Practice in Clinical & Health Psychology
Anxiety Disorders

 

   

 What are Anxiety Disorders?

Anxiety disorders range from feelings of uneasiness to immobilizing bouts of terror. This fact sheet briefly describes the different types of anxiety disorders. This fact sheet is not exhaustive, nor does it include the full range of symptoms and treatments. Keep in mind that new research can yield rapid and dramatic changes in our understanding of and approaches to mental disorders. If you believe you or a loved one has an anxiety disorder, seek competent, professional advice or another form of support.

Generalized Anxiety Disorder

Most people experience anxiety at some point in their lives and some nervousness in anticipation of a real situation. However if a person cannot shake unwarranted worries, or if the feelings are jarring to the point of avoiding everyday activities, he or she most likely has an anxiety disorder.

Symptoms: Chronic, exaggerated worry, tension, and irritability that appear to have no cause or are more intense than the situation warrants. Physical signs, such as restlessness, trouble falling or staying asleep, headaches, trembling, twitching, muscle tension, or sweating, often accompany these psychological symptoms.

Formal diagnosis: When someone spends at least six months worried excessively about everyday problems. However, incapacitating or troublesome symptoms warranting treatment may exist for shorter periods of time.

Treatment: Anxiety is among the most common, most treatable mental disorders. Effective treatments include cognitive behavioral therapy, relaxation techniques, and biofeedback to control autonomic nervous system arousal and muscle tension. Medication, most commonly anti-anxiety drugs, such as benzodiazepine and its derivatives, also may be required in some cases. Some commonly prescribed anti-anxiety medications are diazepam, alprazolam, and lorazepam. The non-benzodiazepine anti-anxiety medication buspirone can be helpful for some individuals.

Panic Disorder

People with panic disorder experience white-knuckled, heart-pounding terror that strikes suddenly and without warning. Since they cannot predict when a panic attack will seize them, many people live in persistent worry that another one could overcome them at any moment.

Symptoms: Pounding heart, chest pains, lightheadedness or dizziness, nausea, shortness of breath, shaking or trembling, choking, fear of dying, sweating, feelings of unreality, numbness or tingling, hot flashes or chills, and a feeling of going out of control or going crazy.

Formal Diagnosis: Either four attacks within four weeks or one or more attacks followed by at least a month of persistent fear of having another attack. A minimum of four of the symptoms listed above developed during at least one of the attacks. Most panic attacks last only a few minutes, but they occasionally go on for ten minutes, and, in rare cases, have been known to last for as long as an hour. They can occur at any time, even during sleep.

Treatment: Cognitive behavioral therapy, biofeedback training of autonomic nervous system balance, and medications such as high-potency anti-anxiety drugs like alprazolam have been shown to be effective. Several classes of antidepressants (such as paroxetine, one of the newer selective serotonin reuptake inhibitors) and the older tricyclics and monoamine oxidase inhibitors (MAO inhibitors) are considered "gold standards" for treating panic disorder. Most clinical research suggests that a combination of psychological therapies and medication is the most effective approach to helping people manage their symptoms. Proper treatment helps 70 to 90 percent of people with panic disorder, usually within six to eight weeks.

Phobias

Most of us steer clear of certain, hazardous things. Phobias however, are irrational fears that lead people to altogether avoid specific things or situations that trigger intense anxiety. Phobias occur in several forms, for example, agoraphobia is the fear of being in any situation that might trigger a panic attack and from which escape might be difficult. Social phobia is a fear of being extremely embarrassed in front of other people. The most common social phobia is fear of public speaking.

Symptoms: Many of the physical symptoms that accompany panic attacks—such as sweating, racing heart, and trembling—also occur with phobias.

Formal Diagnosis: The person experiences extreme anxiety with exposure to the object or situation; recognizes that his or her fear is excessive or unreasonable; and finds that normal routines, social activities, or relationships are significantly impaired as a result of these fears.

Treatment: Cognitive behavioral therapy has the best track record for helping people overcome most phobic disorders. The goals of this therapy are to desensitize a person to feared situations or to teach a person how to recognize, relax, and cope with anxious thoughts and feelings. Medications, such as anti-anxiety agents or antidepressants, can also help relieve symptoms. Sometimes therapy and medication are combined to treat phobias.

Social Anxiety Disorder

Social anxiety is an experience of fear, apprehension or worry regarding social situations and being evaluated by others. People vary in how often they experience anxiety in this way or in which kinds of situations. Anxiety about public speaking, performance, or interviews is common.

