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A Meta-analytic Review of Adult Cognitive-behavioral Treatment Outcome Across the Anxiety Disorders

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Abstract

A plethora of studies take examined the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for adult feet disorders. In recent years, several meta-analyses have been conducted to quantitatively review the evidence of CBT for anxiety disorders, each using different inclusion criteria for studies, such every bit use of control conditions or blazon of written report surround. This review aims to summarize and to discuss the electric current country of the evidence regarding CBT treatment for panic disorder, generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Overall, CBT demonstrates both efficacy in randomized controlled trials and effectiveness in naturalistic settings in the treatment of adult feet disorders. Nevertheless, due to methodological issues, the magnitude of result is currently difficult to estimate. In determination, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but more loftier-quality studies are needed to better estimate the magnitude of the effect.

Existen numerosos estudios que ban examinado la eficacia y efectividad de la terapia cognitivo conductual (TCC) para los trastornos ansiosos del adulto. En los ultimos anos se han efeciuado varios meta-anâiisis para revisar cuantitativamenie la evidencia de la TCC para los trastornos ansiosos, los que han empleado diferentes criterios de inclusion para los estudios, como el uso de condiciones control o el tipo de ambiente del estudio. El objetivo de esta revisión es resumir y discutir la situación actual de la evidencia en relación con el tratamienio de la TCC para el trastorno de pánico, el trastorno de ansiedad generalizada, el trastorno de ansiedad social, el trastorno obsesivo compulsivo y el trastorno por estrés postraumático. La TCC ha demostrado globalmente eficacia en ensayos controlados randomizados y efectividad en estudios naturalísticos en el tratamiento de los trastornos ansiosos del adulto. Sin embargo, debido a aspectos metodológicos, la magnitud del efecto actualmente resulta dificil de estimar. En conclusion, la TCC aparece como un tratamiento eficaz y efectivo para los trastornos ansiosos, pero se requiere de más estudios de alta calidad para una mejor estimación de la magnitud del efecto.

Une pléthore d'études a examiné l'efficacité de la thérapie cognitivo-comportementale (TCC) dans les troubles anxieux de l'adulte. Ces dernières années, plusieurs metaanalyses ont été menées pour examiner quantitativement la preuve de l'efficacité des TCC dans les troubles anxieux, chacune utilisant des critères d'inclusion différents pour les études, comme l'utilisation des weather condition de contrôle ou le type d'environnement de l'étude. Cet article a pour but de résumer et analyser fifty'état actuel des connaissances sur la TCC des troubles paniques, des troubles anxieux généralisés, des troubles anxieux sociaux, des troubles obsessionnels compulsifs et de fifty'état de stress postal service-traumatique. Globalement, la TCC démontre une efficacité à la fois dans les études contrôlées randomisées ainsi qu'en atmospheric condition naturelles dans le traitement des troubles anxieux de l'adulte. Cependant, l'amplitude de 50'effet est actuellement difficile à évaluer du fait de problèmes méthodologiques. Cascade conclure, la TCC semble être efficiente et efficace pour traiter les troubles anxieux, mais il faut des études de meilleure qualité afin de mieux estimer l'importance de son effet

Introduction

Feet disorders are characterized by excessive fearfulness and subsequent abstention, typically in response to a specified object or state of affairs and in the absence of truthful danger. Anxiety disorders have a high prevalence, with a 12-month rate of about 18% and lifetime rates of about 29%. 1-2 Cerebral behavioral therapy (CBT) is considered the gilt standard in the psychotherapeutic handling of anxiety disorders and several meta-analyses and reviews of these meta-analytic findings regarding the efficacy and effectiveness of CBT take been published in recent years. 3-9

CBT is defined every bit:

An amalgam of behavioral and cognitive interventions guided by principles of engineering. The behavioral interventions aim to decrease maladaptive behaviors and increment adaptive ones by modifying their antecedents and consequences and past behavioral practices that result in new learning. The cognitive interventions aim to modify maladaptive cognitions, self-statements or beliefs. The hallmark features of CBT are trouble-focused intervention strategies that are derived from learning theory [as well every bit] cerebral theory principles. eight , 10

While it is beyond the telescopic of this article to review specific handling components of CBT, they mostly include various combinations of the following: psychoeducation about the nature of fright and anxiety, self-monitoring of symptoms, somatic exercises, cerebral restructuring (eg, logical empiricism and disconfirmation), imaginal and in vivo exposure to feared stimuli while weaning from safety signals, and relapse prevention. 8 Depending on the specific anxiety disorder, these CBT techniques are weighted differentially during therapy.

