Cognitive-Behavioral Treatment, Research Paper Example

Abstract

In a paper presented at a 1995 meeting of the American Psychological Association, researchers from the Columbia Presbyterian Medical Center reported the results of a study launched to determine the effectiveness of cognitive-behavioral treatment modalities on elderly patients with acute anxiety disorders.  Patients were “weaned” off their regimens of frequent benzodiazepine consumption and were provided counseling and other cognitive-behavioral interventions.  The interventions were successful with patients reporting an average reduction in post-treatment symptoms of 73.9%.  Physicians who were not involved in the study were so impressed with the results that many of them have begun using similar approaches with their geriatric patients.

Cognitive-Behavioral Treatment of Late-Life Anxiety Disorders

A common course of treatment for panic or anxiety disorders is the use of benzodiazepines.  Medications like Xanax, Librium and Valium tend to be effective in managing the symptoms of anxiety disorders, but are generally not considered to be appropriate for long-term use due to various side effects and the risk of dependency.  In geriatric patients, these considerations are even more pronounced.  In older adults, the risks of cognitive impairment, respiratory issues and falls make the use of benzodiazepines even more problematic.

At the 1995 meeting of the American Psychological Association, a paper outlining the results of a study involving alternative treatment modalities was presented (Gorenstein & Papp, 1995).  The study involved a small sample group of seven older patients at the Behavioral Medicine Program at Columbia Presbyterian Medical Center.

The study outlined the presenting problems of each patient and what cognitive-behavioral approaches were used to address them.  Several of the patients had acute anxiety issues relating to preoccupation with somatic arousal.  For some of these patients, the fear of becoming sick was creating arousal states that precipitated perceptions of actual physical abnormalities.  In some cases these perceptions actually led to heart palpitations.  The presence of heart palpitations led the patients to become even more anxious which resulted in a “vicious cycle” of worry followed by more autonomic arousal.

For these patients cognitive-behavioral approaches were used to reduce the arousal state.  The patients were counseled regarding the physiological facts of autonomic arousal and taught to recognize the arousal state.  They were taught progressive muscle relaxation which yielded almost immediate positive results.  In response to patients’ tendency toward “catastrophic thinking” the therapist had the patients reflect upon the number of times such worries actually came to fruition.  This approach was effective in mitigating these “worry behaviors.”

Another interesting approach used was to encourage the patients to engage in “interoceptive exposure” exercises.  These included deliberate hyperventilation and stair-climbing.  Patients were told that these interventions would initiate an arousal state and exhaust their psychological need to be in that state.

After ten weeks of treatment, these patients reported significant reductions in their anxiety levels (65%) and a reduction in the use of benzodiazepines to an average of once per week.

One subject struggled with somatic anxiety relating to the natural aging process.  The patient recognized the increase in his physical limitations and became so depressed and anxious that he utterly failed to take any action to mitigate these conditions.  He became anxious about having lower energy levels, but his anxiety about this fact prevented him from taking any action (such as exercising) to correct it.  This patient was continually calling or visiting his doctor with the same complaints.

The cognitive-behavioral approach with this subject started with urging him to “routinize” his medical care.  He was to schedule regular visits to the doctor and avoid any other contact for any reason short of a legitimate emergency.  For this (and other similar patients) written guidelines were developed outlining appropriate guidelines for contacting their physician.

The study points out that most of the patients involved had been prescribed benzodiazepines from their family doctor and were taking them regularly when the study began.  Notwithstanding their daily use of these medications, the study found the most of the participants articulated a desire to stop using them.  Many felt that the drugs did not work well enough.  The persistence of unwanted side-effects was another common complaint.  The third common thread was a negative self-image from having to rely on a drug to “manage emotional reactions.”

In that these patients were accustomed to a regimen that included frequent use of benzodiazepines, withdrawal was a concern.  Two factors were considered for dealing with withdrawal – emotional and physical.  To deal with the emotional withdrawal, counselors worked with the patients to understand the dynamics of withdrawal symptoms and “label them appropriately.”  Participants were encouraged to view inevitable withdrawal symptoms as “unpleasant but ultimately harmless.”

To deal with the physical ramifications of withdrawal, the researchers utilized “controlled exposures to physical sensations resembling autonomic arousal (and hence withdrawal) to provide patients with regulated opportunities to practice cognitive and behavioral skills.”  Patients were taught methods of cognitive reappraisal and behavioral coping in order to deal with the unpleasantness of withdrawal.

A common theme among these elderly patients was “worry behavior.”  Elderly adults tend to have fewer demands on their time and energy and can easily become people “with nothing to do but worry.”  This condition can escalate into obsessive-compulsive disorder.  For these patients, the researchers counseled them in being able to recognize and resist worry behavior.  Patients were encouraged to engage in activities requiring dedicated focus that would consume their attention.

The study found that these approaches were successful in reducing worry behavior.  Encouraging compulsive worriers to engage in scheduled, structured activities also helped.  Less free time resulted in shorter periods available for obsessive worry.

Another approach was to work with the patients to “decatastrophize” events upon which they tended to focus.  If for example a friend or spouse was late in arriving for a scheduled meeting, they probably were not lying in a mangled mass on the side of the road because of a horrific car crash.  They are probably just late.  Getting patients to look more realistically at the exaggerated nature of their worry behavior helped them to worry less and become happier in their daily lives.

The results of the study were encouraging.  Pre-treatment levels of symptom severity were posted at 100% for all patients.  Post-treatment symptom severity levels ranged from 50% to less than 10%.  Occurrence of overall symptom reduction ranged from 50% to 100% with a mean reduction of 73.9%.

The implications of this study are remarkable as well as statistically significant.  Given the risks of pharmaceutical treatment within the geriatric population, the success of alternative and less intrusive treatment alternatives is certainly preferred.  The question was whether or not they would work.

The use of cognitive-behavioral treatment modalities for modifying problematic behavior is successfully used in many circumstances.  This study indicates that this treatment model may also be useful in treating anxiety disorders in elderly adults.

The researchers indicated in the paper that their intervention was so successful that other physicians within the hospital have begun favoring similar approaches in dealing with their regular patients rather than continuing with the traditional pharmaceutical treatment methods.

References

(Gorenstein E Papp L 1995811 Cognitive-behavioral treatment of late-life anxiety disorders)Gorenstein, E., & Papp, L. (1995, August 11). Cognitive-behavioral treatment of late-life anxiety disorders. Paper presented at the American Psychological Association. doi:ED 394 089