16 and Cognitive Therapy

Cognitive-behavioral Therapy, Behavioral Therapy, 16 and Cognitive Therapy

Susan E. Sprich, PhD, Bunmi O. Olatunji, PhD, Hannah E. Reese, PhD, Michael W. Otto, PhD, Elizabeth Rosenfield, BA, and Sabine Wilhelm, PhD

KEY POINTS

Background • There is an increasing focus on the dissemination of empirically-supported treatments, such that clinicians in • Cognitive-behavioral therapy (CBT) is one of the most the community are trained in the use of these extensively researched forms of psychotherapy that is treatments. increasingly recognized as the treatment of choice for many disorders. • The question of whether or not to combine pharmacotherapy and CBT may not be straightforward. History • The decision to provide combined treatment must • Cognitive-behavioral therapies represent an integration include a careful examination of the disorder, the ofo tw strong traditions within psychology: behavioral severity and chronicity of the disorder, the patient’s therapyT) (B and cognitive therapy (CT). treatment history, and the stage of treatment. • BT employs principles of learning to change human • There is an increasing emphasis on research that behavior.T B techniques include exposure, relaxation, is focused on dimensions of observable behavior assertion training, social skills training, problem-solving and on neurobiological measures, with the goal of training, modeling, contingency management, and leading to an improved understanding of behavioral activation. psychopathology. • CT, initially developed as a treatment for depression, is Practical Pointers based on the understanding that thoughts influence behavior and that maladaptive thinking styles lead to • CBT is a collaborative treatment. maladaptive behaviors and emotional distress. CT is • CBT is an active treatment. now widely used for a range of disorders. • CBT is a structured treatment. Clinical and Research Challenges • CBT is evidence-based. • A common concern is whether the results found in • CBT is a short-term treatment. well-controlled randomized controlled trials (RCTs) of CBT translate well to routine practice in the community.

OVERVIEW cally consistent relationship between CBT techniques and the disorders that they are designed to treat.15 Depending on the Cognitive-behavioral therapy (CBT) is one of the most exten- disorder, interventions may be directed toward eliminating sively researched forms of psychotherapy that is increasingly cognitive and behavioral patterns that are directly linked to 1 recognized as the treatment of choice for many disorders. Find- the development or maintenance of the disorder, or they may ings from randomized controlled trials (RCTs) typically suggest be directed toward maximizing coping skills to address the thatT CB is better than wait-list control groups, as well as sup- elicitation or duration of symptoms from disorders driven by portive treatment and other credible interventions, for specific other (e.g., biological) factors. disorders. Early implementations of CBT were largely indicated for anxiety and mood disorders.2 However, more recent clinical research efforts have begun to develop CBT for an increasingly BEHAVIORAL THERAPY, COGNITIVE THERAPY, 3,4 widery arra of problems (including bipolar disorder, eating AND COGNITIVE-BEHAVIORAL THERAPY disorders,5 body dysmorphic disorder,6 attention-deficit/hyper- activity disorder,7,8 and psychotic disorders9). Cognitive-behavioral therapies represent an integration of two The empirical evidence for the use of CBT for a broad range strong traditions within psychology: behavioral therapy (BT) of conditions is promising.10 However, there remains a notice- and cognitive therapy (CT). BT employs principles of learning able gap between encouraging reports from clinical trials and to change human behavior. BT techniques include exposure, the widespread adoption of CBT interventions among general relaxation, assertion training, social skills training, problem- practitioners.11 Moreover, questions remain regarding the solving training, modeling, contingency management, and limits of, and indications for, the efficacy of CBT in general behavioral activation. Many of these interventions are a direct practice.12 Nevertheless, it is clear that CBT represents the best outgrowth of principles of operant and respondent condition- of what the psychotherapy community currently has to offer ing. Operant conditioning is concerned with the modification in terms of evidence-supported treatment options. of behaviors by manipulation of the rewards and punish- CBT generally refers to a treatment that uses behavioral and ments, as well as the eliciting events. For example, in the treat- cognitive interventions; it is derived from scientifically- ment of substance dependence, the use of specific contingencies supported theoretical models.13,14 ,Thus there exists a theoreti- between drug abstinence (as frequently confirmed by urine or 152

Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 21, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. Cognitive-behavioral Therapy, Behavioral Therapy, and Cognitive Therapy 153 saliva toxicology screens) and rewards (e.g., the chance to win future (e.g., the presence of the therapist). Effective application a monetary reward) has proven to be a powerful strategy for of exposure therapy also requires prevention of safety behav- 16 achieving abstinence among chronic drug abusers.16 Included iors that may undermine what is learned from exposure. Safety as an operant strategy are also the myriad of interventions that behaviors refer to those behaviors that individuals may use to use stepwise training to engender needed new skills for reassure themselves in a phobic situation. For example, a problem situations. For example, assertiveness training, relaxa- patient with panic disorder may carry a cell phone or a water tion training, and problem-solving training are all core behav- bottle for help or perceived support during a panic attack. ioral strategies for intervening with skill deficits that may be These safety behaviors, while providing reassurance to patients, manifest in disorders as diverse as depression, bipolar disor- appear to block the full learning of true safety.21,22 , That is der, or hypochondriasis. One approach to treating depression, when such safety behaviors are made unavailable, better behavioral activation, emphasizes the return to pleasurable extinction (safety) learning appears to result.23,24 and productive activities, and the specific use of these activities CT was initially developed as a treatment for depression to boost mood. Interventions involve the step-by-step pro- with the understanding that thoughts influence behavior and gramming of activities rated by patients as relevant to their it is largely maladaptive thinking styles that lead to maladap- personal values and likely to evoke pleasure or a sense of tive behavior and emotional distress.25,26 ,Currently however, personal productivity. Behavioral activation will typically CT includes approaches to a wider range of disorders.27,28 consist of construction of an activity hierarchy in which up to As applied to depression, the cognitive model posits that (approximately) 15 activities are rated, ranging from easiest to intrusive cognitions associated with depression arise from most difficult to accomplish. The patient then moves through a synthesis of previous life experiences. The synthesis of the hierarchy in a systematic manner, progressing from the such experiences is also described as a schema, a form of easiest to the most difficult activity.17 Depending on the semantic memory that describes self-relevant characteristics. patient, additional interventions or skill development may be For example, the cognitive model of depression posits that needed. For example, assertion training may include a variety negative “schemas” about the self that contain absolute beliefs of interventions, such as behavioral rehearsal, which is acting (e.g., “I am unlovable” or “I am incompetent”) may result in out appropriate and effective behaviors, to manage situations dysfunctional appraisals of the self, the world, and the future. in which assertiveness is problematic. On exposure to negative life events, negative schemas and Respondent conditioning refers to the changing of the dysfunctional attitudes are activated that may produce symp- meaning of a stimulus through repeated pairings with other toms of depression. Thus, maladaptive cognitive patterns and stimuli, and respondent conditioning principles have been negative thoughts may also be considered risk or maintaining particularly applied to interventions for anxiety disorders. For factors for depression.29 eNegativ automatic thoughts can be example, influential theories such as Mowrer’s18 two-factor categorized into a number of common patterns of thought theory of phobic disorders emphasized the role of respondent referred to as cognitive distortions. As outlined in Table 16-1, conditioning in establishing fearful responses to phobic cues, cognitive distortions often occur automatically and may mani- and the role of avoidance in maintaining the fear. Accordingly, fest as irrational thoughts or as maladaptive interpretations of BT focuses on the role of exposure to help patients re-enter relatively ambiguous life events. phobic situations and to eliminate (extinguish) learned fears CT,30 and a similar approach known as rational-emotive about these phobic stimuli through repeated exposure to them therapy,31 provides techniques that correct distorted thinking under safe conditions. Exposure treatments may include any and offer a means by which patients can respond to maladap- number of modalities or procedures. For example, a patient tive thoughts more adaptively. In addition to examining cog- with social phobia may be exposed to a series of social situa- nitive distortions (see Hollon and Garber32 and Table 16-1), tions that elicit anxiety, including in vivo exposure (e.g., talking CT focuses on more pervasive core beliefs (e.g., “I am unlov- on the phone, talking with strangers, giving a speech), imagi- able” or “I am incompetent”) by assessing the themes that lie nal exposure (e.g., imagining themselves in a social situation), behind recurrent patterns of cognitive distortions. Those exposure to feared sensations (termed interoceptive exposure themesy ma be evaluated with regard to a patient’s learning because exposure involves the elicitation of feared somatic history (to assess the etiology of the beliefs with the goal of sensations, typically sensations similar to those of anxiety and logically evaluating and altering the maladaptive beliefs). panic), and exposure to feared cognitions (e.g., exposure to A commonly used cognitive technique is cognitive restruc- feared concepts using imaginal techniques). Exposure is gener- turing. Cognitive restructuring begins by teaching a patient ally conducted in a graduated fashion, in contrast to flooding, about the cognitive model and by providing a patient with in which the person is thrust into the most threatening situa- tools to recognize (negative) automatic thoughts that occur tion at the start. Exposure is designed to help patients learn “on-line”. Most therapists use a daily log or a diary to monitor alternative responses to a variety of situations by allowing fear negative automatic thoughts. Some patients find it convenient to dissipate (become extinguished) while remaining in the to do this work using an “app” on their smart phone or using feared situation. Once regarded as a passive weakening of their tablet or laptop computer. The next step in cognitive learned exposures, extinction is now considered an active restructuring is to provide the patient with opportunities to process of learning an alternative meaning to a stimulus (e.g., evaluate his or her thoughts with respect to their usefulness, relearning a sense of “safety” with a once-feared stimulus),19 as well as their validity. Through the process of logically ana- and ongoing research on the principles, procedures, and limits lyzing thoughts, a patient is provided with a unique context of extinction as informed by both animal and human studies for replacing distorted thoughts with more accurate and real- has the potential for helping clinicians further hone in on the istic thoughts. One method for helping a patient engage in efficacy of their exposure-based treatments. For example, there critical analysis of thinking patterns is to consider the objective is increasing evidence that the therapeutic effects of exposure evidence for and against the patient’s maladaptive thoughts. are maximized when patients are actively engaged in, and Thus, questions such as, “What is the evidence that I am a bad attentive to, exposure-based learning; when exposure is con- mother? What is the evidence against it?” might be asked. ducted in multiple, realistic contexts; and when patients are Another useful technique places the patient in the role of provided with multiple cues for safety learning.20 Therapists adviser.30 In the role of adviser, a patient is asked what advice should also ensure that the learning that occurs during expo- he or she might give a family member or friend in the same sure is independent of contexts that will not be present in the situation. By distancing the patient from his or her own

TABLE 16-1 Examples of Cognitive Distortions TABLE 16-2 Examples of Well-Established Cognitive, Behavioral, and Cognitive-Behavioral Treatments for Specific Disorders Distortion Description Treatment Condition/Disorder All-or-nothing Looking at things in absolute, black-and- thinking white categories Cognitive Depression Mental filter Dwelling on the negatives and ignoring the Behavioral Agoraphobia positives Depression Discounting the Insisting that accomplishments or positive Social phobia positives qualities “don’t count” Specific phobia Mind reading Assuming that people are reacting Obsessive-compulsive disorder negatively to you when there is no Headache evidence to support the assumptions Oppositional behavior Over-generalization Making a negative conclusion that goes far Enuresis beyond the current situation Marital dysfunction Fortune-telling Arbitrarily predicting that things will turn out Female orgasmic dysfunction badly Male erectile dysfunction Magnification or Blowing things out of proportion or shrinking Developmental disabilities minimization their importance inappropriately Cognitive-behavioral Panic, with and without agoraphobia Emotional reasoning Reasoning from how you feel (“I feel stupid, Generalized anxiety disorder so I must really be stupid”) Social phobia “Should” statements Criticizing yourself (or others) with “shoulds” Irritable bowel syndrome or “shouldn’ts,” “musts,” “oughts,” and Chronic pain “have-tos” Bulimia Labeling Identifying with shortcomings (“I’m a loser”) Adapted from Chambless DL, Baker MJ, Baucom DH, et al. Update Personalization and Blaming yourself for something you weren’t on empirically validated therapies: II, Clin Psychol 51:3–16, 1998.41 blame responsible for (and not considering more plausible explanations) Adapted from Beck JS. Cognitive behavior therapy: basics and beyond, ed 2, New York, 2011, Guilford Press.30 range of behavioral deficits. As outlined in Table 16-2,41 CT, BT, and their combination have garnered empirical support for the treatment of a wide range of disorders. CBT has become increasingly specialized in the last decade, and advances in the maladaptive thinking, the patient is given the opportunity to conceptualization of various disorders have brought a refine- engage in a more rational analysis of the issue. These tech- ment of CBT interventions to target core features and domi- niquesw allo patients to test the validity and utility of their nant behavior patterns that characterize various disorders. thoughts; as they evaluate their thinking and see things more rationally, they are able to function better. In addition to Basic Principles of Cognitive-behavioral techniques for changing negative thinking patterns, CT also Therapy incorporates behavioral experiments. Behavioral tasks and experiments are employed in CT to provide corrective data that As outlined in Table 16-3, contemporary CBT is a collabora- will challenge beliefs and underlying negative assumptions. tive, structured, and goal-oriented intervention.1 The current Concerning the mechanism of relapse prevention in CT, forms of CBT target core components of a given disorder. For there is growing attention to the importance of the processing example, CBT interventions for panic disorder target cata- and form of negative thoughts, not just their content.33,34 strophic misinterpretations of somatic sensations of panic Studies suggest that cognitive interventions may be useful for and their perceived consequences, while exposure procedures helping patients gain perspective on their negative thoughts focus directly on the fear of somatic sensations. Likewise, CBT and feelings so that these events are not seen as “necessarily for social phobia focuses on the modification of fears of a valid reflections of reality” (Teasdale et al.,33 p. 285). Indeed, negative evaluation by others and exposure treatments empha- there is evidence that changes in meta-cognitive awareness size the completion of feared activities and interactions with may mediate the relapse prevention effects of CT.33,35 Accord- others. For generalized anxiety disorder (GAD), CBT treatment ingly, shifting an individual’s emotional response to cogni- focuses on the worry process itself, with the substitution tionsy ma be an important element of the strong relapse of cognitive restructuring and problem-solving for self- prevention effects associated with CT.36 perpetuating worry patterns, and the use of imaginal exposure Although CT was initially developed to focus on challeng- for worries and fears. In the case of depression, CBT targets ing depressive distortions, basic maladaptive assumptions are negative thoughts about the self, the world, and the future, as also observed in a wide range of other conditions, with the well as incorporating behavioral activation to provide more development of CT approaches ranging from panic disorder,37 opportunities for positive reinforcement. Symptom manage- post-traumatic stress disorder (PTSD),38 social phobia,39 and ment strategies (e.g., breathing re-training or muscle relaxa- hypochondriasis,28 to personality disorders27 and the prevention) or social skills training (e.g., assertiveness training) are tion of suicide.40 also valuable adjuncts to exposure and to cognitive restructuring interventions. PUTTING BEHAVIORAL THERAPY AND COGNITIVE THERAPY TOGETHER The Basic Practice of Cognitive-behavioral Therapy As a functional unification of cognitive and behavioral interventions, CBT relies heavily on functional analysis of inter CBT is typically targeted toward short-term treatment, often in related chains of thoughts, emotions, and behavior. Thus, the the range of 12 to 20 sessions, although even shorter treat- principles that underlie CBT are easily exportable to a wide ments, emphasizing the core mechanisms of change, have

