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Anxiety is a biological response which serves as an essential warning adaption in humans

(Rowney & Hermida, 2010). Anxiety can develop into a pathologic disorder when it is

triggered excessively and uncontrollably, requiring no specific stimulus, and manifesting with

a variety of physical and affective symptoms altering behaviour and cognition (Davison &

Neale, 2005). In the year 2000 the American psychiatric association created a certain

category for anxiety disorders in the DSM-IV, this category included the following disorders:

a) panic disorder without agoraphobia, b) panic disorder with agoraphobia, c) agoraphobia

without a history of panic disorder, d) social phobia, e) generalised anxiety disorder, f)

specific phobia, g) posttraumatic stress disorder, h) acute stress disorder, i) obsessive

compulsive disorder, j) anxiety disorder due to a general medical condition and k) substance

induced anxiety (APA, 2000). For all of the subtypes under this classification it must be

acknowledged that each condition shares a similar psychological process involving either or

both cognitive distortions and automatic negative thoughts (ANT) (Davison & Neale, 2005).

Considering the homogeneity of anxiety disorders the recommended treatment is cognitive

behavioural therapy (CBT) (Holmes, 2002). Indeed, cognitive behavioural therapy has much

positive support due to its apparent efficiency across a number of psychiatric disorders

(Holmes, 2002), however the question this paper aims to answer is what exactly is the

empirical status of cognitive behavioural therapy? The current paper will firstly introduce

CBT leading on to the efficacy of CBT for childhood and adolescent anxiety disorders,

following this a review of the empirical evidence supporting adult and older adult treatment

using CBT will be outlined with a final note being given to technological extensions of CBT.

In the past, behaviour therapy (the ‘BT’ in CBT) advanced adhering to the phenomena

proposed by classical and operant conditioning, however it has continued to progress and

evolve incorporating a cognition element due to the recognition that person – environment

interactions are interceded by cognitive processes (Van Hasselt & Hersen, 1993). Nowadays

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purely behavioural therapists work with clients to alter behaviours in order to reduce stressful

thoughts and emotions (Compton, March, Brent, Albano, Weersing & Curry, 2004).

Contrastingly, cognitive therapists work to modify the initial distressing thoughts and

feelings, with improvements in behaviour following simultaneously (Compton et al., 2004).

A defining aspect of CBT is that it proposes that symptoms and dysfunctional behaviours are

more often cognitively mediated and therefore improvements require the transformation of a

negative, dysfunctional thought process into a realistic or positive way of thinking (Dobson &

Dozois, 2001). Despite the popular view that CBT is a unitary treatment, CBT actually

incorporates an assortment of dense and subtle interventions from the social learning outlook

(Compton et al., 2004). CBT involves the development of a case formulation for a client. The

CBT case formulation guides the therapist in administering therapy adapting the techniques

to suit the patient’s presenting mental issues (Compton et al., 2004). Cognitive behavioural

therapy is diverse in its patient base, however, despite the differences in clientele the

intervention method shares five features: 1) Adherence to the scientist-clinician model, in that

treatments are deciphered according to demonstrated evidence. 2) Functional analysis of

target behaviours and cognitive distortions which aid the maintenance of the symptoms. 3)

Prominence of psycho-education. 4) Problem specific treatment and 5) relapse prevention

(Compton et al., 2004). Particularly with the anxiety disorders category CBT employs

techniques such as cognitive restructuring and exposure in order to extinguish inappropriate

fears and thoughts (Compton et al., 2004). As a direct result of how structured and scientific

this method of therapy is, CBT can be recommended as a reliable approach for paediatric

mental illness (Barrett, Duffy, Dadds & Rapee, 2001).

Children’s acquisition of socio-emotional abilities develop with time, however the

failure to develop such skills at relatively the same pace as matched controls may suggest

capacity limitations, a problematic environment or a mental illness (Compton et al., 2004).