A plethora of studies accept examined the efficacy of CBT for developed anxiety disorders. Furthermore, several meta-analyses accept been conducted to quantitatively review the show of CBT for feet disorders. iv,6,ix,eleven In meta-assay, treatment efficacy is quantified in terms of an effect size. An outcome size indicates the magnitude of an observed effect in a standard unit of measurement. Withal, it is important to realize that unlike types of event sizes can exist used to appraise the available evidence. For case, effect sizes are sometimes categorized as "controlled" versus "uncontrolled." iv A controlled effect size expresses the magnitude of a specific handling consequence as compared with alternative treatments or control atmospheric condition. Most often, it is calculated by subtracting the post-treatment mean of the control grouping from the post-treatment mean of the handling group divided by the pooled standard deviation. This result size is called Cohen'southward d. 12 An uncontrolled effect size expresses the magnitude of improvement within a group from pretreatment to postal service-treatment. It is calculated past subtracting a group'due south post-treatment mean from its pretreatment mean divided by the pooled standard deviation. Uncontrolled effect sizes are less preferable than controlled outcome sizes, since they are susceptible to threats to internal validity. 4

Meta-analytic reviews of CBT studies in anxiety disorders accept generally found large effect sizes for the majority of treatment studies. Accordingly, recent reviews that summarized the results of these numerous meta-analyses of CBT treatment in feet disorders concluded that CBT is highly effective. 3 - iv - thirteen

However, these existing meta-analyses are non without limitations. In particular, almost meta-analyses of CBT for anxiety disorders have included studies that vary greatly with respect to control procedures, which range from waitlist, culling treatments, and placebo interventions that were evaluated with or without randomization while some studies did not include whatsoever command groups. However, it is important to make up one's mind how including a command status and their specific nature impacts the efficacy results of CBT in anxiety disorders. Furthermore, ane important question is how results derived from inquiry studies in by and large well-controlled enquiry designs (efficacy) generalize to real-world settings in naturalistic surround (effectiveness).

Therefore, this review will particularly focus on 2 contempo meta-analyses by Hofmann 6 and by Stewart xi regarding CBT treatment for panic disorder, generalized feet disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder.

The first meta-analysis half dozen express the included studies to randomized placebo-controlled trials, the gold standard in clinical outcome inquiry. For example, the Federal Drug Administration (FDA) in the U.s.a. and the European Medicines Agency (EMA) require successful randomized placebo-controlled double-bullheaded trials in order to approve a new medication. Pharmacotherapy trials typically administer a saccharide pill to individuals in the placebo status. Instead of including a pill placebo, a number of psychotherapy trials have employed psychological placebo conditions to control for nonspecific factors. To be included in the meta-assay, 6 the psychological placebo had to involve interventions to control for nonspecific factors (eg, regular contact with a therapist, reasonable rationale for the intervention, discussions of the psychological problem). Although information technology is well-nigh impossible to protect the blind in placebo-controlled psychotherapy trials, the randomized placebo-controlled blueprint is still the almost rigorous and conservative test of the furnishings of an active treatment. This approach assesses the overall efficacy of CBT in feet disorders under well-controlled research weather. Overall, 27 studies met inclusion criteria: n=7 for social anxiety disorder, northward=six for mail-traumatic stress disorder, n=v for panic disorder, n=four for acute stress disorder, n=iii for obsessive-compulsive disorder, and n=ii for generalized anxiety disorder. As a controlled effect size, Hedges' g was calculated, which is a variation of Cohen'south d taking into account small-scale sample sizes.

