Research at UH finds cognitive-behavioral therapy effective in combatting anxiety disorders

Combination of treatments provides improvement for disorders such as fear of flying, public speaking or spiders Whether it is a phobia like a fear of flying, public speaking or spiders, or a diagnosis such as obsessive compulsive disorder, new research finds patients suffering from anxiety disorders showed the most improvement when treated with cognitive-behavioral therapy (CBT) in conjunction with a "transdiagnostic" approach – a model that allows therapists to apply one set of principles across anxiety disorders Anxiety Disorders CE Course The combination was more effective than CBT combined with other types of anxiety disorder treatments, like relaxation training according to Peter Norton, associate professor in clinical psychology and director of the Anxiety Disorder Clinic at the University of Houston (UH) CADC I & II Continuing Education Norton concludes that therapists treating people with anxiety disorders may effectively use a treatment that applies one set of principals across all types of anxiety disorders. The findings are the result of a decade of research, four separate clinical trials and the completion of a five-year grant funded by the National Institute of Mental Health. Norton defines anxiety disorders as when anxiety and fear are so overwhelming that it can start to negatively impact a person's day-to-day life. He notes anxiety disorders include: panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder, specific phobias and generalized anxiety disorder. Often anxiety disorders occur with a secondary illness, such as depression, substance or alcohol abuse. Norton says there are targeted treatments for each diagnosis, but there has been little recognition that the treatments don't differ much, and they only differ in very specific ways. IMAGE:This is Peter Norton, associate professor in clinical psychology and director of the Anxiety Disorder Clinic at the University of Houston. Click here for more information. "The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been an important breakthrough in understanding mental health, but people are dissatisfied with its fine level of differentiation," said Norton. "Panic disorders are considered something different from social phobia, which is considered something different from PTSD. The hope was that by getting refined in the diagnosis we could target interventions for each of these diagnoses, but in reality that just hasn't played out." As a graduate student in Nebraska, Norton couldn't get enough people together on the same night to run a group treatment for social phobia, and that marked the beginning 10 years of work on the transdiagnostic treatment approach. "What I realized is that I could open a group to people with anxiety disorders in general and develop a treatment program regardless of the artificial distinctions between social phobia and panic disorder, or obsessive-compulsive disorder, and focus on the core underlying things that are going wrong," said Norton. Norton finds cognitive-behavioral therapy (CBT), a type of treatment with a specific time frame and goals, helps patients understand the thoughts and feelings that influence behaviors to be the most effective treatment. The twist for him was using CBT in conjunction with the transdiagnostic approach. The patients receiving the transdiagnostic treatment showed considerable improvement, especially with treating comorbid diagnoses, a disease or IMAGE:This is the cover of "Group Cognitive-Behavioral Therapy of Anxiety. A Transdiagnostic Treatment Manual, " by Peter J. Norton. Click here for more information. condition that co-exists with a primary disease and can stand on its own as a specific disease, like depression. "What I have learned from my past research is that if you treat your principal diagnosis, such as social phobia and you hate public speaking, you are going to show improvement on some of your secondary diagnosis. Your mood is going to get a little better, your fear of heights might dissipate. So there is some effect there, but what we find is when we approach things with a transdiagnostic approach, we see a much bigger impact on comorbid diagnoses," said Norton. "In my research study, over two-thirds of comorbid diagnoses went away, versus what we typically we find when I'm treating a specific diagnosis such as a panic disorder, where only about 40 percent of people will show that sort of remission in their secondary diagnosis. The transdiagnostic treatment approach is more efficient in treating the whole person rather than just treating the diagnosis, then treating the next diagnoses." Norton notes the larger contributions of the studies are to guide further development and interventions for how clinical psychologists, therapists and social workers treat people with anxiety disorders. The data collected will be useful for people out on the front lines to effectively and efficiently treat people to reduce anxiety disorders. ### Norton is the author of the book, "Group Cognitive-Behavioral Therapy of Anxiety. A Transdiagnostic Treatment Manual," and co-author of "The Anti-Anxiety Workbook: Proven Strategies to Overcome Worry, Phobias, Panic and Obsessions." He has authored more than 90 research papers on such topics as anxiety disorders, CBT and chronic pain, and he serves on the editorial boards of two scientific journals. He has received early career awards and research grants for his work on studying and treating anxiety from the National Institute of Mental Health, the University of Nebraska – Lincoln, UH, the Anxiety Disorders Association of America and the American Psychological Association. About the Anxiety Disorder Clinic The Anxiety Disorder Clinic (ADC) is a specialty treatment and research clinic at the University of Houston. The goal of the ADC is to help clients overcome their problems with anxiety without medication by using the most effective psychological therapies available. Both research opportunities and low-cost clinical services based on the latest scientific evidence are offered to individuals. For more information about research opportunities and clinical services at ADC, please call 713-743-8600 or visit the ADC website www.uh.edu/anxiety About the University of Houston The University of Houston is a Carnegie-designated Tier One public research university recognized by The Princeton Review as one of the nation's best colleges for undergraduate education. UH serves the globally competitive Houston and Gulf Coast Region by providing world-class faculty, experiential learning and strategic industry partnerships. Located in the nation's fourth-largest city, UH serves more than 39,500 students in the most ethnically and culturally diverse region in the country.

Depression and Mood Disorders

Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide

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Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.

Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.

Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.

Anxiety Disorders

What are anxiety disorders?

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Anxiety disorders range from feelings of uneasiness to immobilizing bouts of terror. This fact sheet briefly describes the different types of anxiety disorders. This fact sheet is not exhaustive, nor does it include the full range of symptoms and treatments. Keep in mind that new research can yield rapid and dramatic changes in our understanding of and approaches to mental disorders. If you believe you or a loved one has an anxiety disorder, seek competent, professional advice or another form of support.


