Motivation and emotion/Book/2021/Cognitive behaviour therapy for anxiety

Overview


Most individuals at any given time get anxious over situations, other people or events. Amongst the different types of therapies that can be used to help individuals deal with general anxiety is Cognitive Behavioral Therapy (CBT). CBT is a recommended first-line treatment for generalised anxiety disorder (GAD). CBT for GAD encompasses a range of cognitive and behavioural components, including cognitive restructuring, imaginal exposure, situational exposure, stimulus control, applied relaxation, self-monitoring and psychoeducation.

GAD is a chronic and disabling condition with a lifetime prevalence of 5–8% and most patients continue to experience symptoms after 6 to 12 years (APA, 2017). The extent to which they experience anxiety determines whether there is need for one to get help or not. However, being anxious is always uncomfortable and the ability to alleviate the feeling would be a source of relief. This chapter explains anxiety, with a focus on general anxiety, CBT, techniques used in CBT, procedure of CBT in treating general anxiety, efficacy of CBT in treating general anxiety, and the advantages and disadvantages of using CBT.


 * What is anxiety?
 * What is cognitive behaviour therapy?
 * How cognitive behaviour therapy can be used to treat anxiety?

Anxiety
The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is used as the standard classification of mental disorders used by health professionals. Within the DSM-5, anxiety disorders is the umbrella term of multiple specific anxiety disorders. Andrews, Hobbs and Borkovec (2006) defined anxiety as a normal reaction to a situation that guides the way we plan and prepare for an eventuality. Anxiety is characterised by fear of what could happen next, what could go wrong or when something will happen. When it becomes excessive or intense over minor daily issues, it becomes an issue of concern. It is classified as a disorder when it disturbs an individual’s functioning in all spheres of life. According to Chavira et al. (2009) anxieties are associated with a lot of medical conditions like hypertension, asthma, arthritis and cardiovascular diseases. They are also most common in women than men, and are known to subside at approximately the age of 50. The DSM-5 has a list of symptoms that can be used to diagnose a person with GAD. The list comprises of excessive worry for at least 6 months, difficulty in controlling worry, inability to function normally. The symptoms are not caused by any other drug or illness and there is no better disorder to explain the symptoms. There are also possible six conditions that have to accompany the symptoms which are irritability, fatigue, loss of sleep, restlessness, loss of concentration and muscle tension. A client has to meet at least three of these conditions for them to be diagnosed with general anxiety disorder. The condition is uncomfortable and causes a disruption of one’s life, which makes treatment necessary.

Types of treatment
The causes of GAD can either be psychological or biological, and are manageable through psychotherapy, pharmacotherapy or a combination of both. Psychological treatment of GAD involves therapies. Persons (2012) posits that therapy is when a practitioner and a client meet to talk and address psychological problems. It makes use of techniques to motivate, train, educate, clarify, or justify change. The individual is empowered to control thoughts or behaviour. Also, treatment may differ as therapy can be based on the view of the humanist, behaviourist or psychoanalytical approach. Roy-Byrne and Cowley (2007) explored the different types of medicine that can be used to treat anxiety. Although some are capable of relieving the symptoms of GAD, they tend to cause dependence, whilst others may cause other side effects. Considering these types of treatment, psychological treatments might be the best help one can get, as it is capable of empowering the individual. Hence, this justifies the selection of CBT in treating GAD.

MacLeod and Mathews (2012) discovered that people who suffer from anxiety when faced with uncertainty are biased in their perception and understanding towards the worst. An example is two individuals migrating to a new country. The one that does not have anxiety issues will be excited and they plan steadily on how they would cope with the changes. The one suffering from GAD will expect the worst and would be constantly afraid that whatever plan they have would not work out. They can even fail to come up with a solid plan in case there is an issue arising. This is the reason why CBT is viewed as the most fitting treatment. CBT is as a therapy that targets thoughts and behaviour to alleviate mental disorders (Butcher, Hooley & Mineka, 2014). This means the therapy is more like a training for the client to control their behaviour or thought pattern. The logic behind this treatment is that the source of mental problems is the information processing system.

