____________________________________________________________________________ Anxiety Disorders
Patients with panic disorder/agoraphobia who display the low- expression allele of the serotonin transporter gene promoter show more favorable exposure therapy response than patients with other 5-HTTLPR genotypes. This genetic contribution to exposure therapy outcome implicates the serotonergic system as a response mediator to exposure treatments [85]. OVERLAPPING PSYCHOLOGIC AND DRUG THERAPY MECHANISMS Emerging evidence is challenging conventional wisdom by showing that antidepressant therapeutic action may begin with the first dose and that psychologic and drug therapy approaches share common mechanisms. In one study, a single dose of norepinephrine reuptake inhibitor reboxetine reduced negative affective bias in depression by increasing recognition of posi- tive facial expressions and enhancing memory for positive vs. negative information [147]. These early changes in emotional processing reflect changes in frontolimbic circuitry involved in detection and response to biologically salient information. These findings were replicated following seven days of escita- lopram treatment [148]. Changes in neurocognitive processing that precede clinical improvement predict later antidepressant response [149]. A 2013 study found that the initial session of CBT administered for panic disorder/agoraphobia led to reduced threat processing the following day, with the magni- tude of early effect predictive of the therapeutic response after four weeks [150]. These findings challenge assumptions that psychologic therapies address conscious thought processes before automatic information processing and suggest a greater similarity between early effects of pharmacologic and psycho- logic treatments for anxiety than previously thought [149]. PSYCHOTHERAPIES: OVERVIEW Psychologic treatments play an integral role in the manage- ment of anxiety disorders, and efficacy is established for several modalities. Most broadly effective are exposure-based and other CBT approaches. When choosing psychologic treatments for individual patients, the forms of therapy developed for the specific anxiety disorder should be used first. Cognitive and Behavioral Approaches Psychotherapy can be as effective as medication for GAD and panic disorder, and CBT has the best level of evidence [121]. CBT is the most extensively evaluated psychologic therapy in anxiety disorders and contains elements of cognitive and behavioral therapy approaches. Behavior therapy consists of using exposure to modify dysfunc- tional behaviors that may contribute to the development and persistence of psychologic symptoms [151]. Cognitive therapy involves cognitive restructuring, a psychotherapeutic process of learning to identify and modify irrational or maladaptive thoughts using strategies such as Socratic questioning, thought recording, and guided imagery [34].
CBT is not a single treatment approach but a process that addresses factors that caused and maintain patient anxiety symptoms. The classic CBT approach involves disorder-specific treatment protocols that target the symptoms and the cogni- tive, behavioral, and emotional vulnerabilities that underlie development and maintenance of each disorder. This approach reflects the assumption that each form of psychopathology has a distinct cognitive profile, to which CBT is tailored accord- ingly. Disorder-specific CBT is the standard of care for anxiety and depressive disorders [152]. However, there are common components of CBT used in anxiety disorders ( Table 2 ) [120]. There is some debate regarding whether the efficacy of CBT that targets common underlying factors would be comparable to standard diagnosis-tailored CBT. Support for CBT that addresses common underlying factors includes frequent comor- bidities in anxious patients, such as major depressive disorder, which some studies found present in close to 50% of patients with anxiety [153]. The frequent co-presence of mood and anxiety disorders, substantial overlap in dimensional symptom ratings, and extensive evidence of shared vulnerability factors enabled identification of common underlying factors that represent targets for CBT. These include [152]: • Motivational enhancement • Psychoeducation and understanding emotions • Emotional awareness training • Cognitive reappraisal • Attenuation of emotional and behavioral avoidance • Awareness and tolerance of physical sensations • Interoceptive and situational exposure • Relapse prevention Psychotherapy and drug therapy show similar efficacy in most anxiety disorders. There is variability and conflicting data on outcome measures from studies of psychotherapy in combi- nation with drug therapy; current evidence does not support routine combination therapy as initial treatment. However, patients lacking response to either CBT or drug therapy may benefit from adding the other modality [120]. Delivery of effective CBT is versatile. Individual or group delivery is effective in most anxiety disorders. A variety of self-directed or minimal intervention formats (e.g., biblio- therapy/self-help books, Internet/computer-based CBT with or without minimal therapist contact) have shown significant improvements in anxiety symptoms, and exposure therapy can be effective using a virtual reality format. These strategies can be very useful when real-life exposure is made difficult by inconvenience or patient reluctance [120].
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