In 2013, there were over 8 million cases of anxiety in the UK, with women being almost twice as likely as men to develop an anxiety disorder. This can come in many forms, from post-traumatic stress disorder (PTSD), to obsessive compulsive disorder (OCD) and generalised anxiety disorder (GAD). However, while there are many psychological treatments available for these patients, it can be argued that there is not enough evidence to support the use of such therapy over other treatments such as medication. In this essay I am going to outline different anxiety disorders and review certain psychological therapies for them, and then evaluate their effectiveness in treating the patient.
Perhaps one of the most common anxiety disorders, GAD is estimated to affect up to 5% of the UK’s population. Those affected suffer from insistent and perpetual worrying about numerous different things, which could include family, relationships or financial concerns. It is diagnosed when a person experiences uncontrollable worrying on more days than not for a period of at least six months. While several different psychological treatments can be suggested for patients, one of the most common is Cognitive Behavioural Therapy (CBT). This form of psychotherapy focuses on how a patient’s inner thoughts, feelings and beliefs shapes their behaviour, and aims to introduce coping skills to help deal with different concerns or problems. It is widely recognised amongst psychologists as a treatment not only for adults with anxiety disorders, but children and adolescents as well.
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Despite the recognition CBT receives, psychologists have still aimed to provide sufficient evidence for its ‘relative efficacy versus non-CBT active treatments’ and it’s long-term effects. In 2015, Anthony C James et al (1) sought to review the effectiveness of CBT for children and adolescents compared to non-CBT treatments as well as medication. Data was reviewed from several search engines including the Cochrane Central Register of Controlled Trials (CENTRAL) and all participants were selected if they met the criteria of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) for an anxiety diagnosis (excluding phobias, OCD, PTSD and elective mutism). Forty-one studies were eventually selected; on average 13.1 CBT sessions were given to the patients. These were delivered in various formats including group or individual therapy and involved helping the child to recognise feelings of anxiety and develop coping skills. The review showed that CBT was superior to waiting list controls (i.e. no therapy), however there was limited support for the use of CBT instead of medication. The authors also note that there is uncertainty as to whether younger patients benefit from this therapy, as they need ‘a certain level of cognitive maturity to participate in the treatment’ (Kendall, 1990) (2). While the appropriate age for the use of CBT is left ambiguous in this review, other research suggests that it can be effective from the age of 9 onwards (Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM et al, 1997) (3). Using a sample of 94 children ranging from 9 to 13 years old who all had a primary anxiety disorder, the authors found that at the end of a 16 week treatment program, 32 children (53%) no longer met diagnostic criteria for their primary anxiety disorder compared with 2 children (6%) in the control group. Those that received CBT who still met their criteria reported better preparedness for dreaded situations and improved over time on multiple anxiety and depression scales. This study is important as it provides strong support for the use of CBT among children and adolescents, especially with its strong sample which can easily be generalised to the target population. It also presents evidence for the long-lasting effects of this treatment with its 1 year follow up.
It could be suggested that from the research I have highlighted so far there is only evidence for CBT being useful in more Western cultures; but this is not the case. A preliminary study in Japan (Ishikawa, S., 2012) (4) comparable to that of Kendall et al’s showed that after treatment of CBT that was modelled after intervention programs developed in Western cultures, similar outcomes were found to other studies that had been conducted before. Of the 33 children and adolescents who participated in the study, 20 of them no longer met criteria for their principal anxiety disorders three months following treatment, and 16 were free from all anxiety disorders.
Exposure therapies are another type of psychological treatment for anxiety disorders. They are most often used to treat severe phobias or PTSD, and they are intended to help the patient take control of their fear or trauma. It must be done very carefully so as not to retraumatise the participant, so part of the treatment involves pairing the stimulus with relaxation techniques such as controlled breathing or imagery exercises. Exposure therapy comes in two main forms - systematic desensitisation and flooding; the patient discusses which option would be most suitable for them with their therapist. Systematic desensitisation focuses around the patient creating a ‘hierarchy of fears’ (a list of the most distressing thing related to their phobia down to the least distressing) and then slowly working their way through this list from the bottom upwards until they feel they can use their knowledge of relaxation techniques to overcome their phobia. Flooding is effectively the opposite of this – the patient confronts all their fears at once and uses their newly-learned coping strategies to gradually calm down from their arousal state.
