Anxiety disorders are a rapidly growing problem in the UK with 15% of the population suffering from anxiety disorders in 2007 compared to 13.3% in 1993 (Halliwell, 2009), clearly showing the increasing need for treatments and therapies. The American Psychological Association (APA) define anxiety as ‘feelings of tension, worried thoughts and physical changes like increased blood pressure.’ (http://www.apa.org, 2017).
Anxiety is a complex disorder, and therefore can be classified into many, more specific conditions, such as phobias and post-traumatic stress disorder (PTSD), which I will be concentrating on in this essay. Various explanations have been presented to explain the initial cause of anxiety disorder and therefore multiple therapies produced. I will be assessing the strength of evidence to support these treatments and any limitations that may impact their use.
PTSD can be defined as ‘a reaction to an extreme traumatic event’, including death or threat to physical integrity (Leahy, Holland and McGinn, 2000, pg181), these reactions often vary between each patient. The Bimodal reaction theory (as cited by Williams H 2017) describes the reactions of PTSD sufferers as either fight or flight, or freeze reaction, suggesting individual differences within the disorder, which treatment should adapt for. Phobias are extreme cases of fear where the fear the patient is experiencing is ‘out of proportion to demands of the situation, cannot be explained or reasoned away, is beyond voluntary control and leads to avoidance of feared situation’ (Fears and Phobias, Marks, 1969, page 3) There are multiple risk factors that may make people more vulnerable to developing anxiety. One of these risks is gender; women are four times as likely to develop PTSD compared to men, putting females at higher risk (as cited by Williams H 2017). It has also been argued that some people may have a genetic predisposition to developing anxiety. It is suggested that people vary genetically in their autonomic liability and therefore, people with a higher autonomic lability are more likely to develop anxiety. This increase in likelihood is due to the fact that arousal is more frequent and therefore the biological ‘fight or flight’ process is frequently triggered, a common symptom in anxiety sufferers (Katkin, E. S., & McCubbin, 1969)
The behavioural explanations of both phobias and PTSD suggest that fear is learnt through classical conditioning where a neutral stimulus is paired with a conditioned stimulus to producing an aversive response, and is negatively reinforced through reduction in arousal when avoiding the situation (Leahy and Holland and McGinn, 2000). Systematic desensitisation uses this theory to treat patients by asking the patient to develop a hierarchy of anxiety-provoking situations, from least to most. They are then gradually exposed to these situations whilst using breathing exercises and muscle relaxation until they are comfortable with each stage before moving on (I.M. Marks, 1969). This method works by removing the negative reinforcement of avoidance and encouraging the patient to unlearn the association of the event with the unconditioned response of fear.
This is supported by Rothbaum’s study in 1995, which looked into acrophobia. In this study Patients were exposed to virtual foot bridges that increased in heights. The control group used no relaxation technique, whilst the experimental group used relaxation therapy throughout. Results showed a reduction in fear for the experimental group, however no change in fear levels in the control (Rothbaum 1989, as cited by the APA). Thus supporting the idea that using relaxation techniques and regular exposure does help decrease fear levels.
However, it could be argued that although this research supports the use of systematic desensitisation, the strength of the evidence is questionable as it lacks ecological validity. The participants used computer-generated virtual reality in order to create the ‘heights’ they were being exposed to. Despite virtual reality being very true-to-life, the participants are aware that the situation they are in is not real and therefore may not produce accurate reactions and results may not be applicable to real-life experiences.
Systematic desensitisation can also be used in conjunction with pharmacological treatments to encourage patients to relax. Friedman, Silverstone and Oxon (1967) used systematic desensitisation and methohexitone sodium, which helps the patient to relax when working through anxiety hierarchy. Friedman, Silverstone and Oxon studied twenty patients with severe phobias and used and average of twelve systematic desensitisation sessions. During exposure to each new stage of the hierarchy, a 5% solution of methohexitone sodium was injected, aiding the patient to relax. After the treatment, patients fear levels were measured when exposed to their phobic situation. Results concluded that at the end of treatment 100 percent of patients showed a marked improvement in their phobic responses. These results were then followed up an average of ten and a half months later and 83 percent of these improvements had remained. These results support that pairing systematic desensitisation with pharmacological treatment is an effective treatment in anxiety both short term and preventing relapse.
An alternative treatment for PTSD is the use of Cognitive Behavioural therapy (CBT). Foa E.B. and Riggs D.S. came up with the emotional processing theory framework, which suggests that people with PTSD either ‘view the world as an exceptionally dangerous place’ or ‘see themselves as particularly incompetent people’ (Foa E.B. and Riggs D.S. 1993, as cited by Shubina 2015, page 210). It is these faulty beliefs as well as a shift of self-efficacy and negative automatic thoughts (NATs) that cause maladaptive behaviour. Therefore, challenging the validity of these faulty beliefs, eliminates of maladaptive behaviour. CBT addresses these issues through discussion at regular one hour sessions, as well as ‘homework’ set by the councilor for the patient to address independently (P. DePrince and R. Shirk, 2015). CBT, like systematic desensitisation, also uses exposure and relaxation training techniques to enable the patient to remain calm in distressing situations that may remind them of the event.