In contrast to well-controlled efficacy studies in inquiry settings, effectiveness studies examine how efficacious interventions are transferred into naturalistic real-world settings. Enquiry treatments might non work every bit well in clinical practice settings because of greater disease severity, or more than comorbid weather in patients in full general do compared with patients in research settings. Another variable that might impact the upshot in naturalistic settings is the treatments themselves and the clinicians who provide them. Treatment protocols in randomized controlled trials are manualized and strictly monitored with an emphasis on treatment integrity. However, therapy manuals are less likely to be used in clinical practice. Furthermore, practitioners typically practise not have access to the level of intensive training, monitoring, and supervision available to therapists in research settings. Clinicians in research settings are more likely to exist expert in the administration of particular treatments and are motivated through adherence measures to stay consequent with the protocol. In summary, treatments delivered in naturalistic settings may not be as rigorous in terms of content or quality, and this may limit how well results of controlled research trials can generalize to actual clinical practice. Therefore, it is important to empirically examine how well findings from enquiry studies (efficacy) translate into real-world settings (effectiveness). Thus, in the second meta-assay xi , 56 effectiveness studies were included to assess how CBT treatment works in less well-controlled real-life settings. CBT was defined broadly and included any handling with cerebral, behavioral (eg, exposure), or a combination of components. In sum, a total of 56 studies were included in these analyses: 17 for panic disorder; 11 each for social anxiety disorder, OCD, and GAD; and 6 for PTSD. No study assessed effectiveness in astute stress disorder. We will present and dissimilarity the meta-analytically derived controlled and uncontrolled effect sizes reflecting the efficacy and effectiveness results for each anxiety disorder.

Results

Panic disorder

Panic attacks are defined as sudden spells of unidentified feelings consisting of at least iv out of thirteen symptoms such as palpitations, chest pains, sweating, shortness of breath, feelings of choking, trembling, nausea, dizziness, paresthesias, chills or hot flushes, depersonalization or derealization, and fear of dying or losing control. In society to brand a diagnosis of panic disorder, additional criteria are that these attacks at to the lowest degree once have been unexpected, followed by at least one month of fearful expectation or concern almost the consequences of an attack. Panic disorder is frequently followed (or accompanied) by agoraphobia, which is defined as follows: (i) fear of beingness in places or situations from which escape might exist difficult or assistance might not be available; (ii) these situations are avoided or endured with marked distress or the patient needs a companion.

CBT for panic disorder typically involves education most the nature and physiology of the panic response, cognitive therapy techniques designed to alter catastrophic misinterpretations of panic symptoms and their consequences, and graduated exposure to panic-related body sensations (ie, interoceptive exposure) and avoided situations.

Efficacy

Five studies examined the efficacy of CBT in panic disorder in a randomized placebo-controlled design. vi The outcome size was 0.35 (95% CI 0.04-0.65), indicating a small to medium effect ((Figure 1). How important it is to have into account the blazon of upshot size when appraising the magnitude of event can exist seen from a different meta-analysis that calculated uncontrolled pre- to mail-treatment effect sizes. 9 . That meta-analysis reported an effect size of 1.53 for CBT in panic disorder.

Figure 1. Average effect size estimates and respective 95% confidence intervals of the acute treatment efficacy of cognitive-behavioral therapy as compared with placebo on the various feet disorders for the principal continuous anxiety measure (dark blue confined) and depression measures (light blueish bars) Adapted from ref half-dozen: Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632. Copyright© Physicians' Postgraduate Press, 2008

Effectiveness

Several studies examined the effectiveness of CBT in panic disorder. 11 The calculated uncontrolled pre- to post-treatment upshot size was one.01 (95% CI 0.77-ane.25) for panic attacks and 0.83 (95% CI 0.sixty-one.06) for avoidance.

Generalized anxiety disorder

Generalized anxiety disorder is marked past excessive and uncontrollable worry. Information technology is believed to exist maintained by cognitive (attention and judgment) biases toward threat-relevant stimuli and the use of worry (and associated tension) and overly cautious behaviors every bit a means to avoid catastrophic images and associated autonomic arousal. eight CBT of generalized anxiety disorder involves cognitive therapy to accost worry and cognitive biases and relaxation to accost tension, too equally imaginal exposure to catastrophic images and exposure to stressful situations while response preventing overly cautious behaviors.

