Clinical Practice Guidelines for Cognitive-Behavioral Therapies in Anxiety Disorders and Obsessive-Compulsive and Related Disorders

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Abstract

INTRODUCTION Anxiety disorders are the most prevalent psychiatric disorders worldwide, with a lifetime prevalence of up to 33%.[1] They often run a chronic course and are highly comorbid with other anxiety and mood disorders. Anxiety disorders are associated with immense healthcare costs and huge burden. Despite the availability of evidence-based interventions, they are often underrecognized and undertreated. The major anxiety disorders in the current classificatory system include panic disorder (PD), generalized anxiety disorder (GAD), specific phobia, and social anxiety disorder (SAD). Obsessive–compulsive disorder (OCD) has been nosologically separated from anxiety disorders and classified under the section of obsessive–compulsive and related disorders (OCRDs) in the DSM-5[2] and ICD-11.[3] Commonly described disorders in this category include OCD, body dysmorphic disorder (BDD), body-focused repetitive behaviors (BFRBs, i.e., trichotillomania and skin-picking disorder), and hoarding disorder. Both pharmacological and psychological interventions are effective in treating anxiety disorders and OCRDs. Clinical practice guidelines often recommend cognitive-behavioral therapy (CBT) as a first-line treatment for both anxiety disorders and OCRDs. In the following sections, we discuss scientifically tested CBT models, their evidence base, and treatment recommendations for individual disorders. Treatment recommendations are graded based on the Strength of Recommendation Taxonomy system, with three levels of recommendation, based on the quality, quantity, and consistency of evidence [Table 1].[4]Table 1: Grading of recommendation based on Strength of Recommendation TaxonomyPANIC DISORDER PD is often a chronic illness with waxing and waning course characterized by recurrent and unexpected panic attacks. The panic attacks are usually associated with anticipatory anxiety/worry of having another panic attack or consequences of the attack and maladaptive behaviors such as avoidance, safety behaviors, and changes in daily routine. Patients often develop agoraphobia in response to panic attacks. Lifetime prevalence of PD ranges between 1.6% and 5.2%, and it is about two times more common in women than in men.[1] PD is often comorbid with other psychiatric disorders, particularly anxiety, mood, and substance use disorders. Assessment Patients with PD often focus on physical symptoms and attribute their symptoms to medical causes. Ruling out medical causes of panic attacks is an important aspect of assessment. Proper diagnosis and assessment of severity of the panic and comorbid disorders play an important role in planning therapy. Comorbidity generally adds to the severity of symptoms, functional impairment, and economic costs and is associated with slower rate of response. For example, the presence of severe depression may interfere with the therapy for PD. Therefore, it is important to assess for comorbid conditions and treat them. Commonly used instruments to diagnose and assess panic attacks are shown in Table 2. Behavioral analysis of the problem is an important aspect of assessment that would provide information on predisposing, precipitating, and perpetuating biopsychosocial and lifestyle factors. Some of the major points gathered by behavioral analysis are shown in Table 3. Comprehensive assessment would aid in identifying the targets of therapy and choosing therapeutic components and appropriate assessment methods to monitor outcome. Having a collaborative therapeutic relationship is crucial for obtaining adequate information, enhancing motivation, and ensuring participation in therapy.Table 2: Instruments for assessing panic disorderTable 3: Behavioral Analysis of panic disorderFormulating a treatment plan Formulating the treatment plan would be based on the targets identified during assessment, which is communicated to the patient. Formulation often includes presenting a model of panic and factors maintaining the disorder, as well as the treatments available. The formulation should also include education about comorbid symptoms if present. The formulations are delivered according to the need, receptivity, and understanding of the patient. Presenting a formulation gives confidence to the patients that their symptoms can be understood, explained, and treated. The typical CBT model is based on the catastrophic misinterpretation of interoceptive stimuli. The model emphasizes a vicious cycle of catastrophic misinterpretation of normal bodily sensations, resulting in anxiety symptoms (arousal symptoms), interpretation of anxiety symptoms as indicators of impending dangerous consequences which further worsens the problem, and consequent avoidance and safety behaviors leading to maintenance of fear and anticipatory anxiety [Figure 1].[14] The standard components of individual CBT are summarized in Table 4.