Exploring Cognitive Behavioral Therapy (CBT) for Anxiety Disorders

Anxiety is a troubling and costly mental health issue that affects millions of people. Yet most people with anxiety disorders do not receive evidence-based treatment.

One of the most effective, evidence-based treatments for anxiety disorders is cognitive behavioral therapy (CBT), which aims to interrupt the mechanisms that keep anxiety alive in the body and brain.

 How can behavioral health professionals do a better job of identifying and treating anxiety?

Unpacking Anxiety

In the CWC training The Science & Art of Cognitive Behavioral Therapy (configio.com), David Tolin, PhD, ABPP, explores the use of CBT for anxiety. Tolin looks at the prevalence of anxiety disorders and the negative impact they have on society. He shares examples of anxiety disorders and also discusses principles of treatment such as exposure, relaxation training, cognitive restructuring, and acceptance.

According to Tolin, most people with anxiety disorders never receive empirically supported treatment.

Why Are People Anxious? 

Rather than focusing on the question of where the anxiety came from, CBT is rooted in a maintenance approach, which asks the question: “What processes keep the anxiety alive in the present?”

The reason a problem started is not always the reason it continues. For example, someone may start smoking out of curiosity or as a result of peer pressure. But they continue to smoke out of habit and to avoid unpleasant withdrawal symptoms.

What Are the Processes That Maintain Anxiety?

There are a number of processes that help keep anxiety activated.

Avoidance

Avoidance is when people avoid the external or internal stimuli that they fear. External stimuli could be activities, places, and people. Internal stimuli are memories, thoughts, emotions, and physical sensations. Safety behaviors are less obvious behaviors that are still considered avoidance, like a person with agoraphobia who will go to the mall, but only with a trusted companion or a person with accident-related PTSD who will only drive slowly in the right lane in light traffic.

Avoidance keeps fear alive, and as Tolin puts it, “You cannot avoid and overcome fear at the same time.”

Distorted Beliefs

Not everything we think or believe is true. Distorted beliefs, or cognitive distortions, are when a person’s thoughts and beliefs about something cause emotional discomfort. The following are examples of some common cognitive distortions that characterize anxiety disorders.

• Probability overestimation: “If I go to the mall, I’ll have a heart attack.”
• Catastrophizing: “If I faint in public, I’ll be so embarrassed that I’ll never recover.”
• Personalizing: “My boss has a sour look on her face. I must have done something to make her mad.”
• All-or-nothing thinking: “If I can’t do it perfectly, I’m a failure.”
• Mind reading: “I’m certain that they don’t like me.”
• Emotional reasoning: “I know it’s dangerous because I feel so anxious.”

When someone has anxiety, the brain pays attention to what is going on in our bodies, and our emotions and decisions are driven, at least in part, by the way the brain understands those sensations. Sensations like sweating, dilated pupils, and an accelerated heartbeat are all signs of physiological arousal caused by the sympathetic nervous system.

How Common Is Anxiety?

The American Psychiatric Association reports that anxiety disorders affect nearly 30% of adults and that women are more likely than men to experience anxiety. Some of the most common types of anxiety disorders and the percentage of occurrence among adults in the U.S. are:

• Specific phobias: 8-12%
• Social anxiety disorder (formerly called social phobia): 7%
• Panic disorder: 2-3%
• Agoraphobia: 1-1.7% among adolescents and adults worldwide
• Generalized anxiety disorder: 0.9% (adolescents), 2.9% (adults)
• Separation anxiety disorder: 4% (children), 1.6% (adolescents), 0.9-1.9% (adults)
• Selective mutism: 0.01-1.9% (U.S., Europe, Israel)

With this many people experiencing symptoms of anxiety, it is important for behavioral health professionals to understand ways to treat it. Often behavioral health professionals use CBT to help people experiencing anxiety disorders.  

CBT for Anxiety

CBT is evidence-based and is one of the most proven therapies for treating anxiety. The goal of CBT is to interrupt the mechanisms that maintain the anxiety disorder.  

There are four main clinical approaches to CBT for anxiety: exposure to avoided stimuli, correction of maladaptive beliefs, relaxation exercises, and skills training.

Exposure Therapy

Clinicians use exposure therapy to help people learn to confront stimuli that they find distressing: external objects, activities, or people or internal thoughts, memories, or sensations. The American Psychological Association (APA) reports that exposure therapy is a proven treatment for the following problems:

• Phobias
• Panic disorder
• Social anxiety disorder
• Obsessive-compulsive disorder (OCD)
• PTSD
• Generalized anxiety disorder

The Connecticut Women’s Consortium training, Face Your Fears: Conducting Good Exposure Therapy Across Diagnoses, is an on-demand course that explores the psychological mechanisms of exposure therapy.

For example, exposure therapy has helped people with panic disorder understand that an elevated heart rate doesn’t mean they will die of a heart attack. People with social anxiety can learn that they won’t be ridiculed for minor social blunders.

Correction of Maladaptive Beliefs (Cognitive Distortions)

Clinicians can also work with clients to understand some of the cognitive distortions that fuel anxiety. For example, if they exhibit all-or-nothing thinking (“If I can’t do it perfectly, I’m a failure.”), the clinician can examine the evidence, as if in a courtroom, by asking: What is the evidence for this interpretation? What is the evidence against this interpretation?

When someone has a cognitive distortion, we ask, “Is this the only way to think about it?” or “What would someone else in this situation think about it?” Or we can help people with simple behavioral experiments.

• Treat the thought as a hypothesis. If X, then Y.
• Test it out. Did Y actually happen?

For example, someone with a phobia about flying in an airplane can look at the real statistics on the number of crashes vs. flights: 1 crash per 45 million flights.

Some people with anxiety benefit from keeping a Thought Change Record where they practice analyzing distorted thoughts and replacing them with fresh interpretations.

Acceptance Interventions

Acceptance interventions help people recognize that unpleasant or unwanted thoughts or feelings are unavoidable. Our distress stems from the way we respond to them. There’s a fine balance between paying too little attention to them and too much attention to them.

Acceptance interventions can include:

• Recognizing that attempts to control our thoughts and feelings might be part of the problem.
• Paying attention to thoughts and feelings and accepting them without judging, labeling, or trying to control or change them.
• Bringing the focus back to the present moment because anxiety is rooted in events of the past and worrying about the future.
• Engaging in behaviors that are consistent with meaningful goals and values.

Relaxation Techniques

Relaxation training is another valuable approach to treating people with anxiety disorders. Many people benefit from sitting in a relaxed posture, closing their eyes, and working through a cycle of tensing and relaxing all their muscles. It can help to focus on breathing and imagine the tension leaving the body.

Breathing retraining can also help calm the sympathetic nervous system as people slow down their breathing and learn to breathe deeply from the diaphragm.

Tolin notes, however, that relaxation and breathing retraining are not for everyone with anxiety disorders. Some people begin to use the techniques as a crutch, thinking “I’d better relax or else.”

Skills Training

Skills training in a clinical setting involves working to boost social skills like verbal, nonverbal, assertiveness, or problem-solving. There are a number of ways that clinicians can help build these skills. Generally, skill training involves assessing what skills could use work and then instructing, modeling, and role-playing to help people improve their life skills.

CBT Is Effective

There are plenty of reasons for people to experience stress and anxiety these days. But no one should have to live with an untreated anxiety disorder. By working with a clinician familiar with using CBT for anxiety, people can learn to accept more of life’s curve balls, understand their own psychological and physical responses, and move toward a healthier future.