Persons with social anxiety disorder experience overwhelming anxiety and excessive self-consciousness in everyday social situations. They often have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Often the triggering social stimulus is perceived or actual scrutiny by others. Their fear may be so severe that it significantly impairs their work, school, social life, and other activities. While many people experiencing social anxiety recognize that their fear of being around people may be excessive or unreasonable, they encounter considerable difficulty overcoming it. This differs from shyness, in that the person is functionally debilitated and avoids such anxiety provoking situations by all means. At the same time, a person with social anxiety may only feel the fear of the disorder during certain situations. For example, an actor or singer may feel fine on stage, but afraid of social situations in everyday life.

Social anxiety is often part of only a certain situation—such as a fear of speaking in formal or informal situations, or eating, or writing in front of others—or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Many people have the specific fear of public speaking, called glossophobia. In this case, the fear is not actually of public speaking, but a fear of doing or saying something which may cause embarrassment. Approximately 13.3% of the general population will experience social phobia at some point in their lifetime; with the male to female ratio being 1.4:1.0, respectively.

Symptoms: Physical symptoms often accompany social anxiety, and include blushing, profuse sweating, trembling, nausea, and stammering. Panic attacks may also occur under intense fear and discomfort. An early diagnosis helps in minimizing the symptoms and having other mental illnesses such as depression. Some sufferers also use alcohol or drugs to reduce fears and inhibitions at social events.

Formal Diagnosis: A certain amount of social anxiety is relatively common but social anxiety disorder is clearly of a greater magnitude than simple “shyness”. The key to making the diagnosis is the strength of the patient’s fear and the extent to which the fear is functionally debilitating in the patient’s life.

Treatment: A person with social anxietyy disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behavior therapy, whether individually or in a group, to be effective in treating social phobics. The cognitive and behavioral components seek to change thinking patterns and physical reactions to anxious situations. This may be done through a technique called role playing. Prescribed medication consists of a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). Such treatment has a high response rate and low risk of dependency but has been criticized for its adverse side-effects and possible increase in suicide risk.

Attention given to social anxiety disorder has significantly increased since 1999 with the approval of drugs for its treatment. Marketing campaigns by pharmaceutical companies may be largely responsible for driving this.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a term for certain psychological consequences of exposure to, or confrontation with, stressful experiences that the person experiences as highly traumatic. The experience must involve actual or threatened death, serious physical injury, or a threat to physical and/or psychological integrity. PTSD can result from directly experiencing or witnessing such terrifying events as childhood abuse, violent physical assault or rape, kidnapping, torture, natural disasters, or war or serious accidents such as airplane crashes. The psychological damage such incidents cause can interfere with a person's ability to hold a job or to develop intimate relationships with others.

It is occasionally called post-traumatic stress reaction to emphasize that it is a routine result of traumatic experience rather than a manifestation of a pre-existing psychological weakness on the part of the patient.

It is possible for individuals to experience traumatic stress without manifesting Post-Traumatic Stress Disorder, as indicated in the Diagnostic and Statistical Manual of Mental Disorders.

Researchers now know that anyone, even children, can develop PTSD if they have experienced, witnessed, or participated in a traumatic occurrence-especially if the event was life threatening.

Symptoms: The symptoms of PTSD can range from constantly reliving the event to a general emotional numbing. Persistent anxiety, exaggerated startle reactions, difficulty concentrating, nightmares, and insomnia are common. People with PTSD typically avoid situations that remind them of the traumatic event, because they provoke intense distress or even panic attacks.

Formal Diagnosis: For most people, the emotional effects of traumatic events will tend to subside after several months; if they last longer, then a psychiatric disorder may be diagnosed. Although the symptoms of PTSD may be an appropriate initial response to a traumatic event, they are considered part of a disorder when they persist beyond three months.

PTSD is thought to be primarily an anxiety disorder and should not be confused with normal grief and adjustment after traumatic events. Most people who experience traumatic events will not go on to develop PTSD.

PTSD may have a delayed onset of months, years or even decades and may be triggered by an external factor or factors.

PTSD is often associated (comorbid) with other psychiatric disorders such as clinical depression, general anxiety disorder and a variety of addictions.