[1516] The steps involved in administering CBT are shown in Figure 2.Figure 1: Cognitive model of panic disorderTable 4: Components of cognitive behavioral therapy for panic disorderFigure 2: Steps in cognitive behavioral therapy for panic disorderChoice of treatment settings Therapy for PD is largely carried out on an outpatient basis. However, in certain situations (e.g., presence of comorbid severe depression/other anxiety disorders/substance abuse or dependence, failed outpatient therapy, and inability to implement therapy on an outpatient basis because of severity of illness), in-patient therapy may be offered. Efficacy of cognitive behavioral therapy in panic disorder CBT is the first-line psychological treatment for PD.[1718] There is well-replicated evidence for short- and long-term effectiveness of CBT.[19] Strength of recommendation for various psychological interventions for PD is shown in Table 5. A recent component network meta-analysis reviewed 72 studies to disentangle the effects of components of CBT and reported that cognitive restructuring, interoceptive exposure, and face-to-face setting were associated with better efficacy and acceptability, while muscle relaxation, breathing retraining, in vivo exposure, and virtual were associated with interventions, in and CBT to be in the treatment of A long-term of PD patients with CBT reported a rate of of for psychological interventions in panic of cognitive behavioral therapy face-to-face of CBT is to be most The of generally between and with is also shown to be interventions such as and been and to be more effective than or However, is to be effective than There is a to and of to treatment treatment is the symptoms i.e., the symptoms identified in with the which may The on of the to or is The patients are for the in the therapy plan is as well as a Patients are for the and of the in the therapy. They are also to the factors that may has been that the of has in are to a of by pharmacological therapy and for maintenance and carried out would the A that maintenance CBT carried out treatment the up to and the rate to maintenance CBT In during would In are that to the maintenance of psychological to be to the of maintenance therapy to chronic of CBT with and therapy or therapy according to the as by a also be However, is a to the of of in DISORDER Patients with and They it to the and often symptoms, such as and The of would include their as well as which are under (e.g., and in a catastrophic They in behaviors to the such as avoidance of and for Lifetime prevalence of ranges between and it is two times more common in women than in men.[1] has a chronic course with during is associated with and in of and economic than of the patients and from often for physical symptoms or for is highly comorbid with other anxiety and mood in the of medical conditions is also Assessment is important to the and of Commonly used of are in Table The assessment to the diagnosis of and comorbid disorders and medical conditions with and Behavioral analysis is crucial to the individual and to the maintenance of symptoms as well as that and the symptoms [Table a therapeutic relationship and for therapy are is also crucial to the and of therapy.Table Instruments for assessing generalized anxiety disorderTable Behavioral analysis for generalized anxiety disorderFormulating a treatment plan cognitive to for avoidance model of and of and The common various include cognitive avoidance and about understanding of and maladaptive with and problem and The individual formulations are according to the of symptoms in a Therapy should be based on the assessment, and of the and The and to be by on the daily CBT the and behavioral symptoms of Cognitive model of of is shown in Figure The components of CBT are in Table Steps involved in the of CBT are shown in Figure 3: Cognitive model of of generalized anxiety disorderTable Components of cognitive behavioral therapy for generalized anxiety disorderFigure 4: Steps in of cognitive behavioral therapy for generalized anxiety disorderChoice of treatment setting CBT for is delivered on an outpatient basis. However, in-patient treatment may be in the presence of comorbid severe anxiety, OCD, substance disorder, disorders, or Efficacy of cognitive behavioral therapy for generalized anxiety disorder CBT is to be more than in treating other is because of of CBT may be for treating comorbid with and of There is evidence that CBT may be more effective than both individual and CBT are individual therapy is associated with a in symptoms, and Therapy with or are also to be more of may be and is to effects to CBT and A meta-analysis has shown that CBT is to and while to face-to-face and to be various disorders been to be in with comorbid efficacy of this therapy is to be There are a of CBT that been with and relaxation, cognitive therapy, and interventions, therapy of therapy, cognitive therapy, therapy, and There is a for further studies to their effectiveness as well as effectiveness to Strength of recommendation for various psychological interventions for is shown in Table for psychological interventions in generalized anxiety to treatment The of for may on the severity of and response to therapy. the of therapy is with may more of a may be by more a Treatment can be the targets are or is of response. for maintenance and There are guidelines for maintenance and of in Therapy is generally and may up to to situations that of for of would in with situations and severity of is as an fear an or that be or and is A the or it with There is in the to include and and situations and and and more than is the most prevalent anxiety disorder, with a lifetime prevalence between to other anxiety disorders, it has a prevalence of