TABLE 16-3 Characteristic Features of Cognitive-behavioral Therapy CBT also emphasizes systematic monitoring of symptom change. This may take the form of asking a patient how he or 16 Feature Description she is feeling as compared to when in previous sessions. CBT is short term The length of therapy in CBT is largely However, more standard CBT practice consists of having a dependent on the time needed to help the patient fill out questionnaires about his or her symptoms. patient develop more adaptive patters of Periodic assessment of symptoms provides an objective look responding. However, CBT treatments at the nature of a patient’s symptoms relative to established generally involve approximately 8 to 20 norms, at which symptoms have improved, and at which sessions. CBT is active CBT provides a context for learning adaptive symptoms require more attention. Essentially, objective assess- behavior. It is the therapist’s role to provide ment during CBT helps inform both the patient and the thera- the patient with the information, skills, and pist about the efficacy of treatment and highlights further opportunity to develop more adaptive issues that require emphasis during the treatment. Monitoring coping mechanisms. Thus, homework is a outcomes can also guide the clinician with regard to case central feature of CBT. formulation or consideration of alternative CBT interventions, CBT is structured CBT is agenda-driven such that portions of if expected treatment goals are not achieved. sessions are dedicated to specific goals. Iny man approaches to CBT, patient and therapist collabo- Specific techniques or concepts are taught ratively set an agenda for topics to be discussed in each session. during each session. However, each session should strike a balance between Particular attention is given to events that occurred since the material introduced by the patient and the previous session that are relevant to the patient’s goals for predetermined session agenda. treatment. Part of the agenda for treatment sessions should CBT is collaborative The therapeutic relationship is generally less focus on the anticipation of difficulties that may occur before of a focus in CBT. However, it is important the next treatment session. These problems should then be that the therapist and patient have a good discussed in the context of problem-solving and the imple- collaborative working relationship in order mentation of necessary cognitive and behavioral skills. This to reduce symptoms by developing may require training in skills that readily facilitate the reduc- alternative adaptive skills. tion of distress. Skills, such as training in diaphragmatic CBT, Cognitive-behavioral therapy. breathing and progressive muscle relaxation, can be particularly useful in this regard. Although the specific interventions used during CBT may vary, the decision about which interventions to use should be informed by cognitive and learning theories that view disorders as understandable within a frame- been developed.42 Treatment begins with a thorough evalua- work of reciprocally-connected behaviors, thoughts, and emo- tion of the problem for which the patient is seeking treatment. tions that are activated and influenced by environmental and This generally consists of a very detailed functional analysis of interpersonal events. thes patient’ symptoms and the contexts in which they occur. As indicated in Table 16-3, CBT is also an active treatment This assessment requires extensive history-taking, a diagnostic with an emphasis on home practice of interventions. Thus, interview, analysis of current function (e.g., social, occupa- review of homework is a major component of the CBT session. tional, relational, and family), and assessment of social In reviewing the patient’s homework, emphasis should be support. Although the assessment may require some consid- placed on what the patient learned, and what the patient wants eration of past events, such information is generally gathered to continue doing during the coming week for homework. The if it is directly relevant to the solution of here-and-now homework assignment, which is collaboratively set, should problems. follow naturally from the problem-solving process in the treat- A key feature of CBT involves the establishment of a strong, ment session. The use of homework in CBT draws from the collaborative working alliance with the patient. This is often understanding of therapy as a learning experience in which initiated in the context of educating the patient about the the patient acquires new skills. At the end of each CBT treat- nature of his or her disorder, explaining the CBT model of the ment session, a patient should be provided with an opportu- etiology and maintenance of the disorder, and the interven- nity to summarize useful interventions from the session. This tion that is derived from the model. Educating the patient should also consist of asking the patient for feedback on the serves the function of normalizing aspects of the disorder; this session, and efforts to enhance memories of and the subse- can help to reduce self-blame. Psychoeducation (including quent home application of useful interventions.43 information on the course of treatment) may also enhance Relapse prevention skills are central to CBT as well. By patient motivation for change. The therapist and patient also emphasizing a problem-solving approach in treatment, a work together to develop clear, realistic treatment goals. patient is trained to recognize the early warning signs of To gather information on the patient’s symptoms, the relapse and is taught to be “his or her own therapist.” Even patient is taught early on how to monitor his or her thoughts after termination, a patient often schedules “booster sessions” and behaviors. This usually requires that the patient document to review the skills learned in treatment. In addition, novel his or her symptoms, as well as the time, date, and the level approaches to relapse prevention, as well as treatment of resid- of distress and the precursors and consequences of symptoms. ual symptoms, emphasize the application of CBT to the pro- Self-monitoring helps a patient become aware of the timing motion of well-being rather than simply the reduction of and occurrence of target symptoms, and provides additional pathology.44,45 information on opportunities for intervention. Self-monitoring procedures are vital to help a patient identify the content of The Practice of Cognitive-behavioral Therapy: his or her thoughts; once these thoughts have been identified, they can be challenged for their accuracy and utility. The accu- The Case of Panic Disorder racy of thoughts and beliefs is often examined in the context CBT for panic disorder generally consists of 12 to 15 sessions; of behavioral experiments, where patients have the opportu- it begins with an introduction of the CBT model of panic nity to test out predictions (e.g., “I will pass out,” “I will not disorder (Figure 16-1).46 The therapist begins by discussing the be able to cope”). symptoms of panic with the patient. The symptoms of panic

