What is Virtual Reality Therapy?

Introduction

Virtual reality therapy (VRT), also known as virtual reality immersion therapy (VRIT), simulation for therapy (SFT), virtual reality exposure therapy (VRET), and computerised CBT (CCBT), is the use of virtual reality technology for psychological or occupational therapy and in affecting virtual rehabilitation.

Patients receiving virtual reality therapy navigate through digitally created environments and complete specially designed tasks often tailored to treat a specific ailment; and is designed to isolate the user from their surrounding sensory inputs and give the illusion of immersion inside a computer-generated, interactive virtual environment. This technology has a demonstrated clinical benefit as an adjunctive analgesic during burn wound dressing and other painful medical procedures. Technology can range from a simple PC and keyboard setup, to a modern virtual reality headset. It is widely used as an alternative form of exposure therapy, in which patients interact with harmless virtual representations of traumatic stimuli in order to reduce fear responses. It has proven to be especially effective at treating post traumatic stress disorder (PTSD), and shows considerable promise in treating a variety of neurological and physical conditions. Virtual reality therapy has also been used to help stroke patients regain muscle control, to treat other disorders such as body dysmorphia, and to improve social skills in those diagnosed with autism.

Description

VRT uses specially programmed computers, visual immersion devices and artificially created environments to give the patient a simulated experience that can be used to diagnose and treat psychological conditions that cause difficulties for patients. In many environmental phobias, reaction to the perceived hazards, such as heights, speaking in public, flying, close spaces, are usually triggered by visual and auditory stimuli. In VR-based therapies, the virtual world is a means of providing artificial, controlled stimuli in the context of treatment, and with a therapist able to monitor the patient’s reaction. Unlike traditional cognitive behavioural therapy (CBT), VR-based treatment may involve adjusting the virtual environment, such as for example adding controlled intensity smells or adding and adjusting vibrations, and allow the clinician to determine the triggers and triggering levels for each patient’s reaction. VR-based therapy systems may allow replaying virtual scenes, with or without adjustment, to habituate the patient to such environments. Therapists who apply virtual reality exposure therapy, just as those who apply in-vivo exposure therapy, can take one of two approaches concerning the intensity of exposure. The first approach is called flooding, which refers to the most intense approach where stimuli that produce the most anxiety are presented first. For soldiers who have developed PTSD from combat, this could mean first exposing them to a virtual reality scene of their fellow troops being shot or injured followed by less stressful stimuli such as only the sounds of war. On the other hand, what is referred to as graded-exposure takes a more relaxed approach in which the least distressing stimuli are introduced first. VR-exposure, as compared to in-vivo exposure has the advantage of providing the patient a vivid experience, without the associated risks or costs. VRT has great promise since it historically produces a “cure” about 90% of the time at about half the cost of traditional CBT authority, and is especially promising as a treatment for PTSD where there are simply not enough psychologists and psychiatrists to treat all the veterans with anxiety disorders diagnosed as related to their military service.

Recently there have been some advances in the field of virtual reality medicine. Virtual reality is a complete immersion of the patient into a virtual world by putting on a headset with an LED screen in the lenses of the headset. This is different from the recent advancements in augmented reality. Augmented reality is different in the sense that it enhances the non-synthetic environment by introducing synthetic elements to the user’s perception of the world. This in turn “augments” the current reality and uses virtual elements to build upon the existing environment. Augmented reality poses additional benefits and has proven itself to be a medium through which individuals suffering from specific phobia can be exposed “safely” to the object(s) of their fear, without the costs associated with programming complete virtual environments. Thus, augmented reality can offer an efficacious alternative to some less advantageous exposure-based therapies.

Brief History

VRT was pioneered and originally termed by Max North documented by the first known publication (Virtual Environment and Psychological Disorders, Max M. North, and Sarah M. North, Electronic Journal of Virtual Culture, 2,4, July 1994), his doctoral VRT dissertation completion in 1995 (began in 1992), and followed with the first known published VRT book in 1996 (Virtual Reality Therapy, an Innovative Paradigm, Max M. North, Sarah M. North, and Joseph R. Coble, 1996. IPI Press). His pioneered virtual reality technology work began as early as 1992 as a research faculty at Clark Atlanta University and supported by funding from US Army Research Laboratory.

An early exploration in 1993-1994 of VRT was done by Ralph Lamson a USC graduate then at Kaiser Permanente Psychiatry Group. Lamson began publishing his work in 1993. As a psychologist, he was most concerned with the medical and therapeutic aspects, that is, how to treat people using the technology, rather than the apparatus, which was obtained from Division, Inc. Psychology Today reported in 1994 that these 1993-1994 treatments were successful in about 90% of Lamson’s virtual psychotherapy patients. Lamson wrote in 1993 a book entitled Virtual Therapy which was published in 1997 directed primarily to the detailed explanation of the anatomical, medical and therapeutic basis for the success of VRT. In 1994-1995, he had solved his own acrophobia in a test use of a third party VR simulation and then set up a 40 patient test funded by Kaiser Permanente. Shortly thereafter, in 1994-1995, Larry Hodges, then a computer scientist at Georgia Tech active in VR, began studying VRT in cooperation with Max North who had reported anomalous behaviour in flying carpet simulation VR studies and attributed such to phobic response of unknown nature. Hodges tried to hire Lamson without success in 1994 and instead began working with Barbara Rothbaum, a psychologist at Emory University to test VRT in controlled group tests, experiencing about 70% success among 50% of subjects completing the testing programme.

In 2005, Skip Rizzo of USC’s Institute for Creative Technologies, with research funding from the Office of Naval Research (ONR), started validating a tool he created using assets from the game Full Spectrum Warrior for the treatment of posttraumatic stress disorder. Virtual Iraq was subsequently evaluated and improved under ONR funding and is supported by Virtually Better, Inc. They also support applications of VR-based therapy for aerophobia, acrophobia, glossophobia, and substance abuse. Virtual Iraq proved successful in normalization of over 70% of PTSD sufferers, and that has now become a standard accepted treatment by the Anxiety and Depression Association of America. However, the VA has continued to emphasize traditional prolonged exposure therapy as the treatment of choice, and VR-based therapies have gained only limited adoption, despite active promotion by DOD, and despite VRT having much lower cost and apparently higher success rates. A $12-million ONR funded study is currently underway to definitively compare the efficacy of the two methods, PET and VRT. Military labs have subsequently set up dozens of VRT labs and treatment centres for treating both PTSD and a variety of other medical conditions. The use of VRT has thus become a mainstream psychiatric treatment for anxiety disorders and is finding increasing use in the treatment of other cognitive disorders associated with various medical conditions such as addiction, depression and insomnia.

Applications

Psychological Therapy

Exposure Therapy

Virtual reality technology is especially useful for exposure therapy – a treatment method in which patients are introduced and then slowly exposed to a traumatic stimulus. Inside virtual environments, patients can safely interact with a representation of their phobia, and researchers do not need to have access to a real version of the phobia itself. One of the primary challenges to the efficacy of Exposure therapy is recreating the level of trauma existing in real environments inside a virtual environment. Virtual Reality aids in overcoming this by engaging with different sensory stimuli of the patient while heightening the realism and maintaining the safety of the environment.

One very successful example of virtual reality therapy exposure therapy is the PTSD treatment system, Virtual Iraq. Using a head mounted display and a game pad, patients navigate a Humvee around virtual recreations of Iraq, Afghanistan, and the United States. By being safely exposed to the traumatic environments, patients learned to reduce their anxiety. According to a review of the history of Virtual Iraq, one study found that it reduced PTSD symptoms by an average of fifty percent, and disqualified over 75% of participants for PTSD after treatment. Virtual Reality Exposure Therapy (VRET) is also commonly used for treating specific phobias, especially small animal phobia. Commonly feared animals such as spiders can be easily produced in a virtual environment, instead of finding the real animal. VRET has also been used experimentally to treat other fears such as public speaking and claustrophobia.

Another successful study attempted treating 10 individuals who experienced trauma as a result of events during 9/11. Through repeated exposure to increasingly traumatic sequences of World Trade Centre events, immediate positive results were self reported by test subjects. In a 6 month follow up, 9 of the test subjects available for follow up maintained their results from exposure.

VRET offers a wide range of advantages compared to traditional exposure therapy techniques. Recent years have suggested an increase in familiarly and trust in virtual reality technology as an acceptable mirror of reality. A higher trust in the technology could lead to more effective treatment results as more phobics seek out help. Another consideration for VRET is the cost effectiveness. While the actual cost of VRET may vary based on the hardware and software implementation, it is supposedly more effective than the traditional in vivo treatment used for exposure therapy while maintaining a positive return on investment. Future research might pave an alternative to extensive automated lab or hospital environments. For instance, in 2011, researchers at York University proposed an affordable VRET system for the treatment of phobias that could be set up at home. Such developments in VRET may pave a new way of customised treatment that also tackles the stigma attached to clinical treatment. While there is still a lot unknown about the long-term effectiveness of the relatively new VRET, the future seems promising with growing studies reflecting the benefits of VRET to combat phobias.

Virtual Rehabilitation

The term virtual rehabilitation was coined in 2002 by Professor Daniel Thalmann of EPFL (Switzerland) and Professor Grigore Burdea of Rutgers University (USA). In their view the term applies to both physical therapy and cognitive interventions (such as for patients suffering from Post Traumatic Stress Disorder, phobias, anxieties, attention deficits or amnesia). Since 2008, the virtual rehabilitation “community” has been supported by the International Society on Virtual Rehabilitation.

Virtual rehabilitation is a concept in psychology in which a therapeutic patient’s training is based entirely on, or is augmented by, virtual reality simulation exercises. If there is no conventional therapy provided, the rehabilitation is said to be “virtual reality-based”. Otherwise, if virtual rehabilitation is in addition to conventional therapy, the intervention is “virtual reality-augmented.” Today, a majority of the population uses the virtual environment to navigate their daily lives and almost one fourth of the world population uses the internet. As a result, virtual rehabilitation and gaming rehabilitation, or rehabilitation through gaming consoles, have become quite common. In fact, virtual therapy has been used over regular therapeutic methods in order to treat a number of disorders.

Some factors to consider when virtual rehabilitation include cultural sensitivity, accessibility, and ability to finance the virtual therapy.

Advantages

Virtual rehabilitation offers a number of advantages compared to conventional therapeutic methods:

It is entertaining, thus motivating the patient:

  • Potential for involvement of the patients’ stimulus modalities for more realistic environments for treatment.
  • It provides objective outcome measures of therapy efficacy (limb velocity, range of movement, error rates, game scores, etc.).
  • These data are transparently stored by the computer running the simulation and can be made available on the Internet.
  • Virtual rehabilitation can be performed in the patient’s home and monitored at a distance (becoming telerehabilitation).
  • The patient feels more actively involved in the desensitisation.
  • The patient may “forget” they are in treatment or undergoing observation resulting in more authentic expressions.
  • Effective for hospitals to reduce their costs because of lowered cost of medicine and equipment.
  • Great impact of virtual reality on pain relief.

Disadvantages

Despite all the merits of VR therapy as listed in the sections above, there are pitfalls and obstacles in the development of widespread VR solutions.

