A woman undergoing treatment for PTSD relating to a sexual assault, for example, may initially think, “All men are bad.” Challenging this thought by examining evidence for and against it may help her replace it with the more realistic belief that some—but not all—men are bad.
Exposure therapy, which is also a firstline treatment for PTSD,12-14 involves presenting the frightening stimuli to patients in a safe environment so that they can learn a new way of responding.9 If a patient is afraid of a specific location because she was assaulted there, for instance, slowly exposing her to the site while ensuring her safety can help her anxiety diminish. Depending on the circumstances, exposure may be conducted in vivo (tangible stimuli), achieved through mental imagery (of a combat zone where an improvised explosive device detonated, for example), or both.
Prolonged exposure has been shown to be very effective in treating PTSD resulting from a variety of traumatic events. Other aspects of treatment include education about the disorder and breathing retraining to reduce arousal and increase the patient’s ability to relax.15
Generalized anxiety disorder: Worry exposure and relaxation
CBT for GAD has 5 components:
- education about the disorder
- cognitive restructuring
- progressive muscle relaxation
- worry exposure
- in vivo exposure.
Relaxation training is a crucial part of treatment for GAD, perhaps more so than for other anxiety disorders.16 Cognitive restructuring is vital, as well. This involves the use of the Socratic means of questioning, asking “Tell me what you mean by ‘horrible,’” for example, and “What about that is of most concern to you?”
Worry exposure occurs by instructing the patient to engage in prolonged worry about one particular topic, rather than jumping from one worrisome subject to another. The single focus reduces the distress that worry causes, thereby decreasing the time spent worrying.17 As treatment progresses, the patient is taught to set aside a specific time to worry. Worrying outside of the designated “worry time” is not allowed.18,19
Panic disorder: Recognizing what's behind physical symptoms
Treatment for PD combines education about the disorder, cognitive restructuring, and exposure.
Education helps the patient understand the reason the increased arousal response occurs at seemingly random times—recognizing that he or she is interpreting normal physiological sensations negatively, for example, and that the physical response is the body’s way of protecting itself.
Cognitive restructuring helps patients reformulate their view of the relationship between physical symptoms and panic attacks. An individual might learn to interpret a rapid heart rate as an indication that his heart is working harder and getting stronger, for instance, rather than as a symptom of cardiovascular distress.
Interoceptive exposure therapy teaches patients to identify their internal physical cues (eg, shortness of breath, shakiness, and tachycardia) and then deliberately induce them—by breathing through a straw, climbing a flight of stairs, or spinning in a chair, for example. With repeated exposure, patients learn that the physical sensations are not dangerous, and the anxiety associated with them decreases.
In vivo exposure involves the creation of a “fear hierarchy” of places and activities that the patient avoids due to fear of having a panic attack, then gradually exposing him or her to them.18,20
Obsessive-compulsive disorder: Exposure and response
Exposure and response prevention (ERP) is the primary treatment for OCD. However, this seemingly straightforward behavioral treatment can be very challenging to implement because the compulsion that reduces a patient’s anxiety may be a mental act—silently repeating a number or phrase until the distress is released, for example—and thus unobservable.
Treatment consists of first helping the patient recognize his or her recurrent thoughts, behaviors, or mental acts, then identifying triggers for these compulsions. Next, the patient is gradually exposed to these triggers without being allowed to engage in the compulsive response that typically follows.21,22 For example, a clinician may have a patient obsessed with germs pick objects out of the trash during a therapy session but not allow hand washing afterwards or repeatedly write or say a number or word that normally elicits compulsive behavior but prevent the patient from engaging in it.
Social anxiety disorder: Group therapy
Group therapy, in which the group setting itself becomes a type of exposure, is a very effective treatment for SAD.23 This can be challenging, however, as patients with this disorder may be less likely to seek treatment if they know they will be put into a group. Individual treatment is another option for patients with SAD, and can be equally effective.24
