Article summary of Cognitive behavioral therapy for anxiety disorders by White & Cheung - 2021

How does Generalized Anxiety Disorder (GAD) reinforce itself?

Individuals suffering from generalized anxiety disorder (GAD) show certain characteristics that maintain the cognitive and behavioral cycle of worry: a tendency to catastrophize negative events, difficulties with problem solving, worrying about worrying, a low tolerance for uncertainty, etc. Their constant worrying can lead to avoidance behavior creating a negative reinforcement cycle, for example through procrastination, constant reassurance seeking, and overpreparation.

How can cognitive behavioral therapy (CBT) treat GAD?

CBT is multimodal and tackles different areas of GAD:

• Psychoeducation teaches patients to identify anxiety-related thoughts, images, and beliefs and search for ways to create alternative, less anxiety-arousing assumptions/interpretations.
• Patients learn controlled breathing techniques, visualization, and mindfulness to encourage normal parasympathetic nervous system functioning.
• Imaginal and in vivo exposure techniques help patients notice their avoidance behaviors and help them become comfortable with their most feared outcomes. 

How do panic disorder and agoraphobia reinforce themselves?

Individuals that suffer from panic disorder are often hypervigilant for physiological changes and try to avoid or escape situations that may cause them panic. This is called interoceptive avoidance: aversion to somatic sensations associated with anxiety and panic leading to abstinence from arousal-inducing experiences. Even though these behaviors give immediate relief from panic attacks, they also perpetuate distorted beliefs and prevent fear extinction.

How can CBT treat panic disorder and agoraphobia?

CBT to treat panic disorder and agoraphobia should include:

• Psychoeducation on the components of panic and anxiety.
• Identifying and restructuring misinterpretations about physiological sensations.
• Exposure to physiological arousal.
• Elimination of safety behaviors.

How come breathing retraining can lead to poorer outcomes when used to treat panic disorder?

For many people, breathing retraining is an avoidance behavior that prevents a person from experiencing the full extent of their physical symptoms. Learning about breathing can help someone to see the role that breathing plays in a panic attack, but patients should learn that panic attacks are harmless and will pass and that breathing is an autonomic nervous system process that does not need retraining.

What is Craske´s Panic Control Treatment?

Panic Control Treatment is a brief, structured, cognitive-behavioral therapy developed for the treatment of panic disorder with limited agoraphobia. It attributes panic disorder to interoceptive conditioning resulting in anticipatory anxiety. Exposure should help to extinguish the feared response and disconfirm distorted thoughts and minimize catastrophizing. It uses an integration of exposure and cognitive restructuring.

How does social anxiety disorder (SAD) reinforce itself?

People with a social anxiety disorder feel debilitating fear of interacting with people and forming social relationships can provoke them panic. They also have an intense fear of negative evaluation from social situations. They show increased social apprehension and self-focused attention, and overestimate the probability of a negative outcome. After social experiences, they use negative tactics to manage their anxiety, such as avoidance and safety behaviors. They also worry post-event and ruminate, which all leads to increased social anxiety.

How can CBT treat social anxiety disorder?

CBT can treat social anxiety disorder through:

• Psychoeducation about normal social worries versus problematic social anxiety. Anxiety is an adaptation which is part of the human condition and it would be unnatural to eradicate it completely. Therefore, social worries are normal.
• Cognitive restructuring teaches patients to detect and restructure automatic thoughts and expectations about social situations.
• Exposure therapy
• If a person appears to be deficient in social skills, CBT may include social skills training.

What are specific phobias?

Specific phobias are marked by a persistent fear of specific objects or situations. Individuals actively avoid the fear stimuli or feel extreme anxiety when they are faced with it. Specific phobias are usually chronic, rarely spontaneously disappear, and show high comorbidity with anxiety and eating disorders. Avoidance is characteristic in patients with specific phobias and they often avoid seeking treatment because they know they will be confronted with their fears.

How can CBT treat specific phobias?

Exposure therapy has the most support for treating specific phobias through fear conditioning. The patient should be exposed to the feared stimuli until the fear has subsided, reducing the strength of the conditioned response. The feared stimuli should be presented in various contexts to generalize fear reduction. For feared stimuli that are difficult to reproduce, virtual reality can be used in treatment. Together with the exposure therapy there should be cognitive interventions to treat irrational thoughts of the safety of the fear stimulus and catastrophizing.