  • Cost effectiveness:
    • VRET may show promising returns on investment but the fact remains that the true development cost of VRET environments depends heavily on the choice of hardware and software chosen.
  • Treatment effectiveness:
    • For the treatment to take effect, a patient should be able to successfully project and experience their anxiety in a virtual environment.
    • Unfortunately, this projection is highly subjective and personalised per patient; and outside the control of the therapists.
    • This limitation might adversely impact the therapy.
  • Migrating back to reality from virtual reality:
    • Another scepticism is the correlation between virtual reality and actual reality. If a patient successfully combats their phobia in a virtual environment, does that guarantee success in real life too?
    • Further, when treating more complicated ailments such as schizophrenia, there is inadequate projection on how delusions and hallucinations may translate from the real world to the virtual one.
  • VR sickness:
    • Movement in a virtual environment is said to cause visual discomfort.
    • Prolonged periods of exposure to VR may lead to side effects like dry eyes, headaches, nausea and sweating; symptoms similar to motion sickness.
  • Ethical and legal considerations:
    • Since VR is a relatively new technology, its ethical implications are not as comprehensive as other forms of treatment.
    • There is a need to formalize the limits, side effects, disclaimers, privacy regulations as we increase the breadth of impact of VR therapy; especially in matters related to forensic cases.
  • Acceptance by the medical community:
    • As VR-based therapy increases, it might pose a challenge to licenced therapists and medical professionals who may perceive VR as a threat.
    • After all, VR deviates from the pre-established norm of “talking cure”.

Therapeutic Targets

Depression

In February 2006 the UK’s National Institute of Health and Clinical Excellence (NICE) recommended that VRT be made available for use within the NHS across England and Wales, for patients presenting with mild/moderate depression, rather than immediately opting for antidepressant medication. Some areas have developed or are trialling.

At Auckland University in New Zealand, a team led by Dr. Sally Merry have been developing a computerised CBT fantasy “serious” game to help tackle depression amongst adolescents. The game, Sparx, has a number of features to help combat depression, where the user takes on a role of a character who travels through a fantasy world, combating “literal” negative thoughts and learning techniques to manage their depression.

Eating Disorders and Body Dysmorphia

Virtual reality therapy has also been used to attempt to treat eating disorders and body dysmorphia. One study in 2013 had participants complete various tasks in virtual reality environments which could not have been easily replicated without the technology. Tasks included showing patients the implications of reaching their desired weight, comparing their actual body shape to an avatar created using their perceived body size, and altering a virtual reflection to match their actual body size.

Gender Dysphoria

Early research suggests that virtual reality experiences may offer therapeutic benefits to transgendered individuals experiencing gender dysphoria. More experimentation and professional examination is needed before virtual reality could be prescribed as a treatment in practice. However, some transgendered individuals have engaged in what can be characterized as an anecdotally, alleviating form of self-administered, virtual sex reassignment therapy. Digital spaces offer a form of anonymous self-expression that trans individuals, due to exposure of discrimination and violence, are not fully granted to them in real life or IRL. The sophistication of virtual reality expands on these newfound liberties by providing an avenue for those with gender dysphoria to embody their gender identity, if it not accessible for them to do so in their real life. Through use of available VR videogames and chat rooms, those suffering from gender dysphoria can create avatars of themselves, interact anonymously, and work towards therapeutic goals.

Acrophobia

A study published in The Lancent Psychiatry proved that Virtual Reality therapy can help treat acrophobia. Over the course of the study, participants were introduced to intimidating heights in a Virtual Reality environment then asked to complete various activities at those heights while under the supervision and support of a coach. This study, although insufficient in terms of scope and scrutiny for direct adoption into remedial practices, surrounds future research and treatment modelling with promise, as a majority of the participants considered themselves no longer afraid of heights.

Physical Therapy

Stroke

Research suggests that patients who suffered from a stroke found Virtual reality (VR) rehab techniques in their Physical Therapy treatment plans very beneficial. Throughout a rehabilitation programme aimed to restore and/or retain balance and walking skills, patients who have suffered a stroke often must relearn how to control certain muscles. In most physical therapy settings, this is done through high intensity, repetitive, and task-specific practice. Programmes of this type can prove to be physically demanding, are expensive, and require several days of training per week. Additionally, regimens may seem redundant, and produce only modest and/or delayed effects in patient recovery. A physical therapy regimen using VR provides an opportunity to individualise training to fit the specific needs of the patient. While the exercises and movements required for proper motor learning can seem repetitive, using VR adds a level of intrigue and engagement for the patient. Training with VR enhances motor learning by giving the patient opportunities to practice their movements/exercise protocol in different VR environments. This ensures that patients are always challenged and may be better prepared to perform in their environments.

Feedback is an important element of physical therapy for patients recovering from stroke and/or other neuromuscular disorders. Within the scope of motor learning, receiving feedback during performance of a task improves the learning rate. According to a Cochrane Review, visual feedback, specifically, has been shown to aid in balance recovery for patients who have had a stroke. VR can provide continuous visual feedback that a physical therapist may not be able to during their sessions. Results have also suggested that in addition to improvements in balance, positive effects are also seen in walking ability. In one study, patients with VR training coupled with their physical therapy programme had better improvements in walking speed than others not using VR training. The most recent review about the effect of VR training on balance and gait ability showed significant benefits of VR training on gait speed, Berg Balance Scale (BBS) scores, and Timed “Up & Go” Test scores when VR was time dose matched to conventional therapy.

Parkinson’s Disease

Many studies (Cochrane Review) have shown that using VR technology during Physical Therapy treatments for patients with Parkinson’s Disease had positive outcomes. For patients with PD the VR therapy:

  • Increased gait and balance.
  • Improved functions of activities of daily living (ADL’s).
  • Improved quality of life.
  • Improved cognitive function.

It is speculated that these improvements occurred because the VR gave increased feedback to the patient regarding their performance during the VR sessions. VR stimulates a patient’s motor and cognitive processes, both of which may be impaired as a result of the disease. Another benefit of VR is that it replicates real life scenarios, allowing patients to practice functional activities.

Wound Care

Additionally, VR provides beneficial outcomes when it is implemented for patients who are receiving wound care rehabilitation. Studies have speculated that the more immersive the VR, the greater the experience and concentration the patient will have on the virtual environment. Equally important, VR has shown to reduce pain, anxiety and depressive symptoms, as well as an increasing their treatment adherence.

In other studies, the results point to the benefits of VR in relation to increased distraction, and patients reported less time thinking about pain, less intense pain and immersion, which facilitates care such as dressing changes and physiotherapy.

Wound dressing often generates a pain-provoking experience. Therefore, use of VR was related to more efficient dressings, increased distraction from the pain during procedures (e.g. dressing and physical rehabilitation) which reduced the patients’ stress and anxiety.

Cardiovascular

The use of VR and video games could be considered as complementary tools for physical training in patients with Cardiovascular diseases. Certain games designed for exercise have been shown to promote increases in heart rate, fatigue perception, and physical activity. In addition, it has been shown to reduce pain and increase adherence to physical therapy programmes in patients with cardiovascular diseases. Finally, Virtual reality and video games enhance motivation and adherence in cardiac rehabilitation programmes.

Occupational Therapy

Autism

Virtual reality has been shown to improve the social skills of young adults with autism. In one study, participants controlled a virtual avatar in different virtual environments and manoeuvred through various social tasks such as interviewing, meeting new people, and dealing with arguments. Researchers found that participants improved in the areas of emotional recognition in voices and faces and in considering the thoughts of other people. Participants were also surveyed months after the study for how effective they thought the treatments were, and the responses were overwhelmingly positive. Many other studies have also explored this occupational therapy option.

Attention Deficit Hyperactivity Disorder

A clinical trial published in the Journal of Attention Disorders found that school age children with ADHD who underwent a virtual classroom cognitive treatment series were able to achieve the same management of symptoms of impulsivity and distractibility as children who were medicated with a stimulant.

Post Traumatic Stress Disorder

It may also be possible to use virtual reality to assist those with PTSD. The virtual reality allows the patients to relive their combat situations at different extremes as a therapist can be there with them guiding them through the process. Some scholars believe that this is an effective way to treat PTSD patients as it allows for the recreation of exactly what they experienced. “It allows for greater engagement by the patient and, consequently, greater activation of the traumatic memory, which is necessary for the extinction of the conditioned fear.”

Stroke

Virtual reality also has applications in the physical side of occupational therapy. For stroke patients, various virtual reality technologies can help bring fine control back to different muscle groups. Therapy often includes games controlled with haptic-feedback controllers that require fine movements, such as playing piano with a virtual hand. The Wii gaming system has also been used in conjunction with virtual reality as a treatment method.

Chronic and Acute Pain

VR has been shown to be effective in immediately decreasing procedural or acute pain. To date there have been few studies on its efficacy in chronic pain. Such chronic pain patients can tolerate the VR session without the side effects that sometimes come with VR such as headaches, dizziness or nausea.

Rehabilitation

Virtual reality is also helping patients overcome balance and mobility problems resulting from stroke or head injury. In the study of VR, the modest advantage of VR over conventional training supports further investigation of the effect of video-capture VR or VR combined with conventional therapy in larger-scale randomised, more intense controlled studies. It shows the VR-assisted patients had better mobility when the doctors checked in two months later. Other research has shown similarly successful outcomes for patients with cerebral palsy undergoing rehab for balance problems.

Surgery

VR smoothly blurs the demarcation between the physical world and the computer simulation as surgeons can use latest versions of virtual reality glasses to interact in a three-dimensional space with the organ that requires surgical treatment, view it from any desired angle and able to switch between 3D view and the real CT images.

Efficacy

Randomised, tightly controlled, acrophobia treatment trials at Kaiser Permanente provided >90% effectiveness, conducted in 1993-94. Of 40 patients treated, 38 showed marked reduction in phobic reaction to heights and self-reported reaching their goals. Research found that VRT allows patients to achieve victory over virtual height situations they could not confront in real life, and that gradually increasing the height and danger in a virtual environment produced increasing victories and greater self-confidence in the patient that they could actually confront the situation in real life. “Virtual therapy interventions empower people. The simulation technology of virtual reality lends itself to mastery oriented treatment … Rather than coping with threats, phobics manage progressively more threatening aspects in a computer-generated environment … The range of applications can be extended by enhancing the realness and interactivity so that actions elicit reactions from the environments in which individuals immerse themselves”.

Another study examined the effectiveness of virtual reality therapy in treating military combat personnel recently returning from the current conflicts in Iraq and Afghanistan. Rauch, Eftekhari and Ruzek conducted a study with a sample of 42 combat servicemen who were already diagnosed with chronic PTSD (post-traumatic stress disorder). These combat servicemen were pre-screened using several different diagnostic self-reports including the PTSD military checklist, a screening tool used by the military in the determination of the intensity of the diagnosis of PTSD by measuring the presence of PTSD symptoms. Although 22 of the servicemen dropped out of the study, the results of the study concerning the 20 remaining servicemen still has merit. The servicemen were given the same diagnostic tests after the study which consisted of multiple sessions of virtual reality exposure and virtual reality exposure therapy. The servicemen showed much improvement in the diagnostic scores, signalling a decrease of symptoms of PTSD. Likewise, a three-month follow-up diagnostic screening was also administered after the initial sessions that were undergone by the servicemen. The results of this study showed that 15 of the 20 participants no longer met diagnostic criteria for PTSD and improved their PTSD military checklist score by 50% for the assessment following the study. Even though only 17 of the 20 participants participated in the 3-month follow-up screening, 13 of the 17 still did not meet the criteria for PTSD and maintained their 50% improvement in the PTSD military checklist score. These results show promising effects and help to validate virtual reality therapy as an efficacious mode of therapy for the treatment of PTSD.