Treatment and in specific are or and Assessment In to a assessment for CBT for specific include functional analysis of of avoidance, safety behaviors, by of symptoms, associated with and of is more than this information is for of them. The functional analysis also information on that are to the of the A fear with an of the with of is for the of therapy. of The by and is a of fear and avoidance of various social and to a are on both avoidance and other are that specific and and may be used in to functional Formulating a treatment plan CBT for specific is based on the that and maintenance of the fear is associated with the and of and is by social Cognitive of on the role of in the of specific on and cognitive psychological treatments of specific focus on to and of fear response and of is the treatment of in the of specific and to of the for a of in avoidance, or other safety behaviors, the fear or the fear is the fear and are two by which can be delivered The most effective is that of in vivo or to by in which the is to the and in or virtual is a in which the is to the a the setting and is and in to has efficacy in specific of and with and maintenance of Despite of the major in therapy is the rate and to in to of in to or if safety behaviors or avoidance during in of fear is a therapeutic based on can be by the by a role model (e.g., in the or (e.g., a medical is used to or behaviors the is a therapeutic is based on the of three steps of in muscle relaxation, a fear and presenting the anxiety by with the of such that the therapy is the treatment of for specific cognitive therapy in to safety behaviors and Cognitive therapy in specific is more effective than and treatment and may be more maintaining factors are related to and safety behaviors than the fear However, studies cognitive to for between Treatment of is a that is characterized by a response that in and is a in than with may avoidance of and other associated such as and is effective in treating avoidance response to generalized a that is on to specific related to the a behavioral has two a and it in specific Treatment with the a for based on the response of in and resulting in is to of this response. the is is to muscle and the a of in the In the three the is to of and and to such as and during which the is to the of treatment setting patients are on an outpatient basis and functional in most of Efficacy of cognitive behavioral therapy in specific of psychological treatments for specific and evidence for of are effective to other treatment in vivo is to and in also treatments that include as a such as with exposure, cognitive restructuring, to factors and of is a the of treatment a with treatments better than Strength of recommendation for various specific is shown in Table for psychological interventions for specific DISORDER is a common anxiety disorder, with a lifetime prevalence from to has an in and is more prevalent is characterized by and fear of social a social or with fear of or situations are or with of include of (e.g., fear of and and (e.g., social cognitive such as and is by functional and is more than normal with may is characterized by of psychiatric The most common comorbid conditions include major disorder, other anxiety disorders, substance use disorders, and disorders and Assessment The most used in are shown in Table A and a cognitive behavioral or functional analysis [Table are steps in the assessment for therapy. Assessment is identifying of of avoidance, of severity of social anxiety, and in and comorbid Instruments for assessing social anxiety disorderTable Behavioral analysis for social anxiety disorderFormulating a treatment plan Cognitive of social anxiety focus on and and of as by and to in social and social model and the steps involved in administering CBT for are shown in and Cognitive model of social anxiety disorderFigure Steps of cognitive behavioral therapy for social anxiety for social anxiety is The components of the are shown in Table Patients may also be to use to in and practice of is and the to better Components of cognitive behavioral therapy for social anxiety is an component of graded to situations or avoidance and safety can be in vivo or in and would be largely on the of the and for is a in the treatment of are in the use of in include to and as social situations may be and in as social situations may be ensuring that adequate is in exposure, to cognitive such as and with the cognitive of social phobia, such as cognitive are behavioral and which provide to consistency Cognitive Cognitive is both and behavioral of the of cognitive restructuring, are to that or situations the of their information from behavioral that are (e.g., that the and based on the information and rate the in Cognitive and are in that and behavioral can be used to of can also be other such as to for social a of that their evidence from the that their and is common in and may interfere with of social and Some patients also panic attacks. The role of in social anxiety has been with with the various of from muscle to relaxation, with the of the response in a to be used in social situations the of is a of and of in the of is to as a The should be of this and should use as a safety it used in studies role in as of with may to anxiety, than The to social has been to social and in with specific such as and and and a component of to social situations as of the and