Is there strong evidence for the use of psychological therapy for treating anxiety disorders?
Anxiety is a feeling which is characterised by nervousness and distress due to a sense of uncertainty of future events. It is entirely normal to feel worried under certain circumstances, however it becomes an issue when this anxiety starts to affect day to day life (NHS website). Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder which occurs after a person has experienced a dangerous or life-threatening event. PTSD could be caused by a one-off event, such as an assault, or by a form of continuous trauma, such as what is experienced by military personnel that work in combat (NHS website). Psychological therapies are a common treatment for mental health disorders that are based around the patient communicating their problems with a therapist. There are many types of psychological therapies, which take slightly different approaches in managing the concerns of the patient.
This essay intends to discuss the evidence of effectiveness for Cognitive Behavioural Therapy, due the large extent of its use throughout clinical psychology – before comparing it to other forms of psychological therapy for PTSD. Thirdly, this essay will take into account other practices of therapy such as medication. Finally, a multi-disciplinary approach will be considered, in order to investigate if that provides more effective results than a single mode of therapy being used by itself, and patients’ preferences will be discussed.
A very commonly used psychological therapy is Cognitive Behavioural Therapy (CBT). The behavioural aspect is based off the idea that emotional problems are learned, and that these problems can be resolved by applying learning principles to them. The cognitive aspect focuses on the importance of cognitions such as thoughts and beliefs (Marzillier & Hall, 1999, p. 38).
Kar (2011) did a meta-analysis reviewing the effectiveness of CBT in the treatment of PTSD. It focuses on the result of CBT following various forms of trauma, the methods used within CBT and its potential to prevent PTSD (Kar, 2011). The study found that for both acute and chronic PTSD, CBT is an effective and safe method of intervention for a range of types of trauma. However, the number of people that have no response to the treatment can reach up to 50% depending on factors such as comorbidity (Kar, 2011). With a high nonresponse rate to the treatment it suggests it is difficult to draw conclusions about the extent of the effectiveness to different populations.
It also makes it difficult to conclude how effective CBT is on different types of anxiety disorders. A meta-analysis study, on remission of anxiety disorders using CBT, found evidence to suggest that CBT brought about higher remission rates in PTSD than it did in other anxiety disorders such as Obsessive-Compulsive Disorder (OCD) and Social Anxiety Disorder (Springer, Levy & Tolin, 2018). This suggests it would be problematic to try and find a general conclusion and apply this to many anxiety disorders. It would be more beneficial to consider the evidence of CBT effectiveness for each anxiety disorder individually, to draw specific conclusions for each disorder. This approach would provide more valid evidence.
Springer, Levy and Tolin (2018) suggested that although CBT is empirically supported by evidence, there is a clear room for improvement of the methods. Monson et al. (2006) compared the effectiveness of CBT to a control group that was put on a waiting list for treatment. They found a significant reduction of the severity of symptoms – after the treatment, 40% of the CBT group and only 3% of the control group no longer met the diagnostic criteria for PTSD (Monson et al., 2006). This research provides reasonably strong evidence in support for the use of CBT in the treatment of PTSD. However, this evidence only compares to a non-treatment control group and so does not compare the effectiveness of CBT to other types of psychological therapy.
Eye Movement Desensitisation and Reprocessing (EMDR) is used to relieve psychological stress through interactive techniques. During the sessions, traumatic memories of trauma are recalled in brief doses while the therapist directs your eye movement. (Gotter, Healthline, 2017). When the therapist is directing your eye movements it diverts your attention from the memories you are recalling and so reduces how distressing this memory becomes. The exposure to these memories, with lower levels of distress, is thought to ease the impact of these thoughts over time (Gotter, Healthline, 2017). Seidler and Wagner (2006) completed a meta-analysis of seven studies comparing CBT and EMDR and found that they were both equally effective at reducing the PTSD symptoms; they also found that CBT and EMDR were found to be more effective than other therapies. This gives strong evidence in support to the use of psychological therapy, while also narrowing down on the most effective types being CBT and EMDR.
Psychodynamic Psychotherapy (PDT) is another type of psychological therapy that approaches treating PTSD by focusing on factors such as early childhood, current relationships and how people protect themselves from thoughts and feelings. (Tull, 2018). This form of therapy places importance on the unconscious mind; suggesting that repression of these thoughts and feelings, to protect ourselves, still has an impact on our behaviour (Tull, 2018). Paintain and Cassidy (2018) examined many studies comparing the effectiveness of CBT and PDT, and the conclusion of this suggested PDT to be an effective approach. However, in terms of relativity, there is more evidence in favour of CBT suggesting it to be the more successful treatment (Paintain & Cassidy, 2018). As CBT is the first-line treatment for PTSD, these results suggest that this is good guideline. In practice PDT could be used as an alternative to CBT in situations where the patient was not responding to CBT (Pantain & Cassidy, 2018). This evidence supports the use of PDT as a psychological therapy as the research showed improvements from pre-treatment to post-treatment, however it also implies that different psychological treatment approaches have different levels of effectiveness. This suggests in order to draw more accurate conclusions of the efficacy of psychological therapies, you need to consider them separately.