VR combined real instrument training was effective at promoting recovery of patients’ upper-extremity and cognitive function, and thus may be an innovative translational neurorehabilitation strategy after stroke. In the study, the experimental group showed greater therapeutic effects in a time-dependent manner than the control group, especially on the motor power of wrist extension, spasticity of elbow flexion and wrist extension, and Box and Block Tests. Patients in the experimental group, but not the control group, also showed significant improvements on the lateral, palmar, and tip pinch power, Box and Block, and 9-HPTs from before to immediately after training.

Continued Development

Larry Hodges, formerly of Georgia Tech and now Clemson University and Barbara Rothbaum of Emory University, have done extensive work in VRT, and also have several patents and founded a company, Virtually Better, Inc.

In the United States, the United States Department of Defence (DOD) continues funding of VRT research and is actively using VR in treatment of PTSD.

Millions of funding is being put towards developments and early trials in the realm of virtual reality as companies race for FDA approval for their medical applications.

BRAVEMIND Software

In 2014, a virtual reality application used as a prolonged exposure (PE) therapy tool for military related trauma called BRAVEMIND was reported BRAVEMIND is as an acronym for Battlefield Research Accelerating Virtual Environments for Military Individual Neuro Disorders. VRET applications have been used to assist civilian populations with anxieties about flying, public speaking, and heights. BRAVEMIND has been studied in populations of military medics as well as survivors of military sexual assault and combat. This technology was developed by researchers at the University of the Southern California in collaboration with the US Army Research Laboratory.

In 2004, reports stated that 40% of military members experience PTSD but only 23% seek medical help. Emory physicians described one of the strongest indicators of PTSD to be avoidance, saying this inhibits those affected from seeking treatment. PE requires that the patient close their eyes and relate the pertinent episode in as much detail as possible. The methodology was based on the concept that in facing the event, the charge of the triggers may be attenuated over time. The VRET application BRAVEMIND differs from PE in that the patient does not reimagine the episode but instead wears a headset that places them in the familiar environment. This headset is equipped with two screens (one for each eye), headphones, and a position monitor that shifts the visual scene to match the patient’s head movements. Depending on the patient’s experience they may be standing or sitting on top of a raised platform with a bass shaker. This allows for vibrations that simulate the experience of riding a military vehicle. Other accessories such as joysticks or mock machine guns are given to the patients, if appropriate, to enhance realism.

The clinician introduces triggers, such as gunfire, explosions, etc. into the virtual environment as they see fit. The clinician can also adapt sound and lighting conditions to match the patient’s description. The researchers who developed the BRAVEMIND system reported that in a 20-patient trial, the patients’ scores on the diagnostic PTSD checklist-military version (PCL-M) dropped from 54.4 pre-treatment to 35.6 post-treatment after eleven sessions. In another clinical trial, consisting of 24 active-duty soldiers, it was reported that after 7 sessions 45% no longer were identified as positive for PTSD while 62% demonstrated symptomatic improvement. These experimental results were compared with those of alternative PE treatments.

The BRAVEMIND software has 14 different environments available including military barracks, Iraqi markets, and desert roads. Included in these are environments specific to military sexual trauma (MST). Designed environments such as US base settings, shower areas, latrines, remote shelters, and others were developed after consulting subject matter experts from Emory University.

Proponents of this research have said that with military based videogames being so prevalent, this technology may be more appealing to patients and reduce the stigma surrounding treatment. They also have argued that as research on PTSD unfolds, possible subtypes may respond to treatments differently, and therefore diversifying treatment options is best. Others have expressed reservations about the capacity to properly personalise VRET for individualised treatment and the use of ethnic stereotyping while developing Arab populated environments.

Treatment for Lesions

Virtual reality therapy has two promising potential benefits for treatment of hemispatial neglect patients. These include improvement of diagnostic techniques and as a supplement to rehabilitation techniques.

Current diagnostic techniques usually involve pen and paper tests like the line bisection test. Though these tests have provided relatively accurate diagnostic results, advances in VRT have proven these tests to not be completely thorough. Dvorkin et al. used a camera system that immersed the patient into a virtual reality world and required the patient to grasp or move object in the world, through tracking of arm and hand movements. These techniques revealed that pen and paper tests provide relatively accurate qualitative diagnoses of hemispatial neglect patients, but VRT provided accurate mapping into a 3-dimensional space, revealing areas of space that were thought to be neglected but which patients had at least some awareness. Patients were also retested 10 months from initial measurements, during which each went through regular rehabilitation therapy, and most showed measurably less neglect on virtual reality testing whereas no measurable improvements were shown in the line bisection test.

Virtual reality therapy has also proven to be effective in rehabilitation of lesion patients suffering from neglect. A study was conducted with 24 individuals suffering from hemispatial neglect. A control group of 12 individuals underwent conventional rehabilitation therapy including visual scanning training, while the VR group were immersed in 3 virtual worlds, each with a specific task. The programmes consisted of

  • “Bird and Ball” in which a patient touches a flying ball with his or her hand and turns it into a bird.
  • “Coconut”, in which a patient catches a coconut falling from a tree while moving around.
  • “Container” in which a patient moves a box carried in a container to the opposite side.

Each of the patients of VR went through 3 weeks of 5-day-a-week 30-minute intervals emerged in these programmes. The controls went through the equivalent time in traditional rehabilitation therapies. Each patient took the star cancellation test, line bisection test, and Catherine Bergego Scale (CBS) 24 hours before and after the three-week treatment to assess the severity of unilateral spatial neglect. The VR group showed a higher increase in the star cancellation test and CBS scores after treatment than the control group (p<0.05), but both groups did not show any difference in the line bisection test and K-MBI before and after treatment. These results suggest that virtual reality programmes can be more effective than conventional rehabilitation and thus should be further researched.

VR Advantages over IVE

The preference of VR exposure therapy over in-vivo exposure therapy is often debated, but there are many obvious advantages of virtual reality exposure therapy that make it more desirable. For example, the proximity between the client and therapist can cause problems when in-vivo therapy is used and transportation is not reliable for the client or it is impractical for them to travel as far as needed. However, virtual reality exposure therapy can be done from anywhere in the world if given the necessary tools. Going along with the idea of unavailable transportation and proximity, there are many individuals who require therapy but due to various forms of immobilisations (paralysis, extreme obesity, etc.) they can not physically be moved to where the therapy is conducted. Again, because virtual reality exposure therapy can be conducted anywhere in the world, those with mobility issues will no longer be discriminated against. Another major advantage is fewer ethical concerns than in-vivo exposure therapy.

Another advantage to virtual reality rehab over the traditional method is patient motivation. When presented with difficult tasks during a prolonged period, patients tend to lose interest in these tasks. This causes a decrease in compliance due to decreased motivation of completing a given task. VR rehab is advantageous in such a way that it challenges and motivates the patient to do more. With simple things like high scores, in-game awards, and ranks, not only are patients motivated to do their daily therapies, they are having fun doing it. Not only is this advantageous to the patients, it is advantageous to the physical therapist. With these high scores, and data the game or application collects, therapists can analyse the data to see progression. This progression can be charted and visually shown to the patient for increased motivation on their performance and the progression they have made thus far in their therapies. This data can then be charted with other participants doing similar tasks and can show how they compare to people with similar therapy regimens. This charted data in the programme or game can then be used by researchers and scientists alike for further evaluation of optimal therapy regimens. A recent study done in 2016 where a VR based virtual simulation of a city named Reh@City was made. This city in virtual reality evoked memory, attention, visuo-spatial abilities and executive functions tasks are integrated in the performance of several daily routines. This study looked at Activities of Daily Living in post stroke patients and found it to have more of an impact than conventional methods in the recovery process.

Concerns

There are a few ethical concerns concerning the use and development of using virtual reality simulation for helping clients/patients with mental health issues. One example of these concerns is the potential side effects and aftereffects of virtual reality exposure. Some of these side effects and aftereffects could include cybersickness (a type of motion sickness caused by the virtual reality experience), perceptual-motor disturbances, flashbacks, and generally lowered arousal. If severe and widespread enough, these effects should be mitigated via various methods by those therapists using virtual reality.

Another ethical concern is how clinicians should receive VRT certification. Due to the relative newness of virtual reality as a whole, there may not be many clinicians who have experience with the nuances of virtual reality exposure or VR programs’ intended roles in therapy. As such, VR technology should only be used as a tool for qualified clinicians instead of being used to further one’s practice or garner an attraction for new clients/patients.

Some traditional concerns with VR therapy is the cost. Since virtual reality in the field of science and medicine is so primitive and new, the costs of VR equipment would be a lot higher than some of the traditional methods. With medical costs growing at an exponential level this would be another cost that is added to the growing list of medical bills for a patients recovery process. Regardless of the benefits with VR rehab, the costs of the equipment and the resources for a VR setup would make it difficult for it to be mainstream and available to all patients including the indigent population. However, a new market of lower cost VR hardware is emerging, specifically with improved head-mounted displays.

In addition there are some issues which are related to VR that can arise from its use such as Social Isolation where the users can become detached from real-world social connections and the overestimation of a person’s abilities where users – especially the young – often fail to distinguish between their feats in real life and VR.

What is Schema (Psychology)?

Introduction

In psychology and cognitive science, a schema (plural schemata or schemas) describes a pattern of thought or behaviour that organises categories of information and the relationships among them. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organising and perceiving new information. Schemata influence attention and the absorption of new knowledge: people are more likely to notice things that fit into their schema, while re-interpreting contradictions to the schema as exceptions or distorting them to fit. Schemata have a tendency to remain unchanged, even in the face of contradictory information. Schemata can help in understanding the world and the rapidly changing environment. People can organise new perceptions into schemata quickly as most situations do not require complex thought when using schema, since automatic thought is all that is required.

People use schemata to organise current knowledge and provide a framework for future understanding. Examples of schemata include academic rubrics, social schemas, stereotypes, social roles, scripts, worldviews, and archetypes. In Piaget’s theory of development, children construct a series of schemata, based on the interactions they experience, to help them understand the world.

Brief History

“Schema” comes from the Greek word schēmat or schēma, meaning “figure”.

Prior to its use in psychology, the term “schema” had primarily seen use in philosophy. For instance, “schemata” (especially “transcendental schemata”) are crucial to the architectonic system devised by Immanuel Kant in his Critique of Pure Reason.

Early developments of the idea in psychology emerged with the gestalt psychologists and Jean Piaget: the term schéma was introduced by Piaget in 1923. In Piaget’s later publications, action (operative or procedural) schémes were distinguished from figurative (representational) schémas, although together they may be considered a schematic duality. In subsequent discussions of Piaget in English, schema was often a mistranslation of Piaget’s original French schéme. The distinction has been of particular importance in theories of embodied cognition and ecological psychology.