Efficacy

The controlled consequence size for CBT in generalized anxiety disorder was 0.51 (95% CI 0.05-0.97), indicating a medium outcome (Figure one) although just 2 studies using a randomized controlled design to examine CBT treatment in patients with generalized anxiety disorder were available. Still, these results were recently corroborated by a Cochrane meta-assay examining psychological treatments of generalized feet disorder. 14 Based on thirteen studies, the authors ended that psychological therapies, all using a CBT arroyo, were more than effective than treatment as usual or wait list control in achieving clinical response at post-handling (RR 0.64, 95% CI 0.55-0.74). However, those studies examining CBT against supportive therapy (nondirective therapy and attention-placebo conditions) did not detect a pregnant difference in clinical response between CBT and supportive therapy at postal service-treatment (RR 0.86, 95%CI 0.70 to 1.06).

Again, the meta-assay computing uncontrolled pre- to postal service-treatment event sizes constitute much a larger overall issue size of 1.eighty. nine

Effectiveness

In 11 effectiveness studies, the pre- to post-treatment effect size for CBT in generalized anxiety disorder was 0.92 (95% CI 0.77-1.07).

Social anxiety disorder

Social anxiety disorder (or social phobia) is characterized past marked fearfulness of performance, excessive fear of scrutiny, and fear of acting in a fashion that may exist embarrassing. About patients are oversensitive to the causeless stance of others and take a low self-esteem, although they feel their fears are exaggerated and out of proportion. Going through the feared situations, or even anticipating them, nearly people suffer from physical symptoms like sweating, trembling, or blushing, and these symptoms tin become a trigger on their own to worry about social consequences. CBT for social phobia typically emphasizes cognitive restructuring and in vivo exposure to feared social situations. Patients are instructed in identifying and challenging their beliefs about their social competence and the probability of experiencing negative social evaluation and consequences. In vivo exposures provide opportunities to confront feared and avoided social encounters and to practice social skills. ((Figure ii).

Figure ii. Average odds ratios of acute handling response to cognitive-behavioral therapy as compared with placebo. *, P<0.05; **, P<0.01 Adapted from ref six: Hofmann SG, Smits JA. Cerebral-behavioral therapy for developed anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632. Copyright© Physicians' Postgraduate Printing, 2008

Efficacy

In seven randomized placebo-controlled treatment studies, the effect of CBT in social feet disorder was 0.62 (95% CI 0.39-0.86, Figure 1) indicating a medium effect. In a dissever meta-analysis, the uncontrolled pre- to post-treatment acute handling effect size was 1.27. 9

Effectiveness

In eleven effectiveness studies, the uncontrolled pre- to mail service-treatment upshot size was 1.04 (95% 0.79-i.29). five

Post-traumatic stress disorder

The DSM-4 definition for mail-traumatic stress disorder (PTSD) contains criteria for: (i) the traumatic experience; (ii) re-experiencing; (iii) abstention of associated stimuli and numbing; and (4) increased arousal. CBT for PTSD typically includes 3 components: (i) psychoeducation about the nature of fearfulness, anxiety, and PTSD; (2) controlled, prolonged exposure to stimuli related to the traumatic outcome; and (iii) cognitive restructuring, processing, or challenging of maladaptive beliefs/appraisals.

Efficacy

In six randomized placebo-controlled efficacy trials of CBT in PTSD, the controlled consequence size was 0.62 (95% CI 0.28-0.96), indicating a medium event. A recent Cochrane assay of psychological treatment in PTSD 15 supported these findings and constitute that trauma-focused CBT was more constructive than handling as usual or wait listing control. The uncontrolled effect size derived from a divide meta-assay was 1.86. 9

Effectiveness

Half dozen studies examined the effectiveness of CBT in the treatment of PTSD 5 and found an uncontrolled pre- to mail service-treatment effect size of ii.59 (95% CI 2.06-three.13).

