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InPsych 2014 | Vol 36

October | Issue 5

Highlights

Treatment guidance for common mental health disorders: Anxiety disorders

Anxiety disorders are the most common mental health problems experienced by Australian adults. Symptoms vary according to the type of anxiety disorder, but the shared hallmark feature is persistent, excessive anxiety and avoidance of feared stimuli and/or anticipated events, which interferes with the ability to undertake daily activities.

  • Generalised anxiety disorder (GAD) is characterised by prolonged periods of uncontrollable anxiety about everyday events as well as apprehensive expectations about future events, accompanied by a range of physiological reactions.
  • Social anxiety disorder (SAD) comprises intense, excessive worry about social interactions, where individuals either avoid or endure social situations, with heightened anxiety due to a persistent fear of acting in an embarrassing way and/or offending or being rejected by others.
  • Panic disorder involves sudden, intense anxiety accompanied by recurring panic attacks which invoke intense fear, exacerbated by misattributions of physiological symptoms.
  • Phobia disorders comprise intense, irrational fear pertaining to a specific object/stimuli or situations, with agoraphobia being the most common.

Excessive worry combined with prolonged avoidance has an adverse impact on the capacity to undertake occupational, family and social activities, and hence in the longer term contributes to deterioration in overall quality of life. Approximately 1 in 8 Australians (12.8%) aged 16 to 85 years meet criteria for an anxiety disorder, with the most prevalent being SAD (4.7%), followed by agoraphobia (2.8%), GAD (2.7%) and panic disorder (2.6%).

General principles of psychological assessment

A detailed clinical history is important to ascertain the specific constellation of anxiety symptoms. Underlying medical conditions need to be ruled out as the primary cause for somatic symptoms. It is important to also screen for other conditions such as depression and substance use, as they frequently co-occur with anxiety disorders.

Validated self-report inventories are useful to further quantify the severity and frequency of anxiety symptoms, as well as to monitor treatment progress. Some recommended measures include: Penn State Worry Questionnaire [indexes excessive and uncontrollable features of worry]; GAD-7 [measures frequency of cognitive and somatic features of GAD]; combined Short Form Social Interaction Anxiety Scale (SIAS-6) and Social Phobia Scale (SPS-6) [measures severity of social anxiety symptoms]; and the Depression Anxiety Stress Scales-21 (DASS-21) [measures severity of depression, stress and anxiety symptoms] (see reference list for details).

Evidence-based psychological treatment guidance

Cognitive behavioural therapy (CBT) has the strongest evidence for treatment efficacy of anxiety disorders relative to other forms of psychotherapy (e.g., Cuipers et al., 2014; Hofmann et al., 2012; Wolitzky et al., 2008). CBT uses a multimodal approach and targets: cognitive symptoms of excessive and irrational fear and worry; behavioural symptoms of avoidance, excessive preparation and/or procrastination, and poor problem-solving and decision-making skills; and physiological symptoms, notably muscular tension, restlessness and irritability. Common CBT components in anxiety disorder interventions are outlined below.

  • Psychoeducation about the nature of anxiety is a core initial component in the treatment of all anxiety disorders. Self-monitoring is typically introduced in the initial sessions and utilised throughout treatment to encourage objective observation and reflection on anxiety responses across various contexts.
  • Relaxation training techniques are utilised for anxiety disorders characterised by prominent somatic symptoms, including GAD and panic disorder, and comprise progressive muscle relaxation, breathing exercises, applied relaxation training (including cue-controlled relaxation) and guided imagery.
  • Cognitive restructuring is used to identify and challenge unhelpful, maladaptive thoughts and beliefs that maintain dysfunctional thinking patterns, and is typically integrated into all CBT interventions for anxiety disorders.
  • Exposure techniques, including graded in vivo, interoceptive and imagery techniques, as well as behavioural tests, are also a core CBT component for anxiety disorders tailored to the specific type of anxiety diagnosis (e.g., social situations for SAD).
  • Problem-solving training offers an additional specific CBT component for treatment of GAD, while social skills training can be particularly relevant in the treatment of SAD.

Emerging treatment directions for the future

Several emerging treatments have made advances in recent years. Internet, CBT-based interventions have demonstrated efficacy in the treatment of anxiety disorders including GAD (Andrews et al., 2010). Attentional/cognitive bias modification (CBM) is an experimental paradigm showing promising results in modifying maladaptive cognitions and reducing anxiety symptoms (Hallion & Ruscio, 2011). ‘Third-wave’ behavioural therapies, which include mindfulness components, have also demonstrated promising effects, with several studies showing acceptance and commitment therapy (ACT) has preliminary efficacy in the treatment of GAD (Roemer et al., 2008) and SAD (Craske et al., in press).

Key reading and information sources

  • Treatment manuals for GAD, SAD, Panic Disorder and Specific Phobias, Clinical Research Unit for Anxiety and Depression (CRUfAD; https://www.crufad.org/index.php/treatment-support/treatment-manuals)
  • Cognitive-Behavioral Therapy for Anxiety Disorders: Mastering Clinical Challenges (Butler, Fennell & Hackmann 2010)
  • Mastery of your anxiety and panic: Therapist guide (3rd ed.) (Craske & Barlow, 2006)
  • CBT for Anxiety Disorders: A Practitioner Book (Simos & Hofmann, 2013)

References

  • Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS One, 5:e13196.
  • Butler, G., Fennell, M., & Hackmann, A. (2010). Cognitive-Behavioral Therapy for Anxiety Disorders: Mastering Clinical Challenges. New York: The Guildford Press.
  • Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and panic: Therapist Guide (3rd ed.). New York: Oxford University Press.
  • Craske, M. G., Niles, A. N., Burland, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P., Arch, J. J., Saxbe, D. E., Lieberman, M. D. (in press). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: Outcomes and moderators. Journal of Consulting and Clinical Psychology. Doi: 10.1037/a0037212
  • Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Anderssson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 34, 130-140. Doi: 10.1016/j.cpr.2014.01.002.
  • Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of the effect of cognitive bias modification on anxiety and depression. Psychological Bulletin, 137, 940-958. Doi: 10.1037/a0024355
  • Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427-440. Doi: 10.1007/s10608-012-9476-1.
  • Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33, 335-343.
  • Peters, L., Sunderland, M., Andrews, G., Rapee, R.M., & Mattick, R.P. (2012). Development of a Short Form Social Interaction Anxiety (SIAS) and Social Phobia Scale (SPS) using nonparametric item response theory: The SIAS-6 and the SPS-6. Psychological Assessment, 24, 66-76. Doi: 10.1037/a0024544
  • Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behaviour therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 1083-1089. Doi: 10.1037/a0012720
  • Simos, G. S., & Hofmann, S. G. (2013). CBT for Anxiety Disorders: A Practitioner book. Oxford: Wiley-Blackwell.
  • Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychological Review, 28, 1021-1037.

Disclaimer: Published in InPsych on October 2014. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.