Stress anxiety. This could include carrying a bottle of pills in the Biological diathesis patient’s pocket or having a cell phone with the patient to call foro help. T maximize the exposure exercises, these behaviors must be gradually eliminated. The patient must learn that he or she will be okay even in the absence of such behaviors. The Alarm Reaction use of relaxation techniques for the treatment of panic may Rapid heart rate, heart palpitations, 48 shortness of breath, smothering sensations, also be beneficial. However, Barlow and associates found that chest pain or discomfort, numbness or tingling adding relaxation to the treatment (emphasizing cognitive restructuring and interoceptive exposure) appeared to reduce the efficacy of the treatment over time (see also Schmidt Increased anxiety Conditioned Catastrophic et al.49). This suggests that, in some cases, a patient may engage and fear fear of somatic misinterpretations in relaxation as a safety technique (i.e., a patient may rely too sensations of symptoms much on relaxation as a panic management technique at the expense of learning not to be afraid of anxiety-related sensations). Although relaxation techniques may come to serve the Hypervigilance to symptoms function of avoidance for some patients with panic disorder, Anticipatory anxiety studies have shown that relaxation strategies offer some benefit Memory of past attacks to patients with a wide range of anxiety disorders.50 ,Thus the decision to offer relaxation techniques in CBT for patients with Figure 16-1. Cognitive-behavioral model of panic disorder. (Adapted panic disorder should be informed by the context in which from Otto MW, Pollack MH, Meltzer-Brody S, Rosenbaum JF. the patient will apply such techniques. Cognitive-behavioral therapy for benzodiazepine discontinuation in panic disorder patients, Psychopharmacol Bull 28:123–130, 1992.) THE EFFICACY OF COGNITIVE-BEHAVIORAL THERAPY (e.g., rapid heart rate, shortness of breath, and trembling) are explained as part of our body’s natural defense system that As outlined in Table 16-1, cognitive and behavioral techniques prepares us for fight or flight in the presence of a real threat. and their combination (CBT) are generally considered to be When these symptoms occur in the presence of a real danger, empirically-supported interventions for a wide range of disor- the response helps us survive. When the symptoms occur in ders. In fact, numerous outcome trials have demonstrated that CBT is effective for a host of psychiatric disorders, as well as the absence of a real danger, the response is a panic attack. 51 Often when a person experiences a panic attack “out of the for medical disorders with psychological components. blue,” he or she fears that something is terribly wrong. The However, diagnostic co-morbidity, personality disorders, or person fears that he or she may be having a heart attack, may complex medical problems may complicate CBT treatment. be seriously ill, or may be “going crazy.” Patients are told that Such complications do not imply that a patient will not these catastrophic misinterpretations of the symptoms of respond well to CBT, but rather that the patient might have a panic disorder serve to maintain the disorder. Such interpreta- slower response to treatment. tions cause the individual to fear another attack; as a conse- In an attempt to integrate findings from RCTs, multiple quence, the person becomes hypervigilant for any somatic meta-analytic studies (which allow researchers to synthesize sensations that may signal the onset of an attack. This hyper- quantitatively the results from multiple studies in an effort to vigilance, in turn, heightens the individual’s awareness of his characterize the general effectiveness of various interventions) or her body and increases somatic sensations that lead to more have been conducted. Two recent reviews of the most compre- anxiety. This cycle continues, culminating in a panic attack. hensive meta-analyses conducted for the efficacy of CBT have Over the course of treatment, the therapist works with the nicely summarized the treatment outcome effect sizes for adult patient to examine the accuracy of catastrophic misinterpreta- unipolar depression, adolescent depression, GAD, panic dis- tions through Socratic questioning and provision of corrective order with or without agoraphobia, social phobia, obsessive- information. For example, the patient may be asked to evalu- compulsive disorder (OCD), PTSD, schizophrenia, marital distress, anger, bulimia, internalizing childhood disorders, ate the evidence for all of the likely consequences of a panic 10,15,52 attack. Additionally, the patient is gradually exposed to the sexual offending, and chronic pain (excluding headache). somatic sensations that he or she fears (a process called inte- A review of these meta-analyses and other relevant findings is roceptive exposure). Interoceptive exposure consists of a wide presented next and summarized in Tables 16-4 to 16-10. variety of procedures (such as hyperventilation, exercise, or 47 spinning in a chair ) meant to expose a patient to feared Adult Unipolar Depression internal bodily experiences (e.g., tachycardia, numbness, or tingling) in a controlled fashion. Through repeated exposure CT has been most extensively studied in adult unipolar depres- to these sensations, a patient habituates to the sensations, sion (Table 16-4). In a comprehensive review of the treatment which results in a decrease in fear and anxiety linked to inter- outcomes, Gloaguen and colleagues53 Tfound C to be better nal stimuli. With repeated exposure, a patient learns that the than (1) being on a wait-list or being placed on a placebo, sensations are not harmful. (2) antidepressant medications, and (3) other miscellaneous Cognitive restructuring is combined with interoceptive therapies. It was also as efficacious as BT. With regard to effec- exposure to aid the patient in reinterpreting the somatic sensa- tiveness, a recent meta-analysis revealed that outpatient CBT tions and reducing fear. For a patient with agoraphobia, was effective in diminishing depressive symptoms in both gradual situational exposure is also conducted to eliminate completer (d = 1.13) and intention-to-treat (ITT) samples avoidance of situations that have been associated with panic. (d = 1.06).54 Although a change in cognitive schemas and In all exposure exercises, special attention must be paid to the automatic negative thoughts has long been thought of as the elimination of safety behaviors that may interfere with habitu- central mechanism through which CT results in improvement, ation to the fear and extinction learning. Safety behaviors this has been called into question by the success of behavioral include anything that the patient may do to avoid experiencing treatments of depression. In an investigation of the relative

TABLE 16-4 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioural Therapy for Unipolar Depression 16 Author(s) Treatment Comparison(s) ES

ADULT UNIPOLAR DEPRESSION Hans & Hiller (2013)54 CBT Pre-treatment to post-treatment, completer 1.13 Pre-treatment to post-treatment, intent-to-treat 1.06 Gloaguen et al. (1998)53 CT Wait-list or placebo .82 Antidepressants .38 Behavior therapy .05 Other therapies .24 ADOLESCENT UNIPOLAR DEPRESSION Weisz et al. (2006)60 CBT Non-cognitive therapies .63 Reinecke et al. (1998)59 CBT Wait-list 1.11 Relaxation .75 Supportive therapy .55 From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. CBT, Cognitive-behavioral therapy; CT, cognitive therapy; ES, effect size.

TABLE 16-5 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioral Therapy for Generalized Anxiety Disorder Author(s) Treatment Comparison(s) ES Gould et al. (1997)66 CBT Wait-list, non-directive therapy, pill placebo, or no treatment .70 Borkovec & Whisman (1996)158 CT Pre-treatment-post-treatment 1.30 BT Pre-treatment-post-treatment 1.71 CBT Pre-treatment-post-treatment 2.13 Westen & Morrison (2001)159 Various treatments Wait-list or other psychosocial treatment .9 Mitte (2005)68 CBT No treatment .82 Placebo .57 Pharmacotherapy .33 From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. BT, Behavioral therapy; CBT, cognitive-behavioral therapy; CT, cognitive therapy; ES, effect size.

