Hari Srinivasan
Psych 135 Treatment of Mental Illness
Prof Alison Harvey
CBT vs CBT+ABFT for Adolescents with Anxiety
The intervention chosen for this paper was Cognitive Behavior Therapy (CBT) for generalized anxiety disorder (GAD). I am no stranger to CBT having gone to bi-monthly sessions to deal with my anxiety and mood disorder for most of my teen years while living in South Bay. Anxiety and depression come with the territory of the frustrations of living a life with a disability, autism in my case.
What was interesting about this study by Siqueland, Rynn and Diamond is not only in its use in the adolescent population but also in trying to see if the combination of CBT and ABFT (Attachment Based Family Therapy) would have better efficacy than just CBT alone. ABFT attempts to also address the interpersonal relationship component that teens have with their parents.
The efficacy of CBT is well supported by independent and well designed studies. The basic presumption of CBT is that thoughts and feelings influence our behaviors and vice versa. Ergo, changing our negative thinking will result in lesser anxiety.
The fundamental underlying symptom that characterizes GAD is excessive and uncontrollable worrying. This worry is perpetuated by a cycle of “maladaptive thinking” about the idea of worrying itself. This catastrophic spiral of negative automatic thoughts means, an inability to relax and further maladaptive behaviors that include avoiding any situations, images or thoughts that may provoke worry.
The need of the hour is cognitive restructuring which aims to modify the cataclysmic thought patterns and belief systems and the change the mistaken impression that worrying serves an useful function. Essentially, cognitive therapy techniques according to the study “focuses specifically on negative predictions about the future, and unhelpful attitudes about one’s ability to cope with difficult situations.”
For instance, one of my CBT exercises for several months was to keep a journal of my thoughts every 20 minutes for 2 hours every day 3x a week. An example follows:
Thought: “Orientation schedule is making me dizzy. I’m gonna fall apart there.”
Feeling association with thought: anxious, scared
Cognitive Distortion: All or nothing - thinking in absolutes
Reframe: Go with do what you can then come right back home.
Therapy techniques incorporate a scheduled “worry time” in order to control and limit exposure to the activities and situations that bring about worry. Pleasurable activities are also incorporated into the day’s schedule as well and the person is taught relaxation techniques.
CBT techniques offer a controlled systematic exposure so that the person learns that their fears of negative outcomes do not necessarily come true. This means that over time, they experience a reduction in their anxiety.
The study being discussed by Siqueland, Rynn and Diamond was done over two phases. The goal of Phase 1 was therapist training and checking the feasibility and acceptability of the combined condition (CBT-FAM). Phase 2 focused on implementing both the individual CBT and CBT-FAM.
Participants enrolled in the study were between the ages of 12-18 and had to meet the DSM-IV criteria for either GAD, Separation Anxiety Disorder or Social Phobia. A parent or caregiver also had to participate in the family treatment component. Participants were recruited through CARes (Child and Adolescent Research Service) at the University of Pennsylvania. Measurements were taken post-treatment and at the 6 and 9 month follow ups.
The 16 session CBT for adolescents was modified from a standard manual designed for children (ages 8-13). There were 2 parent sessions as well.
Skill building in the sessions focused on four areas ‘“(a) recognizing anxious feelings and somatic reactions to anxiety, (b) clarifying cognition in anxiety provoking situations (unrealistic or negative attributions), (c) developing a plan to cope with the situation (modifying anxious self-talk into coping self talk as well as determining what coping actions might be effective), and (d) evaluating performance and administering self-reinforcement as appropriate.’’ Other behavioral techniques included contingent reinforcement and relaxation techniques. A “FEAR” acronym was used - “F: feeling frightened/anxious, E: expecting bad things to happen, A: actions and attitudes that help, and R: results and rewards.”
The results of Phase 1 were not definitive but encouraging enough to proceed to phase 2. The post treatment outcome for phase 2 showed that for CBT alone, 67% (4 out of 6) of the adolescents no longer met their primary anxiety diagnosis, while it was 40% (2 of of 5) for the CBT-FAM. When parenting variables are taken into account, the CBT group reported an increase in psychological control while the combined group reported the opposite. Follow up measures also favored CBT where 100% no longer met the diagnostic criteria compared to 80% in the combined group. Essentially the results for adolescents lined up with those for children in other studies, that is, two thirds no longer met their initial diagnosis
The study admits they were “not sufficiently powered to detect treatment differences.” The sample size was small and there was no control group. The study also failed include comorbidity such as suicide risk, OCD, Bipolar Disorder etc. However it did allow for the medication as long as it had been started 8 weeks before and would not be changed during the study.
It appears from the results of the study that CBT wins hands down as the treatment for anxiety disorders. However this has to tempered with the disappointment of the exclusion of comorbidity which is often the norm and not the exception in the real world when it comes to mental health. From personal experience I also have to wonder if 16 weeks is really enough. Mental health is not like a infection that can quickly be killed by a course of antibiotics.The circumstances and challenges in one’s life keep changing over the decades and there may be some maintenance CBT required, in only to keep the person from slipping back.
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