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Abstract
Anxiety disorder is a blanket term that covers several different forms of abnormal pathological anxiety. Essentially, distinguishing among these different anxiety disorders is the corner stone to reach an accurate diagnosis & hence, effective treatment & a favourable prognosis.
The DSM-IV-TR (APA, 1998) recognizes specific types of anxiety disorders. These are:
• Generalized anxiety disorder
• Panic disorder ± Agoraphobia
• Posttraumatic stress disorder
• Social phobia
• Obsessive-compulsive disorder
• Specific phobias.
The mainstream treatment for anxiety disorders consists of medications e.g. anxiolytic agents, antidepressants, &/or the referral to a cognitive-behavioral therapist. A major limitation of treating anxiety disorders with medication alone is that patients do not come to evaluate their conditioned dysfunctional patterns of behavior or their unhealthy coping strategies which may be the root of their disorders & suffering.
Fundamentally, CBT is based on the assumption that behavior develops & is maintained according to the principles of learning. Based on this, a model of the causes of each anxiety disorder could be formulated. This model illustrates the cause of the disorder in terms of dysfunctional learned cognitions & behaviors.
Therefore, CBT might be regarded as a generic name including techniques for cognitive therapy & behavioral modification. Techniques for cognitive therapy include discussion of the disorder model (psychoeducation), developing awareness of thoughts, affect, behavior & physical symptoms (ABC model), examination of evidence for/against dysfunctional beliefs (cognitive restructuring) & creating an alternative more functional cognitive appraisal of a situation.
A ‘Thoughts record form’ is used for identification of self-defeating thoughts (cognitive distortions), where the client is taught how to identify his or her thinking style. The negative emotions are usually preceded by the ‘Negative Automatic Thoughts’. These are negative learned thoughts based on distorted ‘underlying assumptions’ & core beliefs. Once this relationship & the way thoughts are triggered in such situations are uncovered, an individual is able to stand back & see how such thoughts are unhelpful.
As the patient becomes aware of his or her own thinking style, its strengths & limitations, new ways of thinking & alternative ways of behaving becomes more amenable. By using this newly acquired knowledge, the individual develops more effective & satisfying ways of dealing with challenges.
Behavior therapy is mainly based upon “exposure therapy”. Exposure therapy might be carried out “in imagination” or “in vivo”. Several forms of exposure are practiced including graded or flooding exposure. Prior to commencing exposure the patient learns more adaptive ways to control his fears e.g. relaxation techniques. To ensure complete success of exposure therapy the patient is advised to DROP all safety behaviors e.g. avoidance or escape. The ultimate goal of this therapy is the extinguishment of the conditioned fears.
Generally, CBT focuses on difficulties in the here & now. It relies on the therapist & client developing a collaborative shared view of the individual’s problem & possible ways of dealing with it. CBT is time-limited therapy of an average of 16-20 weekly sessions. Ideally, the goals of the therapy are continually monitored & evaluated to assess for improvement.
As soon as the Internet was invented, its potential for psychotherapeutic communication was apparent. Initially, On-line self-help & support groups were available for different forms of psychological difficulties. The enduring success of these groups has firmly established the potential of computer-mediated psychotherapy. Nowadays, several forms of web serves are available for patients searching for psychotherapy. Accordingly, the interaction between mental health professionals & consumers on the Internet may be divided into four types; e-therapy, mental health advice, adjunct services, & behavioral tele-health & tele-psychiatry.
Occasionally, Internet-delivered CBT is used to denote the entire field of CBT interventions using computers, interactive voice response, palm-top computers, as well as the Internet. However, a vast majority of Internet applications for anxiety disorders are in effect minimal-therapist-contact interventions.
In 2002, the NICE clinical guideline for the management of anxiety & depression included I-CBT as an option in the management of these disorders. It also recommended that clients should be assessed before starting I-CBT & should be given support all through duration of using the treatment program.
In 1997 a non-profit organization to promote the understanding, use & development of online communication & technology for the international mental health community was formed (ISMHO). This organization attempted to regulate the use of internet in the field of psychotherapy & brought attention to several issues which included:
Before receiving online mental health services, an informed consent should be obtained. In particular, the client should be informed about the process, therapist, potential risks & benefits.
The client should be aware that misunderstandings are possible with text-based modalities such as email (since nonverbal cues are relatively lacking).
The client should be informed of how soon after sending an email, for example, he or she may expect a response.
The client should be informed of the potential benefits/risks of receiving mental health services online. This includes both the circumstances in which the therapist considers online mental health services appropriate & the possible advantages of providing those services online.
Confidentiality could be breached in transit by hackers or Internet service providers or at either end by others with access to the email account or the computer. Extra safeguards should be considered.
The client should be informed of the alternatives to receiving mental health services online.
In general, the therapist should follow the same procedures when providing mental health services online as he or she would when providing them in person.
Many studies were conducted to establish a preliminary estimate of the effectiveness of I-CBT & provide some empirical support for this emerging modality of therapy. These studies showed I-CBT have equivalent outcome to CBT. Fewer studies even found that I-CBT can be more effective than therapy as usual. Another study found I-CBT is as effective as bibliotherapy. Although the results of these studies were not conclusive, I-CBT is proving potentially useful in the treatment of anxiety disorders, depression & phobias. Besides, the only published economic evaluation of I-CBT concluded that I-CBT was cost-effective against therapy as usual.
Yet, I-CBT could not be considered a replacement for face-to-face therapy but it can provide an option for patients, especially in light of the fact that there are not always therapists available, or the cost can be prohibitive