Generalized Anxiety Disorder: Most people experience anxiety at some point in their lives and some nervousness in anticipation of a real situation. However if a person cannot shake unwarranted worries, or if the feelings are jarring to the point of avoiding everyday activities, he or she most likely has an anxiety disorder.
Symptoms: Chronic, exaggerated worry, tension, and irritability that appear to have no cause or are more intense than the situation warrants. Physical signs, such as restlessness, trouble falling or staying asleep, headaches, trembling, twitching, muscle tension, or sweating, often accompany these psychological symptoms.
Formal diagnosis: When someone spends at least six months worried excessively about everyday problems. However, incapacitating or troublesome symptoms warranting treatment may exist for shorter periods of time.
Treatment: Anxiety is among the most common, most treatable mental disorders. Effective treatments include cognitive behavioral therapy, relaxation techniques, and biofeedback to control muscle tension. Medication, most commonly anti-anxiety drugs, such as benzodiazepine and its derivatives, also may be required in some cases. Some commonly prescribed anti-anxiety medications are diazepam, alprazolam, and lorazepam. The non-benzodiazepine anti-anxiety medication buspirone can be helpful for some individuals.


Panic Disorder: People with panic disorder experience white-knuckled, heart-pounding terror that strikes suddenly and without warning. Since they cannot predict when a panic attack will seize them, many people live in persistent worry that another one could overcome them at any moment.
Symptoms: Pounding heart, chest pains, lightheadedness or dizziness, nausea, shortness of breath, shaking or trembling, choking, fear of dying, sweating, feelings of unreality, numbness or tingling, hot flashes or chills, and a feeling of going out of control or going crazy.
Formal Diagnosis: Either four attacks within four weeks or one or more attacks followed by at least a month of persistent fear of having another attack. A minimum of four of the symptoms listed above developed during at least one of the attacks. Most panic attacks last only a few minutes, but they occasionally go on for ten minutes, and, in rare cases, have been known to last for as long as an hour. They can occur at any time, even during sleep.
Treatment: Cognitive behavioral therapy and medications such as high-potency anti-anxiety drugs like alprazolam. Several classes of antidepressants (such as paroxetine, one of the newer selective serotonin reuptake inhibitors) and the older tricyclics and monoamine oxidase inhibitors (MAO inhibitors) are considered "gold standards" for treating panic disorder. Sometimes a combination of therapy and medication is the most effective approach to helping people manage their symptoms. Proper treatment helps 70 to 90 percent of people with panic disorder, usually within six to eight weeks.


Phobias: Most of us steer clear of certain, hazardous things. Phobias however, are irrational fears that lead people to altogether avoid specific things or situations that trigger intense anxiety. Phobias occur in several forms, for example, agoraphobia is the fear of being in any situation that might trigger a panic attack and from which escape might be difficult. Social phobia is a fear of being extremely embarrassed in front of other people. The most common social phobia is fear of public speaking.
Symptoms: Many of the physical symptoms that accompany panic attacks - such as sweating, racing heart, and trembling - also occur with phobias.
Formal Diagnosis: The person experiences extreme anxiety with exposure to the object or situation; recognizes that his or her fear is excessive or unreasonable; and finds that normal routines, social activities, or relationships are significantly impaired as a result of these fears.
Treatment: Cognitive behavioral therapy has the best track record for helping people overcome most phobic disorders. The goals of this therapy are to desensitize a person to feared situations or to teach a person how to recognize, relax, and cope with anxious thoughts and feelings. Medications, such as anti-anxiety agents or antidepressants, can also help relieve symptoms. Sometimes therapy and medication are combined to treat phobias.


Post-traumatic Stress Disorder: Researchers now know that anyone, even children, can develop PTSD if they have experienced, witnessed, or participated in a traumatic occurrence-especially if the event was life threatening. PTSD can result from terrifying experiences such as rape, kidnapping, natural disasters, or war or serious accidents such as airplane crashes. The psychological damage such incidents cause can interfere with a person's ability to hold a job or to develop intimate relationships with others.
Symptoms: The symptoms of PTSD can range from constantly reliving the event to a general emotional numbing. Persistent anxiety, exaggerated startle reactions, difficulty concentrating, nightmares, and insomnia are common. People with PTSD typically avoid situations that remind them of the traumatic event, because they provoke intense distress or even panic attacks.
Formal Diagnosis: Although the symptoms of PTSD may be an appropriate initial response to a traumatic event, they are considered part of a disorder when they persist beyond three months.
Treatment: Psychotherapy can help people who have PTSD regain a sense of control over their lives. They also may need cognitive behavior therapy to change painful and intrusive patterns of behavior and thought and to learn relaxation techniques. Support from family and friends can help speed recovery and healing. Medications, such as antidepressants and anti-anxiety agents to reduce anxiety, can ease the symptoms of depression and sleep problems. Treatment for PTSD often includes both psychotherapy and medication.

For more information, as well as referrals to specialists and self-help groups in your State, contact:

Anxiety Disorders Association of America
8730 Georgia Avenue - Suite 600
Silver Spring, MD 20910
Telephone: 240-485-1001
Fax: 240-485-1035
www.adaa.org

Mental Help Net
CenterSite, LLC
570 Metro Place
Dublin, OH 43017
http://mentalhelp.net/poc/center_index.php?id=1

National Mental Health Association
2001 Beauregard Street, 12th Floor
Alexandria, VA 22311
Telephone: 800-969-6642
Fax: 703-684-5968
(TDD): 800-433-5959
www.nmha.org/infoctr/factsheets/index.cfm

The National Institute of Mental Health's toll-free information line is
1-866-615-6464; their web address is www.nimh.nih.gov/healthinformation/anxietymenu.cfm.