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When CBT is applied to child therapy the therapist must gain an in depth understanding of

the presenting issues and view the environment of the child to learn of any possible

developmental constraints. This information must then be used in the formulation to form a

detailed therapeutic strategy with the aim of restoring the child’s level of development to that

of their healthy peers (Compton et al, 2004). Children suffering an anxiety disorder often

view the world as threatening and respond to their perceived threatening stimuli through

avoidance (Compton et al., 2004). Cognitive behavioural therapy for children assists the child

to reconceptualise those situations which trigger fear and build a new successful coping

template (Barrett, Duffy, Dadds & Rapee, 2001). Treatment for children regularly includes

relaxation training, imagery, development of problem solving skills, role play and in-vivo

exposure (Compton et al., 2004). It was long thought that CBT was not applicable for

children with mental illnesses however Albano and Kendall (2002) investigated the efficacy

of CBT for childhood panic disorder and found that this prior view of childhood CBT was

incorrect. Findings from this study supported the results revealed by earlier researchers such

as Borkovec and Costello (1993) comparing relaxation therapy to CBT for children with

generalised anxiety disorder. Overall results showed in favour of CBT as being the most

effective method of treatment.

Kendall (1994) conducted a randomised clinical trial of cognitive behavioural

therapy with anxious children between nine and thirteen years of age. Children selected to

participate in the CBT trial received sixteen CBT sessions. An analysis of self-repost

measures, parental reports and behavioural observations indicated significant improvements

in the children who received CBT in comparison to those who as the control group did not.

This experiment followed up the initial findings with a maintenance test one year later. It was

discovered that only sixteen sessions of CBT for anxious children sustained the benefits

originally gained even after a period of one year post-treatment (Kendall, 1994).

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In 2001 Barrett, Duffy, Dadds and Rapee followed up a study originally started by

Barrett, Dadds and Rapee in 1996 in which it was identified that CBT was effective for

childhood anxiety problems. The researchers included Fifty two of the original seventy nine

children who had received CBT treatment approximately 6.17yrs earlier. The aim of the

study was to test the efficacy of CBT in the long-term. Results were impressive revealing that

85.7% were no longer classified as suffering an anxiety disorder thus supporting the idea that

CBT is a long-lasting therapeutic method for children (Barrett, Duffy, Dadds & Rapee,

2001).

Cognitive behavioural therapy as a form of psychotherapy has been researched at

length. In excess of one hundred and twenty controlled clinical studies have been published

between 1986 and 1993 with this trend extending each year (Hollon & Beck, 1994). This

surge in CBT research is understood to be related to the realisation that CBT is applicable for

a wide range of mental disorders (Beck, 1997). CBT for adults diagnosed with an anxiety

disorder focuses on modifying thought and transferring learned skills from therapy to the

client’s everyday life (Butler, Chapman, Forman & Beck, 2006). CBT makes adults their own

therapist in order to alter cognitive distortions (Beck, 1997). The major attribute of CBT

which has given this treatment style the edge over other methods is its evident effectiveness

in the long-term (Dobson & Dozois, 2001). Borkovec and Costello (1993) compared the

long-term effectiveness of CBT and relaxation therapy for generalised anxiety disorder

(GAD) in adults. The researchers identified a superior result of 58% of CBT patients no

longer meeting criteria for GAD, comparatively relaxation therapy revealed a 38% statistic of

those patients no longer within range of a diagnosis of GAD (Borkovec & Costello, 1993).

In relation to the successful treatment of panic disorder Gould, Otto and Pollack

(1995) conducted a meta-analytic comparison of purely cognitive intervention therapies and

CBT using exposure treatment. The CBT approach combining the exposure technique was

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distinguished as the most productive in treating patients with panic disorder. This

combination of interventions is the method of choice for CBT practitioners. Oei, Llamas and

Devilly (1999) studied the efficacy of CBT for patients suffering panic disorder with

agoraphobia comparing their anxiety levels to that of undiagnosed community members. It

was discovered that CBT can produce anxiety levels lower than that of the community by the

final therapy session and these scores were consistent during a follow up study conducted one

year later (Oei, Llamas & Devilly, 1999). Another form of anxiety disorder also linked to

social situations is social phobia. DeRubeis and Crits-Cristoph (1998) reviewed the long-term

validity of CBT for this particular disorder and it was concluded that CBT is also an effective

therapy for social phobia.

Previously in psychology the prevalent method for the treatment of obsessive

compulsive disorder (OCD) was simply exposure with response prevention, the ERP of

counselling psychology, now however due to the level of support for CBT there is also

growing evidence that CBT incorporating exposure is more effective than exposure treatment

alone (Chambless & Ollendick, 2001). This hypothesis was tested by van Balkom, van

Oppen, Vermuelen, van Dyck, Nauta and Vorst (1994), the authors concluded that CBT led

to substantial reductions in obsessive thoughts and compulsive behaviours. According to

patients ratings and clinical assessments CBT showed more impressive results than the more

traditional method of simple exposure treatment even at a twelve month follow up report (van

Balkom et al., 1994).

