Evidence-Based Reviews

Using CBT effectively for treating depression and anxiety

Current Psychiatry. 2014 June;13(6):45-53

References

1. Collins K, Westra H, Dozois D, et al. Gaps in accessing treatment for anxiety and depressions: challenges for the delivery of care. Clin Psychol Rev. 2004;24(5):583-616.
2. Foa EB, Gillihan SJ, Bryant RA. Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: lessons learned from prolonged exposure therapy for PTSD. Psychological Science in the Public Interest. 2013;14(2):65-111.
3. Rahman A, Malik A, Sikander S, et al. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008;372(9642):902-909.
4. Aguilera A, Muench F. There’s an app for that: information technology applications for cognitive behavioral practitioners. Behavior Therapist. 2012;35(4):65-73.
5. Dimidjian S, Hollon SD, Dobson KS, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol. 2006; 74(4):658-670.
6. Hollon SD, Jarrett RB, Nierenberg AA, et al. Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? J Clin Psychiatry. 2005;66(4):455-468.
7. Cuijpers P, Hollon SD, van Straten A, et al. Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open. 2013;3(4):1-8.
8. Stewart R, Chambless D. Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psychol. 2009;77(4): 595-606.
9. Wright JH, Basco MR, Thase M. Learning cognitive behavior therapy: an illustrated guide. Arlington, VA: American Psychiatric Publishing; 2006.
10. Barlow DH, Craske MG. Mastery of your anxiety and panic. 4th ed. New York, NY: Oxford University Press, Inc.; 2007.
11. Foa EB, Yadin E, Lichner TK. Exposure and response prevention for obsessive-compulsive disorder: therapist guide. New York, NY: Oxford University Press, Inc.; 2012.
12. Dugas MJ, Robichaud M. Cognitive-behavioral treatment for generalized anxiety disorder. New York, NY: Routledge; 2007.
13. Zlomke K, Davis TE. One-session treatment of specific phobias: a detailed description and review of treatment efficacy. Behav Ther. 2008;39(3):207-223.
14. Foa EB, Hembree E, Rothbaum B. Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences. Therapist guide. New York, NY: Oxford University Press, Inc.; 2007.
15. Resick PA, Schnicke MK. Cognitive processing therapy for rape victims. London, United Kingdom: Sage Publications; 1996.
16. Whittal ML, Robichaud M, Woody SR. Cognitive treatment of obsessions: enhancing dissemination with video components. Cognitive and Behavioral Practice. 2010;17(1):1-8.
17. Westra H, Arkowitz H, Dozois D. Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: a preliminary randomized controlled trial. J Anxiety Disord. 2009;23(2): 1106-1117.
18. Dobson KS. The science of CBT: toward a metacognitive model of change? Behav Ther. 2013;44(2):224-227.
19. Kabat-Zinn J. Full catastrophe living. Using the wisdom of your body and mind to face stress, pain, and illness. Revised edition. New York, NY: Bantam Books; 2013.
20. Hayes SC, Strosahl KD. Acceptance and commitment therapy. The process and practice of mindful change. 2nd ed. New York, NY: The Guilford Press; 2012.
21. Hofmann S, Sawyer A, Witt A, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78(2): 169-183.
22. Arch J, Eifert G, Davies C, et al. Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. J Consult Clin Psychol. 2012;80(5):750-765.
23. Brown TA, Campbell LA, Lehman CL, et al. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. J Abnorm Psychol. 2001;110(4):585-599.
24. Norton P, Barrera T. Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: a preliminary randomized controlled noninferiority trial. Depress Anxiety. 2012;29(10):874-882.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompanied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
• patient education about the nature of panic
• breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
• cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, without patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the normalcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be catastrophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD recognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a metacognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive therapy (MBCT) and acceptance and commitment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was developed as a relapse prevention program for patients who had recovered from depression. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative automatic thoughts and find ways to change their relationship with these thoughts, learning that thoughts are not facts. This process mainly is carried out by practicing mindfulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mindful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless person,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sensations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to practice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 studies found mindfulness-based therapy effective in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Using CBT effectively for treating depression and anxiety

References

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