Short-Term Treatment
for Anxiety Disorders
May / June 2004
The Center
for the Treatment and Study of Anxiety (CTSA),
a part of Penn Behavioral Health, is an internationally renowned
research and clinical facility where psychologists develop
short-term treatments for anxiety disorders with a particular
emphasis on post-traumatic stress disorder (PTSD), obsessive-compulsive
disorder (OCD), and social anxiety disorder (SAD).
The psychologists
work in collaboration with Penn psychiatrists to combine
psychological
and pharmacological treatments. The center conducts ongoing
research projects to compare the combination of medication
and cognitive behavior programs in order to achieve the best
possible results for adults with PTSD and adults and children
with OCD.
Post-traumatic Stress Disorder
Developed by Edna B. Foa, PhD, professor of psychology in
the Department of Psychiatry at the University of Pennsylvania
School of Medicine and director of the CTSA, “prolonged
exposure therapy” is considered the most successful
treatment for post-traumatic stress disorder (PTSD). Affecting
approximately eight percent of the U.S. population, PTSD
develops in response to a traumatic event such as rape,
serious car
accident, or combat.
Symptoms may be experienced years after
the trauma occurs. Prolonged exposure combines two types
of
exposure techniques. The first type of exposure therapy is “reliving
the traumatic memory,” also
called imaginal exposure, whereby psychologists help patients
process the
traumatic memory, gain new perspective, and engage the traumatic
memory without fear of danger. At the same time, an exposure
technique called "invivo exposure" is utilized
in which the patient and the therapist construct a list
of
situations that the patient avoids because they are trauma
reminders, such as going to the grocery story or being in
crowded places. The patient is instructed to begin with moderate
anxiety provoking situations and then progress into more
anxiety
evoking situations.
“Through this therapy patients achieve a sense of competence,
relearn that the world is not so dangerous, and gain a feeling
that they can engage in life and control the traumatic memory
instead of the traumatic memory controlling them,” says
Dr. Foa. Most patients attend sessions once or twice a week
for nine to 16 weeks, depending on their diagnosis and severity
of the condition.
Social Phobia and Depression
Social phobia, a condition in which individuals are afraid
they will shame themselves in public and believe others
will find them boring or reject them, affects seven percent
of the U.S. population. "Through behavioral exercises,
called exposures, both during sessions and in between
sessions, patients enter feared social situations and
are helped to experience them in a new way," says
Dr. Foa. "As
part of their homework we encourage patients to gradually
participate in more difficult social situations. With
each anxiety disorder we tailor the exposure therapy a
little differently, depending on the core fear of the
patient."
Although more than one-third of individuals with social
phobia experience depression, most treatment studies of
social phobia
exclude patients with depression. Specialists at Penn's
CTSA have developed a unique cognitive behavioral treatment
program that is specifically designed for patients with this
dual diagnosis. “Learning how to best treat these
patients is of great importance, particularly since patients
with social
phobia and depression tend to have more severe social phobia
symptoms, higher rates of suicide attempts, and poorer
overall
functioning than patients who have a sole diagnosis of social
phobia,” adds Dr. Foa.
Obsessive-Compulsive Disorder
People with OCD have disturbing thoughts, images, or impulses
that create fear, extreme worry, or an overpowering need
to
do things perfectly. They also rely on repetitive rituals
or compulsions such as excessive hand washing, double
checking,
or repetitive counting to reduce their obsessional distress.
OCD affects between 2 and 3 percent of people in the
United
States. The CTSA recently completed multi-center controlled treatment
trials evaluating the relative and combined efficacy of
cognitive-behavioral
therapy (CBT) involving exposure and response prevention,
medication, and their combination for both adult and pediatric
OCD. The efficacy of exposure and ritual prevention therapy
as an initial treatment for adult OCD is now clearly established,
with 85 percent of those who complete therapy benefit from
treatment at post-treatment and 75 percent maintain treatment
gains at one year after treatment.
The CTSA is currently investigating
whether adult patients with OCD who have experienced only
a partial response to pharmacotherapy with serotonin reuptake
inhibitors alone can further benefit from the addition of
exposure and ritual prevention therapy. Partial response
to these medications is also the norm in pediatric OCD and
a
new study is about to be launched at the CTSA in which two
forms of CBT augmentation will be compared: a full course
of CBT augmentation delivered by a study psychologist and “CBT lite” to be delivered by a psychiatrist
in the context of regular medication management visits. General Anxiety
The CTSA along with the Mood and Anxiety Disorders Program
in the Department of Psychiatry at Penn is developing
an innovative
new program for the treatment of general anxiety for use
in primary care and general medical settings. Dr. Foa
and Karl
Rickels, MD, professor of Psychiatry and chief of
the Mood and Anxiety Disorders Section in the Department
of Psychiatry
at Penn, have developed the Managing Anxiety Series to improve
patient compliance and provide access to effective treatment.
This
program includes modifications of many of the techniques
of effective anxiety disorder treatments into a largely
self-help
format. Participants work through the skills with only
minimal contact with a primary care provider or nurse who
has been
instructed in the program elements.
For patients without medical coverage, free treatment may
be available through various clinical trials.
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