Treatment: Psychotherapy can help people who have PTSD regain a sense of control over their lives. They also may need cognitive behavior therapy to change painful and intrusive patterns of behavior and thought and to learn relaxation techniques. Support from family and friends can help speed recovery and healing. Medications, such as antidepressants and anti-anxiety agents to reduce anxiety, can ease the symptoms of depression and sleep problems. Treatment for PTSD often includes both psychotherapy and medication. Treatment is frequently complicated by comorbid conditions such as clinical depression, generalized anxiety, and various addictions.

  

Psychological Treatments for Anxiety Disorders
 

Anxiety disorders are real, serious and treatable. Experts believe that anxiety disorders are caused by a combination of biological and environmental factors, much like other disorders, such as heart disease and diabetes.

The vast majority of people with an anxiety disorder can be helped with professional care. Success of treatment varies with the individual. Some people may respond to treatment after a few months, while others may take a year or more. Treatment may be complicated by the fact that people very often have more than one anxiety disorder, or suffer from depression or substance abuse concurrently. This is why treatment must be tailored to the individual.

Although treatment is individualized, there are several standard approaches that have proven to be effective. Therapists will use one, or a combination of these therapies.

 

TREATMENT OPTIONS

Behavior Therapy

The goal of Behavior Therapy is to modify and gain control over unwanted behavior. The individual learns to cope with difficult situations, often through controlled exposure to them. This kind of therapy gives the individual a sense of having control over their life.

Cognitive Therapy

The goal of Cognitive Therapy is to change unproductive or harmful thought patterns. The individual examines his feelings and learns to separate realistic from unrealistic thoughts. As with Behavior Therapy, the individual is actively involved in her own recovery and has a sense of control.

Cognitive Behavior Therapy (CBT)

Many therapists use a combination of Cognitive and Behavior Therapies, this is often referred to as CBT. One of the benefits of these types therapies is that the patient learns recovery skills that are useful for a lifetime.

The primary goal of cognitive behavior therapy is to identify and modify thoughts, feelings, and behavior that interferes with a desired outcome in life. Each individual's therapy is unique; however, there are common components in Cognitive Behavior Therapy treatment of an Anxiety Disorder. Education about a particular Anxiety Disorder and how it is interfering in key areas of life must be addressed first. Treatment may begin by addressing "readiness" issues or "treatment interfering behaviors". New learning and planned steps to accomplish desired behavior change are developed with the patient. Anxiety management skills and behavioral skills are a key component of treatment.

CBT targets the specific fears, perceptions, coping, and emotions that maintain an Anxiety Disorder. The following chart gives an overview of treatment components.

·   A feared stimulus can be any number of things such as: an object, a place, a thought, a feeling, an idea, a desire, a number, etc.

·   Physiological arousal, genetic predisposition, past experiences, repeated stress, etc. can create a perception about the feared stimulus.

·   Physiologic arousal of anxiety and fear become paired with the feared stimulus.

·   Avoidant behavior or rituals to relieve anxiety from the feared stimulus temporarily relieves the anxiety and fear, reinforcing the avoidant behavior.

An Anxiety Disorder can occur when fear and anxiety disrupts everyday life, limits one's ability to work, socialize, perform, go to school, restricts a person's emotional and physical mobility. An untreated or under treated Anxiety Disorder can diminish quality of life and severely limit one's ability to freely participate in their life.

Combinations of Cognitive Behavior Therapy (CBT) and guided gradual. Exposure/Response Prevention (ERP) are utilized to provide a corrective learning experience.

Relaxation Techniques

Relaxation Techniques help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. The techniques taught include breathing re-training and exercise.

Biofeedback Techniques

Biofeedback is often combined with CBT in treating anxiety disorders. By monitoring and displaying physiological responses associated with autonomic nervous system function, biofeedback can be a very effective learning tool in helping the patient recognize thoughts and behaviors that result in sympathetic-mediated arousal— the “fight or flight response”— or parasympathetic-mediated relaxation. Through biofeedback, the patient can learn to become more aware of their physiological response to anxiety and gain better control of this response. Combining cognitive therapy with biofeedback is an excellent “mind-body” treatment approach.

Medications

From a psychological point-of-view, the ultimate goal of therapy for anxiety disorders is to achieve successful management of the anxiety without the need for long-term medication. However, when anxiety is quite severe, anxiolytic or antidepressive medications may be necessary in the short-term to help settle the patient enough for psychotherapy and learning to occur.

