Cognitive Behavior Therapy for Anxiety # 1302

Cognitive Behavior Therapy for Anxiety
Harvey C. Parker, Ph.D.
Clinical Psychologist

Cognitive Behavior Therapy (CBT) is an effective, scientifically well-established treatment for anxiety.

CBT combines two very effective kinds of psychotherapy—cognitive therapy and behavior therapy.

Behavior therapy helps you weaken the connections between stimuli (people, situations, or events) and your habitual, undesirable reactions to them. These undesirable reactions may include fear, sadness, anger, self-defeating or self-damaging behavior, worry, panic, etc. Behavior therapy also teaches relaxation strategies to calm the mind and body so you can feel better and think more clearly.

Cognitive therapy emphasizes the role of thinking in how we feel and what we do. Cognitive therapists instruct clients to identify unhealthy thoughts that can lead to unwanted feelings and behavior. Clients are taught how to replace unhealthy thoughts with healthier thoughts that lead to more desirable reactions.

When combined into CBT, behavior therapy and cognitive therapy provide very powerful tools for stopping symptoms of worry, fear, anxiety, anger, depression, etc.

What are the Different Types of Anxiety Disorders

Anxiety disorder often occurs in combination with depression and substance abuse. People with anxiety disorder may have problems with excessive worry, obsessional traits, behavioral rituals, significant shyness, depressive symptoms, or substance abuse. Anxiety disorders can be divided into several types:

  1. Panic disorder. This is characterized by a rapid onset where the person experiences a severe anxiety episode accompanied by physical symptoms that are often suggestive of cardiac, endocrine or neurological disorder. People with panic disorder become frightened of the panic itself and its symptoms. They become fearful of situations involving crowds, driving, being closed in, being far from home alone, waiting in lines, etc. Panic episodes can last from five minutes to over 30 minutes. CBT and/or medications such as selective serotonin uptake inhibitors (SSRIs) can be effective treatments for panic disorder.

  2. Social phobia. This is extremely common and is characterized by excessive anxiety or distress in nearly all situations in which the person is subject to attention, social scrutiny, or social appraisal. Because social anxiety is so common it is often minimized or ignored and may go untreated. People with social anxiety may avoid public speaking, asking or answering questions in a group, use of public restrooms, etc. Social phobia can be treated with CBT and with social skills training and medication.

  3. Obsessive-compulsive disorder (OCD). Obsessions are recurrent, disturbing thoughts that intrude on a person's normal thinking. These thoughts often involve fears of harm that may come to self or others. Common are recurring and unrelenting thoughts about germ contamination, about making mistakes, and thoughts of a violent or sexual nature. Compulsions are repetitive behaviors such as washing, counting, checking, repeating that are performed in a specific manner. People with compulsions are often able to hide them from others, but usually cannot control them. CBT and medication can be effective treatments for OCD.

  4. Specific phobia. This is a marked fear of specific objects or situations. People with specific phobias avoid these objects or situations. They may often not feel impaired because they are so used to their avoidant behavior. Phobias about height and claustrophobia are among the most commonly treated phobias and other phobias such as snake and spider phobias are very common but often are not treated. CBT for phobias is extremely effective.

  5. Generalized anxiety disorder (GAD). This is best described as excessive worry. People with this disorder often realize that they worry too much and they constantly struggle with ways to control it. They may experience restlessness, sleep problems, difficulty with concentration, fatigue and irritability. General anxiety disorder can occur by itself, but it is often accompanied with depression or other anxiety disorders (see above). Medication is the first line treatment for GAD.
CBT Interventions for the Different Type of Anxiety Disorders
CBT has been found to be an effective treatment for anxiety disorders in children and adults. Clients usually visit a therapist weekly and combine these visits with daily practice exercises (homework) designed to help them apply CBT skills in their daily life. A person with an anxiety disorder will tend to avoid the object or situation that makes them anxious. By their avoidance they become more frightened over time. If the avoidance is overcome, and frightening objects or situations are faced over and over without leading to any dangerous result, the person becomes less frightened over time. This is called desensitization and it can only occur when the person is exposed to situations that cause anxiety.