to the in The common used for include behavioral and of treatment settings with social anxiety are in outpatient settings they are often or in other their setting may be has other comorbid such as severe Efficacy of cognitive behavioral therapy in social anxiety disorder the various interventions, individual CBT to the for the treatment of The most components of CBT for include cognitive and relaxation, and or in with cognitive has the the various components of and other components with in changes in and efficacy in that evidence for in However, social in with exposure, are reported to than The recommendations for psychological components of CBT are shown in Table for psychological interventions for social anxiety and other psychological for social anxiety disorder There is evidence for therapeutic CBT such as and interventions, as well as for and therapy. components in of been for social also to of and it may be to that in with in and of cognitive behavioral therapy to CBT in been include cognitive behavioral therapy CBT and CBT and therapy and cognitive behavioral therapy model has been individual CBT with CBT that both are effective in levels of social There is a of evidence for the efficacy of evidence that this may be a cognitive behavioral therapy In a of of both and for in social anxiety were with and long-term from to However, may be in patients with and of patients is be that been largely A with face-to-face therapy that the two of CBT were effective for for social anxiety disorder is an CBT component for for to and other under from virtual to social situations may be a in vivo and are on virtual for social anxiety that is as effective as to individual in vivo therapy or virtual that social A meta-analysis of interventions for and cognitive that both and in symptoms of and that an therapeutic and such as and in to for efficacy and CBT is may be in to treatment of in CBT is by the in symptoms, on of anxiety, may be the on both and is that the of the therapy, the and discuss the of therapy and in other anxiety disorders, of anxiety is in is particularly patients generalized social anxiety for maintenance and is an component of CBT for to the of practice of is of is by the is to with situations of during the of the and discuss and a of to of and the of may be to and for specific on CBT maintenance of in social anxiety up to a following therapy. DISORDER is a psychiatric disorder characterized by the presence of and are repetitive and often or which are associated with anxiety or Patients with repetitive and often behaviors to the associated with The current classificatory that of patients the or of their symptoms may from to to has a lifetime prevalence of often a chronic waxing and waning is often comorbid with other conditions such as mood, anxiety, and disorders, as well as conditions such as disorders and disorder. obsessive–compulsive conditions such as and hoarding disorder are often underrecognized CBT are the first-line treatments for Assessment a diagnosis of OCD, a of is therapy. is to psychiatric mood, anxiety, and disorders, which and also the the course of therapy would be to assess various of of of avoidance, and Assessment of such as and may therapy in certain instruments for assessing are summarized in Table Behavioral analysis of symptoms [Table in understanding the symptoms from a behavioral and in planning therapy.Table Instruments for assessing disorderTable analysis of disorderFormulating a treatment plan it is important to discuss an CBT model for OCD, therapeutic of to anxiety as a of for and of if CBT been for The behavioral based on the of while the recent cognitive as normal cognitive which are as by patients with to certain such as for and of and to may be to factors such as and The of therapy has been and response which graded to the while and avoidance the anxiety The is the of fear response and of also patients of having to on avoidance or on cognitive interventions behavioral are also The CBT model for is in Figure The components of CBT for are summarized in Table Steps involved in CBT are shown in Figure Cognitive behavioral therapy model for obsessive–compulsive disorderTable Components for cognitive behavioral therapy for disorderFigure Steps involved in cognitive behavioral therapy for obsessive–compulsive should be based on a formulation the symptoms and identified cognitive A collaborative understanding of the formulation with the is of treatment settings CBT for is generally on an outpatient basis as individual therapy. CBT is delivered of a for to and are major in the such as or CBT and the therapy can be delivered in the The of CBT are to that of the major of the is by to a and administering or may be to and in from is evidence in the of this of has been in the treatment is a of in-patient treatment for OCD, which is generally for severe and to outpatient is a treatment that of behavioral therapy, and therapy. The CBT are more with of by a of are by therapeutic and Efficacy of cognitive behavioral therapy in obsessive–compulsive disorder CBT has been shown to be in the treatment of treatment recommend CBT as a first-line treatment for are may be as in severe patients may a of CBT and an CBT is the first-line for to A recent meta-analysis in efficacy between individual and However, therapy individual CBT has been in to studies from shown in of A meta-analysis of studies a of points