Which type of therapy focuses on replacing maladaptive actions with more adaptive ones?

DESCRIPTION

• Cognitive behavioral therapy (CBT) is an empirically supported approach to psychotherapy characterized by teaching the patient a set of coping skills.
  • The skills are intended to modify maladaptive cognitions, behaviors, and physiological responses that maintain and/or exacerbate psychopathology.
• The approach is present–focused and problem-specific.
  • CBT sessions are structured and goal-oriented.
  • The course is time-limited (typically one hour session per week for 10-20 weeks), and the CBT therapist is directive- and action-oriented.

MECHANISM

The mechanisms of action are unclear but researchers have explored:

• Cognitive mechanisms: Increase in adaptive cognitions may occur through restructuring of maladaptive thought patterns, correction of misinterpretations, changes in attentional focus, and development of adaptive coping thoughts.
• Behavioral mechanisms: Increase of adaptive behavioral responses may occur through habituation, extinction of maladaptive responses, behavioral activation, associative learning, and reinforcement of adaptive responding.
• Physiological mechanisms: Normalization of physiological arousal may occur through habituation, incompatible response training, and changes in autonomic nervous system activity.

INDICATIONS

• In adults, studies evaluating CBT have reported positive outcomes with a variety of disorders including:
  • Anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia and generalized anxiety disorder)
  • Obsessive compulsive disorder
  • Post-traumatic stress disorder
  • Depression
  • Eating disorders (bulimia nervosa)
  • Personality disorders (e.g., dialectical behavior therapy for borderline personality disorder)
  • Substance use disorders
  • Chronic pain and medical conditions (e.g., headaches, insomnia)
• CBT can also be an effective adjunctive treatment for patients with bipolar disorder and schizophrenia when used in combination with medication[1][2].
• In children and adolescents, CBT has been found effective in treating anxiety disorders, obsessive compulsive disorder, body dysmorphic disorder, post-traumatic stress disorder, depression, tic disorders and Tourette’s syndrome, eating disorders, oppositional defiant disorder, and chronic pain and medical conditions (headaches, recurrent abdominal pain)[1][2].

CONTRAINDICATIONS

• For patients with significant illness, such as a severe mood disorder for example, providers may need to initiate a trial of medications prior to starting CBT in order to facilitate session attendance and adherence.
• Individuals with very limited intellectual functioning may not fully benefit from CBT.
• CBT strategies should be modified/adapted for use with special groups (e.g., older adults, young children) to ensure it is delivered in a developmentally appropriate and culturally competent manner.
• CBT therapists should routinely monitor the need for alternative treatments for comorbid conditions (e.g., in patients who are suicidal).

TECHNIQUE

• CBT typically consists of 10-20 sessions, lasting approximately one hour, once per week, that are delivered individually, with a family, or in small groups. Innovative methods involving Internet-based and clinician-assisted computer programs have begun to emerge in recent years.

• CBT includes a variety of therapeutic strategies, including:
  • Psychoeducation: Providing information to help the patient understand the nature of mental illness
  • Cognitive restructuring: Identifying, challenging, and replacing maladaptive thoughts with adaptive, realistic, coping thoughts
  • Exposure: Reducing avoidance (which maintains anxiety states via negative reinforcement) and increasing approach behavior (e.g., facing fears rather than avoiding them)
  • Behavioral activation: Increasing engagement in pleasurable or useful activities (e.g., exercise), and utilizing social support
  • Relaxation training: Reducing physiological reactivity by learning and practicing relaxation exercises including deep diaphragmatic breathing, guided imagery, progressive muscle relaxation, and present sensory focus
  • Homework: Conducting out-of-session practice to facilitate the acquisition and mastery of coping skills
  • Relapse prevention: Normalizing “slips” and preventing future episodes by continuing to practice CBT skills and develop proactive plans for coping with future stressors and/or symptoms

• Traditional CBT has been modified to adapt to the needs of patients with specific psychiatric disorders:
  • For obsessive compulsive disorder = Exposure and Response Prevention (ERP)
  • For tic disorders and Tourette syndrome = Habit Reversal Training (HRT)
  • For borderline personality disorder = Dialectical Behavior Therapy (DBT)
  • For post-traumatic stress disorder = Trauma Focused Cognitive Behavioral Therapy (TF-CBT)

EFFICACY

• A recent review of 269 meta-analyses found strong evidence to support the use of CBT to treat anxiety disorders, somatoform disorders, eating disorders, anger problems, and general stress[3].
• The evidence supporting CBT for anxiety disorders is consistently strong[1][2][3][4].
• CBT for depression is more effective than treatment as usual and waitlist control conditions, but there is insufficient evidence to suggest that it is more effective than other active treatments[3][5].

SPECIAL POPULATIONS

Children: evidence supporting the efficacy of CBT in young children is promising but limited.

• Autism spectrum: CBT appears to be effective in children and adolescents with high-functioning autism spectrum disorders.
• Older adults: CBT is more effective than treatment as usual and wait list control treatments in reducing symptoms of depression in older adults but is equally effective compared to other active psychological treatments[5].

ADVERSE REACTIONS

• There are no known significant long-term side effects.

COMMENTS

• CBT is the most widely studied psychotherapeutic approach.
• A wealth of evidence supports its use with a variety of psychiatric symptoms and illnesses. Moreover, positive findings have been reported with patients across the lifespan. More rigorous evidence is needed to evaluate CBT in comparison with other active treatments before conclusions can be drawn regarding its superiority to other treatments. Notwithstanding, given the existing evidence and time-limited nature of CBT, the intervention may be a useful and cost-effective first-line of treatment for many patients.

References

1. Butler AC, Chapman JE, Forman EM, et al. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;26(1):17-31.  [PMID:16199119]
2. Chambless DL, Ollendick TH. Empirically supported psychological interventions: controversies and evidence. Annu Rev Psychol. 2001;52:685-716.  [PMID:11148322]
3. Gould RL, Coulson MC, Howard RJ. Cognitive behavioral therapy for depression in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc. 2012;60(10):1817-30.  [PMID:23003115]
4. Hofmann SG, Asnaani A, Vonk IJ, et al. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res. 2012;36(5):427-440.  [PMID:23459093]
5. James AC, James G, Cowdrey FA, et al. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2013;6:CD004690.  [PMID:23733328]
6. Cuijpers P, Gentili C, Banos RM, et al. Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis. J Anxiety Disord. 2016;43:79-89.  [PMID:27637075]
7. David D, Cotet C, Matu S, et al. 50 years of rational-emotive and cognitive-behavioral therapy: A systematic review and meta-analysis. J Clin Psychol. 2018;74(3):304-318.  [PMID:28898411]
8. Novick DM, Swartz HA. Evidence-Based Psychotherapies for Bipolar Disorder. Focus (Am Psychiatr Publ). 2019;17(3):238-248.  [PMID:32047369]