners, skeptical attitudes about randomized controlled trials and psychotherapy research generally, organizational and economic concerns, and a lack of attention to practitioner concerns in dissemination efforts (Gunter & Whittal, Reference Gunter and Whittal2010). Specific to anxiety disorders, many therapists have reservations about delivering exposure therapy, which leads them to not use such techniques at all, or to deliver them suboptimally (Deacon et al., Reference Deacon, Kemp, Dixon, Sy, Farrell and Zhang2013). Research examining ways to overcome such barriers and disseminate evidence-based treatments for anxiety disorders has been conducted (e.g., Harned et al., Reference Harned, Dimeff, Woodcock, Kelly, Zavertnik, Contreras and Danner2014), but more work is needed if we hope to continue increasing the ability for individuals with anxiety to access effective treatments and attain wellness.