The use of CBT has gained support from many studies, including a systematic review by Bisson, J. and Andrew, M. 2013 of thirty-three studies which measured the decrease in PTSD symptoms after treatment. The results showed that the use of CBT showed a much larger reduction in symptoms compared to the control group, therefore supporting the use of CBT in the treatment of PTSD. Interestingly, the research also concluded that individual sessions of CBT showed a higher reduction of symptoms between two and five months later, compared to group sessions (Bisson, J. and Andrew, M. 2013). Therefore, one could argue that individual CBT is a better long-term solution that group CBT.
A limitation of this study is that it does not look into relapse rates of the patients studied. Relapse in PTSD patients is very common, Schumm, Pukay-Martin and Gore (2017) found that many patients relapsed after their first round of CBT. Schumm and colleagues also found that negative view on their progress, caused patients to develop more PTSD symptoms such as distress, and therefore only temporarily treated symptoms, before relapse. This suggests that although CBT is useful in treating PTSD on a short-term basis, for some patients it may not be a long-term cure and may require further treatment.
An additional problem with this research is that it only addresses the problem of PTSD independently, however research suggests that 80% of PTSD sufferers also suffer with another comorbid issue (Grinage 2003), such as depression or generalized anxiety disorder (GAD). Therefore, the results may not applicable to real-life situations, as it is unable to provide evidence for the success of CBT on comorbid disorders.
CBT can also be adapted for individual differences, such as culture. Support for culturally adapted CBT (CA-CBT) comes from research by Devon E. Hinton, Stefan G. Hofmann, Edwin Rivera, Michael W. Otto and Mark H. Pollack (2011). Hinton and colleagues used CA-CBT in female Latino patients with PTSD and compared these results with applied muscle relaxation (AMR). The Latino women were given fourteen weekly sessions of CA-CBT and completed a PTSD checklist before and after treatment. These PTSD scores showed a reduction of an average score of 69.8 before treatment to 39.1 after treatment, compared to the AMR condition whose scores reduced from 71.1 to 61.1, revealing CBT to have a greater decrease in symptoms and therefore a more effective treatment. Hinton and colleagues also measured these scores twelve weeks after treatment and found scores to be 36.4 on the PTSD checklist, providing evidence that this treatment has long term improvements.
Another psychological treatment commonly used for anxiety is psychoanalysis. Psychoanalysis was developed off the basis of Freud’s psychodynamic explanation, which looks at the power of the unconscious mind. This explanation suggests that when a patient experiences a traumatic event, the ‘ego’ feels threatened and as one of its defense mechanisms, it represses the memory into the unconscious mind. However, when the memory is repressed it cannot be dealt with, additionally when the conscious mind is weak (often when the patient is experiencing anxiety) the memory is brought back out from the unconscious mind and causes recurring trauma, without being able to deal with the cause.
This treatment works by looking at the relationship between the patient’s development in early life and the current problems they are facing. The psychologist can use free association to allow the patient to talk about whatever they want and therefore can explore all areas of the patient’s life and each treatment is tailored to the patient’s individual case. The treatment aims to move the memories from the unconscious thought to the conscious so that the patient can understand their feelings towards it, rather than avoiding and suppressing them. Psychotherapy focusses on grief, role dispute and role transition (Markowitz, and colleagues 2009, as cited by Klein Rafaeli).
The use of psychotherapy has been supported by work from Bleiberg KL, Markowitz JC, who ran a study using fourteen patients suffering with PTSD, according to DSM-IV guidelines, who were given fourteen weeks of psychotherapy. Results revealed that, of the thirteen patients who completed the treatment, twelve of them no longer met the criteria for PTSD, therefore showing strong support for the use of psychoanalysis (Bleiberg & Markowitz, 2005).
Not only did it show a decrease in PTSD itself, the research also took into consideration depressive symptoms, anger reactions, and interpersonal functioning, which are common comorbid issues with PTSD, and therefore the findings can be generalised to a wide variety of PTSD sufferers. A limitation of this research is that it lacks population validity, as the sample size used was only fourteen participants and therefore their results may not be representative of the wider population, as their results could be subject to individual differences. However, a limitation of using psychoanalysis could be that the psychodynamic theory is unfalsifiable (Popper 1963, as cited by Tijiattas 2001), as there is no empirical way to test the existence of the ‘ego’ or ‘unconscious mind’ and as a result, cannot be proven correct. Consequently, the use of this treatment is questionable as should psychologists be using a treatment that they cannot scientifically explain.
Overall there is strong support for the use of psychological therapies. The variety of types of CBT, such as culturally specific, individual and group sessions, enable treatment of a large variety of patients can adapt for individual differences, compared to systematic desensitisation which follows a regulated procedure and therefore may not be applicable to all patients. However, both systematic desensitisation and CBT create personalized hierarchies when treating phobias and PTSD, which allows the patient to adapt the treatment to their specific situation. Both systematic desensitisation and CBT look at biological and cognitive causes of PTSD and phobias, which are strongly supported with empirical evidence, however the use of psychotherapy lacks scientific understanding and therefore could be argued that it should not be used on patients if the mode of action is unknown. To conclude, there is some support to support the use of psychological therapies in treating anxiety, however CBT receives the strongest support in its use for a variety of patients and in treating the comorbid issues that are often experienced.
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