How effective is CBT for anxiety?

1.

Elsevier ClinicalKey Derived Clinical Overview

• Recent systematic review of RCTs demonstrate that cognitive-behavioral therapy (CBT) and short-term psychodynamic therapy are reliable first-line psychotherapies. • Cognitive-behavioral therapy (CBT), in particular panic control treatment (PCT), is generally very effective, with strongest results for cognitive restructuring (i.e., challenging catastrophic misinterpretations of somatic symptoms), in vivo or imaginal exposures (i.e., exposure to panic triggers in a controlled graded hierarchical fashion from least to most difficult with the goal of habituation and extinction of the fear response), and interoceptive exposures (i.e., repeated recreation and management of feared somatic sensations via activities such as chair spinning, straw breathing, and hyperventilation)., • CBT effect sizes are equal to or larger than for pharmacotherapy, attrition rates are lower, and relapse rates are lower. Treatment may take several sessions spread over weeks and may require referral to a behavioral specialist. CBT has been shown to be the most effective intervention for panic disorder with or without agoraphobia across treatment sites. CBT may also be effectively delivered online (e.g., iCBT). • A recent dismantling study of cognitive-behavioral therapy components for panic disorder suggests that interoceptive exposure and a face-to-face setting were associated with better treatment efficacy whereas muscle relaxation and virtual reality exposure were associated with significantly lower efficacy.

2.

Lyness, Jeffrey M., Lee, Hochang B. (2024). In Goldman-Cecil Medicine (pp. 2336). DOI: 10.1016/B978-0-323-93038-3.00362-2

Empirical evidence from controlled trials demonstrates the efficacy of cognitive-behavioral psychotherapies for most of the anxiety disorders.The behavioral component of such therapies uses the principles of learning theory to extinguish unhelpful behavior and positively reinforce more functional behavior. The cognitive component of the therapy helps the patient learn to identify and correct the dysfunctional patterns of thinking (“automatic thoughts”) that underlie or trigger the cognitive-physiologic cascade of pathologic anxiety responses. Cognitive-behavioral therapy may be used as sole therapy, particularly for specific phobias, or in combination with pharmacotherapy for panic disorder and social phobia. Although cognitive-behavioral therapy may be administered in individual therapy with the patient, it also may be used as part of family therapy (e.g., to help family members avoid behavior that inadvertently reinforces the patient’s symptoms) or in group therapy settings. When available, cognitive-behavioral therapy generally should be a first-line approach for most outpatients with most anxiety disorders. Pharmacotherapy should be combined with cognitive behavioral therapies for more severe or treatment-refractory anxiety disorders.Although anxiolytic drugs such as the benzodiazepines (Table 362-9) will usually relieve acute anxiety symptoms, for most patients they should not be the mainstay of chronic treatment because of concerns about their long-term efficacy and side effects (e.g., risk for abuse, risk for neurocognitive impairment or falls). Antidepressant medications (seeTable 362-5) are the better pharmacologic agents for most anxiety disorders.In general medical settings, SSRIs including sertraline and paroxetine are often first-line choices for panic disorder, generalized anxiety disorder, and social phobia, although most antidepressants, with the probable exception of bupropion, can be helpful.,β-Adrenergic blockers have been used for sympathetic symptoms of anxiety in acute situations for which benzodiazepines might unacceptably impair performance (e.g., public speaking, stage performance) but do not address other symptoms and are not recommended for longer-term use in panic disorder or phobias.

3.

Kim, Rosa K. (2025). In Nelson Textbook of Pediatrics (pp. 246). DOI: 10.1016/B978-0-323-88305-4.00038-9

Cognitive-behavioral therapy (CBT)is a therapy that targets the cognitions, behaviors, and physiologic symptoms of anxiety, with a particular focus on the interconnections between the three. Its framework typically involves homework assignments for practicing the skills in real-life environments. The goal is to achieve functional improvement within approximately 18 sessions. Because it is a skills-based treatment, CBT is thought to be a durable treatment, an important consideration when treating children and adolescents. It is specifically recommended to patients 6-18 years old with social anxiety, generalized anxiety, separation anxiety, specific phobia, and panic disorder. Specialized training and experience are paramount to the effective delivery of this treatment modality, and it is worth taking the time to ensure that patients identify therapists with the training and experience to provide rigorous CBT. CBT typically should incorporate graduated exposure, in which stepwise mastery of a hierarchy of fearful stimuli results in desensitization. Family therapyis often needed as an adjunct to CBT. Its focus is to improve relationships, strengthen problem-solving and communication skills, address parental anxiety, and foster adaptive coping within the family unit. School-directed interventions can also be an important component of treatment, and specific plans for anxiety management can be included in a child’s 504 plan or individualized education plan (IEP). The therapy with the most evidence for PTSD is a subtype of CBT called trauma-focused CBT (TF-CBT). Given that standard anxiety medications are less effective in PTSD, it is particularly crucial that clinicians refer these patients to trauma-focused therapy. In TF-CBT, the therapist amplifies stress management techniques in preparation for exposure-based interventions with the goal of achieving mastery over trauma triggers. In small adult trials, ketamine- or 3,4-methylenedioxymethamphetamine (MDMA)-assisted therapy have shown benefit. There is insufficient evidence to currently recommend either therapy.