in with a of There is evidence to that the may up to However, in obtaining of evidence for this A recent is the which therapy a for of by the of The therapy is described as treatment delivered in a and is to be highly in interventions and been to be in symptoms of in therapy has to be in with to therapy is more or a cognitive that from about based on an which is from to an interpretation of a as while from as if the is Therapy targets by in with shown efficacy to There is a for in with such as and cognitive therapy are to be tested in and evidence as treatments for The role of pharmacological of such as is to be The treatment recommendations for psychological interventions for are summarized in Table for cognitive behavioral therapy for to treatment The for of therapy should be based on the in to the of therapy. is important to monitor symptoms for the and of response. evidence that the of treatment long-term it be a in patients with Therapy may be based on a most of the targets are with for as for of therapy should be in such as for exposure, and functional for maintenance and is evidence to that are following CBT as to in of such as severity of the of of more and better long-term A plan for plan is CBT patients on The long-term of patients is may to be to CBT is as an been include and lifestyle with may be with during DISORDER is a psychiatric characterized by and with or in is under of DSM-5[2] and the ICD-11.[3] Patients with repetitive behaviors such as behaviors, or cognitive in response to has an which to patients with with having to a diagnosis of disorder. also has a for muscle disorder, and substance use disorders are common comorbid conditions in is in The prevalence of both and is and it is more common Assessment The of the is the standard of and this has been used as the in various The is a which severity the is to changes with treatment and has The is a with Formulating a treatment plan The the for the use of CBT as the treatment for The other evidence-based treatment includes with as in and factors in the and of symptoms been and the CBT of that with of of to a They also the of physical to Patients may also as major is that in the of which in are with such as and they social situations to behaviors are to be they in of anxiety in maladaptive and The CBT model for is in Figure Cognitive behavioral therapy model for body dysmorphic for with assessment of is by for the symptoms are with of the CBT The components include cognitive restructuring, exposure, and and CBT also include a component of to The components of CBT for are in Table Components of cognitive behavioral therapy for body dysmorphic of cognitive behavioral therapy in body dysmorphic disorder in efficacy of CBT in severity as to as well as other interventions, such as anxiety and A of in an that the the of CBT were in the CBT has also be tested and to be in this There been response of response to motivation, from as well as better the may with based on the CBT has of recommendation A for DISORDER is a disorder of repetitive out of while skin-picking disorder is characterized by recurrent of conditions are often under a common DSM-5[2] and trichotillomania and disorder the OCRDs. has a prevalence of studies in prevalence is times women to There are prevalence studies for disorder. However, the studies a prevalence of for Anxiety disorders and depression are is the most common for in trichotillomania by the may be by various (e.g., on the and cognitive in stimuli. However, patients that they are of and this is to as of with trichotillomania in of may to a medical In disorder, the and to certain in the with and The of may of the body that are of the and are Assessment A of instruments for the assessment of and skin-picking been by is generally for the severity of The is a that to of the and the associated the The for for has been as a to the severity of anxiety disorders, and are comorbid with trichotillomania and disorder, it is important to assess for the presence of analysis of the to be and consequences or following Cognitive behavioral therapy for body-focused repetitive behaviors the evidence is to the other disorders CBT is often as a first-line treatment for both trichotillomania and skin-picking disorder. Behavioral are more In therapy is the most The components of are in Table Components of of cognitive behavioral therapy in body-focused repetitive behaviors the efficacy of for while are studies on skin-picking disorder has been in from to behavioral and been tested in may in The components of this include patients are to the associated as they the for and may also be used as a component in the of the is to and having to on them. are for disorder disorder, a has been has been to be for skin-picking disorder in a of while has been tested in The recommendations for are summarized in Table Recommendation for CBT is a first-line treatment for most anxiety disorders and disorders. has also been to be in with response to Despite of certain such as and cognitive restructuring, individual disorders CBT models, which been tested and to be For disorders, such as specific and behavioral been to be graded is in the is for the face-to-face therapy has been the most therapy also has been effective in therapy, such as therapy, may be used with virtual with and are and for the effects of and of There are of

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