TABLE 16-6 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioral Therapy for Panic Disorder with or without Agoraphobia Author(s) Treatment Comparison(s) ES Mitte (2005)160 CBT No treatment .87 Placebo .51 Behavior therapy .09 Pharmacotherapy .27 Pharmacotherapy + CBT .23 Westen & Morrison (2001)159 Various treatments Wait-list or other psychosocial treatment .8 Oei et al. (1999)71 CBT Community norms −.48 van Balkom et al. (1997)70 Psychological management Pre-treatment-post-treatment 1.25 Panic exposure Pre-treatment-post-treatment .79 Gould et al. (1995)69 CBT Wait-list, relaxation, pill placebo, supportive therapy, .68 minimal contact control, or psychoeducation Clum et al. (1993)161 Flooding Drug or psychological placebo 1.36 Psychological coping Drug or psychological placebo 1.41 Cox et al. (1992)162 Exposure Pre-treatment-post-treatment 2.28 From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. CBT, Cognitive-behavioral therapy; ES, effect size.

TABLE 16-7 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioral Therapy for Social Phobia Author(s) Treatment Comparison(s) ES Hofmann et al. (2008)75 CBT Placebo .62 Fedoroff & Taylor (2001)77 Exposure Pre-treatment-post-treatment 1.08 CT Pre-treatment-post-treatment .72 CT + exposure Pre-treatment-post-treatment .84 Gould et al. (1997)76 CBT Wait-list, minimal contact control, psychoeducation and group support, .74 attention placebo control Taylor (1996)163 Exposure Pre-treatment-post-treatment .82 CT Pre-treatment-post-treatment .63 CT + exposure Pre-treatment-post-treatment 1.06 Feske & Chambless (1995)164 CBT Pill placebo, wait-list, educational-supportive psychotherapy .38 Exposure Wait-list 1.06 From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. CBT, Cognitive-behavioral therapy; CT, cognitive therapy; ES, effect size.

TABLE 16-8 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioral Therapy for Obsessive-Compulsive Disorder Author(s) Treatment Comparison(s) ES Olatunji et al. (2013)83 CBT Control treatment 1.39 Abramowitz et al. (2002)82 ERP No treatment 1.50 CT No treatment 1.19 ERP Cognitive therapy .07 Abramowitz (1997)81 ERP Relaxation 1.18 ERP Cognitive therapy −.19 ERP Exposure alone or response prevention alone .59 van Balkom et al. (1994)80 BT Pre-treatment-post-treatment 1.46 CT Pre-treatment-post-treatment 1.09 CBT Pre-treatment-post-treatment 1.30 From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. BT, Behavioral therapy; CBT, cognitive-behavioral therapy; CT, cognitive therapy; ERP, exposure and response prevention; ES, effect size.

TABLE 16-9 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioral Therapy for Post-traumatic Stress Disorder Author(s) Treatment Comparison(s) ES Hoffman et al. (2008)75 CBT Placebo .62 National Collaborating Centre for Mental Health (2005)88 CBT Wait-list 1.70 Van Etten & Taylor (1998)165 BT Pre-treatment-post-treatment 1.27 Sherman (1998)166 Exposure, CPT, hypnosis, EMDR, Wait-list, supportive, or dynamic therapy .52 SIT, or inpatient treatment From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. BT, Behavioral therapy; CBT, cognitive-behavioral therapy; CPT, cognitive processing therapy; EMDR, eye movement desensitization and reprocessing; ES, effect size. efficacy of individual components of CT, it was found that A large trial comparing BA with CT and antidepressants the behavioral components of CBT resulted in as much found that BA was as effective as antidepressant medication acute improvement and prevention of relapse as was the and more effective than CT at reducing the symptoms of fullT C treatment.55,56 Since these findings emerged, research- depression.57 The success of this treatment is a promising ers have worked to refine and to develop the behavioral development in the treatment of depression because the tech- components into a treatment called behavioral activation A;(B niques used in BA are much more easily learned by clinicians. which abandons the cognitive components of treatment They ease b which BA is learned by clinicians may facilitate in favor of behavioral techniques aimed at encouraging posi- its dissemination to settings (i.e., primary care, community tive activities, engaging with the environment, and reducing mental health settings) where quick, easy, and effective treat- avoidance). ments for depression are needed.

TABLE 16-10 Summary of Meta-Analyses of Studies Examining the Efficacy of Cognitive-behavioral Therapy for Other Disorders/Problems 16 Author(s) Treatment Comparison(s) ES

SCHIZOPHRENIA Newton-Howes & Wood (2013)99 CBT Placebo .22 Wykes et al. (2008)97 CBT Pre-treatment-post-treatment .40 Rector & Beck (2001)96 CBT Pre-treatment-post-treatment 1.50 MARITAL DISTRESS Dunn & Schwebel (1995)105 CBT No treatment .71 BT No treatment .78 ANGER Sukhodolsky et al. (2004)107 CBT No treatment .67 Beck & Fernandez (1998)106 CBT No treatment .70 BULIMIA NERVOSA Spielmans et al. (2013)167 CBT Non-CBT .24 Whittal et al. (1999)5 CBT Pre-treatment-post-treatment Binging 1.28 Purging 1.22 Eating attitudes 1.35 INTERNALIZING CHILDHOOD DISORDERS Grossman & Hughes (1992)108 CBT No treatment or psychological placebo Anxiety .93 Depression .87 SEXUAL OFFENDING Nagayama Hall (1995)109 CBT No treatment .35 CHRONIC PAIN (NOT HEADACHE) Morley et al. (1999)110 CBT Wait-list Pain experience .33 Social functioning .61 BT Wait-list Pain experience .32 From Butler AC, Chapman JE, Forman EM. The empirical status of cognitive-behavioral therapy: a review of meta-analyses, Clin Psychol Rev 26:17–31, 2006; Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings, J Clin Psychol 60:429–441, 2004. Positive ES scores indicate superiority of treatment over the comparison group. Negative ES scores indicate superiority of comparison over the treatment group. BT, Behavioral therapy; CBT, cognitive-behavioral therapy; ES, effect size.

