Anxiety disorders come in many shapes and sizes. Panic disorder is typified by recurrent panic attacks1. People with agoraphobia avoid public spaces out of a fear of experiencing panic attacks, incontinence, and other embarrassing events in view of others. Those suffering from social anxiety (also called social phobia) experience extreme fear of scrutiny in social situations. Individuals with specific phobias are afraid of certain situations (such as heights) or objects (such as spiders), and people with generalized anxiety disorder (GAD) worry excessively across a broad range of circumstances. Someone diagnosed with an anxiety disorder may experience a variety of symptoms.
Anxiety disorders can be truly disruptive professionally, socially, and personally2-3. Which is why it’s imperative to develop and deliver treatments efficiently to those who are suffering. In this regard, researchers and clinicians have had some success: Mounting evidence has demonstrated that cognitive-behavioral therapy (CBT)4-5 and SSRI (selective serotonin reuptake inhibitor) medications6-7 can help ameliorate anxiety symptoms.
The difficulty remains in getting these treatments to those who need them most. Individuals seeking CBT may be put on wait lists if there’s an overwhelming demand in their area2. Others may have a fear of the stigma associated with seeking treatment for a mental disorder8. In some cases, one’s symptoms may lead him or her to actively avoid in-person therapeutic approaches. For instance, individuals with agoraphobia and social anxiety disorder may find the intimate, social nature of therapy to be overly stressful. Thus, new approaches are necessary to help people in these circumstances.
The Internet Expands Treatment’s Reach
One emerging option is to provide CBT-like therapies through the internet, also known iCBT9-10. Such approaches allow individuals seeking therapy to receive treatment immediately while waiting to see a therapist in person. They also provide greater privacy, reducing the fear of stigma. Some studies suggest that internet-delivered therapies can be used to treat the symptoms of a range of disorders11-12. This means that clinicians don’t need to develop a different treatment program for every single possible combination of symptoms, which would also be extremely cost prohibitive.
But these studies have looked only at long-term programs that extend 8 to 12 weeks. And questions remain regarding the factors moderating the effectiveness of iCBT. One focuses on whether personal views of internet-based treatments affect the outcome: If you do not expect a program to meet your needs, does that expectation affect how much it helps you?
Investigating Short-Term Treatment
To investigate these questions, Dr. Johanna Schröder and her colleagues13 at University Medical Center Hamburg-Eppendorf in Hamburg, Germany, examined 179 adults with anxiety to study the effectiveness of ConfID, a German iCBT program. Participants were randomly assigned to receive treatment either from ConfID or a wait-list control.
The ConfID program used video, written, and audio sessions to teach various cognitive-behavioral interventions for anxiety that participants could apply at home. It also explained how participants’ symptoms might arise and how they might affect their relationships with others.
The researchers limited the treatment period to four weeks and their sample to individuals with panic disorder, agoraphobia, social anxiety disorder, and/or specific phobias. Throughout the study, they asked participants about how they viewed internet-based treatments and if this program was meeting their needs.
Brief Treatment Helps Across the Board
Participants in the ConfID condition experienced significantly greater improvements in their levels of psychological distress, anxiety, and depression as compared to participants in the control condition. Importantly, participants’ symptoms as related to panic disorder, agoraphobia, and social anxiety all improved to a greater degree than in the control condition, indicating that this treatment helped reduce disorder-specific symptoms. The researchers also found that the treatment was effective for all genders, ages, education levels, and initial anxiety levels, suggesting that it could be useful for many different types of people.
However, an individual’s view of internet-based therapies appeared to predict the effectiveness of the treatment. Participants who had a negative view of internet-based therapies at the beginning of treatment seemed to benefit less than those who held a positive view of such approaches. One reason may be that those with a negative view may have been less engaged with the program. This finding is important, even if unsurprising. If someone has strong feelings against internet-based treatment, a clinician may be wise to use another therapeutic approach.
iCBT Going Forward
This study adds to the growing body of research showing that iCBT can help individuals across a range of disorders and symptoms. Importantly, it shows that such treatments can be effective over a short time and that their effectiveness depends on a person’s view of internet-based therapies.
But important issues remain. Although participants generally benefited from the program, most did not feel that it met all their needs, so this form of therapy is not likely to replace standard CBT and medicinal approaches. But it could be a useful alternative for people on wait lists or those hesitant to try more typical treatments. To investigate this possibility, further research is needed to determine the optimum length of iCBT treatment and to examine how iCBT compares to traditional, in-person CBT.
Sources
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J., et al. (2001). The prevalence and correlates of untreated serious mental illness. Health Services Research, 36, 987-1007.
3. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National comorbidity survey replication. Archives of General Psychiatry, 62, 593-602.
4. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology Review, 26, 17-31.
5. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research, 36, 427-440.
6. Steffens, D. C., Krishnan, K. R. R., & Helms, M. J. (1997). Are SSRIs better than TCAs? Comparison of SSRIs and TCAs: A meta‐analysis. Depression and Anxiety, 6, 10-18.
7. van der Linden, G. J., Stein, D. J., & van Balkom, A. J. (2000). The efficacy of the selective serotonin reuptake inhibitors for social anxiety disorder (social phobia): a meta-analysis of randomized controlled trials. International Clinical Psychopharmacology, 15, S15-S23.
8. Ebert, D. D., Berking, M., Cuijpers, P., Lehr, D., Pörtner, M., & Baumeister, H. (2015). Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms. A randomized controlled trial. Journal of Affective Disorders, 176, 9-17
9. Andersson, G., Bergström, J., Carlbring, P., & Lindefors, N. (2005). The use of the internet in the treatment of anxiety disorders. Current Opinion in Psychiatry, 18, 73-77.
10. Christensen, H., Batterham, P., & Calear, A. (2014). Online interventions for anxiety disorders. Current Opinion in Psychiatry, 27, 7-13.
11. Johnston, L., Titov, N., Andrews, G., Spence, J., & Dear, B. F. (2011). A RCT of a transdiagnostic Internet-delivered treatment for three anxiety disorders: examination of support roles and disorder-specific outcomes. PLoS ONE, 6, e28079.
12. Titov, N., Andrews, G., Johnston, L., Robinson, E., & Spence, J. (2010). Transdiagnostic Internet treatment for anxiety disorders: a randomized controlled trial. Behaviour Research and Therapy, 48, 890-899.
13. Schröder, J., Jelinek, L., & Moritz, S. (2017). A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias – One size fits all. Journal of Behavior Therapy and Experimental Psychiatry, 54, 17-24.
Sam Hunley holds a doctorate in cognitive psychology from Emory University. He pursued his Bachelor's degree in psychology from Furman University and a master's from Emory. Sam's research, alongside Dr. Stella Lourenco, focuses on human perception of the space surrounding the body, exploring the impact of anxiety and phobias on this perception. Together, they contribute to Anxiety.org articles. Post-graduation, Sam became a Presidential Management Fellow.