Acute stress disorder

Acute stress disorder is an anxiety disorder characterized past a cluster of dissociative and feet symptoms that occur within a month of a traumatic stressor. Astute stress disorder may be diagnosed in patients who (i) lived through or witnessed a traumatic consequence to which they (2) responded with intense fear, horror, or helplessness, and are (iii) currently experiencing three or more of the post-obit dissociative symptoms: psychic numbing, being dazed or less aware of surroundings, derealization, depersonalization, or dissociative amnesia.

Efficacy

In four randomized placebo-controlled efficacy trials of CBT in acute stress disorder, the controlled effect size was one.31 (95% CI 0.93-i.69) indicating a large result. Consequent with these results, a recent Cochrane metaanalysis concluded that at that place was evidence that individual trauma-focused CBT was constructive for individuals with acute traumatic stress symptoms compared with both waiting list and supportive counseling interventions. 16

Effectiveness

No effectiveness information were available/included in the meta-analysis of CBT handling in acute stress disorder. v

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is defined as the presence of recurrent obsessions (persistent thoughts, impulses, or images) or compulsions (repetitive behavior or thought patterns induced in an effort to prevent anxiety) that are excessively time-consuming (taking more than than an hour a day) or cause marked distress or meaning impairment. The subject recognizes that these patterns are excessive. Components of CBT in the handling of OCD include exposure and response prevention every bit well every bit cognitive interventions. 3

Efficacy

3 studies examined CBT treatment in OCD in a randomized placebo-controlled blueprint. The controlled consequence size was one.37 (95% CI 0.64-2.xx) indicating a big result, in fact the largest effect size for CBT in any of the anxiety disorders (Figure ane). However, the 95% confidence interval was big due to the minor numbers of included studies (north=3). Interestingly, the uncontrolled pre- to mail-treatment effect size of ane.50 that was calculated in a split meta-analysis' was only marginally larger than the controlled effect size.

These results were corroborated by a Cochrane analysis of eight studies, all of which compared cognitive and/or behavioral treatments versus handling as usual control groups. 17 These studies demonstrated that patients receiving any variant of cognitive behavioral handling exhibited significantly fewer symptoms post-handling than those receiving treatment as usual.

Effectiveness

Consequent with the acute efficacy effects of CBT in OCD, eleven effectiveness studies plant an uncontrolled event size of i.32 (95% CI ane.19-one.45) in real-world settings. 5

Summary

According to contempo meta-analyses examining CBT in anxiety disorders in randomized placebo-controlled trials 6 and in naturalistic real-life settings, five both the efficacy and effectiveness of CBT for feet in adults appears to be well established. These favorable effects of CBT are further corroborated by several Cochrane analyses of psychological treatments for several feet disorders. 14-16

The controlled consequence sizes from 27 randomized placebo-controlled trials involving 1496 patients ranged from 0.35 in panic disorder (modest effect) to 1.37 in obsessive-compulsive disorder (large outcome) indicating that CBT compared favorably to placebo conditions in all anxiety disorders. In post-hoc comparisons, the only significant difference among the different anxiety disorders regarding the efficacy of CBT was between panic disorder and obsessive-compulsive disorder. Furthermore, the effect size for ASD was significantly greater relative to those observed for all other anxiety disorders except OCD. Still, these results should be interpreted with caution given the small numbers of included studies for each anxiety disorder (n of studies ranging from 2 to 7 for each specific disorder).

Although this meta-analysis circumvented many methodological problems of other meta-analyses of psychotherapy studies by including just randomized, placebo-controlled trials, at that place still remained methodological issues that need to be taken into account when appraising these results. Every bit indicated by the authors, a concerning issue is the lack of intention-to-care for (ITT) analyses in most studies included. An ITT assay is based on the initial handling intent, non on the treatment eventually administered. ITT analysis is intended to avoid various misleading arti-facts that can arise in intervention research. For example, if people who have a more refractory or serious trouble tend to drop out at a college rate, fifty-fifty a completely ineffective handling may appear to be providing benefits if one merely compares the status before and after the treatment for only those who finish the treatment (ignoring those who were enrolled originally, but have since been excluded or dropped out). For the purposes of ITT assay, everyone who begins the treatment is considered to exist part of the trial, whether he or she finishes it or non. This is different from the completer or per-protocol analysis, which only includes those patients finishing the trial. Thus, the ITT analysis is a much more than bourgeois measure and is generally used in pharmacotherapy studies.