Another approach to treating anxiety disorders such as PTSD could be through the use of medication, instead of through psychological therapy. Symptoms of PTSD such as depression and anxiety have been shown to be reduced by the use of antidepressants (U.S. Department of Veterans Affairs website, 2017). Antidepressants affect certain chemicals (e.g. serotonin) that occur naturally in the brain and factor into the way we feel and how the cells in the brain communicate (U.S. Department of Veteran Affairs website, 2017).
Serotonin is an important part of regulating body functions such as mood, anxiety, sleep and appetite (Jeffereys, 2011). A study by Davidson (1997) on tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), which are two types of antidepressant, found that they demonstrated efficacy in long-term and larger trials of the drugs. This suggests the use of antidepressants as an alternative to psychological therapies is a successful one as they produced the intended result in treating PTSD. The use of antidepressants may be preferred by some as making regular therapy appointments may be disruptive to their daily life, especially if patients have kids or other forms of dependent family to look after.
Berger et al. (2017) found that approximately 60% of patients with PTSD that used SSRIs had an overall response to the treatment. However, they also found that only 20% to 30% of the patients managed to reach full remission (Berger et al. 2017). This suggests that the use of SSRIs is useful in improving the quality of life for those living with PTSD as it reduces the symptoms; this could make the use of psychological therapies less necessary as antidepressants works as an effective alternative.
Another factor to be considered is that often the use of antidepressants brings accompanying side effects. It is questionable whether the positive effects of the antidepressants outweigh the negatives of the side effects. Possible side effects that people have experienced from taking SSRIs include indigestion, blurred vision and a loss of sex drive (Flanagan, Berry, Jarvis & Liddle. 2015). Tricyclics have more severe side effects, with some people experiencing tremors, weight gain and few people having more serious problems such as disruption to blood pressure and heart rhythm (Flanagan, Berry, Jarvis & Liddle. 2015). This factor works as a support for psychological therapies as they don’t produce side effects which may make them a more appealing and safe option – this suggests it would make more sense to use them.
Another form of treatment is to take less of a reductionist approach by using forms of therapy from multiple approaches. This can be done through using a biological approach through the use of medication and cognitive and behavioural approaches with the use of CBT. Hetrick, Purcell, Garner, and Parslow (2010) carried out research of the use of any psychological therapy and pharmacotherapy and followed with a comparison to each intervention alone, placebo and those on a waiting list. The patients were tested for a change in the severity of their PTSD symptoms as a way of calculating the efficacy of the different methods.
One of the trials was done on children and adolescents, with which the patients used an SSRI and underwent a form of cognitive behavioural intervention (Hetrick, Purcell, Garner & Parslow. 2010). Other trials in the same study were done similarly with various forms of psychological therapy combined with pharmacological treatment. It was reported that there were no significant differences between combination and single intervention groups (Hetrick, Purcell, Garner, & Parslow. 2010). This suggests that the current data does not support the use of combination therapy as it does not prove to be more effective than the use of a psychological therapy alone. This provides strong evidence for the use of psychological treatments as it suggests that the adoption of a biological approach is not needed in combination as it is just as effective by itself.
A study was done by Cochran, Pruitt, Fukuda, Zoellner and Feeny (2008) which explored the preferences that women have on different treatments and the factors that influence these preferences. The participants were asked to read options of standardised treatments and hypothetically make a choice on which they would favour. While the effectiveness of the treatments was what was mostly considered by the participants, they also cited reasons such as wariness of the effects of medication and positive thoughts associated with talking through their problems in psychotherapy (Cochran, Pruitt, Fukuda, Zoellner, & Feeny (2008). This supports the use of psychological therapies as the procedure is favoured, which could mean they would have lower dropout rates and that patients may be able to engage more with the treatment. However, the participants for this investigation were all women so it may not be generalisable to men, giving it limited validity.
In conclusion, the evidence has shown that the psychological therapies used in treating PTSD can be highly effective in reducing the symptoms, however they may not have the methods to enable the individual to return to their pre-trauma levels. Despite not necessarily being able to bring about full remission in every patient, this does not mean that there aren’t effective results; these benefits make the treatments valuable for the quality of life of the sufferers.
Research into the use of these treatments has consistently shown the efficacy of them and refined the most effective of them to be at the front-line use. While there may be issues of validity in some studies, the large supply of evidence predominantly points in the direction for the use of these types of therapy of which the majority will have good validity. This provides strong evidence and explains why psychological therapies are so widely used in the treatment of anxiety disorders – they may not have faultless results but they undeniably are some of the best treatments available.
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