Upon reviewing the available research into the effectiveness of systematic desensitisation, it appears there is limited evidence in support of the use of this treatment on its own. Aside from the original study from which the therapy was developed (Wolpe, J., 1958) (5) – which claimed to have achieved the recovery of 188 out of 210 neurotic cases in an average of 34.8 sessions – there has been little more significant evidence to suggest the efficacy of systematic desensitisation without the support of another kind of therapy. In an article titled ‘Treatment of Phobic Patients by Systematic Desensitisation’ (Friedman, D.E.I., & Trevor Silverstone, J., 1967) (6), the authors observed: “Wolpe’s (1961) results were impressive: he reported striking improvement in 90% of his patients. Less striking successes have been reported by other workers”. Hence the authors felt the need to test the treatments effectiveness alongside the use of intravenous methohexitone sodium (‘Brietal’) in small doses to produce relaxation and to counter anxiety. Participants underwent the process of systematic desensitisation, and at any time they experienced anxiety they received an injection of the Brietal, the effects of which last for approximately only 5 minutes. At the end of the treatment period all patients were assessed to have significantly improved, and 5 were judged to be ‘symptom-free’. However, at a follow-up session 6 months after the end of treatment, one patient had relapsed completely while another 3 were ‘not as well as they had been at the end of treatment’. Despite this, the authors also report some cases of great improvement: ‘Patient no. 20, for example, had originally presented with severe cancerophobia which involved avoidance of any possible mention of the word cancer or tumour and which eventually led to complete suppression of all television and radio programmes in her house for fear of her inadvertently hearing or seeing the word cancer. After a 7-week course of treatment she was completely untroubled by any fear of cancer whatsoever’. The results from this study are inconclusive; while the authors clearly state there are some improvements, the long-lasting effects of this treatment do not provide strong evidence for its use. Another study (Lazarus, A.A., 1961) (7) that focused on group therapy of phobic disorders by systematic desensitization showed similar results, with 5 of the 18 patients considered to have ‘failed’ the treatment after not passing the symptomatic criteria for the study. This would suggest that there is only a 72% chance of this type of treatment working. However, there is not sufficient evidence as to how effective systematic desensitisation is in treating anxiety disorders due to the low sample sizes of the studies and the relative sensitive nature of the experimental method.
Evidence in support of flooding is far more widely available; research tends to be in case study format due to the specific nature of phobias. It is most commonly given to patients for a specific severe phobia, and in most cases only lasts one or two sessions. One study (Yule, W., Sacks, B. & Hersov, L., 1974) (8) describes the use of flooding treatment in an 11-year-old (‘Bill’) with a phobia of loud noises after unsuccessful systematic desensitisation treatment. The treatment took place over two sessions and focused on the boy’s fear of balloons (specifically the loud noise made when they burst). It involved taking Bill into a confined room which was filled with balloons, and gradually getting him to burst them himself. 25 months after the flooding session, Bill was no longer phobic of the noises which had once scared him. He was reported to be much happier and tended to socialise more at school. Another study (Sreenivasan, U. , Manogha, S. N. and Jain, V. K., 1979) (9) focuses on an eleven-year-old girl, Colleen, who’s fear of dogs had become so bad she had become house-bound most of the time. Again, after initial use of systematic desensitisation (which was unsuccessful), a trial of flooding was deemed to be the most suitable treatment. Six sessions of flooding took place over 10 days – these involved Colleen sitting in a room with a dog taken off the lead. For the first session, Colleen was obviously apprehensive for several hours before, and when the dog was first introduced, she began crying and begging for the dog to be put back on its lead. By the sixth session, she held the dog on her lap and even took it for a walk. At the beginning of treatment, Colleen’s anxiety level was rated at 5 – after the six sessions, it was down to one, and remained that way when she was seen at follow-up sessions 12 and 24 weeks later.
From this evidence, it is clear that flooding tends to be more successful than systematic desensitisation. It appears that flooding can be extremely useful in curing specific phobias, but there is limited evidence to support it’s use for other anxiety disorders such as PTSD, for example. There is also a lack of modern research into the effectiveness of both flooding and systematic desensitisation, which questions the generalisability of this type of therapy in the present day. While the two case studies I reviewed show strong support for the use of flooding, there is not enough sufficient evidence to categorically support it’s use. On the other hand, the use of CBT has been shown to be very effective in helping anxiety disorders in children and adolescents, however research supporting its use in adults is harder to come across. Nevertheless, I would still say there is enough strong evidence to support its use in treating anxiety disorders.
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