In 2005 the royal college of psychiatrists and the British psychological society

completed a thorough meta-analysis of clinical research to date on posttraumatic stress

disorder (PTSD).The patient population reviewed was extensive incorporating backgrounds

such as survival from a serious accident, sexual assault, domestic violence, military combat

and refugees. CBT was by and large identified as the most effective treatment for PTSD

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(RCP & BPS, 2005). This conclusion was later supported by Hofmann and Smits (2008)

comparing CBT in PTSD patients to a placebo controlled trial.

Despite impressive advances observed for CBT since it first emerged in the 1980’s

not a lot of attention has been focused on treating anxiety disorders in the older adult (Beck &

Stanley, 1997). According to Flint (1994) the prevalence of anxiety disorders in the elderly is

considerably lower than that of the younger population. Lawton, Kleban and Dean (1993)

provide an explanation for this by asserting that the nature of anxiety is different in older

adults. In their study the researchers included two hundred and seven young adults, two

hundred and thirty one middle aged adults, and eight hundred and twenty eight older adults.

The aim of the study was to compare the varying age groups on response to affect terms. The

results revealed that elderly participants reported less of most of the negative emotional states

particularly anxiety. Regardless of the reduction in prevalence of anxiety disorders among the

elderly Regier, Boyd, Burke, Rae, Myers and Kramer (1988) report that GAD in older adults

is as prevalent as major depression and that in general anxiety disorders are more of an issue

among the elderly than mood disorders. However, the question remains, can CBT benefit the

elderly who do suffer some form of anxiety disorder? Older people consume a large share of

anti-anxiety medications which in itself suggests that anxiety is an issue worth addressing in

the elderly population (Graham & Vidal-Zeballos, 1998). Anxiolytic pills including

benzodiazepines are among the most common medications provided to the elderly for the

treatment of anxiety (Blazer, George & Hughes, 1991). However, the major issue with this

method of treatment involves the risk of cognitive impairment which is linked to these

medications (Blazer, George & Hughes, 1991). This calls for a new more acceptable way of

treating anxiety disorders in the elderly.

In the year 2001 Barrowclough, King, Colville, Russell, Burns and Tarrier found that

home delivered CBT for the elderly suffering GAD was more effective than supportive

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counselling. This method also allowed the patient to relax as the therapy was carried out in

the comfort of their own home. Wetherell, Gatz and Craske (2003) conducted another study

to test the value of CBT for GAD in an elderly patient base. CBT was compared to a

discussion group and a waiting period group. There were a total of seventy five participants,

averaging in age at sixty seven years. Participants in both the CBT and discussion group

showed benefits over the waiting period group, however in a long-term follow up of twelve

months CBT showed stronger lasting effects (Wetherall, Gatz & Craske, 2003). This suggests

that the empirically supported hypothesis that CBT acts as a sound alternative to medication

for the elderly suffering from anxiety disorders can with future research gain even more

appreciation.

Another less well highlighted area within cognitive behavioural therapy is its apparent

effectiveness in the treatment of anxiety disorders following traumatic brain injury (TBI)

(Williams, Evan & Fleminger, 2003). Williams, Evan and Fleminger (2003) studied patient

‘DC’ who acquired TBI subsequent to a serious accident. DC suffered amnesia, attention

difficulties and self-doubt as a result which manifested as OCD. DC’s self-doubt stemmed

from his amnesia which likely caused him to develop obsessive thoughts and checking

compulsions. DC developed a maladaptive coping strategy of avoidance behaviours

involving avoiding social situations. Anxiety disorders are thought to be quite common in

TBI patients however, the difficulty in distinguishing an anxiety disorder from other

impairment consequences often leads to an overlook of the problem (Williams, Evan &

Fleminger, 2003). It must also be considered that chronic anxiety in a patient has been shown

to produce neurotoxins decreasing the size of the hippocampi through cell atrophy (Bremner,

Randall, Scott, Bronen, Seibyl, Southwick, Delaney, McCarthy & Charney, 1995). CBT as

previously expressed by this paper has been regarded as a highly effective method of treating

anxiety disorders. A combination of CR (cognitive rehabilitation) and CBT has been

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emphasised as the appropriate measure for treating anxiety disorders in neurologically

impaired individuals (Williams, Evan & Fleminger, 2003). Cognitive behavioural therapy

applied to the case of ‘DC’ involved exposure, response prevention and management of

automatic negative thoughts which maintained his self-doubt. Overall the treatment for DC

which comprised of CBT reduced significantly DC’s automatic negative thoughts allowing

him to build his self-esteem. Exposure treatment helped reduce the obsessions and

compulsions which accompanied DC’s OCD (Williams, Evan & Fleminger, 2003).