The evidence for long-term efficacy of CBT for adult uni- Bipolar Disorder polar depression is also promising. Patients treated to remission with CT are approximately half as likely to relapse as are In the last decade, there has been a striking increase in the patients who are treated to remission with antidepressant application of psychosocial treatment as an adjunctive strategy medications.58 TC has also been shown to be superior to anti- to the pharmacological management of bipolar disorder. depressants at preventing recurrence of major depression fol- Cognitive-behavioral approaches have been prominent among 3 lowing the discontinuation of treatment.36 these innovations, with clear evidence that interest in, and acceptance of, psychosocial treatment is rising among experts in bipolar disorder.61 The treatment literature has progressed Adolescent Unipolar Depression from initial CBT protocols aimed at improving medication 62 The importance of treatment and prevention of psychiatric adherence to broader protocols that are targeted toward illness in children and adolescents has been increasingly rec- relapse prevention, as well as the treatment of bipolar ognized. Although treatment of children and adolescents is depression. These broader CBT protocols, which include psy- often complicated by developmental considerations, positive choeducation, cognitive restructuring, problem-solving skills, results have been reported in the treatment of adolescent uni- and sleep and routine management, have reduced manic, polar depression (see Table 16-4). Reinecke and colleagues’ hypomanic, and depressive episodes and resulted in fewer review of CBT for adolescents with major depression59 found days spent in a mood episode and in shorter lengths of hos- 63–65 CBT to be superior to wait-list, relaxation training, and sup- pital stays. The management of bipolar disorder is an portive therapy (with effect sizes ranging from .45 to 1.12). In excellent example of when CBT can be a very effective supple- a more recent meta-analysis, Weisz and colleagues60 found ment to medication. cognitive treatments were no more effective than non-cognitive 10 interventions (ES = .34). Butler et al. noted, however, that Generalized Anxiety Disorder the sample sizes are small in this area of research and the findings should be interpreted with caution and treated as An early meta-analysis by Gould et al.66 revealed that CBT was preliminary at best. superior to wait-list and to no-treatment conditions and

Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 21, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 160 PART IV The Psychotherapies equally as effective as medication in the treatment of GAD. more effective than wait list and psychological and pill placebo The authors also compared the effect sizes for CBT, BT, and control conditions at post-treatment (Hedges’s g = 1.39) and CT and found that CBT resulted in an effect size of .91, whereas at follow-up (Hedges’s g = 0.43).83 However, effect sizes did forT C alone the effect size was .59 and for BT alone it was .51. not y vary b type of CBT. Taken together these results suggest Therefore, the optimal treatment for GAD appears to consist that CT, CBT, and BT (ERP) are effective treatments for OCD of both cognitive and behavioral components (see Table (see Table 16-8). CT may prove to be an effective and more 16-5). Gains achieved via long-term treatment of GAD tolerable treatment alternative.84,85 TCB also shows long-term (through CBT) have also been reported. In a comparison of efficacy for OCD.86,87 CBT, dynamic psychotherapy, and medication, Durham and 67 co-workers found that CBT for GAD resulted in the most Post-traumatic Stress Disorder enduring improvement 8 to 14 years after treatment. With regard to pharmacotherapy, results of a meta-analysis revealed Considerable evidence supports the efficacy of CBT for PTSD thatT CB was more effective than control conditions. However, (see Table 16-9). A meta-analysis of psychological treatments results of comparisons of the relative efficacy of CBT and for PTSD revealed that CBT was superior to a wait-list condi- pharmacotherapy varied depending on the meta-analytic tion (with a mean effect size of 1.49)88 and to a variety of method used, so definitive conclusions could not be drawn control conditions (Hedges’ g = 0.62).75 TCB is considered a regarding their relative effectiveness.68 first-line treatment according to a 2000 consensus statement.89 Well-controlled trials have consistently shown benefit for CBT Panic Disorder over control conditions, with support for treatments emphasizing imaginal or in vivo exposure to trauma cues, as well as CBT is also efficacious for panic disorder (see Table 16-6). In those emphasizing cognitive restructuring in the context of an early meta-analysis by Gould and colleagues,69 TCB was repeated exposure to accounts of the trauma.90–94 Cognitive- found to be superior to wait-list and placebo; treatments com- behavioral approaches share a focus on helping patients sys- posed of cognitive restructuring and interoceptive exposure tematically re-process the traumatic event and reduce the resulted in the greatest improvements (d = .88). Similarly, a degree to which cues associated with the trauma are capable meta-analysis by van Balkom and colleagues70 revealed that BT of inducing strong emotional responses, typically through a consisting of in vivo exposure was very effective for the treat- combination of exposure and cognitive-restructuring interven- ment of panic (d = .79) and agoraphobia (d = 1.38). In a tions. There is also evidence to support the long-term efficacy comparison between community norms and patients with ofT CB for PTSD.95 panic disorder,71 TC reduced symptoms (to normal levels) by the end of treatment. CBT also results in more enduring treat- Schizophrenia ment gains when compared with medication treatment.72–74 CBT has been found to be effective as an adjunct to pharma- Social Anxiety Disorder cotherapy in the treatment of schizophrenia (see Table 16-10). One review revealed that CBT plus routine care was shown to CBT has also been effective for reducing social anxiety75 (see reduce positive, negative, and overall symptoms (d = 1.23).96 Table 16-7). A meta-analysis by Gould and colleagues76 dem- Those treated only with routine care showed modest symptom onstrated that CBT was superior to wait-list and to placebo improvements, over the same period (d = .17). In a more recent with an effect size of .93. The pre-treatment-to-post-treatment meta-analysis, CBT had a small to medium effect on positive effect sizes for CBT, CT, and BT were found to be .80, .60, and ande negativ symptoms, as well as on general functioning and .89, respectively. A second meta-analysis examining the effi- mood.97 Additionally, CT may be effective as a prevention cacy of CBT, CT, and BT found effect sizes of .84, .72, and 1.08, strategy in individuals at ultra-high risk of developing the respectively.77 Together, these findings suggest that cognitive disorder.98 In contrast, a 2013 meta-analysis revealed that CBT and behavioral interventions are effective for social anxiety was no more effective than non-CBT interventions.99 disorder. Furthermore, it appears that the elements of BT (i.e., exposure) may be responsible for the majority of the treat- Eating Disorders ment gains observed in social anxiety disorder. Moreover, CBT for social anxiety disorder results in more long-lasting treat- CBT is a first-line treatment of choice for bulimia nervosa (see ment effects when compared with medication.78,79 Table0). 16-1 100 Meta-analytic review of CBT for bulimia indi- cates clinically significant reductions in binging frequency Obsessive-Compulsive Disorder (d = 1.28), purging frequency (d = 1.22), and improvements in eating attitudes (d = 1.35) from pre-treatment to post- A meta-analysis by Van Balkom and colleagues80 examined treatment.4 TCB also compares well to other treatments, with pre-treatment-to-post-treatment effect sizes for BT (exposure equal or greater efficacy than medications101 and other relevant and response prevention [ERP] and other exposure-based alternative treatments.102,103 treatments), CT (cognitive techniques in the absence of any exposure), and CBT (treatments combining both cognitive Substance Dependence techniques and exposure) for OCD. The clinician-rated effect sizes were found to be 1.47, 1.04, and 1.85, respectively, sug- A range of cognitive-behavioral approaches have been repeat- gesting that all three treatments were effective and that the edly found to be effective for treating substance use disorders. addition of cognitive techniques to BT may result in additional These interventions prominently include contingency man- gains. In another meta-analysis that compared CT directly to agement techniques (where social, monetary, or other voucher ERP,T C was found to be slightly more effective.81 However, a rewards are provided contingent on negative toxicology third meta-analysis82 revealed that ERP had a stronger effect screens for substance use), skill acquisition and relapse pre- size than CT when both were compared to a no-treatment vention approaches (where responses for avoiding or coping group. However, when the two treatments were directly com- with high-risk situations for drug use are identified and pared against each other, they were found to be equally effec- rehearsed, as are alternative non-drug behaviors), and behav- tive. Similarly, a 2013 meta-analysis revealed that CBT appeared ioral family therapy (where contingency management,

Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 21, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. Cognitive-behavioral Therapy, Behavioral Therapy, and Cognitive Therapy 161 interpersonal support, and skill-building interventions might However, pharmacotherapy may not produce a complete be combined).16,104 Despite the success of these approaches, remission of symptoms and at times may be associated with 16 treatment of drug dependence is an area in great need of a delayed effectiveness. CBT can complement, if not replace, additional strategies for boosting treatment response and the pharmacotherapy for various disorders. CBT can be offered to maintenance of treatment gains. patients to control symptoms while awaiting a response to medications and to supplement or strengthen treatment Other Psychological Conditions response. Indeed, CBT has also been shown to be an effective treatment in addition to medication for chronic mental ill- CBT has been studied for numerous other psychological con- nesses (such as bipolar disorder and schizophrenia).118 These ditions (see Table 16-10). When compared to no treatment, findings seem to support the notion that two treatments (CBT CBT has been found to be effective in reducing marital distress plus pharmacotherapy) must be better than one. However, a (d = .71), although it was not significantly more effective than recent examination of the treatment outcome literature has behavioral marital therapy or interpersonally oriented marital revealed that the question of whether or not to combine phar- therapy.105 A similar effect size has been reported for CBT for macotherapy and CBT may not be straightforward.119 The deci- anger and aggression when compared to no treatment in sion to provide combined treatment must include a careful adults (d = .70)106 and children (d = .67).107 In a meta-analysis examination of the disorder, the severity and chronicity of the examining the efficacy of CBT for childhood internalizing dis- disorder, the patient’s treatment history, and the stage of orders, Grossman and Hughes108 found that CBT, when com- treatment. pared to no treatment or to psychological placebo, resulted in For unipolar depression it appears that combining medica- significant improvements in anxiety (d = .93), depression (d = tion and CBT results in a slight advantage over either treatment .87), and somatic symptoms (d = .47). More modest treatment alone.58,119 However, the advantage of combined treatment is effects have been reported for CBT for other psychological most pronounced for individuals with severe or chronic conditions. For example, in a review of CBT for sexual offend- depression. CBT has been effective at preventing relapse in ing, Nagayama Hall109 found an overall effect size of .35 on individuals who have already responded to antidepressants measures of recidivism when compared with no treatment. A and wish to discontinue the medication. In this case, medica- meta-analysis of CBT for pain revealed effect sizes that ranged tion and CBT would be delivered in a sequential rather than from .06 on measures of mood to .61 on measures of social simultaneous manner. Hollon and colleagues58 suggest that role functioning, and on direct measures of the experience of CBT and pharmacotherapy may complement each other due pain,T CB was found to have an effect size of .33.110 to their different rates of change. Pharmacotherapy is typically associated with a more rapid initial change, whereas CBT has The Effectiveness of been associated with improvements slightly later, after the initiation of treatment. Thus, individuals receiving both types Cognitive-behavioral Therapy of treatment benefit from the early boost of medication and A common concern is whether the results found in well- the later improvements associated with CBT. CBT and medica- controlled RCTs of CBT translate well to routine practice in tion for depression may also complement each other in their the community.111 Relative to this concern, Westbrook and mechanisms of change in the brain. Treatment of depression Kirk112 recently published a large outcome study examining withT CB operates through the medial frontal and cingulate cortices to effect change in the prefrontal hippocampal path- the effectiveness of CBT in a free mental health clinic. They 120 found that of 1,276 patients who started treatment, 370 ways. Treatment with paroxetine (a selective serotonin dropped out before the agreed-on end of treatment. This is a reuptake inhibitor [SSRI]) also produced changes in the pre- higher dropout rate than is usually reported in clinical trials frontal hippocampal pathways, but through the brainstem, of CBT; however, the authors did not provide information insula, and subgenual cingulate. Thus, CBT and medication regarding reason for dropout, which makes interpretation of may operate through different pathways to reach the same result. However, some of the unique advantages of CBT com- this finding difficult. Because the patients in the clinic were 121 not reliably diagnosed using a structured clinical interview, the pared to medication for depression are as follows : consist- authors relied on two measures as their outcome variables for ent evidence for equal efficacy in patients with mild to all patients: the Beck Anxiety Inventory (BAI) and the Beck moderate depression, without exposure to medication risks Depression Inventory (BDI). For treatment completers, the or side effects; evidence for lower relapse rates than pharma- overall effect size for pre-treatment-to-post-treatment improve- cotherapy when treatment is discontinued; evidence for ment was .52 on the BAI and .67 on the BDI. When the long-term effectiveness equal to that of maintenance pharma- authors examined only those individuals who entered treat- cotherapy; greater tolerability than many pharmacological ment with a score in the clinical range on either of these agents; and avoidance of long-term medication effects, includ- measures, the pre-treatment-to-post-treatment effect sizes rose ing potential effects on chronicity and pregnancy-related to .94 and 1.15, respectively. These findings are consistent with health outcomes. indications that clinical practice frequently encounters patients The decision to provide combined treatment for anxiety who are less severe than those in clinical trials113 and supports disorders involves even more complicating factors. A recent the efficacy of CBT in the community setting for a wide range review of the treatment for panic disorder suggests that com- of psychiatric disorders. Additionally, these results are very bined treatment is associated with modest short-term gains similar to other effectiveness and bench-marking trials,114–117 over each modality alone for panic disorder. However, in suggesting that these are fairly reliable and representative out- analysis of long-term outcome, combined treatment remained comes for care in the community. superior to medication alone, but was not more effective than CBT. alone 122 The results of a multi-center study investigating combination treatments for social anxiety disorder (CBT COMBINING COGNITIVE-BEHAVIORAL THERAPY alone, fluoxetine alone, the combination of these treatments, WITH MEDICATION or placebo) revealed that there was less than a 3% improvement in response rates for the addition of fluoxetine to CBT; Psychiatric medications are commonly considered the first patients treated with CBT plus fluoxetine demonstrated a line of treatment for a wide range of psychiatric disorders. response rate of 54.2% relative to a response rate of 51.7% for