Panic Disorder
The first goal of treating panic disorder is to help the person with panic attacks be less fearful of them. This can be done through cognitive restructuring. Cognitive restructuring focuses on helping the person realize their misconceptions about the attacks (i.e., "I may be dying", "I am having a heart attack", "I'm going to have a stroke", "I'm going to faint", "I'm losing my mind"). The person acknowledges that nothing terrible has occurred as a consequence of the panic attack and can begin to reassure themselves through a series of self-statements ("I am not going to die", "This is just a panic attack and I will be fine in a little while", etc.) The person is taught to reduce their fear of the attack itself.

The second goal of treating panic disorder is to reduce the person's fear of the physical symptoms associated with the panic or anxiety. To do this CBT uses the technique of exposure and desensitization. For example, a person who is fearful of fainting is exposed to the physical symptoms (dizziness, lightheadedness, shortness of breath, nausea, etc.) These symptoms can be induced by hyperventilation. The person is taught to stay calm when feeling these symptoms and is encouraged to practice calming themselves when the symptoms appear.

The third goal of treating panic disorder is to help the person face the person, situation, or event that is feared by exposing them to the situation and preventing them from fleeing. So, if a person is afraid of heights, then the solution is to be in a high place. The exposure is done gradually to allow the person to relax and become used to the situation before moving to the next level (i.e., a higher place).

Obsessive Compulsive Disorder (OCD)
Cognitive restructuring is not very helpful for persons suffering from OCD. Exposure therapy is the most effective CBT. The person is directly exposed to the situations that trigger obsessions or compulsive rituals. In addition, they must not be allowed to perform any rituals used to prevent harm that they anticipate as a result of the exposure. This is called response prevention. Exposure and response prevention are used together in the behavioral treatment of OCD. For example, a person who is afraid of germ contamination and compulsively cleans their bedroom is exposed to their fear by being required to touch objects in the room, the floor, toilet seats, under the bed, etc and must resist all urges to wash or engage in any other "decomntaminating" or anxiety reducing rituals in response to the exposure. Often at least 20 hours of actual exposure and response prevetion are necessary for improvement to occur.

Social Phobia
Cognitive restructuring can help people with social phobia by helping them focus on the distorted expectations of negative social outcomes and overly critical self-evaluation that is common with social phobia. The person is shown how to identify negative thoughts (i.e. "It would be terrible if I said the wrong thing", "I know they think I am ugly."). The person is gradually encouraged to participate in social situations. This repeated exposure and cognitive restructuing will eventually reduce social anxiety.

Specific Phobia
This is the simplest of the anxiety disorders to help using CBT. Graded exposure to the feared object or situation generally leads to desensitization.

Suggested Reading and Resources
Beck, Aaron. Cognitive Therapy and the Emotional Disorders. This is a basic introduction to cognitive therapy by its most famous founder. This book is among the most cited on the subject.

Beck, Judith. Cognitive Therapy: Basics and Beyond. This book was written as a training manual for therapists but it is an excellent introduction to CBT for non-therapists as well.

Burns, David. The Feeling Good Handbook.This is an excellent guide to help the reader change thinking, control mood swings, deal with troublesome situations, and feel better about yourself.

Edwards, C. Marketing Yourself with You're Shy. A comprehensive guide to representing yourself, your services or your skills in the professional maretplace.

Greist, J. H., et al. Social Anxiety Disorder: A Guide. This book provides an excellent discussion of social anxiety disorder, the causes and treatment. Both medication and behavior therapy are well covered.

Fitzgerald, M. I Count the Tide A fictionale tale based on the author's experience growin up with a mother with severe and untreated OCD.

Goldstein, S., Hagar, K., & Brooks, R. Seven Steps to Help Your Child Worry Less. An practical, step by step guide for parents to help them manage anxiety in children. Based on a cognitive behavior therapy approach.

Luciani, Joseph. Self-Coaching: How to Heal Anxiety and Depression. A terrific book for those who want to work on improving their thoughts and feelings by using a CBT approach. Contains practical worksheets and exercises.

Wagner, A. P. Worried No More: Help and Hope for Anxious Children. A valuable resource for teaching practical thinking and problem solving skills to professionals, parents and teachers who are helping children with anxiety.

Anxiety Disorders Association of America.

Parker, Harvey. Cognitive Behavior Therapy for Anxiety. 2004. This form may be copied for personal use by active members of For further information refer to:

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