Thus far this paper has not considered medication in direct competition with CBT, the

efficacy of imipramine versus CBT for panic disorder in adults will now be discussed.

Barlow, Gorman, Shear & Wood (2000) identified a lifetime prevalence for panic disorder of

approximately three percent. The researchers questioned whether medication, CBT or a

combination of both would aid the recovery from panic disorder. Randomised, double blind,

placebo controlled trials were created in four major anxiety research clinics following three

hundred and twelve patients over a seven year period. Eighty three patients were randomly

assigned to the imipramine study. Seventy seven patients were selected at random for the

CBT study. Twenty four patients were assigned to the placebo only study. Sixty five patients

were allocated to the CBT plus imipramine study while the remaining sixty three took part in

the CBT plus placebo study. The combination of imipramine and CBT revealed the most

impressive results. CBT alone and imipramine alone showed equal efficiency in the twelve

month follow up study (Barlow, Gorman, Shear & Woods, 2000).

Finally the current paper will consider some of the technological tools which have

been manufactured in recent years to aid the efficacy of CBT. Newman, Consoli and Taylor

(1999) describe the Palmtop computer program developed for the treatment of GAD.

According to the authors, identified advantages of this program include continuous,

unobtrusive collection of process data on treatment adherence, therapy in the patient’s natural

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setting, therapy beyond the set hour with a therapist and the insurance of homework

completion. Palmtops allow repeated assessment and the program has been created to cater

for specific responses modifying the therapy given depending on the situation presented. The

device has been programmed to provide cognitive restructuring, exposure, relaxation training,

breathing retraining, and positive imagery (Newman, Consoli & Taylor, 1999). Newman,

Kenardy, Herman and Taylor (1997) reported that from their studies involving patients Miss

Q, Mr. J and Mr. K the use of palmtop computers as an extension of CBT in conjunction with

normal CBT therapist applied therapy was even more beneficial than CBT alone. CBT is

particularly well suited for technological aid as it is well described, structured and specific

(Anderson, Jacobs & Rathbaum, 2004).

Virtual reality therapy is another form of exposure utilised by CBT particularly for

those suffering agoraphobia as they must overcome their fear of leaving their home

environment (Anderson, Jacobs & Rathbaum, 2004). Virtual environments afford the client

the opportunity to participate in the environment in which they feel anxious however, this

environment is completely controlled by the therapist, this allows the exposure to be graded

according to the exact requirements of the patient (Pull, 2005). Rothbaum, Hodges, Ready,

Graap and Alarcan (2001) utilised virtual reality exposure treatment in conjunction with CBT

for PTSD in Vietnam veterans. This overcame the inability to ethically create in-vivo

exposure and produced gains significant at the six month follow up period. In 2002

Emmelkamp, Krijn, Holsbosch, de Vries, Schuemie and van der Mast (2002) compared the

relative efficacy of in-vivo exposure and virtual reality exposure for a specific phobia, the

fear of heights. Results showed that virtual reality exposure was as efficient as in-vivo

exposure for reducing anxiety and avoidance behaviours (Emmelkamp et al., 2002).

This paper has considered the relative efficacy of cognitive behavioural therapy for

children, adults, the elderly and neurologically impaired patients suffering from anxiety

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disorders. Each of the patient groups were provided with satisfactory empirical evidence

further revealing the adaptive and successful nature of this therapeutic method. The key to the

success shown by CBT is its incorporation of the classic behavioural technique and the more

modern cognitive treatment measure (Holmes, 2002). As a result of the research noted in this

paper it can be concluded that cognitive behavioural therapy does in fact have an empirically

supported evidence base which is even more concentrated when combined with a

technological device such as the palmtop computer or virtual reality therapy.

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