Outcomes of Self-help Efforts in Anxiety Disorders

Amy J Morgan; Anthony F Jorm

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(5):445-459. 

In This Article

Psychological Methods

Autogenic Training

Description Autogenic training is a relaxation technique that involves regular practice of simple mental exercises in body awareness. The exercises involve passive concentration on breathing, heartbeat, warmth and heaviness of body parts.

Therapeutic Mechanism Autogenic training is thought to be helpful because it aims to improve a person's ability to relax by retraining the mind to calm itself. This is achieved through self-regulation of autonomic nervous system processes.

Review of Efficacy Two systematic reviews of autogenic training have only uncovered one controlled trial of autogenic training for anxiety disorders;[52,53] however, this trial did not use an adequate method of randomization. In addition to this study, one RCT in 25 adult patients with generalized anxiety disorder evaluated autogenic training (n = 6) compared with either anti-anxiety medication (n = 13) or breathing relaxation training (n = 6).[54] Patients in the two relaxation conditions received a 20- or 30-min supervised session three times a week for 6 weeks, followed by sessions once a month for 4 months. All treatments produced significant decreases in anxiety scores. However, the reduction was significantly greater in both relaxation groups compared with the medication group, after 6 weeks and 4 months. The anti-anxiety medication or dose used was not reported. A trial has also been conducted on 31 outpatients with obsessive–compulsive disorder where autogenic training was used as a control for behavior therapy.[55] In this trial, autogenic training was given with a pill placebo and compared with two active conditions (behavior therapy plus pill placebo and autogenic training plus fluvoxamine). Both active conditions showed significantly more improvement in symptoms than the autogenic control condition.

Safety Issues No safety issues have been reported.

Conclusion Autogenic training for anxiety disorders has received little research attention and has inconsistent findings. Additional research of a higher quality is required before firm conclusions can be made.

Bibliotherapy

Description Bibliotherapy is a form of self-help that uses structured written materials, such as books, to present a treatment program that an individual works through on their own. The materials encourage the reader to make changes leading to improved self-management, such as through psychoeducation, relaxation, graded exposure, cognitive restructuring and anxiety management.[9] Although the top selling self-help books for anxiety vary widely in quality and most have not been evaluated for efficacy, there are some highly rated by experts for being based on CBT approaches and useable by consumers (see [56]). Self-help books can be used in a number of ways – they could be purchased by an individual and used autonomously, they can be used as an independent intervention with varying levels of professional contact or support (guided self-help), or they can be used as an adjunct to therapy to speed up improvement. Most of the research focuses on guided self-help.

Therapeutic Mechanism The therapeutic mechanism is the same as for therapist-delivered psychological therapy.

Review of Efficacy In the last 5 years, CBT-based bibliotherapy has received increasing research attention, and a number of systematic reviews and meta-analyses have been published in the period.[9,57–63] Overall, these reviews and meta-analyses indicate that bibliotherapy for anxiety disorders is more effective than no treatment, with increasing therapist contact more beneficial. Effect sizes are moderate-to-large (e.g., standard mean difference [SMD]: 0.68; 95% CI: 0.57–0.79 in the largest meta-analysis[58]). Follow-up data also suggest that effects persist.[57,58] Types of anxiety disorder targeted were mostly panic with or without agoraphobia, specific phobia and social anxiety disorder. Fewer trials have targeted generalized anxiety disorder and post-traumatic stress disorder, and there are no RCTs targeting obsessive–compulsive disorder.[58,59] Comparisons with therapist-delivered interventions are less consistent, with some reviews concluding no significant difference in effect size[57,60] and others showing it is less effective.[58] As research in this area always involves some participant contact with a researcher or clinician (even if only for assessment purposes), the effects of unguided 'pure' bibliotherapy are unknown.

Safety Issues Many self-help books have exaggerated claims of effectiveness and promote themselves as an easy cure yet have no theoretical underpinnings to support these claims.[56] Potential risks include users not applying the treatment correctly or failing to work through the intervention on their own. It has been speculated that this could exacerbate the person's symptoms because of disappointment or feelings of helplessness and lower mastery. Users could also then be reluctant to accept face-to-face therapy owing to their lack of success with the bibliotherapy version.[9]

Conclusion Bibliotherapy is moderately effective for anxiety disorders, particularly panic disorder, specific phobia and social anxiety disorder. Clinician contact is recommended to improve outcomes.

Computer or Internet CBT Interventions

Description Computer or internet CBT interventions consist of structured sessions of CBT, similar to bibliotherapy, but via an interactive computer interface. This is a rapidly growing research area, stimulated because of the internet's potential for interactivity, and ease of collecting data, providing feedback and dissemination. Examples of these interventions include FearFighter, OCFighter/BTSteps, Panic Online and Interapy.

Therapeutic Mechanism The therapeutic mechanism for computer or internet CBT interventions is the same as for therapist-delivered CBT.

