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Abstract: Cognitive-Behavioral Therapy for adult anxiety disorders
posted Sunday, 29 June 2008
J Clin Psychiatry. 2008 Apr;69(4):621-32.
Cognitive-Behavioral Therapy for Adult Anxiety Disorders: A Meta-Analysis of Randomized Placebo-Controlled Trials
Hofmann SG, Smits JA.
Department of Psychology, Boston University, Mass 02215, USA.
OBJECTIVE: Cognitive-behavioral therapy (CBT) is frequently used for various adult anxiety disorders, but there has been no systematic review of the efficacy of CBT in randomized placebo-controlled trials. The present study meta-analytically reviewed the efficacy of CBT versus placebo for adult anxiety disorders.
DATA SOURCES: We conducted a computerized search for treatment outcome studies of anxiety disorders from the first available date to March 1, 2007. We searched MEDLINE, PsycINFO, PubMed, Scopus, the Institute of Scientific Information, and Dissertation Abstracts International for the following terms: random*, cognitive behavior*therap*, cognitive therap*, behavior*therap*, GAD, generalized anxiety disorder, OCD, obsessive compulsive disorder, social phobia, social anxiety disorder, specific phobia, simple phobia, PTSD, post-traumatic stress disorder, and acute stress disorder. Furthermore, we examined reference lists from identified articles and asked international experts to identify eligible studies.
STUDY SELECTION: We included studies that randomly assigned adult patients between ages 18 and 65 years meeting DSM-III-R or DSM-IV criteria for an anxiety disorder to either CBT or placebo. Of 1165 studies that were initially identified, 27 met all inclusion criteria.
DATA EXTRACTION: The 2 authors independently identified the eligible studies and selected for each study the continuous measures of anxiety severity. Dichotomous measures reflecting treatment response and continuous measures of depression severity were also collected. Data were extracted separately for completer (25 studies for continuous measures and 21 studies for response rates) and intent-to-treat (ITT) analyses (6 studies for continuous measures and 8 studies for response rates).
DATA SYNTHESIS: There were no significant differences in attrition rates between CBT and placebo. Random-effects models of completer samples yielded a pooled effect size (Hedges' g) of 0.73 (95% CI = 0.88 to 1.65) for continuous anxiety severity measures and 0.45 (95% CI = 0.25 to 0.65) for depressive symptom severity measures. The pooled odds ratio for completer treatment response rates was 4.06 (95% CI = 2.78 to 5.92).
The strongest effect sizes were observed in obsessive-compulsive disorder and acute stress disorder, and the weakest effect size was found in panic disorder. The advantage of CBT over placebo did not depend on placebo modality, number of sessions, or study year.
CONCLUSIONS: Our review of randomized placebo-controlled trials indicates that CBT is efficacious for adult anxiety disorders. There is, however, considerable room for improvement. Also, more studies need to include ITT analyses in the future.
(Text has been reformatted for clarity; ed.)
comments (2)
1. Tore G left...
Monday, 30 June 2008 10:16 pm
Thanks for adressing this meta-analytic study. Please expand the
conclusions beyond what the abstract said. The conclusions is what I'm most
interested in.
2. Anxiety Insights left...
Tuesday, 1 July 2008 1:13 am
Your best bet is to read the full study. We can't supply that but authors
usually will when asked. You can email Stefan Hofmann at: shofmann
<at> bu.edu
Action-potential
Wave of electrochemical activity generated by the flow of positively charged ions across the neuronal membrane which causes a neuron to 'fire'- Click page link for more information -
Affective disorders
Mental disorders characterized by dramatic changes or extremes of mood - depression, mania, or both - including depression, bipolar disorder (manic depression), and schizo affective disorders.- Click page link for more information -
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Two almond-shaped groups of neurons - there is one amygdala (Greek for almond) in each brain hemisphere. They have the primary role in processing and storing memories of emotional reactions.Part of the Limbic System the amygdalae trigger an instant fear reaction to perceived threats, real or imagined.
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Anterior cingulate cortex
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Arousal of the autonomic nervous system which regulates many bodily functions and produces the physical symptoms of stress including the 'fight-or-flight' response.Brain-derived neurotrophic factor
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Client-centered therapy
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Type of psychotherapy emphasizing the important role of thinking in how we feel and what we do.Based on the concept that our thoughts cause our feelings and behaviors, not external things like people, situations, and events. The benefit of this fact is that we can change the way we think to feel/act better even if the situation does not change.
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Cytokines are increasingly being used to treat cancers and viral infection, however, depression onset is a common side effect.
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Note 2: GABA does not normally penetrate the Brain-Blood-Barrier (the BBB tends to pull GABA from the brain into the blood stream (Kakee A, 2001)) so GABA supplements are, at best, expensive placebos.
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Support cells in the brain and spinal cord which provide physical and nutritional support for neurons, form the blood-brain barrier, clear dead cells and other debris, insulate neurons and, as part of the immune system, protect the brain from microorganisms.Long thought not to conduct electrical impulses as the neurons do, there is growing evidence that they do modulate neurotransmission.
