Is There Strong Evidence For The Use Of Psychological Therapy For Treating Anxiety Disorders?

In 2013, there were 8.2 million cases of anxiety in the United Kingdom (Fineberg, N., Haddad, P., Carpenter, L., Gannon, B., Sharpe, R., Young, A., Joyce, E., Rowe, J., Wellsted, D., Nutt, D. and Sahakian, B. 2013), proving it to be a both prevalent and increasing mental health problem. As stated by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there are numerous conditions which are categorised as anxiety disorders. This is inclusive, but not limited to, generalised anxiety disorder (GAD), several phobias such as agoraphobia and separation anxiety disorder. Differently to previous editions of the DSM, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are no longer considered anxiety disorders. However, CBT as a psychotherapy is still the most effective treatment for PTSD (Rothbaum et al, (2000) ). With this is mind, the most utilised method of treating this mental health condition within the United Kingdom (UK) is in fact psychological therapies such as cognitive behavioural therapy (CBT). Despite alternative treatments such as drug therapy being available, psychological therapies are usually a first point of call due to strong evidence suggesting their effectiveness in treating such anxiety disorders. In this essay I will evaluate the empirical support provided for psychological therapies, specifically CBT, meanwhile contrasting this with alternatives that have also appeared effective such as self-help and drug therapies.

Firstly, CBT is the most common psychological therapy used to address anxiety which originated in the 1960 s when psychiatrist Aaron T Beck identified negative thought patterns in his anxiety patients. It involves challenging and altering unhelpful cognitive distortions and behaviours on the assumption that anxiety is the consequence of these negative thoughts. Despite the presumptions of a cognitive basis of anxiety initiating decades ago, an updated perspective on psychotherapy as effective in treating anxiety has been published by both Aaron T Beck and David A Clark in collaboration with one another (Cognitive Therapy of Anxiety Disorders: Science and Practice (Clark Beck, 2010, from Guilford Press, pp. 628)). This revised approach considers modern advances in medicine and psychology yet still exhibits numerous pieces of empirical support.

Furthermore, there are numerous examples of empirical support that provide evidence for CBT as an effective treatment when compared with behavioural therapy (BT). During one controlled clinical trial in 1991, which incorporated numerous follow-ups and assessments at different intervals, it was found that not only was CBT more effective in recovery and reducing symptoms, but also displayed no attrition. On the other hand, drop-out rates were noticeably higher in the BT condition (Butler, G., Fennell, M., Robson, P., Gelder, M. (1991)). However, the findings of this study can be perceived to be culturally biased due to only being applicable in England and Holland after replications in these locations and application to their populations therefore, this empirical support is not generally applicable and could be a result of cultural variance instead. As well as this, research originating from a previous century is considered outdated due to the rapid pace of psychological advances providing another weakness to this particular example.

Despite this, more recent support can be derived from a 2008 study on GAD, separation anxiety and social phobias in children aged 7-17 (John T. Walkup, Anne Marie Albano, John Piacentini, et al 2008). Participants were randomly allocated to either a condition of CBT, sertraline, a combination or a placebo. No significant placebo effect was demonstrated as it resulted in being the least effective condition in treating the symptoms of the variety of anxiety disorders. However, psychotherapy as a treatment for anxiety was found as a more effective monotherapy than drug therapy (sertraline as a chosen selective serotonin reuptake inhibitor (SSRI) according to the Clinician Global Impression Improvement scale. Moreover, a combination of both a biological and psychological approach appeared most beneficial to the sample. Nonetheless, it must be noted that this study s results cannot be applied to the target population due to only using child participants and a relatively small sample size. In addition to this, only a small collection of anxiety disorders were examined meaning that the results may not be relevant to less common anxiety disorders such as panic disorder. When considering the numerous anxiety disorders in existence, it could also be perceived that the study displays that one treatment will be just as effective on one anxiety disorder as the other (psychotherapy was the most beneficial monotherapy for GAD, separation anxiety and social phobias). This could suggest that examining the effect of psychotherapy in reducing symptoms of one anxiety disorder will provide reasonable evidence for a treatments ability to reduce anxiety disorder symptoms in general.

Additionally, CBT and the ways it can be adapted to meet the demands of modern-day society are currently being researched. Adding to the findings of a 2010 meta-analysis, a study was carried out during 2018 to investigate if internet CBT (iCBT) is effective or not (G.Andrews, A.Basu, P.Cuijpers, M.G.Craske, P.McEvoy, C.L.English, J.M.Newby, 2018). Despite discovering that the method of delivering CBT (face to face or online) did not alter the effectiveness of the treatment, it was found that iCBT is a more practical and easily accessible method of psychotherapy for treating not only anxiety disorders but depression too. It appears important to not only assess the effectiveness of treatment directly on an anxiety disorder, but also the accessibility of such treatments in terms of price and the platform by which it is delivered. CBT, as a prime example of psychotherapy, displays the benefits of such treatment for anxiety disorders due to its flexible and dynamic nature meaning it can easily be adjusted to suit the service user and their situation. However, it was discovered that participants who failed to complete the iCBT course tended to be younger and from rural locations, suggesting this is not as effective for some as it is others. With this in mind, it is important to recognise that the standard CBT treatment is still available in addition to the internet version. Such options increase the likelihood that CBT will be utilised through both referral and independently seeking assistance. In spite of this, two recent trials in the UK did not find incremental effects of iCBT compared to treatment as usual (Gilbody et al., 2015, Phillips et al., 2014), suggesting that increased accessibility is the only true benefit to this new edition of CBT.

