Elsevier

Journal of Anxiety Disorders

Volume 43, October 2016, Pages 79-89
Journal of Anxiety Disorders

Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis

https://doi.org/10.1016/j.janxdis.2016.09.003Get rights and content

Highlights

  • Effects of CBT on panic are larger than those on social anxiety and generalized anxiety disorder.

  • This remained significant after adjustment for other characteristics of the studies.

  • We found no difference in effect of CBT for social anxiety and generalized anxiety disorder.

Abstract

Although cognitive and behavioral therapies are effective in the treatment of anxiety disorders, it is not clear what the relative effects of these treatments are. We conducted a meta-analysis of trials comparing cognitive and behavioral therapies with a control condition, in patients with social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder. We included 42 studies in which generic measures of anxiety were used (BAI, HAMA, STAI-State and Trait). Only the effects of treatment for panic disorder as measured on the BAI (13.33 points; 95% CI: 10.58–16.07) were significantly (p = 0.001) larger than the effect sizes on GAD (6.06 points; 95% CI: 3.96–8.16) and SAD (5.92 points; 95% CI: 4.64–7.20). The effects remained significant after adjusting for baseline severity and other major characteristics of the trials. The results should be considered with caution because of the small number of studies in many subgroups and the high risk of bias in most studies.

Introduction

It is well-established that cognitive and behavioral therapies are effective in the treatment of anxiety disorders, including social anxiety disorder (Acarturk, Cuijpers, van Straten, & de Graaf, 2009; Eskildsen, Hougaard, & Rosenberg, 2010), generalized anxiety disorder (Cuijpers, Sijbrandij et al., 2014; Hunot, Churchill, Silva de Lima, & Teixeira, 2007) and panic disorder (Sánchez-Meca, Rosa-Alcázar, Marín-Martínez, & Gómez-Conesa, 2010). Although some other types of treatment have been developed for the treatment of anxiety disorders, like psychodynamic (Leichsenring et al., 2009, Milrod et al., 2007) and interpersonal psychotherapies (Dagöö et al., 2014; Lipsitz et al., 2008; Vos, Huibers, Diels, & Arntz, 2012), cognitive and behavioral therapies have been examined in dozens of randomized trials and have been consistently shown to be effective in the treatment of anxiety disorders with large effect sizes across disorders.

It is not clear, however, what are the relative effects of the treatment of one anxiety disorder compared to another. Most outcome instruments are specifically designed to measure the effects of each disorder separately. For example many studies examining the effects of treatments of social anxiety disorder use the Liebowitz Social Anxiety Scale (Baker, Heinrichs, Kim, & Hofmann, 2002; Liebowitz, 1987) as outcome measure, but many studies on generalized anxiety disorder use the Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec, 1990), while studies on panic disorder use the frequency of panic attacks as main outcome measure. This makes it impossible to compare the relative effects of cognitive and behavioral treatments in different anxiety disorders.

The relative effects of treatments for different anxiety disorders are, however, important for several reasons. Firstly, how well a disorder can be treated is important from a public health perspective (GBD 2013 DALYs and HALE Collaborators et al., 2015). If a disorder can be treated effectively it is less important to develop new treatments that could potentially be better than existing ones since the disease burden of this disorder can be ameliorated with existing treatments. If a disorder cannot be treated effectively, it is more important to develop new or improved therapies. Understanding the relative effectiveness of a treatment is also important for clinicians and patients when deciding whether and how to treat the disorder. From a scientific perspective, differences in effectiveness may be helpful in understanding the underlying processes that lead to these disorders and in explaining how treatments work.

The relative effects of cognitive and behavioral treatments between various anxiety disorders can be assessed in meta-analyses, which delineate the relative effects by giving estimates in terms of effect sizes (standardized mean difference). However, these effect sizes are still statistical concepts, indicating the difference between a treatment and control group in terms of standard deviations, and do not say anything about the clinical effect of a treatment (Cuijpers, Turner, Koole, van Dijke, & Smit, 2014). For example, an effect size of d = 0.1 on mortality would by most clinicians and patients be considered a highly clinically important effect, while an effect of d = 0.1 on social skills would not be considered be relevant by most. This implies that effect sizes cannot be directly compared across disorders, because from a clinical perspective an effect size in one disorder may have different implications than that same effect size in another disorder.

However, in the field of anxiety there are several outcome instruments that measure general levels of anxiety and that are not related to specific anxiety disorders, such as the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988)), the Hamilton Rating Scale for Anxiety (HAMA; Hamilton (1959)), and the State-Trait Anxiety Inventory (STAI-S tate and STAI-Trait; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). These instruments may not fully capture the specific effects of treatments on a specific disorder, because they measure anxiety in general, and not the specific symptoms of particular anxiety disorders. However, they can give an indication about the relative effects of treatments across disorders because they give a generic assessment of anxiety, not attached to a specific anxiety disorder. Effect sizes based on these measures can be considered comparable across disorders, because they use exactly the same instrument, in contrast to disorder-specific outcomes whose effect sizes cannot be compared directly. These outcome instruments are used in a considerable number of trials on cognitive and behavioral therapies for anxiety disorders.

We decided to conduct a meta-analysis of trials including instruments that measure general anxiety symptoms in order to make a comparison between the outcomes of cognitive and behavioral therapies in three of the most common anxiety disorders: panic disorder, social anxiety disorder, and generalized anxiety disorder. We focused on these three disorders because these are among the most important and common anxiety disorders in adults according to the DSM-5 (American Psychiatric Association, 2013).