Moreover, because most people suffering from anxiety symptoms will see their primary care physician first, it is very common for patients to be referred to psychologists after they have already been given medications for their anxiety. From the prescribing physician’s point-of-view, psychological therapies are seen as adjunctive treatment to medications. In such cases, the psychologist must work with the physician toward alleviating the anxiety disorder with a minimum amount of medication initially and then, as the patient improves, to help support the patient while he/she is slowly weaned off anxiolytic medications.

 (See: Arch, J.J. & Craske, M.G. (2009). First-line treatment: A critical appraisal of cognitive behavioral therapy developments and alternatives. Psychiatric Clinics of North America, vol. 32, pp. 525-547.)

 For more information on medications for anxiety... GOTO:  Medication 

 Choosing a Therapist

Anxiety Disorders can be treated by a wide range of mental health professionals, including: psychiatrists, psychologists, clinical social workers and psychiatric nurses. Primary care physicians are also becoming increasingly aware of the problems of anxiety disorders and depression and are making these diagnoses with more frequency. A primary care physician may prescribe medication, or may refer a patient to a mental health provider.

Finding the right therapist can be tricky, as satisfactory credentials are not the only factors to take into consideration. It is important to feel comfortable with one's therapist. Speak to the therapist, either on the phone or in his/her office, and do not be embarrassed if you feel uncomfortable and would rather see someone else.

Questions to Ask Your Therapist

A therapist should be willing to answer any questions you may have about their methods, training and fees. Here are some questions you may want to ask a therapist during an initial consultation:

  • Are you a registered health care provider under the Alberta Health Professions Act?
  • What training and experience do you have in treating anxiety disorders?
  • What is your basic approach to treatment?
  • Will you work cooperatively with my primary care physician?
  • Can you prescribe medication or refer me to someone who can, if that proves necessary?
  • How long is the course of treatment?
  • How frequent are treatment sessions and how long do they last?
  • Do you include family members in therapy?
  • Will you or a staff member go to the home of a phobic person, if necessary?
  • What is your fee schedule, and do you have a sliding scale for varying financial circumstances?
  • Are your fees covered by Alberta Health Insurance?
  • What kinds of health insurance do you accept?
  • What are your policies with respect to patient confidentiality and personal privacy?

Remember, if a therapist is reluctant to answer your questions, or if you do not feel comfortable, see someone else.

 

BIOFEEDBACK FOR ANXIETY

Overview & Efficacy: Everybody gets anxious from time to time. Treatment is called for if the amount of anxiety is out of proportion to the problem or lasts too long. Many methods for helping people reduce and control their anxiety have been shown to be effective. Behavioral techniques include relaxation training, cognitive restructuring, and biofeedback. Any form of biofeedback that helps people become aware of their physiological responses as they become anxious and that helps people learn to relax is apparently at least as effective as any other behavioral technique.

This therapy is rated as efficacious (level 4 on a scale of 1 to 5 with 5 being the best).

Why biofeedback would help this problem: There are several different underlying problems which cause abnormal levels of anxiety. Biofeedback helps each for different reasons.

A) Breathing problems which cause anxiety: Half or more of people who habitually breathe too rapidly with shallow breaths are anxious because of the effects of their breathing on their brains' chemistry. Most of these people are not aware they have incorrect breathing patterns. These incorrect patterns are easily detected using psychophysiological assessments and are corrected using several types of biofeedback related to helping people normalize their breathing patterns. When the breathing is normalized, the anxiety goes away.

B) When a person experiences greater levels of anxiety or the anxiety lingers far longer than it should, the body's normal responses to an emergency situation fail to shut down. This can cause the body to wear out while thinking and memory patterns change. The physiological reactions to anxiety are accurately assessed using psychophysiological recording techniques so both the patient and therapist always know when any therapy is helping and how much. Biofeedback treatments show the patient the abnormal physiological response levels. Patients use this knowledge to recognize when they are becoming abnormally anxious (so they learn to identify when something is actually causing the anxiety) and to control their anxiety.

In the case of EEG biofeedback, children who are successfully trained to increase brain waves in the 12-16 Hz range (SMR) from central and frontal locations over the cortex show decreased activity levels. Successful neurofeedback training to decrease Theta while increasing Beta results in increased attention span and increased ability to learn math. Similarly, training to reduce excess amounts of high frequency Beta brainwaves (>24 Hz) is associated with reductions in hypervigilance and anxiety.

