Evidence-Based Reviews

Using CBT effectively for treating depression and anxiety

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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

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CBT effective for social anxiety disorder even with comorbidities

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