Cognitive therapy pharmacotherapy and a combination of both
Rapid growth in cognitive science has led to improved psychological treatments for anxiety disorders. These models have led to empirically validated treatment approaches for anxiety. Cognitive-behavioural therapy CBT is a time-limited, present-oriented approach to psychotherapy that teaches patients the cognitive and behavioural competencies needed to function adaptively 9.
The relative efficacy cognitive therapy pharmacotherapy and a combination of both CBT and medication alone or of the two in combination is now being studied. This research trend is particularly relevant to clinicians treating patients with anxiety disorders. Some important questions to consider are as follows: Is it best to start a medication first to promote quicker entry into feared situations?
Should CBT be administered sequentially to medication to decrease relapse rate? Might CBT interventions be used most effectively to augment gains in partial responders to pharmacotherapy? These commonly encountered questions are the impetus for this article, which describes an empirically proven cognitive-behavioural approach to anxiety disorders and then reviews recent literature that has begun to examine some of the advantages and disadvantages of combining medication and CBT.
A comprehensive review of CBT is beyond the scope of this article. Simply put, however, most variations of CBT for anxiety disorders include as central components exposure and exploration of thoughts about feared situations. Exposure techniques are designed to help patients face the situations they fear and yet stay psychologically engaged, so that the natural conditioning processes involved in fear reduction for example, habituation and extinction can occur.
As a first step, patient and therapist develop a rank- ordered list of anxiety-provoking situations. To keep anxiety within a tolerable range, the patient begins by facing the least-feared situation; as mastery of the lesser situations is achieved, the patient approaches increasingly more difficult situations. Cognitive therapy pharmacotherapy and a combination of both is also important for patients to examine their thoughts about feared situations and the beliefs that may underlie them.
In cognitive restructuring, individuals are taught to 1 identify negative thoughts that occur before, during or after anxiety-provoking situations; 2 evaluate the accuracy cognitive therapy pharmacotherapy and a combination of both their thoughts in light of data derived from Socratic questioning or as a result of so- called behavioural experiments; and 3 derive rational alternative thoughts based on acquired cognitive therapy pharmacotherapy and a combination of both.
Cognitive restructuring techniques contain a significant exposure component; however, exposure in this context cognitive therapy pharmacotherapy and a combination of both on collecting information that will allow patients to revise their judgements about the degree of risk to which they are exposed in feared situations.
The essence of both exposure and behavioural experiments is to engineer fear-arousing situations in which the patient is expecting unrealistically that something bad will happen but in which the negative consequences do not occur. Methodological limitations in some of these studies excluded them from a recent meta-analysis undertaken by Foa After setting stringent inclusion criteria, this author reviewed 10 studies and calculated within-subject effect sizes to compare treatment conditions within and across studies.
The results suggest that combining CBT and medication may have differing effects across anxiety disorders. A more complex picture emerges from the few studies allowing a direct comparison of combined treatment and pharmacotherapy alone.
Franklin and others have reported preliminary data showing that CBT in combination with medication is better than medication alone for the treatment of OCD Similarly, preliminary results by Connor and others suggest that adding CBT to sertraline substantially improved a modest response in PTSD patients In contrast, a recent one-year follow-up of SAD patients treated with placebo, exposure, exposure plus sertraline or sertraline alone found that only those treated with exposure alone or placebo alone did not deteriorate after the completion of treatment This suggests that there may be a negative effect of simultaneously combining medication and CBT for the treatment of SAD.
A negative benefit of combined treatment has been more clearly shown with PD. Two studies of combined treatment of PD showed that the addition of medication interfered with long-term maintenance of gains arising from CBT 19, A plausible explanation for these findings is found in the cognitive model of panic.
It is postulated that panic patients are hyper- sensitive to anxiety-related physiological responses such as tachycardia or dizziness.
Moreover, these physiological responses are interpreted as potentially dangerous; that is, as signs of impending heart attack or seizure. For PD, CBT is designed to elicit such responses, with the absence of the anticipated disaster providing corrective information about their safety. Cognitive therapy pharmacotherapy and a combination of both diminishes anxiety responses and thus may interfere with CBT exercises aimed at allowing patients to understand their erroneous beliefs about these responses.
Several methodological limitations bear mentioning. First, many studies of combined treatment define combined as simultaneous treatment; however, sequential treatment may be more optimal and better reflect clinical reality. Further, studying the interaction between medication and CBT is daunting because there is little a priori reason to assume that all medications combine with CBT in the same way. Medications with more intrusive side effects may lead the person to attribute positive changes to the medication 21 and to be more vulnerable to relapse.
Similarly, we cannot automatically assume that different dosages will combine in the same way with CBT. Modest dosages of benzodiazepines may facilitate approach to a feared stimulus when treating a specific phobia; however, larger dosages may reduce the efficacy of exposure by inhibiting the physiological arousal necessary for habituation and extinction to occur. The limited number of studies thus far, as well as methodological limitations, make it difficult to draw conclusions about combined treatments across different anxiety disorders, different CBT protocols and different medication classifications.
These studies of combined CBT and medication raise several therapeutic points. First and foremost, it is important for clinicians to be aware of empirically proven treatments to provide a rationale cognitive therapy pharmacotherapy and a combination of both anxiety patients for choosing CBT, medication or both. Second, the addition of CBT has never been found harmful and may cognitive therapy pharmacotherapy and a combination of both decrease relapse.
Further, the benefit of adding basic principles of CBT to the pharmacologic treatment of anxiety requires further exploration. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder.
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Science and practice of cognitive therapy. Oxford University Press; Anxiety and its disorders: Clark DM, Wells A. A cognitive model of social phobia. A cognitive-behavioral model of anxiety in social phobia. A guide to treatments that work. Fedoroff IC, Taylor S. Psychological and pharmacological treatments of social phobia: J Clin Psychopharmacol ; Westen D, Morrison K. A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: J Consult Clin Psychol ; A meta-analysis of the treatment of panic disorder with or without agoraphobia: J Nerv Men Dis ; Context in the clinic: How well do cognitive-behavioral therapies and medications work in combination?
Cognitive behavioral group therapy vs phenelzine therapy for social phobia: Arch Gen Psychiatry ; Cognitive therapy pharmacotherapy and a combination of both group therapy versus phenelzine in social phobia: A controlled study of exposure therapy, clomipramine, and combination for OCD. A controlled trial of combined sertraline and prolonged exposure therapy in posttraumatic stress disorder. Eur Neuropsychophamacol ;12 Suppl 3: Exposure therapy and sertraline in social phobia: I-year follow-up of a randomised controlled trial.
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Residents Psychotherapy Training and Empirical Evidence: Research Briefs Nouvelles de la recherche. Call for Nominations Appel de candidatures.
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