Despite the rigid dichotomy presented between different therapies such as psychological therapies and biological therapies, it is important to remember that all behaviour, even personal experiences, are associated with brain activity. Epigenetics are a prime example of a combined influence of both genetic and environmental influence. Recent studies have displayed how genes can be essentially switched on or off as a result of an individual s environmental stressors, which may lead to an increased sensitivity or vulnerability (Weaver et al, 2004). Recent advancements in psychological and biological perspectives of behaviour suggest that psychotherapy simply isn t effective in considering the numerous influences on the development of anxiety disorders and only looks to treat one cause whilst disregarding biological factors. This links to Roiser s (2015) statement that there is not a simple cause for mental health conditions and so simple diagnostic tests can and will miss the complexity and subjectivity of symptoms and experience. Different causes may cause the same symptoms to be exhibited, however standardised treatment may not be effective due to these different causes.

With a similar methodology to the 2008 study assessing CBT and sertraline as treatments for anxiety disorders (John T. Walkup, Anne Marie Albano, John Piacentini, et al 2008), a piece of empirical support for the use of drug therapies in reducing anxiety disorder symptoms focused on the same specific conditions GAD, separation anxiety and social phobias (John T. Walkup, Michael J. Labellarte, Mark A. Riddle, et al, Apr 26, 2001). In place of sertraline, this particular study examined fluvoxamine as a SSRI compared to a pill placebo. This study also used the Clinical Global Impressions Improvement scale to measure and compare effectiveness which makes it a suitable study to parallel with the 2008 piece of research. 76% of participants responded positively to the drug therapy whilst only 29% demonstrated a placebo effect. This exhibits a significant advantage with administering SSRI s as a form of treatment. Despite this, drug therapy did display a higher attrition rate than CBT did in the 2008 study due to adverse effects. In light of this, it is important to consider that there is a diverse range of drugs available with slightly different compositions. This allows different versions to be trialled until one appears effective with an individual s symptoms. Linking to Roiser s (2015) modern perspective that a treatment must consider the individuality of anxiety disorders, drug therapy can offer just this due to the various options available. CBT on the other hand remains relatively standardised on the basis of a 1960 s proposal by Aaron T Beck.

Further to this, investigations into the cause of anxiety disorders have identified numerous biological influences on development. One prime example is abnormalities in the regulation of the hypothalamic pituitary adrenal axis and the sympathoadrenomedullary system (Margaret Altemus, 2006) which causes a predisposition, but typically requires an environmental stressor such as stress. In addition to this, the prevalence rate of developing anxiety disorders is much higher in women than in men which displays sex differences implying a further biological basis for the conditions. Despite this, looking into stress responses for different sexes using animal models was not successful in exhibiting sex as a differentiating factor. It has been considered that hormonal differences, and more specifically fluctuations, could be what divides the sexes and their development of anxiety disorders (Margaret Altemus, 2006).

In the face of this conclusive research, it appears that biological influences are limited in their role of the development of anxiety disorders, and that instead an environmental stressor is required for onset. This provides further support for the use of psychotherapy as a treatment for anxiety disorders due to its basis on cognition and environment. As well as CBT, family therapy is incorporated as a type of psychotherapy which understands the influence of environment and relationships.

In light of the above research, it appears that managing stress may be an effective way of preventing the onset of anxiety disorders. Self-help is a new and upcoming phenomenon which requires no referral and instead a self-motivated individual who can access resources themselves. One piece of research looked to compare the effectiveness of self-help and face-to-face guided therapy in the reduction of anxiety disorders symptoms (P. Cuijpers, T. Donker, A. van Straten, J. Li, 2010), findings that self-help was in fact favoured. However, attrition rates between the two treatments were both zero and self-help was only found to be marginally more beneficial. This suggests that individual differences such as temperament, found to be a significant influence (Joseph Biederman, Jerrold F. Rosenbaum, Elizabeth A. Bolduc-Murphy, Stephen V. Faraone, Jonathan Chaloff, Dina R. Hirshfeld, Jerome Kagan, 1993), may influence which treatment is most beneficial for each person. This piece of research identified behavioural inhibition, a tendency to withdrawal from unfamiliar situations and frequently experience distress, may be a strong indication that an individual will develop an anxiety disorder and this is usually identifiable in early childhood. This further exhibits the benefit of family therapy as a psychotherapy as it can be used to identity behaviours and traits that could lead to the development of anxiety disorders.

To conclude, a variety of both older and more modernised research provides empirical support for psychotherapy as effective in treating anxiety disorders. Despite the alternative evidence for a biological basis, it is still acknowledged that there is a cognitive predisposition or environmental stressor needed for this to have an effect on the development of these mental health conditions. Whilst still acknowledging that different monotherapies or combinations of treatments will suit some better than others, it appears relatively consistent that psychotherapy is effective in treating anxiety disorders due to an accumulation of evidence and findings both in the UK and internationally.