CBT, alone and a response rate of 50.8% for fluoxetine alone.123 other towards developing treatments that are more broadly Similar findings were reported in a multi-center study of com- applicable across multiple different diagnostic categories, such bination treatment for adults with OCD. Outcomes for as the “unified protocol for transdiagnostic treatment of emo- patients who received combined CBT (exposure and response tional disorders”.153,154 The unified protocol is consistent with prevention) and clomipramine were not significantly better a component of the strategic plan outlined by the National than for patients who received CBT alone, and both of these Institute of Mental Health (NIMH) that is known as the groups achieved a better outcome than those treated with Research Domain Criteria (RDoC).155 The RDoC calls for the clomipramine alone.124 However, in the Pediatric OCD Treat- development of new ways of classifying psychopathology ment Study (POTS), combined treatment proved superior to based on dimensions of observable behavior and neurobio- CBT alone and to sertraline alone which did not differ from logical measures.155 The RDoC is encouraging researchers each. other 125 towards conceptualizing psychopathology in more dimen- Thus, it appears that combining medication and CBT for sional ways. As outlined above, there is much more existing anxiety disorders may not result in treatment gains substan- research on protocols designed for specific categorical disor- tially greater than those achieved through CBT alone. Consid- ders; however, preliminary studies on the unified protocol are ering that CBT is a more cost-effective treatment than is use of promising.156 In the future, it is likely that more treatments will medication,126 practitioners should consider CBT as a first-line be developed for broader dimensions of psychopathology. treatment for the anxiety disorders, with pharmacotherapy as an alternative treatment for CBT non-responders. The addi- CONCLUSION tionT of CB to medication, however, is beneficial. There is also evidence that the addition of CBT during and after medi- CBT consists of challenging and modifying irrational thoughts cation discontinuation enables patients to maintain treatment and behaviors. CBT interventions have been well articulated gains.127 in the form of treatment manuals and their efficacy has been More recent developments in combination treatment have tested in numerous RCTs. CBT is an empirically-supported examined a very different strategy for combination treatments: intervention and is the treatment of choice for a wide variety rather than combining antidepressant or anxiolytic agents of conditions.1 Despite such findings, CBT has not been widely with CBT, this new strategy seeks to strengthen the retention adoptedy b community practitioners, primary care settings, of therapeutic learning from CBT. To date, the most successful and pharmacotherapists. Researchers are actively trying to strategy of this kind has been augmenting CBT with the identify and address the factors that may be contributing to glutamatergic N-methyl-D-aspartate (NMDA) agonist, D- this gap between science and practice. Indeed, dissemination cycloserine.128–131 This approach stems from animal research and implementation research is a major funding priority of that has implicated NMDA receptors in extinction-learning. the National Institutes of Mental Health and the topic of Extinction-learning appears to be enhanced by NMDA partial intense academic debate and research. We are hopeful that agonists, such as D-cycloserine.132,133 This basic animal labora- with increasing funding and attention to this important topic, tory research has been repeatedly applied to patients with CBT will become widely available to patients in need.157 anxiety disorders, and preliminary evidence suggests that D-cycloserine may enhance the effectiveness of exposure-based Access the complete reference list and multiple choice questions CBT for acrophobia,134 social phobia,135 OCD,130,136–138 and (MCQs) online at https://expertconsult.inkling.com panic disorder.139 In this application, the medication is given in individual dosages only in the context of (before or after) exposure therapy sessions, with recently emerging evidence KEY REFERENCES that D-cycloserine augmentation effects are stronger when 1. Hollon SD, Beck AT. Cognitive and cognitive-behavioral thera- applied to exposure sessions resulting in low fear.140,1 14 pies. 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MULTIPLE CHOICE QUESTIONS MULTIPLE CHOICE ANSWERS 16 Select the appropriate answer. Q1 The answer is: Behavioral therapy. Q1 Which of the following types of therapy is most closely Behavioral therapy refers to any of a large number of specific allied with use of exposure, relaxation, assertion techniques that employ principles of learning to change training, problem-solving training, and contingency human behavior. These techniques include exposure, relaxa- management? tion, assertion training, social skills training, problem-solving training, modeling, contingency management, and behavioral ○ Aromatherapy activation. Many of these interventions are a direct outgrowth ○ Behavioral therapy of principles of operant and respondent conditioning. Operant conditioning is concerned with the modification of behaviors ○ Hypnotherapy by manipulation of the rewards and punishments, as well as ○ Pharmacotherapy the eliciting events for behavior. ○ Psychodynamically-oriented psychotherapy Q2 The answer is: Cognitive therapy. Cognitive therapy was initially developed as a treatment for Q2 Which of the following types of therapy is most closely depression with the understanding that thoughts influence allied with the correction of distorted thinking and behavior and it is largely maladaptive thinking styles that lead offers a means by which a patient can respond to to maladaptive behavior and emotional distress, but currently maladaptive thoughts more adaptively? includes approaches to a wide range of disorders. ○ Behavior therapy Cognitive therapy provides techniques that correct distorted ○ Cognitive therapy thinking and offers a means by which patients can respond to maladaptive thoughts more adaptively. In addition to examin- ○ Hypnotherapy ing cognitive distortions, cognitive therapy examines more ○ Pharmacotherapy pervasive core beliefs (e.g., “I am unlovable” or “I am incompetent”) by assessing the themes that lie behind recurrent ○ Psychodynamically-oriented psychotherapy patterns of cognitive distortions. Those themes may be evaluated in regard to a patient’s learning history (to assess the Q3 Which of the following types of therapy is most closely etiology of the beliefs with the goal of logically evaluating and allied with development of a strong, collaborative altering the maladaptive beliefs). working alliance in the context of obtaining a detailed functional analysis of the patient’s symptoms and the Q3 The answer is: Cognitive-behavioral therapy. contexts in which they occur and educating the patient Contemporary cognitive-behavioral therapy (CBT) is a col- about the nature of their disorder? laborative, structured, and goal-oriented intervention that ○ Aromatherapy often lasts 12 to 20 sessions. Treatment begins with a very detailed functional analysis of the patient’s symptoms and ○ Cognitive-behavioral therapy the contexts in which they occur. Although the assessment ○ Hypnotherapy may require some consideration of past events, such information is generally gathered if it is directly relevant to the ○ Pharmacotherapy solution of here-and-now problems. A collaborative relation- ○ Psychodynamically-oriented psychotherapy ship is often initiated in the context of educating the patient about the nature of the disorder, explaining the CBT model of the etiology and maintenance of the disorder, and the Q4 Which of the following types of therapy is most closely intervention that is derived from the model. Educating the allied with having the patient practice interventions at patient serves to normalize aspects of the disorder; this can home (i.e., do homework)? help to reduce self-blame. Psychoeducation (which includes ○ Aromatherapy information on the course of treatment) may also enhance patient motivation for change. The therapist and the patient ○ Cognitive-behavioral therapy also work together to develop clear, realistic treatment goals. ○ Hypnotherapy CBT also emphasizes systematic monitoring of symptom change. ○ Pharmacotherapy Q4 The answer is: Cognitive-behavioral therapy. ○ Psychodynamically-oriented psychotherapy CBT emphasizes home practice of interventions. Thus, review Q5 Which of the following terms best categorizes patterns of homework is a major component of the CBT session. In that involve all-or-nothing thinking, discounting the reviewing the patient’s homework, emphasis should be placed positives, jumping to conclusions, and magnifying and on what the patient learned, and what the patient wants to minimizing? continue doing during the coming week for homework. The homework assignment, which is collaboratively set, should ○ Cognitive distortions follow naturally from the problem-solving process in the treatment session. The use of homework in CBT draws from the ○ Denial understanding of therapy as a learning experience in which ○ Projection the patient acquires new skills. At the end of each CBT treatment session, a patient should be provided with an opportu- ○ Psychotic thinking nity to summarize useful interventions from the session. This ○ Splitting should also consist of asking the patient for feedback on the