Cognitive behavioural theory
Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, substance use problems, eating disorders, and severe mental illness (American Psychological Association, 2017). Cognitive behaviour theory is based on the main principle that problems are based on maladaptive thoughts or learned patterns of behaviour. Through CBT, people that are struggling with psychological problems learn better ways of coping with them, allowing them to become relieved from their symptoms and become more effective within their life (American Psychological Association, 2017). CBT treatment incorporates a range of components within the process such as psychoeducation, cognitive restructuring and problem solving (Davies, Calwell & Lopez-Lopez, 2018). If an individual was overthinking about a math test, the cognitive error might be magnifying the test to be a matter of life and death. The CBT technique taught might target helping the client to view this test as an opportunity that he or she can have again. The other advantage of this therapy is that whatever is learned can be used in different situations when the client would be alone. These components aim to change a persons thought process and behaviours, and is typically the first approach before the use of medication, as research shows CBT to be more effective and has less side effects (Miller, Gu & Henry et. al, 2021). Multiple research studies also that show that CBT is more beneficial as evidence shows significant improvement in functioning and quality of life (American Psychological Association, 2017). Routinely, CBT would be administered face to face with a professional, however CBT can become an extensive process targeting problem areas, therefore, with technology improving, there has been a start on digital CBT treatment that can be accessed on smartphones and computers.

Techniques
Newman, Zainal and Hoyer (2020) carried out a meta-analysis of literature on the use of CBT to help an individual struggling with general anxiety. These techniques and skills are associated with CBT:

Relaxation Techniques: It is believed that anxiety disturbs the autonomic nervous system and the sympathetic branches associated with it after being triggered. CBT must be able to teach relaxation techniques and apply them during therapy. Examples of these techniques are meditation, breathing techniques, guided imagery, and muscle relaxation. The techniques are meant to help in stabilising breathing and, in turn, blood pressure, and other related systems.

Self-monitoring: Clients with GAD’s main issue is to fail to realize when the triggering thoughts start, how they intensify, and automatically spiral out of control. CBT allows for self-monitoring of the client. They learn how to identify triggering thoughts, notice when they are taking over and learn to control them.

Self‐control desensitization: GAD has no specific source of fear, it can be anything. This makes its treatment non-specific. Self-control desensitisation gives a framework that is flexible for use diffusing any kind of fear. This technique involves exposure to triggering thoughts or situation, and step by step procedure to diffuse them. These steps include relaxation techniques and cognitive processes control.

Stimulus Control: CBT has also been known to equip a client with the capacity to detect stimulus that cause triggering thoughts. Stimulus control is when one can decide to shelf or manage the stimuli. This is done through self-talk; an example would be using the proverb given by Newman, Zainal and Hoyer (2020:212) which says “You cannot prevent the birds by care and worry from flying over your head, but you can prevent them from building a nest in your head.” This means instead of worrying over an issue one might take action instead.

Cognitive Restructuring: This technique is employed after recognition of triggering thoughts. It entails teaching the client how to challenge irrational fears or cognitions. This is done by questioning if the thought is the true reflection of the situation. They then learn how to gather evidence for and against this thought. The aim is to learn how to develop evidence-based thoughts, whilst disregarding baseless irrational thoughts.

Procedure
CBT’s main focus is to manage the effect or impact of cognitive errors which result in anxiety symptoms. To achieve this, there is need for willingness and participation of the individual concerned. With the client’s cooperation, Brandt (2019) posits that the therapist should follow three steps with the client, namely identify thought, challenge thought and then replace the thought. This means finding out what is the magnifying stimuli, and subsequently going through the process of gathering facts to support or discard the thought, then finally find a realistic thought to replace the problematic one.