The concept was popularised in psychology and education through the work of the British psychologist Frederic Bartlett, who drew on the term body schema used by neurologist Henry Head. It was expanded into schema theory by educational psychologist Richard C. Anderson. Since then, other terms have been used to describe schema such as “frame”, “scene”, and “script”.

Schematic Processing

Through the use of schemata, a heuristic technique to encode and retrieve memories, the majority of typical situations do not require much strenuous processing. People can quickly organise new perceptions into schemata and act without effort.

However, schemata can influence and hamper the uptake of new information (proactive interference), such as when existing stereotypes, giving rise to limited or biased discourses and expectations (prejudices), lead an individual to “see” or “remember” something that has not happened because it is more believable in terms of his/her schema. For example, if a well-dressed businessman draws a knife on a vagrant, the schemata of onlookers may (and often do) lead them to “remember” the vagrant pulling the knife. Such distortion of memory has been demonstrated. (See Background Research below.)

Schemata are interrelated and multiple conflicting schemata can be applied to the same information. Schemata are generally thought to have a level of activation, which can spread among related schemata. Which schema is selected can depend on factors such as current activation, accessibility, priming and emotion.

Accessibility is how easily a schema comes to mind, and is determined by personal experience and expertise. This can be used as a cognitive shortcut; it allows the most common explanation to be chosen for new information.

With priming, a brief imperceptible stimulus temporarily provides enough activation to a schema so that it is used for subsequent ambiguous information. Although this may suggest the possibility of subliminal messages, the effect of priming is so fleeting that it is difficult to detect outside laboratory conditions.

Background Research

The original concept of schemata is linked with that of reconstructive memory as proposed and demonstrated in a series of experiments by Frederic Bartlett. By presenting participants with information that was unfamiliar to their cultural backgrounds and expectations and then monitoring how they recalled these different items of information (stories, etc.), Bartlett was able to establish that individuals’ existing schemata and stereotypes influence not only how they interpret “schema-foreign” new information but also how they recall the information over time. One of his most famous investigations involved asking participants to read a Native American folk tale, “The War of the Ghosts”, and recall it several times up to a year later. All the participants transformed the details of the story in such a way that it reflected their cultural norms and expectations, i.e. in line with their schemata. The factors that influenced their recall were:

  • Omission of information that was considered irrelevant to a participant;
  • Transformation of some of the details, or of the order in which events, etc., were recalled; a shift of focus and emphasis in terms of what was considered the most important aspects of the tale;
  • Rationalization: details and aspects of the tale that would not make sense would be “padded out” and explained in an attempt to render them comprehensible to the individual in question; and
  • Cultural shifts: the content and the style of the story were altered in order to appear more coherent and appropriate in terms of the cultural background of the participant.

Bartlett’s work was crucially important in demonstrating that long-term memories are neither fixed nor immutable but are constantly being adjusted as schemata evolve with experience. In a sense it supports the existentialist view that people construct the past and present in a constant process of narrative/discursive adjustment, and that much of what people “remember” is actually confabulated (adjusted and rationalised) narrative that allows them to think of the past as a continuous and coherent string of events, even though it is probable that large sections of memory (both episodic and semantic) are irretrievable at any given time.

An important step in the development of schema theory was taken by the work of D.E. Rumelhart describing the understanding of narrative and stories. Further work on the concept of schemata was conducted by W.F. Brewer and J.C. Treyens, who demonstrated that the schema-driven expectation of the presence of an object was sometimes sufficient to trigger its erroneous recollection. An experiment was conducted where participants were requested to wait in a room identified as an academic’s study and were later asked about the room’s contents. A number of the participants recalled having seen books in the study whereas none were present. Brewer and Treyens concluded that the participants’ expectations that books are present in academics’ studies were enough to prevent their accurate recollection of the scenes.

In the 1970s, computer scientist Marvin Minsky was trying to develop machines that would have human-like abilities. When he was trying to create solutions for some of the difficulties he encountered he came across Bartlett’s work and decided that if he was ever going to get machines to act like humans he needed them to use their stored knowledge to carry out processes. To compensate for that he created what was known as the frame construct, which was a way to represent knowledge in machines. His frame construct can be seen as an extension and elaboration of the schema construct. He created the frame knowledge concept as a way to interact with new information. He proposed that fixed and broad information would be represented as the frame, but it would also be composed of slots that would accept a range of values; but if the world did not have a value for a slot, then it would be filled by a default value. Because of Minsky’s work, computers now have a stronger impact on psychology. In the 1980s, David Rumelhart extended Minsky’s ideas, creating an explicitly psychological theory of the mental representation of complex knowledge.

Roger Schank and Robert Abelson developed the idea of a script, which was known as a generic knowledge of sequences of actions. This led to many new empirical studies, which found that providing relevant schema can help improve comprehension and recall on passages.

Modification

New information that falls within an individual’s schema is easily remembered and incorporated into their worldview. However, when new information is perceived that does not fit a schema, many things can happen. The most common reaction is to simply ignore or quickly forget the new information. This can happen on an unconscious level – frequently an individual may not even perceive the new information. People may also interpret the new information in a way that minimizes how much they must change their schemata. For example, Bob thinks that chickens do not lay eggs. He then sees a chicken laying an egg. Instead of changing the part of his schema that says “chickens do not lay eggs”, he is likely to adopt the belief that the animal in question that he has just seen laying an egg is not a real chicken. This is an example of disconfirmation bias, the tendency to set higher standards for evidence that contradicts one’s expectations. However, when the new information cannot be ignored, existing schemata must be changed or new schemata must be created (accommodation).

Jean Piaget (1896-1980) was known best for his work with development of human knowledge. He believed knowledge was constructed on cognitive structures, and he believed people develop cognitive structures by accommodating and assimilating information. Accommodation is creating new schema that will fit better with the new environment or adjusting old schema. Accommodation could also be interpreted as putting restrictions on a current schema. Accommodation usually comes about when assimilation has failed. Assimilation is when people use a current schema to understand the world around them. Piaget thought that schemata are applied to everyday life and therefore people accommodate and assimilate information naturally. For example, if this chicken has red feathers, Bob can form a new schemata that says “chickens with red feathers can lay eggs”. This schemata will then be either changed or removed, in the future.

Assimilation is the reuse of schemata to fit the new information. For example, when a person sees an unfamiliar dog, they will probably just integrate it into their dog schema. However, if the dog behaves strangely, and in ways that does not seem dog-like, there will be accommodation as a new schema is formed for that particular dog. With Accommodation and Assimilation comes the idea of equilibrium. Piaget describes equilibrium as a state of cognition that is balanced when schema are capable of explaining what it sees and perceives. When information is new and cannot fit into existing schema this is called disequilibrium and this is an unpleasant state for the child’s development. When disequilibrium happens, it means the person is frustrated and will try to restore the coherence of his or her cognitive structures through accommodation. If the new information is taken then assimilation of the new information will proceed until they find that they must make a new adjustment to it later down the road, but for now the child remains at equilibrium again. The process of equilibration is when people move from the equilibrium phase to the disequilibrium phase and back into equilibrium.

Self-Schema

Schemata about oneself are considered to be grounded in the present and based on past experiences. Memories are framed in the light of one’s self-conception. For example, people who have positive self-schemata (i.e. most people) selectively attend to flattering information and selectively ignore unflattering information, with the consequence that flattering information is subject to deeper encoding, and therefore superior recall. Even when encoding is equally strong for positive and negative feedback, positive feedback is more likely to be recalled. Moreover, memories may even be distorted to become more favourable, for example, people typically remember exam grades as having been better than they actually were. However, when people have negative self views, memories are generally biased in ways that validate the negative self-schema; people with low self-esteem, for instance, are prone to remember more negative information about themselves than positive information. Thus, memory tends to be biased in a way that validates the agent’s pre-existing self-schema.

There are three major implications of self-schemata. First, information about oneself is processed faster and more efficiently, especially consistent information. Second, one retrieves and remembers information that is relevant to one’s self-schema. Third, one will tend to resist information in the environment that is contradictory to one’s self-schema. For instance, students with a particular self-schema prefer roommates whose view of them is consistent with that schema. Students who end up with roommates whose view of them is inconsistent with their self-schema are more likely to try to find a new roommate, even if this view is positive. This is an example of self-verification.

As researched by Aaron Beck, automatically activated negative self-schemata are a large contributor to depression. According to Cox, Abramson, Devine, and Hollon (2012), these self-schemata are essentially the same type of cognitive structure as stereotypes studied by prejudice researchers (e.g. they are both well-rehearsed, automatically activated, difficult to change, influential toward behaviour, emotions, and judgments, and bias information processing).

The self-schema can also be self-perpetuating. It can represent a particular role in society that is based on stereotype, for example: “If a mother tells her daughter she looks like a tom boy, her daughter may react by choosing activities that she imagines a tom boy would do. Conversely, if the mother tells her she looks like a princess, her daughter might choose activities thought to be more feminine.” This is an example of the self-schema becoming self-perpetuating when the person at hand chooses an activity that was based on an expectation rather than their desires.

Schema Therapy

Schema therapy was founded by Jeffrey Young and represents a development of cognitive behavioural therapy (CBT) specifically for treating personality disorders. Early maladaptive schemata are described by Young as broad and pervasive themes or patterns made up of memories, feelings, sensations, and thoughts regarding oneself and one’s relationships with others. They are considered to develop during childhood or adolescence, and to be dysfunctional in that they lead to self-defeating behaviour. Examples include schemata of abandonment/instability, mistrust/abuse, emotional deprivation, and defectiveness/shame.

Schema therapy blends CBT with elements of Gestalt therapy, object relations, constructivist and psychoanalytic therapies in order to treat the characterological difficulties which both constitute personality disorders and which underlie many of the chronic depressive or anxiety-involving symptoms which present in the clinic. Young said that CBT may be an effective treatment for presenting symptoms, but without the conceptual or clinical resources for tackling the underlying structures (maladaptive schemata) which consistently organize the patient’s experience, the patient is likely to lapse back into unhelpful modes of relating to others and attempting to meet their needs. Young focused on pulling from different therapies equally when developing schema therapy. The difference between cognitive behavioural therapy and schema therapy is the latter “emphasizes lifelong patterns, affective change techniques, and the therapeutic relationship, with special emphasis on limited reparenting”. He recommended this therapy would be ideal for clients with difficult and chronic psychological disorders. Some examples would be eating disorders and personality disorders. He has also had success with this therapy in relation to depression and substance abuse.

What is Rational Emotive Behaviour Therapy?

Introduction

Rational emotive behaviour therapy (REBT), previously called rational therapy and rational emotive therapy, is an active-directive, philosophically and empirically based psychotherapy, the aim of which is to resolve emotional and behavioural problems and disturbances and to help people to lead happier and more fulfilling lives.

REBT posits that people have erroneous beliefs about situations they are involved in, and that these beliefs cause disturbance, but can be disputed with and changed.