Section snippets

Identification and selection of studies

We searched four major bibliographical databases (PubMed, PsycInfo, Embase and the Cochrane Database of randomized trials) by combining terms (both MeSH terms and text words) indicative of social anxiety disorder (such as social phobia, social anxiety, public-speaking anxiety), generalized anxiety disorder (such as worry and generalized anxiety), and panic (such as panic, panic disorder), with filters for randomized controlled trials. We also checked the references of earlier meta-analyses of

Selection and inclusion of studies

After examining a total of 10,368 abstracts (6196 after removal of duplicates), we retrieved 1072 full-text papers for further consideration. We excluded 1031 of the retrieved papers. The PRISMA flowchart describing the inclusion process, including the reasons for exclusion, is presented in Fig. 1. A total of 42 studies met inclusion criteria for this meta-analysis (two of the studies were described in one paper; Mohlman et al. (2003)), 20 studies on GAD, 12 studies on panic disorder, and 10 on

Discussion

We wanted to examine whether the effects of cognitive and behavioral psychotherapies on generic anxiety measures differed across three of the most prevalent anxiety disorders: generalized anxiety disorder, social anxiety disorder and panic disorder. We examined generic anxiety measures utilized across anxiety disorders, because disorder-specific measures do not allow for direct comparisons of the effects across disorders. We found that the effects as measured with the BAI on panic disorder were

Acknowledgement

Ioana A. Cristea was supported for this work by a grant of the Romanian National Authority for Scientific Research and Innovation, CNCS – UEFISCDI, project number PN-II-RU-TE-2014-4-1316 awarded to Ioana A. Cristea.

References1 (71)

  • J.A. *Himle et al.

    Work-related CBT versus vocational services as usual for unemployed persons with social anxiety disorder: A randomized controlled pilot trial

    Behaviour Research and Therapy

    (2014)
  • H.C. Kraemer et al.

    Size of treatment effects and their importance to clinical research and practice

    Biological Psychiatry

    (2006)
  • T.J. Meyer et al.

    Development and validation of the penn state worry questionnaire

    Behaviour Research and Therapy

    (1990)
  • J. *Mohlman et al.

    Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder: Two pilot investigations

    The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry

    (2003)
  • K.G. *Power et al.

    A controlled comparison of cognitive- behaviour therapy, Diazepam, and placebo, alone and in combination, for the treatment of generalised anxiety disorder

    Journal of Anxiety Disorders

    (1990)
  • J. Sánchez-Meca et al.

    Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis

    Clinical Psychology Review

    (2010)
  • U. *Stangier et al.

    Cognitive therapy for social phobia: Individual versus group treatment

    Behaviour Research and Therapy

    (2003)
  • M.A. *Stanley et al.

    Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: Preliminary findings

    The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry

    (2003)
  • R.P. *Swinson et al.

    Efficacy of telephone-administered behavioral therapy for panic disorder with agoraphobia

    Behaviour Research and Therapy

    (1995)
  • C. *van der Heiden et al.

    Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder

    Behaviour Research and Therapy

    (2012)
  • R.E. *Zinbarg et al.

    Dyadic predictors of outcome in a cognitive-behavioral program for patients with generalized anxiety disorder in committed relationships: A spoonful of sugar and a dose of non-hostile criticism may help

    Behaviour Research and Therapy

    (2007)
  • C. Acarturk et al.

    Psychological treatment of social anxiety disorder: A meta-analysis

    Psychological Medicine

    (2009)
  • E. *Akillas et al.

    Symptom prescription and reframing: Should they be combined?

    Cognitive Therapy and Research

    (1995)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2013)
  • G. *Andersson et al.

    Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial

    Journal of Consulting and Clinical Psychology

    (2006)
  • G. *Andersson et al.

    Therapist experience and knowledge acquisition in internet-delivered CBT for social anxiety disorder: A randomized controlled trial

    PloS One

    (2012)
  • G. *Andersson et al.

    Internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: A randomized controlled trial

    Psychotherapy and Psychosomatics

    (2012)
  • N.M. *Bakhshani et al.

    Effectiveness of short term cognitive behavior therapy in patients with generalized anxiety disorder

    Journal of Medical Sciences (Faisalabad)

    (2007)
  • A. *Bakker et al.

    Paroxetine, clomipramine, and cognitive therapy in the treatment of panic disorder

    The Journal of Clinical Psychiatry

    (1999)
  • A.T. Beck et al.

    An inventory for measuring clinical anxiety: Psychometric properties

    Journal of Consulting and Clinical Psychology

    (1988)
  • J.G. *Beck et al.

    Comparison of cognitive therapy and relaxation training for panic disorder

    Journal of Consulting and Clinical Psychology

    (1994)
  • M. Borenstein et al.

    Introduction to meta-Analysis

    (2009)
  • G. *Butler et al.

    Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder

    Journal of Consulting and Clinical Psychology

    (1991)
  • P. *Carlbring et al.

    Remote treatment of panic disorder: A randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls

    The American Journal of Psychiatry

    (2006)
  • P. *Carlbring et al.

    Treatment of social phobia: Randomised trial of internet-delivered cognitive-behavioural therapy with telephone support

    The British Journal of Psychiatry: The Journal of Mental Science

    (2007)
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    References marked with an asterisk are included in the meta-analysis.

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