Borza (2017) gives a detailed procedure of CBT for a client suffering from GAD. He viewed the therapy as more than a tool to address anxiety. He proposed that it be used to understand people more. The procedure is based on detailed research on cognitive errors and cognitive functions. The steps proposed by Brandt (2019) were maintained in this procedure, with only detailed explanations for each stage.

Identify thought: After consent and assessment, the first step is to identify what thoughts are triggering the anxiety. This is done through functional analysis. It is a process where the practitioner, together with the client, finds out how frequent the triggering thought is occurring, the conditions in which it is happening (where and when), and the intensity of the anxiety experienced. This process allows for exploration of the individual’s psychological functioning, thereby making therapy smooth. To achieve full functional analysis, the client might be asked to respond to questions in line with investigating the triggers. Another method is to ask the client to record every occurrence, taking note of conditions and intensity. The therapist may also try to expose the client to their triggers during therapy so that they can try and understand the situation better. This process helps in separating the triggers from other thoughts.

Identifying effective tools: Borza (2017) noted that this stage involves psychoeducation, where techniques are tried out and the best is selected. This is where relaxation tools are taught to the client. These might be breathing exercises or muscle relaxation techniques, which the client may employ when feeling overwhelmed. These tools act as ‘cognitive breaks', which disrupt overwhelming thoughts. An example would be when one is constantly thinking of a journey that they have to take the following day. Fear of a possible accident may take over and they would start imagining the worst, imagining different scenarios and even wondering if they should take it or not. They get time to disengage from thoughts that would be spiralling out of control through this technique. The aim is to target on changing interpretation of situations (maximisation or generalisation), paying attention to negative information only and automatic processing. Using the example of the journey the error caused by interpretation of situations can be due to maximization, where maybe there are scratches on the paint of the bus the individual might view this as sign that the bus is not serviced well. They would see this as a major problem and begin to stress about it. Generalization is if they read in a paper about an accident on the route they are taking, they would start stressing thinking, they are going to be involved in an accident. They would focus on that even if there are reports or knowledge of thousands of people using that route safely, showing the error of focusing on negative information. The automatic processing lets them think along that negative line over and over again until they experience crippling intense fear. When they do these exercises, they will get a break from that line of thought and they might then employ cognitive techniques to counter this error. The exercises may also prepare them for exposure to their triggers.

Cognitive techniques are meant to teach the client to gather evidence against their fears. In the case of the journey the client will be asked, for instance, about the effect of paint on the functionality of the bus or if they have knowledge of accidents that are caused by scratches on the bus. The aim is to diffuse the negative baseless ideas. They can then reinforce this by getting positive evidence to calm their thoughts. This might be information about the number of successful trips completed by the bus. Practicing these techniques will equip the client to deal with triggering situations in the future. The therapist may use role playing, where they play out scenarios that were reported to be triggering in step one and then help the client practice how to diffuse such anxieties. The client might also get to practice and report using a diary or during sessions in a bid to find what works best for them.

Practice and adjustment: This stage is when the client will be mostly practicing what they would have learned during therapy. They come to therapy to report their progress and to get help in adjusting if there is a problem. An example would be failing to get a cognitive break or getting stuck when challenging the triggering thoughts even when they know what they should do in such situations. The therapist might assist by going over what they did or finding a way, together with the client, of diffusing the thoughts in a way that works for them. Borza (2017) argues that this therapy is proven to be best in helping people that are suffering from general anxiety. He also says it can work even for children who also get anxious over issues.