Brief History

Rational emotive behaviour therapy (REBT) was created and developed by the American psychotherapist and psychologist Albert Ellis, who was inspired by many of the teachings of Asian, Greek, Roman and modern philosophers. REBT is the first form of cognitive behavioural therapy (CBT) and was first expounded by Ellis in the mid-1950s; development continued until his death in 2007. Ellis became synonymous with the highly influential therapy. Psychology Today noted, “No individual—not even Freud himself—has had a greater impact on modern psychotherapy.”

REBT is both a psychotherapeutic system of theory and practices and a school of thought established by Ellis. He first presented his ideas at a conference of the American Psychological Association in 1956 then published a seminal article in 1957 entitled “Rational psychotherapy and individual psychology”, in which he set the foundation for what he was calling rational therapy (RT) and carefully responded to questions from Rudolf Dreikurs and others about the similarities and differences with Alfred Adler’s Individual psychology. This was around a decade before psychiatrist Aaron Beck first set forth his “cognitive therapy”, after Ellis had contacted him in the mid 1960s. Ellis’ own approach was renamed Rational Emotive Therapy in 1959, then the current term in 1992.

Precursors of certain fundamental aspects of rational emotive behaviour therapy have been identified in ancient philosophical traditions, particularly to Stoicists Marcus Aurelius, Epictetus, Zeno of Citium, Chrysippus, Panaetius of Rhodes, Cicero, and Seneca, and early Asian philosophers Confucius and Gautama Buddha. In his first major book on rational therapy, Ellis wrote that the central principle of his approach, that people are rarely emotionally affected by external events but rather by their thinking about such events, “was originally discovered and stated by the ancient Stoic philosophers”. Ellis illustrates this with a quote from the Enchiridion of Epictetus: “Men are disturbed not by things, but by the views which they take of them.” Ellis noted that Shakespeare expressed a similar thought in Hamlet: “There’s nothing good or bad but thinking makes it so.” Ellis also acknowledges early 20th century therapists, particularly Paul Charles Dubois, though he only read his work several years after developing his therapy.

Theoretical Assumptions

The REBT framework posits that humans have both innate rational (meaning self-helping, socially helping, and constructive) and irrational (meaning self-defeating, socially defeating, and unhelpful) tendencies and leanings. REBT claims that people to a large degree consciously and unconsciously construct emotional difficulties such as self-blame, self-pity, clinical anger, hurt, guilt, shame, depression and anxiety, and behaviours and behaviour tendencies like procrastination, compulsiveness, avoidance, addiction and withdrawal by the means of their irrational and self-defeating thinking, emoting and behaving.

REBT is then applied as an educational process in which the therapist often active-directively teaches the client how to identify irrational and self-defeating beliefs and philosophies which in nature are rigid, extreme, unrealistic, illogical and absolutist, and then to forcefully and actively question and dispute them and replace them with more rational and self-helping ones. By using different cognitive, emotive and behavioural methods and activities, the client, together with help from the therapist and in homework exercises, can gain a more rational, self-helping and constructive rational way of thinking, emoting and behaving.

One of the main objectives in REBT is to show the client that whenever unpleasant and unfortunate activating events occur in people’s lives, they have a choice between making themselves feel healthily or, self-helpingly, sorry, disappointed, frustrated, and annoyed or making themselves feel unhealthily and self-defeatingly horrified, terrified, panicked, depressed, self-hating and self-pitying. By attaining and ingraining a more rational and self-constructive philosophy of themselves, others and the world, people often are more likely to behave and emote in more life-serving and adaptive ways.

Beliefs about Circumstances, and Disputing the Beliefs

A fundamental premise of REBT is humans do not get emotionally disturbed by unfortunate circumstances, but by how they construct their views of these circumstances through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others. This concept has been attributed as far back as the Roman philosopher Epictetus, who is often cited as utilising similar ideas in antiquity.

In REBT, clients usually learn and begin to apply this premise by learning the A-B-C-D-E-F model of psychological disturbance and change. The following letters represent the following meanings in this model:

  • A – The adversity.
  • B – The developed belief in the person of the Adversity.
  • C – The consequences of that person’s Beliefs i.e., B.
  • D – The person’s disputes of A, B, and C. In latter thought.
  • E – The effective new philosophy or belief that develops in that person through the occurrence of D in their minds of A and B.
  • F – The developed feelings of one’s self either at point and after point C or at point after point E.

The A-B-C model states that it is not an A, adversity (or activating event) that cause disturbed and dysfunctional emotional and behavioural Cs, consequences, but also what people B, irrationally believe about the A, adversity. A, adversity can be an external situation, or a thought, a feeling or other kind of internal event, and it can refer to an event in the past, present, or future.

The Bs, irrational beliefs that are most important in the A-B-C model are explicit and implicit philosophical meanings and assumptions about events, personal desires, and preferences. The Bs, beliefs that are most significant are highly evaluative and consist of interrelated and integrated cognitive, emotional and behavioural aspects and dimensions. According to REBT, if a person’s evaluative B, belief about the A, activating event is rigid, absolutistic, fictional and dysfunctional, the C, the emotional and behavioural consequence, is likely to be self-defeating and destructive. Alternatively, if a person’s belief is preferential, flexible and constructive, the C, the emotional and behavioural consequence is likely to be self-helping and constructive.

Through REBT, by understanding the role of their mediating, evaluative and philosophically based illogical, unrealistic and self-defeating meanings, interpretations and assumptions in disturbance, individuals can learn to identify them, then go to D, disputing and questioning the evidence for them. At E, effective new philosophy, they can recognise and reinforce the notion no evidence exists for any psychopathological must, ought or should and distinguish them from healthy constructs, and subscribe to more constructive and self-helping philosophies. This new reasonable perspective leads to F, new feelings and behaviours appropriate to the A they are addressing in the exercise.

Psychological Dysfunction

One of the main pillars of REBT is that irrational and dysfunctional ways and patterns of thinking, feeling, and behaving are contributing to human disturbance and emotional and behavioural self-defeatism and social defeatism. REBT generally teaches that when people turn flexible preferences, desires and wishes into grandiose, absolutistic and fatalistic dictates, this tends to contribute to disturbance and upset. These dysfunctional patterns are examples of cognitive distortions.

Core Beliefs that Disturb Humans

Albert Ellis has suggested three core beliefs or philosophies that humans tend to disturb themselves through:

“I absolutely MUST, under practically all conditions and at all times, perform well (or outstandingly well) and win the approval (or complete love) of significant others. If I fail in these important—and sacred—respects, that is awful and I am a bad, incompetent, unworthy person, who will probably always fail and deserves to suffer.”“Other people with whom I relate or associate, absolutely MUST, under practically all conditions and at all times, treat me nicely, considerately and fairly. Otherwise, it is terrible and they are rotten, bad, unworthy people who will always treat me badly and do not deserve a good life and should be severely punished for acting so abominably to me.”“The conditions under which I live absolutely MUST, at practically all times, be favorable, safe, hassle-free, and quickly and easily enjoyable, and if they are not that way it’s awful and horrible and I can’t bear it. I can’t ever enjoy myself at all. My life is impossible and hardly worth living.”
Holding this belief when faced with adversity tends to contribute to feelings of anxiety, panic, depression, despair, and worthlessness.Holding this belief when faced with adversity tends to contribute to feelings of anger, rage, fury, and vindictiveness.Holding this belief when faced with adversity tends to contribute to frustration and discomfort, intolerance, self-pity, anger, depression, and to behaviours such as procrastination, avoidance, addictive behaviours and inaction.

Rigid Demands that Humans Make

REBT commonly posits that at the core of irrational beliefs there often are explicit or implicit rigid demands and commands, and that extreme derivatives like awfulising, low frustration tolerance, people deprecation and over-generalisations are accompanied by these. According to REBT the core dysfunctional philosophies in a person’s evaluative emotional and behavioural belief system, are also very likely to contribute to unrealistic, arbitrary and crooked inferences and distortions in thinking. REBT therefore first teaches that when people in an insensible and devout way overuse absolutistic, dogmatic and rigid “shoulds”, “musts”, and “oughts”, they tend to disturb and upset themselves.

Over-Generalisation

Further, REBT generally posits that disturbed evaluations to a large degree occur through over-generalisation, wherein people exaggerate and globalise events or traits, usually unwanted events or traits or behaviour, out of context, while almost always ignoring the positive events or traits or behaviours. For example, awfulising is partly mental magnification of the importance of an unwanted situation to a catastrophe or horror, elevating the rating of something from bad to worse than it should be, to beyond totally bad, worse than bad to the intolerable and to a “holocaust”. The same exaggeration and overgeneralising occurs with human rating, wherein humans come to be arbitrarily and axiomatically defined by their perceived flaws or misdeeds. Frustration intolerance then occurs when a person perceives something to be too difficult, painful or tedious, and by doing so exaggerates these qualities beyond one’s ability to cope with them.

Secondary Disturbances

Essential to REBT theory is also the concept of secondary disturbances which people sometimes construct on top of their primary disturbance. As Ellis emphasizes:

“Because of their self-consciousness and their ability to think about their thinking, they can very easily disturb themselves about their disturbances and can also disturb themselves about their ineffective attempts to overcome their emotional disturbances.”

Origins of Dysfunction

Regarding cognitive-affective-behavioral processes in mental functioning and dysfunctioning, originator Albert Ellis explains:

“REBT assumes that human thinking, emotion, and action are not really separate or disparate processes, but that they all significantly overlap and are rarely experienced in a pure state. Much of what we call emotion is nothing more nor less than a certain kind—a biased, prejudiced, or strongly evaluative kind—of thought. But emotions and behaviors significantly influence and affect thinking, just as thinking influences emotions and behaviors. Evaluating is a fundamental characteristic of human organisms and seems to work in a kind of closed circuit with a feedback mechanism: First, perception biases response, and then response tends to bias subsequent perception. Also, prior perceptions appear to bias subsequent perceptions, and prior responses appear to bias subsequent responses. What we call feelings almost always have a pronounced evaluating or appraisal element.”

REBT then generally proposes that many of these self-defeating cognitive, emotive and behavioural tendencies are both innately biological and indoctrinated early in and during life, and further grow stronger as a person continually revisits, clings and acts on them. Ellis alludes to similarities between REBT and the general semantics when explaining the role of irrational beliefs in self-defeating tendencies, citing Alfred Korzybski as a significant modern influence on this thinking.

REBT differs from other clinical approaches like psychoanalysis in that it places little emphasis on exploring the past, but instead focuses on changing the current evaluations and philosophical thinking-emoting and behaving in relation to themselves, others and the conditions under which people live.

Irrational Beliefs

REBT proposes four core irrational beliefs;

  1. Demands: The tendency to demand success, fair treatment, and respect (e.g. I must be treated fairly).
  2. Awfulizing: The tendency to consider adverse events as awful or terrible (e.g. It is awful when I am disrespected).
  3. Low Frustration Tolerance (LFT): The belief that one could not stand or tolerate adversity (e.g. I cannot stand being treated unfairly).
  4. Depreciation: The belief that one event reflects the person as a whole (e.g. When I fail it shows that I am a complete failure).