The training almost always takes place in a therapist's office. Sensors are pasted onto the scalp over the parts of the patient's brain, which are to be trained. The sensors are connected to a computer, which runs a special training program. The program usually appears in the guise of a videogame. The videogame's progress or simply continuation is dependent upon the patient producing the desired proportion of brain waves. The treatment may require 30 to 50 or more training sessions for effects to be apparent and lasting.

Brief summary of evidence supporting the efficacy of biofeedback for abnormal levels of anxiety:

Yucha and Gilbert (2004) report that "very few well- controlled, randomized studies have shown biofeedback to be superior to other relaxation and self-control methods for reducing anxiety. Most show biofeedback (EMG, GSR, thermal, or neurofeedback) to be roughly equivalent to progressive relaxation or meditation. Two studies showed biofeedback's efficacy in reducing anxiety without making comparisons with other relaxation techniques. Hurley and Meminger (1992) used frontal EMG biofeedback with 40 subjects trained to criterion and assessed anxiety over time using the State-Trait Anxiety Inventory (STAI). State anxiety improved more than trait anxiety. Wenck, Leu, and D'Amato (1996) trained 150 7th and 8th-graders with thermal and EMG feedback, and found significant reduction in state and trait anxiety. Roome and Romney (1985) compared progressive muscle relaxation to EMG biofeedback training with 30 children and found an advantage for biofeedback; Scandrett, Bean, Breeden, & Powell (1986) found some advantage of progressive muscle relaxation over EMG biofeedback in reducing anxiety in adult psychiatric inpatients and outpatients. Vanathy, Sharma, and Kumar (1998), applying EEG biofeedback to generalized anxiety disorder, compared increased alpha with increased theta. The two procedures were both effective in decreasing symptoms.

Rice, Blanchard, and Purcell (1994) studied reduction in generalized anxiety by comparing groups given EMG frontal feedback, EEG alpha-increase feedback, EEG alpha- decrease feedback, a pseudo-meditation condition, and a wait-list control. All treatment groups had comparable and significant decreases in the STAI as well as drops in Psychosomatic Symptom Checklist. Similar results were obtained by Sarkar, Rathee, and Neera (1999) by comparing the generalized anxiety disorder response to pharmacotherapy and to biofeedback; the two treatments had similar effects on symptom reduction. Hawkins, Doell, Lindseth, Jeffers, and Skaggs (1980), concluded from a study with 40 hospitalized schizophrenics that thermal biofeedback and relaxation instructions had equivalent effect on anxiety reduction. Fehring (1983) found that adding GSR biofeedback to a Benson-type relaxation technique reduced anxiety symptoms more than relaxation alone."

* Much of the information provided here is from Carolyn Yucha and Christopher Gilbert's 2004 book "Evidence Based Practice in Biofeedback & Neurofeedback" AAPB, Wheat Ridge, CO.

 

Cognitive-Behavior Therapy for
Anxiety Disorders

 

New Review Shows Cognitive-Behavior Therapy Effective
With Disabling Anxiety Disorder

 

Source: Health Behavior News Service    Released: Thu 18-Jan-2007

Newswise — People with generalized anxiety disorder worry — about many things at a time — to the point that it interferes with their day-to-day living. Now, a newly published review of studies suggests that a specific type of psychotherapy is effective in reducing symptoms.

“GAD is a very common and extremely disabling condition and psychological therapies are a popular and widely used treatment for anxiety disorders,” said lead author Vivien Hunot, Ph.D. “The review showed that psychological therapy using a cognitive behavioral therapy approach is effective for GAD.”

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The review included 25 studies with 1,305 participants.

“Forty-six percent of people assigned to CBT [showed] some improvement in their anxiety symptoms at the end of treatment compared with just 14 percent assigned to a waiting list or usual care,” said Hunot, a senior research associate with the Institute of Psychiatry in London.

The studies in this review looked at cognitive behavioral therapy, a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Treatment involves recognizing unhelpful or destructive patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones.

Investigators compared results for generalized anxiety disorder patients who received CBT with those on a list awaiting therapy or receiving usual therapy. Treatment as usual was defined as any appropriate medical care delivered during the course of the study, including medications and/or psychological therapy.

The investigators also compared results for patients who received CBT versus other types of psychotherapy.

CBT patients were more likely to have reduced anxiety at the end of treatment than those treated as usual or on the waiting list.

Because of the small number of studies with a wide variety of differing results, no conclusions could be made reliably when CBT was compared to other forms of therapy such as psychodynamic or supportive therapy. In addition, none of studies looked at possible long-term effects of CBT.

