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The goal of cognitive-behavioral therapy (CBT) is to regain control of reactions to stress and stimuli, thus reducing the feeling of helplessness that often accompanies anxiety disorders. CBT works on the principle that the thoughts that produce and maintain anxiety can be recognized and altered using various techniques that change behavioral responses and eliminate the anxiety reaction.

CBT and medication are each effective alone but many studies have shown that a combination of CBT and medication works best for treating anxiety disorders. Combination CBT and medication is particularly effective for children and adolescents. Evidence clearly supports the combination approach’s benefits for treating pediatric cases of generalized anxiety disorder, separation anxiety, social phobia, and obsessive compulsive disorder.

Studies suggest that CBT is also helpful for patients who have additional conditions, such as depression, a second anxiety disorder, or alcohol dependency. (It may take longer to achieve a successful outcome in such cases, however.)

Both individual and group treatments work well. However, people with social phobia may do better in individual sessions.

Anxiety disorders are chronic and recurrence is common, even after successful short-term therapy. Some patients with anxiety disorders may require long-term or intensive therapy of at least a year or 50 sessions. Medications, then, are also generally recommended for most patients.

Basic Cognitive Therapy Techniques. Treatment usually takes about 12 - 20 weeks. The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations.

- First, the patient must learn how to recognize anxious reactions and thoughts as they occur. One way of accomplishing this is by keeping a daily diary that reports the occurrences of anxiety attacks and any thoughts and events associated with them. A patient with OCD, for instance, may record repetitive thoughts.

- These entrenched and automatic reactions and thoughts must be challenged and understood. Using the OCD example, one approach is to record and play back the words of the repetitive thoughts, overexposing the patient to the thoughts and reducing their effect. For patients with generalized anxiety disorder, CBT targets their intolerance of uncertainty and helps them develop methods to cope with it.

- Patients are usually given behavioral homework assignments to help them change their reactions. For example, a person with generalized social phobia may be asked to buy an item and then return it the next day. As patients perform these actions, they learn to recognize fears and thoughts triggered by similar events and to understand that these fears are unrealistic.

- As the patient continues with self-observation, they begin to perceive the false assumptions that underlie the anxiety. For example, patients with OCD may learn to recognize that their heightened sense of responsibility for preventing harm in non-threatening situations is neither necessary nor useful.

- At that point, the patient can begin substituting new ways of coping with the feared objects and situations.

Systematic Desensitization. Systematic desensitization is a specific technique that breaks the link between the anxiety-provoking stimulus and the anxiety response. This treatment requires the patient to gradually confront the object of fear. There are three main elements to the process:

- Relaxation training

- A list composed by the patient that prioritizes anxiety-inducing situations by degree of fear

- The desensitization procedure itself, confronting each item on the list, starting with the least stressful

This treatment is especially effective for simple phobias, social phobias, agoraphobia, and post-traumatic stress syndrome.

Exposure and Response Treatment. Exposure treatment purposefully generates anxiety by exposing the patient repeatedly to the feared object or situation, either literally or using imagination and visualization. It uses the most fearful stimulus first. (This differs from the desensitization process because it does not involve relaxation or a gradual approach to the source of anxiety.)

Exposure treatments are usually known as either flooding or graduated exposure:

- Flooding exposes the person to the anxiety-producing stimulus for as long as 1 - 2 hours.

- Graduated exposure gives the patient a greater degree of control over the length and frequency of exposures.

In both cases, the patient experiences the anxiety over and over until the stimulating event eventually loses its effect. Combining exposure with standard cognitive therapy may be particularly beneficial. This approach has helped certain patients in most anxiety disorder categories, including post-traumatic stress disorder.

Modeling Treatment. Phobias can often be treated successfully with modeling treatment:

- The therapy typically uses an actor who approaches an anxiety-producing object or engages in a fear-provoking activity that is similar to the patient's specific problem. Either a live or videotaped situation may be used, although the live model is considered to be more effective.

- The patient observes this event and tries to learn how to behave in a comparable manner.

Anxiety Management Therapy. Anxiety management therapy is sometimes used as an alternative to CBT for generalized anxiety disorder. It involves patient education, relaxation training, and exposure to anxiety-provoking stimuli but does not include exercises in cognitive retraining.

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