Other Insights

Other insights of REBT (some referring to the ABCDEF model above) are:

  • Insight 1:
    • People seeing and accepting the reality that their emotional disturbances at point C are only partially caused by the activating events or adversities at point A that precede C.
    • Although A contributes to C, and although disturbed Cs (such as feelings of panic and depression) are much more likely to follow strong negative As (such as being assaulted or raped), than they are to follow weak.
    • As (such as being disliked by a stranger), the main or more direct cores of extreme and dysfunctional emotional disturbances (Cs) are people’s irrational beliefs – the “absolutistic” (inflexible) “musts” and their accompanying inferences and attributions that people strongly believe about the activating event.
  • Insight 2:
    • No matter how, when, and why people acquire self-defeating or irrational beliefs (i.e. beliefs that are the main cause of their dysfunctional emotional-behavioural consequences), if they are disturbed in the present, they tend to keep holding these irrational beliefs and continue upsetting themselves with these thoughts.
    • They do so not because they held them in the past, but because they still actively hold them in the present (often unconsciously), while continuing to reaffirm their beliefs and act as if they are still valid.
    • In their minds and hearts, the troubled people still follow the core “musturbatory” philosophies they adopted or invented long ago, or ones they recently accepted or constructed.
  • Insight 3:
    • No matter how well they have gained insights 1 and 2, insight alone rarely enables people to undo their emotional disturbances.
    • They may feel better when they know, or think they know, how they became disturbed, because insights can feel useful and curative.
    • But it is unlikely that people will actually get better and stay better unless they have and apply insight 3, which is that there is usually no way to get better and stay better except by continual work and practice in looking for and finding one’s core irrational beliefs; actively, energetically, and scientifically disputing them; replacing one’s absolute “musts” (rigid requirements about how things should be) with more flexible preferences; changing one’s unhealthy feelings to healthy, self-helping emotions; and firmly acting against one’s dysfunctional fears and compulsions.
    • Only by a combined cognitive, emotive, and behavioural, as well as a quite persistent and forceful attack on one’s serious emotional problems, is one likely to significantly ameliorate or remove them, and keep them removed.

Intervention

As explained, REBT is a therapeutic system of both theory and practice; generally one of the goals of REBT is to help clients see the ways in which they have learned how they often needlessly upset themselves, teach them how to “un-upset” themselves and then how to empower themselves to lead happier and more fulfilling lives. The emphasis in therapy is generally to establish a successful collaborative therapeutic working alliance based on the REBT educational model. Although REBT teaches that the therapist or counsellor is better served by demonstrating unconditional other-acceptance or unconditional positive regard, the therapist is not necessarily always encouraged to build a warm and caring relationship with the client. The tasks of the therapist or counsellor include understanding the client’s concerns from his point of reference and work as a facilitator, teacher and encourager.

In traditional REBT, the client together with the therapist, in a structured active-directive manner, often work through a set of target problems and establish a set of therapeutic goals. In these target problems, situational dysfunctional emotions, behaviours and beliefs are assessed in regards to the client’s values and goals. After working through these problems, the client learns to generalise insights to other relevant situations. In many cases after going through a client’s different target problems, the therapist is interested in examining possible core beliefs and more deep rooted philosophical evaluations and schemas that might account for a wider array of problematic emotions and behaviours. Although REBT much of the time is used as a brief therapy, in deeper and more complex problems, longer therapy is promoted.

In therapy, the first step often is that the client acknowledges the problems, accepts emotional responsibility for these and has willingness and determination to change. This normally requires a considerable amount of insight, but as originator Albert Ellis explains:

“Humans, unlike just about all the other animals on earth, create fairly sophisticated languages which not only enable them to think about their feeling, their actions, and the results they get from doing and not doing certain things, but they also are able to think about their thinking and even think about thinking about their thinking.”

Through the therapeutic process, REBT employs a wide array of forceful and active, meaning multimodal and disputing, methodologies. Central through these methods and techniques is the intent to help the client challenge, dispute and question their destructive and self-defeating cognitions, emotions and behaviours. The methods and techniques incorporate cognitive-philosophic, emotive-evocative-dramatic, and behavioural methods for disputation of the client’s irrational and self-defeating constructs and helps the client come up with more rational and self-constructive ones. REBT seeks to acknowledge that understanding and insight are not enough; in order for clients to significantly change, they need to pinpoint their irrational and self-defeating constructs and work forcefully and actively at changing them to more functional and self-helping ones.

REBT posits that the client must work hard to get better, and in therapy this normally includes a wide array of homework exercises in day-to-day life assigned by the therapist. The assignments may for example include desensitisation tasks, i.e. by having the client confront the very thing he or she is afraid of. By doing so, the client is actively acting against the belief that often is contributing significantly to the disturbance.

Another factor contributing to the brevity of REBT is that the therapist seeks to empower the client to help himself through future adversities. REBT only promotes temporary solutions if more fundamental solutions are not found. An ideal successful collaboration between the REBT therapist and a client results in changes to the client’s philosophical way of evaluating himself or herself, others, and his or her life, which will likely yield effective results. The client then moves toward unconditional self-acceptance, other-acceptance and life-acceptance while striving to live a more self-fulfilling and happier life.

Applications and Interfaces

Applications and interfaces of REBT are used with a broad range of clinical problems in traditional psychotherapeutic settings such as individual-, group- and family therapy. It is used as a general treatment for a vast number of different conditions and psychological problems normally associated with psychotherapy.

In addition, REBT is used with non-clinical problems and problems of living through counselling, consultation and coaching settings dealing with problems including relationships, social skills, career changes, stress management, assertiveness training, grief, problems with aging, money, weight control etc. More recently, the reported use of REBT in sport and exercise settings has grown, with the efficacy of REBT demonstrated across a range of sports.

REBT also has many interfaces and applications through self-help resources, phone and internet counselling, workshops & seminars, workplace and educational programmes, etc. This includes Rational Emotive Education (REE) where REBT is applied in education settings, Rational Effectiveness Training in business and work-settings and SMART Recovery (Self Management And Recovery Training) in supporting those in addiction recovery, in addition to a wide variety of specialised treatment strategies and applications.

Efficacy

REBT and CBT in general have a substantial and strong research base to verify and support both their psychotherapeutic efficiency and their theoretical underpinnings. Meta-analyses of outcome-based studies reveal REBT to be effective for treating various psychopathologies, conditions and problems. Recently, REBT randomised clinical trials have offered a positive view on the efficacy of REBT.

In general REBT is arguably one of the most investigated theories in the field of psychotherapy and a large amount of clinical experience and a substantial body of modern psychological research have validated and substantiated many of REBTs theoretical assumptions on personality and psychotherapy.

REBT may be effective in improving sports performance and mental health.

Limitations and Critique

The clinical research on REBT has been criticised both from within and by others. For instance, originator Albert Ellis has on occasions emphasized the difficulty and complexity of measuring psychotherapeutic effectiveness, because many studies only tend to measure whether clients merely feel better after therapy instead of them getting better and staying better. Ellis has also criticised studies for having limited focus primarily to cognitive restructuring aspects, as opposed to the combination of cognitive, emotive and behavioural aspects of REBT. As REBT has been subject to criticisms during its existence, especially in its early years, REBT theorists have a long history of publishing and addressing those concerns. It has also been argued by Ellis and by other clinicians that REBT theory on numerous occasions has been misunderstood and misconstrued both in research and in general.

Some have criticised REBT for being harsh, formulaic and failing to address deep underlying problems. REBT theorists have argued in reply that a careful study of REBT shows that it is both philosophically deep, humanistic and individualised collaboratively working on the basis of the client’s point of reference. They have further argued that REBT utilises an integrated and interrelated methodology of cognitive, emotive-experiential and behavioural interventions. Others have questioned REBTs view of rationality, both radical constructivists who have claimed that reason and logic are subjective properties and those who believe that reason can be objectively determined. REBT theorists have argued in reply that REBT raises objections to clients’ irrational choices and conclusions as a working hypothesis and through collaborative efforts demonstrate the irrationality on practical, functional and social consensual grounds. In 1998 when asked what the main criticism on REBT was, Albert Ellis replied that it was the claim that it was too rational and not dealing sufficiently enough with emotions. He repudiated the claim by saying that REBT on the contrary emphasizes that thinking, feeling, and behaving are interrelated and integrated, and that it includes a vast amount of both emotional and behavioural methods in addition to cognitive ones.

Ellis has himself in very direct terms criticised opposing approaches such as psychoanalysis, transpersonal psychology and abreactive psychotherapies in addition to on several occasions questioning some of the doctrines in certain religious systems, spiritualism and mysticism. Many, including REBT practitioners, have warned against dogmatising and sanctifying REBT as a supposedly perfect psychological panacea. Prominent REBTers have promoted the importance of high quality and programmatic research, including originator Ellis, a self-proclaimed “passionate sceptic”. He has on many occasions been open to challenges and acknowledged errors and inefficiencies in his approach and concurrently revised his theories and practices. In general, with regard to cognitive-behavioural psychotherapies’ interventions, others have pointed out that as about 30-40% of people are still unresponsive to interventions, that REBT could be a platform of reinvigorating empirical studies on the effectiveness of the cognitive-behavioural models of psychopathology and human functioning.

REBT has been developed, revised and augmented through the years as understanding and knowledge of psychology and psychotherapy have progressed. This includes its theoretical concepts, practices and methodology. The teaching of scientific thinking, reasonableness and un-dogmatism has been inherent in REBT as an approach, and these ways of thinking are an inextricable part of REBT’s empirical and sceptical nature.

I hope I am also not a devout REBTer, since I do not think it is an unmitigated cure for everyone and do accept its distinct limitations. (Albert Ellis).

Mental Wellness

As would be expected, REBT argues that mental wellness and mental health to a large degree results from an adequate amount of self-helping, flexible, logico-empirical ways of thinking, emoting and behaving. When a perceived undesired and stressful activating event occurs, and the individual is interpreting, evaluating and reacting to the situation rationally and self-helpingly, then the resulting consequence is, according to REBT, likely to be more healthy, constructive and functional. This does not by any means mean that a relatively un-disturbed person never experiences negative feelings, but REBT does hope to keep debilitating and un-healthy emotions and subsequent self-defeating behaviour to a minimum. To do this, REBT generally promotes a flexible, un-dogmatic, self-helping and efficient belief system and constructive life philosophy about adversities and human desires and preferences.

REBT clearly acknowledges that people, in addition to disturbing themselves, also are innately constructivists. Because they largely upset themselves with their beliefs, emotions and behaviours, they can be helped to, in a multimodal manner, dispute and question these and develop a more workable, more self-helping set of constructs.

REBT generally teaches and promotes:

  • That the concepts and philosophies of life of unconditional self-acceptance, other-acceptance, and life-acceptance are effective philosophies of life in achieving mental wellness and mental health.
  • That human beings are inherently fallible and imperfect and that they are better served by accepting their and other human beings’ totality and humanity, while at the same time they may not like some of their behaviours and characteristics.
    • That they are better off not measuring their entire self or their “being” and give up the narrow, grandiose and ultimately destructive notion to give themselves any global rating or report card.
    • This is partly because all humans are continually evolving and are far too complex to accurately rate; all humans do both self-defeating/socially defeating and self-helping / socially helping deeds, and have both beneficial and un-beneficial attributes and traits at certain times and in certain conditions.
    • REBT holds that ideas and feelings about self-worth are largely definitional and are not empirically confirmable or falsifiable.
  • That people had better accept life with its hassles and difficulties not always in accordance with their wants, while trying to change what they can change and live as elegantly as possible with what they cannot change.