“CBT has been shown to be a very effective therapy for other kinds of anxiety disorders and this review adds to the evidence that this is a very effective form of therapy,” said Wayne Katon, M.D., vice-chair in the department of psychiatry and behavioral sciences at the University of Washington School of Medicine. “I think it a hopeful message that there is a brief structured therapy that works for people with GAD.”

Katon joins with the Cochrane researchers in urging caution when looking at CBT versus other forms of psychotherapy.

“When CBT was tested against waiting-list controls, the studies included in their review tended to find clear evidence of its efficacy,” Katon said. “The results were more mixed compared to supportive therapies. I would agree with the authors of the need to do more head-to-head studies comparing CBT to other forms of therapy.”

The Cochrane reviewers also found that people attending CBT-based group therapy were more likely to drop out of studies than those placed on a waiting list or receiving usual care. In contrast, people attending individual CBT sessions were less likely to drop out.

“This may suggest that group therapy is less popular than individual therapy, although since reasons for dropout were underreported in studies, we cannot be certain that lower acceptability of group therapy influenced dropout rates,” Hunot said.

“The idea of using group therapy at the outset is hard for many patients and I am not surprised at higher dropout rates for groups than individuals,” Katon said. “It does point out that the strategy of using groups for initial treatment may not work for a lot of people.”

Published in:  Hunot V, et al. (2007). Psychological therapies for generalised anxiety disorder (Review). Cochrane Database of Systematic Reviews, 2007, Issue 1.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

Empirical Efficacy of CBT for Anxiety Disorders

Meta-analyses of CBT for anxiety disorders provide a snapshot of efficacy findings across a large number of treatment studies. Meta-analyses use effect-size statistics to capture the magnitude of the differences between disparate types of treatment (or treatment and controls); frequently, treatment differences are measured with Cohen's d effect size (ES) statistics. A Cohen's d effect size of 0.80 or higher is considered a large effect size or difference between groups, 0.50 represents a medium or moderate effect size, and 0.20 represents a small effect size. In translating a moderate effect size (d = 0.50) to the percentage of clients showing improvement, a recent study demonstrated clinically significant improvement in two-thirds of socially anxious patients in a CBT treatment group, versus one-third of patients in the active control group.

A review of meta-analyses of randomized, controlled trials by Butler and colleagues (Butler, Chapman, Forman, et al., 2006 in Clinical Psychology Review) revealed large effect sizes for CBT in treating a range of anxiety disorders, including panic disorder with or without agoraphobia, generalized anxiety disorder, social phobia, and posttraumatic stress disorder. Compared with no treatment, wait-list, or placebo controls, the comparison-weighted grand mean effect size of CBT across these anxiety disorders and uni-polar depression in adults and children was 0.95 (SD = 0.08) from pre- to posttreatment. These effects are consistent with a second, more recent meta-analysis of CBT for all anxiety disorders (with the exception of specific phobia) carried out by Norton and Price (2007 in Journal of Nervous & Mental Disease) which showed CBT to be more effective than no treatment or "expectancy control" (i.e., pill placebo, attentional placebo, nonspecific therapy) conditions across all anxiety disorders.

For panic disorder, a meta-analysis by Gould and colleagues (Gould, Otto, Pollack, et al., 1997 in Behavior Therapy) found that CBT yielded an effect size of 0.68, that was higher than the effect size for pharmacotherapy (ES = 0.47) or combined CBT and pharmacotherapy (ES = 0.56). More impressively, CBT showed no slippage of gains (ES = 0.6) at follow-up (usually about 6 months posttreatment) as compared to pharmacotherapy (ES = -0.46) and demonstrated lower attrition rates (6% with CBT vs 20% in pharmacotherapy and 22% in combined treatment).

For the treatment of generalized anxiety disorder (GAD), a carefully conducted meta-analysis by Mitte (2005 in Psychological Bulletin) found that CBT was superior to no treatment (ES = 0.82) and to medication and therapy placebo (ES = 0.57), with persistence of effects through at least 6 months follow-up.

For social anxiety, Gould and colleagues (Gould, Buckminster, Pollack, et al., 1997 in Clinical Psychology Science & Practice) showed equivalent pre- to posttreatment effects for CBT (ES = 0.74) and pharmacotherapy (ES = 0.62).

Interestingly, at least for generalized anxiety disorder and panic disorder, the addition of pharmacotherapy to CBT actually results in an increase in dropout rates as compared to CBT alone.