4.

Elsevier ClinicalKey Clinical Overview

Treatment CBT is the preferred psychotherapy for adolescent anxiety, given the robust empiric support and recommendations of national and international guidelines Sessions can include individual therapy, group therapy, and family therapy Interventions include: Psychoeducation about anxiety and fear Exposures to the feared stimulus/situation Cognitive and behavioral coping strategies Somatic management strategies Problem-solving Behavioral skills rehearsal (eg, social skills) Reinforcement of progress by self and others in the adolescent’s life CBT with parent/caregiver involvement is effective for treating adolescent anxiety Acceptance and commitment therapy (ACT) may be another evidence-based treatment option for adolescents with anxiety There is also evidence that mindfulness-based stress reduction (MBSR) can reduce anxiety symptoms in adolescents Collaborate with school personnel as indicated Continue collaboration with treatment team members throughout therapy, especially the patient’s primary therapist

5.

Elsevier ClinicalKey Clinical Overview

Treatment Direct all patients and their families to self-help internet sites for education on generalized anxiety disorder (eg, Anxiety and Depression Association of America Educate patients on lifestyle changes that may help reduce symptoms Improving quality and quantity of sleep Regular exercise Exercise has been shown to have significant ability to reduce anxiety symptoms and is encouraged Minimizing caffeine and alcohol intake Avoiding nicotine and other drugs Psychotherapy Cognitive behavioral therapy Multiple types of psychotherapy have been applied to the treatment of generalized anxiety disorder, with evidence strongest for the efficacy of cognitive behavioral therapy Recommended for all patients, although use may be guided by resource availability, patient finances, or patient preference Teaches patients to substitute positive thoughts for anxiety-provoking ones Brief description: Present a cognitive model of anxiety to the patient and train in self-monitoring and identification of cues that contribute to interpretations of threat Inform patients that therapy focuses on learning different, less anxiety-provoking ways of viewing the self, the world, and the future Use standard cognitive therapy procedures (eg, outlining cognitive predictions, interpretations, beliefs, and assumptions that lead to threatening perceptions); emphasize Socratic method (ie, stimulate critical thinking by asking and answering questions) Focus discussions on multiple alternative perspectives for any given situation of daily living; homework emphasizes frequent applications of alternative perspectives and behavioral tasks Reduction in intolerance of uncertainty is an important predictor of outcome Therapy can be delivered in 6 to 12 sessions at weekly intervals

6.

Lee, Erica H., Sinclair-McBride, Keneisha R., DeMaso, David R., Walter, Heather J. (2025). In Nelson Textbook of Pediatrics (pp. 231). DOI: 10.1016/B978-0-323-88305-4.00034-1

Cognitive-behavioral therapy (CBT) is based on social and cognitive learning theories and extends behavior therapy to address the influence of cognitive processes on behavior. CBT is a short-term, problem- and goal-oriented treatment centered on correcting problematic patterns in thinking and behavior that lead to emotional difficulties and functional impairments. The CBT therapist seeks to help the patient identify and change cognitive distortions (e.g., learned helplessness, irrational fears); identify and incrementally approach aversive situations; and identify and practice distress-reducing behavior.Self-monitoring(daily thought records),self-instruction(brief sentences asserting thoughts that are comforting and adaptive), andself-reinforcement(rewarding oneself for adaptive behaviors) are key tools used to facilitate achievement of the CBT goals. CBT has good-quality evidence for the treatment of anxiety, obsessive-compulsive disorder (OCD), behavior disorders, substance abuse, and insomnia, and fair evidence for the treatment of depression. For many childhood psychiatric disorders, CBT alone provides outcomes comparable to psychotropic medication alone, and the combination of both may convey additional benefit in symptom and harm reduction. Modified versions of CBT have shown applicability to the treatment of other disorders.

7.

Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJ. How Effective Are Cognitive Behavior Therapies for Major Depression and Anxiety Disorders? A Meta-Analytic Update of the Evidence. World Psychiatry : Official Journal of the World Psychiatric Association (WPA). 2016;15(3):245-258. doi:10.1002/wps.20346.

Publish date: October 6, 2016.

We report the current best estimate of the effects of cognitive behavior therapy (CBT) in the treatment of major depression (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD), taking into account publication bias, the quality of trials, and the influence of waiting list control groups on the outcomes. In our meta-analyses, we included randomized trials comparing CBT with a control condition (waiting list, care-as-usual or pill placebo) in the acute treatment of MDD, GAD, PAD or SAD, diagnosed on the basis of a structured interview. We found that the overall effects in the 144 included trials (184 comparisons) for all four disorders were large, ranging from g=0.75 for MDD to g=0.80 for GAD, g=0.81 for PAD, and g=0.88 for SAD. Publication bias mostly affected the outcomes of CBT in GAD (adjusted g=0.59) and MDD (adjusted g=0.65), but not those in PAD and SAD. Only 17.4% of the included trials were considered to be high-quality, and this mostly affected the outcomes for PAD (g=0.61) and SAD (g=0.76). More than 80% of trials in anxiety disorders used waiting list control groups, and the few studies using other control groups pointed at much smaller effect sizes for CBT.