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Mathematical technique to amalgamating, summarizing, and reviewing previous quantitative research to arrive at one overall measure of treatment effect.A weakness of the method is that sources of bias in the original research are not controlled by the method. A good meta-analysis of badly designed studies will still result in bad statistics.
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"Mindfulness is not a quick fix. The mindful approach encourages the person suffering from anxiety to move in close to their uncomfortable feelings, to watch the feelings of panic and racing heart, trembling hands, etc., with curiosity, openness and acceptance because, in fact, they are already there. This is a practice. We begin to become more tolerant of so-called negative states of mind, and then comfortable with them, then aware that everything changes constantly, including these states of mind. We begin to see anxiety for what it is: our body's adaptation to stress or to a thought and its subsequent attempt at communicating it to us."Barbara Wilkinson,
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Mindfulness meditation/ psychotherapy
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Narrative Exposure Therapy
Therapy developed to treat PTSD. Based on cognitive behavioral exposure therapy, it adapts classical exposure therapy to meet needs of traumatized survivors of war and torture.Survivors are asked to describe what happened to them in great detail, focusing on what they saw, heard, smelt, etc, and their feelings and thoughts at the time. Initially, sessions are distressing, but as they are long enough to allow habituation, distress levels diminish towards the end and more and more details are recalled.
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Neurogenesis
Process by which new neurons are generated after the postnatal stage of development. It appears to only occur in two areas of the brain, the hippocampus and the olfactory bulbs. Hippocampal neurogenesis is thought to counter anxiety and depression.- Click page link for more information -
Neuropeptide
One of about 100 peptides including endorphins, enkephalins, oxytocin and vasopressin which mediate brain function by regulating gene expression, local blood flow and synaptogenesis. The neuropeptides Cholecystokinin, Substance P and Neuropeptide Y have been linked to anxiety and depressive disorders.- Click page link for more information -
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The brain's ability to reorganize itself by forming new neural connections.- Click page link for more information -
Nucleus accumbens
Twin brain structures (one in each hemisphere) involved in reward, laughter, pleasure, addiction, fear, and the placebo effect.- Click page link for more information -
Polymorphism
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Tests a specific question, usually about how a specific exposure(s) affects a specific outcome(s) by recruiting appropriate participants and checks the outcomes over the following months or years.Psychodynamic psychotherapy
Talking therapy used to help a person find relief from emotional pain. It is based on the theories and techniques of Freudian/Jung style psychoanalysis. However, practitioners don't necessarily accept the 'classical' psychoanalysis theory that emotional conflicts are primarily sexual in nature.Receptor
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Receptor agonist
A chemical which is able to bind to receptors of a neurotransmitter and trigger the same biological response as that neurotransmitter.Receptor antagonist
A drug that is so similar chemically to a neurotransmitter that it is capable of binding to a receptor for the neurotransmitter but which does not trigger the biological response of that neurotransmitter. By blocking its receptors the antagonist disrupts or inhibits the action of the neurotransmitter.Retrospective study
Research using data on exposures and/or outcomes that have already been collected through medical records or as part of another study. Such data may not be as reliable as data collected prospectively, as it relies on the accuracy of records made at the time, and on people’s recall of past events, which can be inaccurate (referred to as recall bias).Safety behavior
Behavior undertaken to reduce anxious thoughts, or to keep yourself 'safe' from imagined threats, or to hide your anxious state from others. Examples include constant monitoring of breathing or heart rate, shopping during quiet retail hours, taking precautionary tranquillizers "just in case," taking circuitous routes to avoid highways or bridges when driving, sitting close to exits, avoiding eye contact, playing with keys to hide trembling hands.Seasonal affective disorder
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Manifests as chronic, persistent complaints of varied physical symptoms that have no identifiable organic origin or basis. Often co morbid with other psychological disorders, particularly anxiety or mood disorders, plus irritable bowel syndrome and chronic pain. Occurs in 0.2% to 2% of females and 0.2% of males. Also known as Briquet's disorder.Sympathetic nervous system
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Brain region high in serotonin transporter-binding sites, with strong projections to the hypothalamus and brain stem. Modulates autonomic/neuroendocrine responses and neurotransmitter transmission during the neural processing of reward, fear, and stress. May be critical for modulating widespread behavioral changes mediated by the cortex. Volume is often decreased in mood disorders patients.Also known as Brodmann area 25.
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Regulates sleep and awake states, arousal and awareness. Processes and relays sensory information to the cerebral cortex where they are experienced as sensations of pain, touch, or temperature. Damage to the thalamus can produce permanent coma.- Click page link for more information -
Tumor necrosis factor-α
A cytokine which has wide range of pro inflammatory actions and induce necrosis (death) of tumor cells. Exacerbates chronic inflammatory autoimmune diseases such as rheumatoid arthritis.Blood plasma levels are raised in patients with depression. Research had shown that antidepressants reduce its expression.
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White matter
Regions of the brain and spinal cord largely composed of nerve fibers (axons) sheathed in insulating myelin composed of lipids (fats) which give them their color.White matter abnormalities (hyperintensities):
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