Most treatment guidelines recommend cognitive behavioral therapy as first-line psychotherapy for anxiety disorders. In some cases, such as PTSD and simple phobias, Cognitive Beahvioral Therapy (CBT) is thought to be more effective than medications. CBT has received more support from controlled trials than all other forms of psychotherapy combined. Yet CBT therapists are hard to find in many areas, making referrals difficult. In this article, I will give you a brief primer of CBT techniques for panic disorder, social phobia, and obsessive-compulsive disorder. I will also critically review whether, for these conditions, CBT is indeed superior to other forms of therapy, such as psychodynamic therapy and supportive therapy. One limitation to note: Nearly all studies described below are based on small samples—typically, treatment groups consisted of between 15-30 people.
CBT Techniques. CBT for panic disorder is based on the “fear of fear” model, which holds that the main problem is the patient’s fear of panic attacks and their associated symptoms. Our job as clinicians is to identify and to defuse the underlying “catastrophic beliefs.” For example, patients might believe that dizziness is a prelude to fainting, that palpitations signal an upcoming heart attack or that racing thoughts mean that they are “going crazy.” We expose patients to these sensations in session, to teach them that these feelings do not inevitably lead to the feared outcome. For example, we can produce racing heart rate by having the patient jog in place, or dizziness by spinning the patient in a chair. In the related technique of “cognitive restructuring,” we help our patients reframe anxiety as a normal response to life stressors. For example, we might try to shift a patient’s thinking from “heart palpitations mean I’m having a heart attack” to “it’s normal for my heart rate to increase when I’m tense or anxious.” Finally, CBT includes relaxation training to reduce a patient’s sense of generalized tension—common among panic disorder patients.
CBT vs. other therapies for panic disorder.
Supportive therapy. Several studies have compared CBT with “nondirective therapy” (NT). NT is a type of supportive therapy that consists of a warm, caring therapist who listens to the patient’s concerns and does not provide specific advice on how to alleviate panic. The patient is told that panic comes from life stress and that if stress is decreased, the severity of panic will likewise decrease. To reduce stress, the therapist works with the patient in solving problems of living.
Most, but not all, studies have shown that CBT is superior to NT for panic disorder. In the most stringent test of NT for panic disorder to date, 113 patients were assigned to receive CBT, NT, imipramine, or placebo tablet. At the end of the 12-week acute phase, response rates among those completing treatment were 82% (CBT), 52% (NT), 93% (imipramine), and 64% (placebo). Although patients assigned to NT had the lowest response rate, they also had the lowest rate of dropout (Shear MK et al., Am J Psychiatry 2001;58:1993-1998). However, another study comparing NT to CBT found that both treatments achieved similarly high levels of response (66% in CBT and 78% in NT; Shear MK et al., Am J Psychiatry 1994;151:395- 401). Several other studies of NT for panic disorder have shown mixed results and are difficult to interpret due to methodological problems (e.g., Beck AT et al., Am J Psychiatry 1992;149:778-783; Craske MG et al., J Behav Ther Exp Psychiat 1995;26:113-120).
Psychodynamic therapy. No trial has directly compared CBT to psychodynamic therapy for panic disorder. However, one randomized trial found brief psychodynamic therapy superior to applied relaxation (a common component of CBT; Milrod B et al., Am J Psychiatry 2007;164:265-272) and two uncontrolled trials of psychodynamic treatment have yielded positive results, with remission rates of 53% and 76%, close to the improvement rates reported in typical CBT trials (Ablon JS et al., Psychother Theo Res Pract Train 2006;43:216-23; Milrod B et al., J Psychother Pract Res 2001;10:239-245). Finally, one open trial of interpersonal therapy for panic disorder produced a 75% response rate (Lipsitz JD et al., J Nerv Ment Dis 2006; 194:440-445).
Bottom line: CBT is probably more effective than nondirective supportive therapy for panic disorder, although more study is needed. Both psychodynamic therapy and interpersonal therapy have promising evidence of efficacy but have yet to be directly compared with CBT.
