Therapy as Anxiety Medicine, Part 1: What works?

Happy Sunday everyone! On this lovely day, I thought I would share a little information on evidence-based treatment for anxiety and OCD- the magic of Cognitive Behavior Therapy, or CBT.

CBT is one of the most widely used evidence-based treatment approaches for anxiety and emphasizes the link between our thoughts, our feelings, and our behavior. By working with a therapist to understand how anxious feelings and physiology are directly influenced by our thoughts and actions, we are better able to identify the unhelpful patterns of thinking or behavior that tend to keep anxiety hanging around for kids. Once we can see those tricky patterns at play, the therapist and child work together to develop the skills necessary to break any troublesome habits (boo) and replace them with thought and behavior patterns that will reduce anxiety over time (woo!).

CBT has been studied and tested in many randomized controlled trials (“RCTs”, that glorious gold standard of clinical research!), and guess what researchers found? Here’s a summary of the 50 years of research on CBT for anxiety. Spoiler- it’s good news. CBT is Capital-E-Effective in treatment of anxiety in children and adolescents. The American Academy of Child and Adolescent Psychiatry deems it a “first line” treatment for anxiety (a.k.a. one of the first things to prescribe/try).

In fact, CBT seems to work like a medicine in the treatment of anxiety- neuroimaging studies have shown that CBT for anxiety will actually rewire the brain by changing neural connectivity and levels of neurotransmitters such as serotonin. No pills required!

However, just like a medicine, in order for CBT to work, you have to make sure that you are getting an appropriate dose of the “active ingredient” in this medicine. For anxiety, that active ingredient is exposure.

In exposure-based CBT, kids and teens work to overcome fears by gradually “exposing” themselves to thoughts and situations which provoke discomfort. These exposure exercises are designed by the child and therapist together and are usually designed to help kids move toward what matters to them. For example, a child that really wants to be in the school play but is terrified of public speaking may decide to raise their hand in class twice a day as a way to practice speaking in front of a room full of people.

The child is in the driver's seat during this “brave practice”, with control over how long and/or difficult the exposure is. Improvement in symptoms typically comes after gradually building up the difficulty of exposures over time.

In the case of OCD, we pair this exposure with response or ritual prevention (ERP). How this works: Individuals with OCD have developed rigid habits called rituals or compulsions that provide short term relief from anxiety, but make it worse in the long term (for example, washing hands 5 times after touching a doorknob to avoid illness). In ERP, by resisting the urge to perform compulsions during an exposure, we help to correct inaccurate beliefs about these actions as "protective." For example, by not washing after touching a doorknob, a child is able to learn that touching a doorknob without washing is, in fact, a safe thing to do and does not lead to getting sick... and that the anxiety/discomfort experienced is both tolerable and temporary.

The research says that kids who complete a full “course” of Exposure-based CBT show improvements in functioning that last, particularly if they continue to practice the skills learned over the course of therapy after treatment has ended.

In part 2, I’ll share the dosing guidelines for this anxiety medicine.