Book: The Little CBT Workbook

Book Title:

The Little CBT Workbook: A Step-By-Step Guide to Gaining Control of your Life.

Author(s): Dr. Michael Sinclair and Dr. Belinda Hollingsworth.

Year: 2012.

Edition: First (1st), UK Edition.

Publisher: Crimson Publishing.

Type(s): Paperback and Kindle.

Synopsis:

Introducing essential Cognitive Behavioural Therapy (CBT) techniques, this practical workbook allows readers to explore the key principles behind CBT and discover how to apply them to improve their lives. With interactive exercises and checklists, this is suitable for self-teaching or for supplementing a CBT course.

Book: CBT Journal for Dummies

Book Title:

CBT Journal for Dummies.

Author(s): Rob Wilson and Rhena Branch.

Year: 2012.

Edition: First (1st).

Publisher: Wiley.

Type(s): Hardcover.

Synopsis:

Keep track of the progress you are making with Cognitive Behavioural Therapy.

Cognitive Behavioural Therapy (CBT) is a hugely popular self-help technique that teaches you how to break free from destructive or negative behaviours and make positive changes to both your thoughts and your actions. CBT Journal For Dummies offers a guided space for you to keep a record of your progress, used in conjunction with either CBT For Dummies and/or alongside consultation with a therapist.

This book features an introduction to CBT, followed by a guided 100-day journal. Each chapter focuses on a new CBT technique, with information on how to use the journal space and assessment advice. Topics covered include; establishing the link between thoughts and feelings; preventing ‘all or nothing’ thinking; turning mountains into molehills; focusing on the present; using emotional reasoning; avoiding over-generalising; thinking flexibly; keeping an open mind; assessing the positives; coping with frustration; tackling toxic thoughts; naming your emotions; comparing healthy and unhealthy emotions; working through worry; defining your core beliefs; adopting positive principles; and much more.

  • Has a removable band, leaving a discreet black journal.
  • The small trim size makes it perfect to use on the go.
  • A CBT ‘thought for the day’ appears on alternate blank pages.
  • Content is progressive, encouraging you to keep working through the following days.
  • Coverage is generalized enough to be applicable to every user of CBT.

Book: Managing Anxiety with CBT for Dummies

Book Title:

Managing Anxiety with CBT for Dummies.

Author(s): Graham C. Davey, Kate Cavanagh, Fergal Jones, Lydia Turner, and Adrian Whittington.

Year: 2012.

Edition: First (1st).

Publisher: Wiley.

Type(s): Paperback, Audiobook, and Kindle.

Synopsis:

Don’t panic! Combat your worries and minimise anxiety with CBT!
Cognitive Behavioural Therapy (CBT) is a hugely popular self-help technique, which teaches you to break free from destructive or negative behaviours and make positive changes to both your thoughts and your actions. This practical guide to managing anxiety with CBT will help you understand your anxiety, identify solutions to your problems, and maintain your gains and avoid relapse.

Managing Anxiety with CBT For Dummies is a practical guide to using CBT to face your fears and overcome anxiety and persistent, irrational worries. You’ll discover how to put extreme thinking into perspective and challenge negative, anxiety-inducing thoughts with a range of effective CBT techniques to help you enjoy a calmer, happier life.

  • Helps you understand anxiety and how CBT can help.
  • Guides you in making change and setting goals.
  • Gives you tried-and-true CBT techniques to face your fears and keep a realistic perspective.

Managing Anxiety with CBT For Dummies gives you the tools you need to overcome anxiety and expand your horizons for a healthy, balanced life.

Book: Retrain Your Brain: Cognitive Behavioural Therapy in 7 Weeks

Book Title:

Retrain Your Brain: Cognitive Behavioural Therapy in 7 Weeks: A Workbook for Managing Depression and Anxiety.

Author(s): Seth J. Gillihan (PhD).

Year: 2018.

Edition: First (1st).

Publisher: Althea Press.

Type(s): Paperback and Kindle.

Synopsis:

Cognitive behaviour therapy strategies to help you manage anxiety and depression.

Get lasting relief from anger, panic, stress, and other mood-related conditions by applying the principles of cognitive behavioural therapy to your daily life.

From writing down your goals to addressing negative thought patterns, this accessible, easy-to-understand cognitive behavioural therapy book gives you everything you need to let the healing begin in one convenient CBT workbook. Learn to grow as a person, overcome challenges, and boost your overall health and well-being.

Explore cognitive behaviour therapy through:

  • 10 Soothing strategies: Discover proven CBT principles, like setting goals, maintaining mindfulness, and more.
  • Positive self-evaluations: Track your progress and reflect on what you’ve learned along the way.
  • Practice opportunities: Use this workbook in tandem with clinical cognitive behavioural therapy or post-therapy.

Progress toward healing with a simplified approach to cognitive behaviour therapy.

What is Interpersonal Psychotherapy?

Introduction

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centres on resolving interpersonal problems and symptomatic recovery.

It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12-16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true.

It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications.

Along with cognitive behavioural therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice.

Brief History

Originally named “high contact” therapy, IPT was first developed in 1969 at Yale University as part of a study designed by Gerald Klerman, Myrna Weissman and colleagues to test the efficacy of an antidepressant with and without psychotherapy as maintenance treatment of depression. IPT has been studied in many research protocols since its development. The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Programme (TDCRP) demonstrated the efficacy of IPT as a maintenance treatment and delineated some contributing factors.

Foundations

IPT was influenced by CBT as well as psychodynamic approaches. It takes its structure from CBT in that it is time-limited, employs structured interviews and assessment tools. In general, however, IPT focuses directly on affects, or feelings, whereas CBT focuses on cognitions with strong associated affects. Unlike CBT, IPT makes no attempt to uncover distorted thoughts systematically by giving homework or other assignments, nor does it help the patient develop alternative thought patterns through prescribed practice. Rather, as evidence arises during the course of therapy, the therapist calls attention to distorted thinking in relation to significant others. The goal is to change the relationship pattern rather than associated depressive cognitions, which are acknowledged as depressive symptoms.

The content of IPT’s therapy was inspired by Attachment theory and Harry Stack Sullivan’s Interpersonal psychoanalysis. Social theory is also influenced in a lesser role to emphasis on qualitative impact of social support networks for recovery. Unlike psychodynamic approaches, IPT does not include a personality theory or attempt to conceptualise or treat personality but focuses on humanistic applications of interpersonal sensitivity.

  • Attachment Theory, forms the basis for understanding patients’ relationship difficulties, attachment schema and optimal functioning when attachment needs are met.
  • Interpersonal Theory, describes the ways in which patients’ maladaptive metacommunication patterns (Low to high Affiliation & Inclusion and dominant to submissive Status) lead to or evoke difficulty in their here-and-now interpersonal relationships.

The aim of IPT is to help the patient to improve interpersonal and intrapersonal communication skills within relationships and to develop social support network with realistic expectations to deal with the crises precipitated in distress and to weather ‘interpersonal storms’.

Clinical Applications

It has been demonstrated to be an effective treatment for depression and has been modified to treat other psychiatric disorders such as substance use disorders and eating disorders. It is incumbent upon the therapist in the treatment to quickly establish a therapeutic alliance with positive countertransference of warmth, empathy, affective attunement and positive regard for encouraging a positive transferential relationship, from which the patient is able to seek help from the therapist despite resistance. It is primarily used as a short-term therapy completed in 12-16 weeks, but it has also been used as a maintenance therapy for patients with recurrent depression. A shorter, 6-week therapy suited to primary care settings called Interpersonal counselling (IPC) has been derived from IPT.

Interpersonal psychotherapy has been found to be an effective treatment for the following:

  • Bipolar disorder.
  • Bulimia nervosa.
  • Post-partum depression.
  • Major depressive disorder.
  • Cyclothymia.

Adolescents

Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults.

IPT for children is based on the premise that depression occurs in the context of an individual’s relationships regardless of its origins in biology or genetics. More specifically, depression affects people’s relationships and these relationships further affect our mood. The IPT model identifies four general areas in which a person may be having relationship difficulties:

  • Grief after the loss of a loved one;
  • Conflict in significant relationships, including a client’s relationship with his or her own self;
  • Difficulties adapting to changes in relationships or life circumstances; and
  • Difficulties stemming from social isolation.

The IPT therapist helps identify areas in need of skill-building to improve the client’s relationships and decrease the depressive symptoms. Over time, the client learns to link changes in mood to events occurring in his/her relationships, communicate feelings and expectations for the relationships, and problem-solve solutions to difficulties in the relationships.

IPT has been adapted for the treatment of depressed adolescents (IPT-A) to address developmental issues most common to teenagers such as separation from parents, development of romantic relationships, and initial experience with death of a relative or friend. IPT-A helps the adolescent identify and develop more adaptive methods for dealing with the interpersonal issues associated with the onset or maintenance of their depression. IPT-A is typically a 12- to 16-week treatment. Although the treatment involves primarily individual sessions with the teenager, parents are asked to participate in a few sessions to receive education about depression, to address any relationship difficulties that may be occurring between the adolescent and his/her parents, and to help support the adolescent’s treatment.

Elderly

IPT has been used as a psychotherapy for depressed elderly, with its emphasis on addressing interpersonally relevant problems. IPT appears especially well suited to the life changes that many people experience in their later years.

Book: The Resilience Workbook

Book Title:

The Resilience Workbook – Essential Skills to Recover from Stress, Trauma, and Adversity.

Author(s): Glenn R. Schiraldi (PhD).

Year: 2017.

Edition: First (1st), Illustrated Edition.

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

What is resilience, and how can you build it? In The Resilience Workbook, Glenn Schiraldi-author of The Self-Esteem Workbook-offers invaluable insight and outlines essential skills to help you bounce back from setbacks and cultivate a growth mindset.

Why do some people sail through life’s storms, while others are knocked down? Resilience is the key. Resilience is the ability to recover from difficult experiences, such as death of loved one, job loss, serious illness, terrorist attacks, or even just daily stressors and challenges. Resilience is the strength of body, mind, and character that enables people to respond well to adversity. In short, resilience is the cornerstone of mental health.

Combining evidence-based approaches including positive psychology, cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), mindfulness, and relaxation, The Resilience Workbook will show you how to bounce back and thrive in any difficult situation. You will learn how to harness the power of your brain’s natural neuroplasticity; manage strong, distressing emotions; and improve mood and overall well-being. You will also discover powerful skills to help you prevent and recover from stress-related conditions like post-traumatic stress disorder (PTSD), anxiety, depression, anger, and substance abuse disorders.

When the going gets tough, you need real, proven-effective skills to manage your stress and heal from setbacks. The comprehensive and practical exercises in this workbook will help you cultivate resilience, stay calm under pressure, and face all of life’s challenges.

What is Generalised Anxiety Disorder (GAD)?