Review of Efficacy In response to the increasing number of trials evaluating Internet or computer CBT interventions for anxiety, several systematic reviews or meta-analyses have been published within the last 5 years.[64] The most recent meta-analysis included all literature published through 2007 and found 19 RCTs of internet- or computer-based cognitive behavioral treatments for anxiety in adults.[65] There were six trials in panic disorder, five in post-traumatic stress disorder and three in phobia. Included trials were scored for methodological quality, with less than half scoring well, mostly due to small sample sizes, high rates of attrition, unblinded patients and unblinded assessment. Across all anxiety disorders, internet or computer interventions were superior to wait-list controls for anxiety outcomes in ten trials (SMD: 0.77; 95% CI: 0.56–0.98), superior to placebos in six trials (SMD: 0.88; 95% CI: 0.70–1.31), and no different from therapist-delivered treatment in seven trials (SMD: 0.00; 95% CI: -0.38 to 0.38). There were no meta-analyses carried out for longer term effects. A subgroup analysis found no difference in effect sizes between wait-list-controlled trials with face-to-face clinician contact versus those with no clinician contact except via email in some cases. There of also no difference in effect sizes for wait-list-controlled trials with participants with diagnosed anxiety disorders (four trials) versus trials that used subclinical samples (six trials). These large effect sizes for wait-list or placebo trials are consistent with a previous meta-analysis,[66] except that it found a significantly greater mean effect size with clinician contact than with no support. A separate review evaluated the effectiveness of computer or internet interventions specifically for obsessive–compulsive disorder.[67] Two RCTs were identified that both used the package BTSteps (now called OCFighter), which involves exposure with response prevention via a computer or touchtone telephone. One trial with 176 participants found that BTSteps was significantly more effective than a relaxation control but less effective than therapist-delivered CBT. The other trial found better outcomes with brief scheduled support compared with brief on-demand phone support when using BTSteps. NICE in the UK has also reviewed the evidence for computer or internet CBT interventions for anxiety disorders and recommends the use of FearFighter for the management of panic and phobia.[68]

Safety Issues Potential risks include users not applying the treatment correctly or failing to work through the intervention on their own. It has been speculated that these could exacerbate the person's symptoms because of disappointment or feelings of helplessness and lower mastery. Users could also then be reluctant to accept face-to-face CBT because of their lack of success with the online version.[9] It has also been suggested that internet interventions may result in obsessive use of the internet by patients with obsessive–compulsive disorder.[62]

Conclusion Computer or internet CBT interventions have promising support for efficacy in the literature for panic, phobia and traumatic stress in adults. There is less support for obsessive–compulsive disorder. Further quality trials with larger samples are needed to evaluate specific anxiety disorders, such as social phobia, and to clarify the usefulness of clinician support.

Meditation

Description Meditation is a variety of self-regulation practices that focus on training attention and awareness. There are two main types of meditation: concentrative meditation, which emphasizes concentration on something (such as a phrase or the breath), and mindfulness meditation, which involves awareness of thoughts without judgment

Therapeutic Mechanism Meditation can be considered a form of relaxation, which can counteract the stress response of anxiety. Alternatively, mindfulness meditation may lead to distancing oneself from negative thoughts.

Review of Efficacy A Cochrane review of RCTs of meditation for anxiety disorders found only two trials to review.[69] They were small trials (n = 45) of moderate quality and used anti-anxiety drugs as a standard treatment. Neither trial had a no-treatment or placebo comparison group. One study in patients with anxiety neurosis found transcendental meditation reduced anxiety to a similar degree as electromyography–biofeedback and relaxation therapy. The second trial, in patients with obsessive–compulsive disorder, found no difference in anxiety between Kundalini Yoga and relaxation/mindfulness meditation.

A further two RCTs have been published since the Cochrane review. One was an 8-week meditation-based stress-reduction program in 46 patients with generalized anxiety disorder or panic disorder with or without agoraphobia.[70] The meditation group was compared with an anxiety disorder education program as a control. Patients were taking medication but their symptoms had been stable for the past 2 months. The meditation program involved meditation, exercise, stretching, relaxation and hypnotic suggestion. The meditation group significantly improved more than the control group on measures of anxiety symptoms, but there was no long-term follow-up. The other trial was a mindfulness-based stress reduction program in patients with moderate or severe generalized social anxiety disorder.[71] A total of 53 patients were randomized to 8 weeks of the meditation condition or 12 weekly sessions of group CBT. Patients in both treatment groups significantly improved, but the CBT group showed greater improvement.

Safety Issues Several case reports of short-lasting acute psychotic states associated with meditation have been reported. Meditation can act as a stressor in vulnerable patients who have a psychiatric history (especially a psychotic disorder) or are sleep-deprived or exhausted.[72]

Conclusion Meditation for anxiety disorders has not been adequately researched and no firm conclusions can be made.

Relaxation

Description There are a variety of relaxation training methods. The most common is progressive muscle relaxation, which involves teaching a person to become aware of and release muscle tension. Relaxation training can also involve the use of imagery and breathing exercises.

Therapeutic Mechanism Progressive muscle relaxation is based on the theory that anxious patients have elevated muscle tension and that learning to relax muscles will have more general effects on the physiological, psychological and behavioral manifestations of anxiety. The evidence for this mechanism is mixed.[73] Another possible mechanism is that relaxation training works cognitively, with patients gaining an increased sense of control over anxiety.[73]

Review of Efficacy A systematic review of studies carried out up to 2002 found that relaxation training was generally superior to control conditions (e.g., wait-list or placebo) for generalized anxiety disorder, panic disorder, post-traumatic stress disorder and social phobia, but not specific phobias.[15] When compared with active psychological treatments (mainly cognitive and behavioral therapies), relaxation training performed comparably for generalized anxiety disorder, panic disorder, social phobia and dental phobia. However, it was generally not as effective as active psychological treatments for post-traumatic stress disorder and obsessive–compulsive disorder. There have been a few more recent controlled trials of relaxation training for anxiety disorders, but these generally showed findings consistent with the earlier literature.[73,74] However, one more recent study found that computer-delivered relaxation was less effective than exposure therapy for phobia or panic disorder.[75]

Safety Issues No safety issues are currently known.

Conclusion Relaxation training appears to be effective for a range of anxiety disorders, except for specific phobias.

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