CBT Techniques. By definition, patients with social phobia have unreasonable fears and thoughts about social evaluation, beliefs that are ripe for CBT-style challenge. For example, if a patient says that “everyone in the room thinks I sound stupid,” you can challenge this by seeking evidence that refutes the belief. Most people with social phobia have learned that the best way to eliminate their anxiety is to simply avoid social situations. Hence, exposure is an important element of treatment: patients should face their social fears. The usual technique is to create a “hierarchy” of exposure, starting with tasks that provoke mild anxiety and moving up to items which produce a high level of fear. For example, early in treatment, you might assign your patient to ask a stranger for the time and directions to a local destination. After becoming comfortable with this simple social interaction, you might ask your patient to speak briefly at the next work meeting or strike up an innocuous chat with a stranger. As patients demonstrate mastery, tasks can become more challenging—such as haggling with a store clerk over merchandise pricing or expressing disagreement with a coworker.
CBT vs. other therapies for social phobia. Oddly enough, there have been no head-to-head trials comparing CBT with any other psychotherapy. Two studies found that CBT group treatment was more effective than a “support group” (Heimberg EG et al., Cognitive Ther Res 1990;14:1-23; Heimberg et al., Arch Gen Psychiatry 1998;55:1133-1141), but the support group was not a legitimate psychotherapy—the researchers acknowledged that it was merely a placebo. In another trial, patients receiving combined group and individual CBT improved more than those assigned to individual supportive therapy (ST), but there was a major imbalance in the methodology: CBT participants received 20 hours of treatment whereas ST participants received only three hours (Cottraux J et al., Psychother Psychosom 2000;69: 137-146). A recent randomized trial did find that both interpersonal therapy and short-term psychodynamic therapy are effective treatments for social phobia (Lipsitz JD et al., Depress Anxiety 2008;25:542-553). A comparative trial of short-term psychodynamic therapy versus CBT is currently underway, and we eagerly await the results.
Bottom line: CBT has the most solid evidence of efficacy for social phobia but interpersonal and psychodynamic approaches are also likely beneficial for some patients. There is as yet no research directly comparing CBT to other legitimate psychotherapies.
CBT Techniques. There are two components of CBT for OCD: cognitive restructuring and exposure and response prevention (ERP). Cognitive restructuring (CR) focuses on questioning a patient’s beliefs, for example by pointing out that people touch unclean surfaces daily yet very few people contract deadly diseases from doing so. The other key element is exposure and response prevention (ERP). Patients are exposed to something that triggers an obsessive thought (such as touching a dirty floor) and are then forbidden from engaging in a compulsive behavior which would relieve anxiety (such as hand washing). The patient is taught stress-reduction exercises to deal with the anxiety, and can gradually tolerate greater exposure.
CBT vs. other therapies for OCD. Unfortunately there is essentially no literature investigating non-CBT psychotherapies, such as psychodynamic treatment, for OCD. However, a few trials have attempted to sort out what combination of exposure and cognitive treatment works best. In these studies, ERP had a cognitive component and CR had an exposure component, so neither method was used in isolation. Two trials comparing ERP with CR found generally equivalent results in the short-term and at follow-up, with 54% of patients in either arm no longer meeting diagnostic criteria for OCD at five year follow-up (van Oppen P et al., J Clin Psychiatry 2005;66:1415-1422). There is a general trend for higher dropout rates in ERP than cognitive restructuring, though this has not been consistent across studies (Abramowitz JS et al., Cognitive Behaviour Therapy 2005;34:140-147). Given the anxiety-provoking nature of exposure treatment, this is not surprising and it suggests that therapists need to carefully pace the degree of exposure in sessions.
Bottom line: ERP and cognitive restructuring are both clearly effective for OCD, and there is no research to support any other psychological treatment at this point.
TCPR VERDICT: For anxiety disorders, CBT remains the most useful form of psychotherapy, but other approaches also have merits.