Efficacy of CBT
The CBT treatment for general anxiety was confirmed to be effective by Hirsch, Beale, Grey and Liness (2019). However, they felt it could be improved by making scientific modifications. They put forward that the interventions had to be guided by source of error and also cognitive processes principles. They came up with a model that targets attention and cognitive biases, thinking styles, and failure to refrain from worrying. They tested their model on individuals struggling with general anxiety and it yielded 74% success. They built their model based on the work of Borkovec and Shapless (2004) who targeted behaviour and came up with a procedure that focused on processes. Their trial had 57 (43 female and 14 male) GAD diagnosed patients who had been sent for treatment. They also recruited people with comorbidities, however with confirmed GAD as their main problem. Pre-test was conducted after participants had gone through a basic CBT therapy. They would then go through Hirsch et al’s (2019) model and a post-test assessment would be made.

The scientifically proven modifications on CBT procedure proved to be effective in helping people in dealing with general anxiety. The implication of these findings are that it is possible to make modifications on CBT. This means procedure can be personalised, taking note of scientifically proving the effectiveness of the modification before applying it.

Another investigation on the effectiveness of CBT in treating general anxiety was carried out by Kehle-Forbes (2008) at a frontline service in Minneapolis. She recruited 29 participants from various backgrounds. The participants were not tested if they met the DSM-5 diagnostic criteria; the focus was just on clients reported to have worrying issues. They used the Penn State Worry Questionnaire (PSWQ) to select clients, and a cut-off of 71% and above to select participants. The participants received 12 sessions that followed the procedure of CBT; identify trigger, choose techniques and practice. Techniques used included relaxation techniques, cognitive restructuring and self-control desensitisation. She engaged 15 therapists who received training before starting therapy with participants. Although CBT was effective in helping people with anxiety issues, the results were lower than those obtained from a controlled randomised trial. This indicated that it was not as effective as expected at the frontline. The sessions had been cut from 12 to eight, most participants dropped out and the therapists had been trained for just a short time. This might have been the reason why the results were not as expected. The findings from this investigation show that CBT might not help everyone who is struggling with anxiety.

Advantages and Disadvantages of CBT
According to the literature reviewed, the advantages of CBT in helping people deal with general anxiety are as follows: it is better than medicinal interventions, it has been proven to be effective, it can be modified to increase efficiency, and it equips the client with techniques they can use later. The disadvantages of CBT in helping people deal with general anxiety is that they need to commit for it to work, it is not suitable for everyone especially those with learning disabilities, all the work is to be done by the affected individual, therapists have to be trained in the area, and the process of exposure may not be comfortable to some.

Quiz
Choose the correct answers and click "Submit": {Q1: Generalised anxiety has a lifetime prevalence of? + A - 5-8% - B - 10-12% - C - 3-7% - D - 20-23%
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{Q2: According to the DSM V, what is the minimum time a person experiences excessive worry for it to be seen as a symptom? - A - 3 months + B - 6 months - C - 9 months - D - 4 months
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{Q3: Psychotherapy and pharmacotherapy can be used as treatment for anxiety. + A - Ture - B - False
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{Q4: Which is not one of Newman, Zainal & Hoyers (2020) techniques and skills associated with CBT? - A - Self monitoring + B - Cognitive control - C - Stimulus control - D - Cognitive restructuring
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{Q5: What is not considered an advantage of CBT? - A - No risk of drug dependency + B - It is a quick treatment - C - Can be modified for individuals - D - more efficient than pharmacotherapy
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Conclusion
This chapter explored how CBT can be used to help people deal with general anxiety or GAD. These are fears or worries that are out of control, which can affect a person’s optimal functioning. CBT is a structured therapy that employs several techniques in order to control behaviour or cognitions. It uses techniques like cognitive restructuring, self-desensitisation, relation techniques, application of techniques, stimulus control, and self-monitoring. Although there may be different variations by therapists, the procedure is basically done in three steps of identifying triggers, exploring techniques, and practicing. Studies that show efficacy of CBT in treating general anxiety have been explored. The advantage of this therapy is that it is known to be effective, and it equips the client with techniques for future use. However, it may not be for everyone, and it requires commitment and effort from the affected individual. Overall, CBT is proven to be effective in managing anxieties.