Not surprisingly therefore, in the meta-analysis of randomized, placebo-controlled trials, pooled analyses using data from ITT samples yielded much smaller effect sizes than those derived from completer samples. In the completer sample, the overall Hedges' 1000 for anxiety disorder severity was 0.73 (95% CI: 0.56-0.90 and the pooled odds ratio for handling response was 4.06 (95% CI: 2.78-5.92). Even so, in ITT analyses that were only provided for the minority of included studies, the Hedges' g for feet disorder severity was 0.33 (95% CI: 0.110.54), and the odds ratio for treatment response was 1.84 (95% CI: ane.17-two.91). The authors of the meta-assay 6 concluded the post-obit:

Given the status of CBT as the gilt-standard psychosocial intervention for treating anxiety disorders, it is very surprising and concerning that after more than 20 years of CBT treatment research, we were only able to identify 6 loftier-quality randomized placebo controlled CBT trials that provided ITT analyses for continuous measures and only 8 trials for ITT response charge per unit analyses. In our opinion, this is an unacceptable situation that volition have to change for psychosocial intervention to go a viable alternative to pharmacotherapy in the medical customs.

In 56 effectiveness studies of CBT in feet disorders in naturalistic real-life settings, the (uncontrolled) consequence sizes ranged from 0.92 in generalized feet disorder to 2.59 in postal service-traumatic stress disorder. Information technology is important to keep in mind that these uncontrolled pre-to mail-treatment effect sizes cannot be readily compared with the controlled effect sizes. Nevertheless, these upshot sizes seem to signal that CBT likewise works in real-world settings in the treatment of anxiety disorders. Again, in that meta-analysis only 4 out of 56 included reports of intention-to-treat data, prohibiting a meaningful ITT-analysis. Newer therapies for feet disorders include mindfulness-based therapies. These therapies propose dissimilar approaches for dealing with anxiety-related cognition, including cognitive defusion (eg, distancing from the content of fright-based thinking) and mindfulness and credence, and are more contextually based. They are old called the "third wave" of CBT. A recent meta-assay establish that mindfulness-based therapy in patients with feet disorders was associated with a large effect size (Hedges' g) of 0.97 (95% CI: 0.72-one.22) for improving feet. eighteen Thus, mindfulness-based therapy is a promising newapproach in the treatment of feet disorders.

Furthermore, pharmacological augmentation strategies designed to heighten the learning that occurs with CBT approaches for anxiety disorders may concord particular promise. For example, recent studies demonstrated that glucocorticoids administered i hour prior to therapy sessions enhance extinction-based psychotherapy in anxiety disorders. 19,20 Furthermore, d-cycloserine, a drug used in the treatment of tuberculosis, has been shown to raise fear extinction in several preclinical studies 21 but besides in clinical trials in patients with dissimilar anxiety disorders: 22 Thus, combining exposure therapy with pharmacological agents holds significant hope for improving the efficacy of CBT.

Conclusion

Despite some weaknesses of the original studies, the quantitative literature review of randomized placebo-controlled trials and of trials in naturalistic handling settings provides strong back up for both the efficacy and effectiveness of CBT as an acute intervention for adult feet disorders. At the aforementioned time, the results too suggest that in that location is notwithstanding considerable room for further improvement of study and analysis methods. Thus, the verbal magnitude of issue is currently hard to gauge. Notwithstanding, the meta-analyses confirm that CBT is by far the most consistently empirically supported psychotherapeutic option in the treatment of anxiety disorders. Thus, CBT tin can be recommended as a gold standard in the psychotherapeutic handling of patients with anxiety disorders.

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Source: https://www.tandfonline.com/doi/full/10.31887/DCNS.2011.13.4/cotte

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