Introduction

Generalised anxiety disorder (GAD) is an anxiety disorder characterised by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and sufferers are overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

Symptoms must be consistent and ongoing, persisting at least six months, for a formal diagnosis of GAD. Individuals with GAD often suffer from other disorders including other psychiatric disorders (e.g. major depressive disorder), substance use disorder, obesity, and may have a history of trauma or family with GAD. Clinicians use screening tools such as the GAD-7 and GAD-2 questionnaires to determine if individuals may have GAD and warrant formal evaluation for the disorder. Additionally, sometimes screening tools may enable clinicians to evaluate the severity of GAD symptoms.

GAD is believed to have a hereditary or genetic basis (e.g. first-degree relatives of an individual who has GAD are themselves more likely to have GAD) but the exact nature of this relationship is not fully appreciated. Genetic studies of individuals who have anxiety disorders (including GAD) suggest that the hereditary contribution to developing anxiety disorders is only approximately 30-40%, which suggests that environmental factors may be more important to determining whether an individual develops GAD.

The pathophysiology of GAD implicates several regions of the brain that mediate the processing of stimuli associated with fear, anxiety, memory, and emotion (i.e. the amygdala, insula and the frontal cortex). It has been suggested that individuals with GAD have greater amygdala and medial prefrontal cortex (mPFC) activity in response to stimuli than individuals who do not have GAD. However, the relationship between GAD and activity levels in other parts of the frontal cortex is the subject of ongoing research with some literature suggesting greater activation in specific regions for individuals who have GAD but where other research suggests decreased activation levels in individuals who have GAD as compared to individuals who do not have GAD.

Traditional treatment modalities include variations on psychotherapy (e.g. cognitive-behavioural therapy (CBT)) and pharmacological intervention (e.g. citalopram, escitalopram, sertraline, duloxetine, and venlafaxine). CBT and selective serotonin reuptake inhibitors (SSRIs) are the respectively predominant psychological and pharmacological treatment modalities; other treatments (e.g. selective norepinephrine reuptake inhibitors (SNRIs)) are often considered depending on individual response to therapy. Areas of active investigation include the usefulness of complementary and alternative medications (CAMs), exercise, therapeutic massage and other interventions that have been proposed for study.

Estimates regarding prevalence of GAD or lifetime risk (i.e. lifetime morbid risk (LMR)) for GAD vary depending upon which criteria are used for diagnosing GAD (e.g. DSM-5 vs ICD-10) although estimates do not vary widely between diagnostic criteria. In general, ICD-10 is more inclusive than DSM-5, so estimates regarding prevalence and lifetime risk tend to be greater using ICD-10. In regard to prevalence, in a given year, about two (2%) percent of adults in the United States and Europe have been suggested to suffer GAD. However, the risk of developing GAD at any point in life has been estimated at 9.0%. Although it is possible to experience a single episode of GAD during one’s life, most people who experience GAD experience it repeatedly over the course of their lives as a chronic or ongoing condition. GAD is diagnosed twice as frequently in women as in men.

Diagnosis

DSM-5 Criteria

The diagnostic criteria for GAD as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (2013), published by the American Psychiatric Association, are paraphrased as follows:

  1. “Excessive anxiety or worry” experienced most days over at least six (6) month and which involve a plurality of concerns.
  2. Inability to manage worry.
  3. At least three (3) of the following occur:
    • Restlessness.
    • Fatigability.
    • Problems concentrating.
    • Irritability.
    • Muscle tension.
    • Difficulty with sleep.
    • Note that in children, only one (1) of the above items is required.
  4. One experiences significant distress in functioning (e.g. work, school, social life).
  5. Symptoms are not due to drug abuse, prescription medication or other medical condition(s).
  6. Symptoms do not fit better with another psychiatric condition such as panic disorder.

No major changes to GAD have occurred since publication of the Diagnostic and Statistical Manual of Mental Disorders (2004); minor changes include wording of diagnostic criteria.

ICD-10 Criteria

The 10th revision of the International Statistical Classification of Disease (ICD-10) provides a different set of diagnostic criteria for GAD than the DSM-5 criteria described above. In particular, ICD-10 allows diagnosis of GAD as follows:

  • A period of at least six months with prominent tension, worry, and feelings of apprehension, about everyday events and problems.
  • At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).
    • Autonomic arousal symptoms:
      • (1) Palpitations or pounding heart, or accelerated heart rate.
      • (2) Sweating.
      • (3) Trembling or shaking.
      • (4) Dry mouth (not due to medication or dehydration).
    • Symptoms concerning chest and abdomen:
      • (5) Difficulty breathing.
      • (6) Feeling of choking.
      • (7) Chest pain or discomfort.
      • (8) Nausea or abdominal distress (e.g. churning in the stomach).
    • Symptoms concerning brain and mind:
      • (9) Feeling dizzy, unsteady, faint or light-headed.
      • (10) Feelings that objects are unreal (derealization), or that one’s self is distant or “not really here” (depersonalization).
      • (11) Fear of losing control, going crazy, or passing out.
      • (12) Fear of dying.
    • General symptoms:
      • (13) Hot flashes or cold chills.
      • (14) Numbness or tingling sensations.
    • Symptoms of tension:
      • (15) Muscle tension or aches and pains.
      • (16) Restlessness and inability to relax.
      • (17) Feeling keyed up, or on edge, or of mental tension.
      • (18) A sensation of a lump in the throat or difficulty with swallowing.
    • Other non-specific symptoms:
      • (19) Exaggerated response to minor surprises or being startled.
      • (20) Difficulty in concentrating or mind going blank, because of worrying or anxiety.
      • (21) Persistent irritability.
      • (22) Difficulty getting to sleep because of worrying.
  • The disorder does not meet the criteria for panic disorder (F41.0), phobic anxiety disorders (F40.-), obsessive-compulsive disorder (F42.-) or hypochondriacal disorder (F45.2).
  • Most commonly used exclusion criteria: not sustained by a physical disorder, such as hyperthyroidism, an organic mental disorder (F0) or psychoactive substance-related disorder (F1), such as excess consumption of amphetamine-like substances, or withdrawal from benzodiazepines.[21]

See ICD-10 F41.1

Note: For children different ICD-10 criteria may be applied for diagnosing GAD (see F93.80).

History of Diagnostic Criteria

The American Psychiatric Association introduced GAD as a diagnosis in the DSM-III in 1980, when anxiety neurosis was split into GAD and panic disorder. The definition in the DSM-III required uncontrollable and diffuse anxiety or worry that is excessive and unrealistic and persists for 1 month or longer. High rates in comorbidity of GAD and major depression led many commentators to suggest that GAD would be better conceptualised as an aspect of major depression instead of an independent disorder. Many critics stated that the diagnostic features of this disorder were not well established until the DSM-III-R. Since comorbidity of GAD and other disorders decreased with time, the DSM-III-R changed the time requirement for a GAD diagnosis to 6 months or longer. The DSM-IV changed the definition of excessive worry and the number of associated psychophysiological symptoms required for a diagnosis. Another aspect of the diagnosis the DSM-IV clarified was what constitutes a symptom as occurring “often”. The DSM-IV also required difficulty controlling the worry to be diagnosed with GAD. The DSM-5 emphasized that excessive worrying had to occur more days than not and on a number of different topics. It has been stated that the constant changes in the diagnostic features of the disorder have made assessing epidemiological statistics such as prevalence and incidence difficult, as well as increasing the difficulty for researchers in identifying the biological and psychological underpinnings of the disorder. Consequently, making specialized medications for the disorder is more difficult as well. This has led to the continuation of GAD being medicated heavily with SSRIs.

Risk Factors

Genetics, Family and Environment

The relationship between genetics and anxiety disorders is an ongoing area of research. It is broadly understood that there exists an hereditary basis for GAD, but the exact nature of this hereditary basis is not fully appreciated. While investigators have identified several genetic loci that are regions of interest for further study, there is no singular gene or set of genes that have been identified as causing GAD. Nevertheless, genetic factors may play a role in determining whether an individual is at greater risk for developing GAD, structural changes in the brain related to GAD, or whether an individual is more or less likely to respond to a particular treatment modality. Genetic factors that may play a role in development of GAD are usually discussed in view of environmental factors (e.g. life experience or ongoing stress) that might also play a role in development of GAD. The traditional methods of investigating the possible hereditary basis of GAD include using family studies and twin studies (there are no known adoption studies of individuals who suffer anxiety disorders, including GAD). Meta-analysis of family and twin studies suggests that there is strong evidence of a hereditary basis for GAD in that GAD is more likely to occur in first-degree relatives of individuals who have GAD than in non-related individuals in the same population. Twin studies also suggest that there may be a genetic linkage between GAD and major depressive disorder (MDD), which may explain the common occurrence of MDD in individuals who suffer GAD (e.g. comorbidity of MDD in individuals with GAD has been estimated at approximately 60%). When GAD is considered among all anxiety disorders (e.g. panic disorder, social anxiety disorder), genetic studies suggest that hereditary contribution to the development of anxiety disorders amounts to only approximately 30-40%, which suggests that environmental factors are likely more important to determining whether an individual may develop GAD. In regard to environmental influences in the development of GAD, it has been suggested that parenting behaviour may be an important influence since parents potentially model anxiety-related behaviours. It has also been suggested that individuals who suffer GAD have experienced a greater number of minor stress-related events in life and that the number of stress-related events may be important in development of GAD (irrespective of other individual characteristics).

Studies of possible genetic contributions to the development of GAD have examined relationships between genes implicated in brain structures involved in identifying potential threats (e.g. in the amygdala) and also implicated in neurotransmitters and neurotransmitter receptors known to be involved in anxiety disorders. More specifically, genes studied for their relationship to development of GAD or demonstrated to have had a relationship to treatment response include:

  • PACAP (A54G polymorphism): remission after 6 month treatment with Venlafaxine suggested to have a significant relationship with the A54G polymorphism (Cooper et al. (2013)).
  • HTR2A gene (rs7997012 SNP G allele): HTR2A allele suggested to be implicated in a significant decrease in anxiety symptoms associated with response to 6 months of Venlafaxine treatment (Lohoff et al. (2013)).
  • SLC6A4 promoter region (5-HTTLPR): Serotonin transporter gene suggested to be implicated in significant reduction in anxiety symptoms in response to 6 months of Venlafaxine treatment (Lohoff et al. (2013)).

Pathophysiology

The pathophysiology of GAD is an active and ongoing area of research often involving the intersection of genetics and neurological structures. GAD has been linked to changes in functional connectivity of the amygdala and its processing of fear and anxiety. Sensory information enters the amygdala through the nuclei of the basolateral complex (consisting of lateral, basal and accessory basal nuclei). The basolateral complex processes the sensory-related fear memories and communicates information regarding threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices. Neurological structures traditionally appreciated for their roles in anxiety include the amygdala, insula and orbitofrontal cortex (OFC). It is broadly postulated that changes in one or more of these neurological structures are believed to allow greater amygdala response to emotional stimuli in individuals who have GAD as compared to individuals who do not have GAD.

Individuals who GAD have been suggested to have greater amygdala and medial prefrontal cortex (mPFC) activation in response to stimuli than individuals who do not have GAD. However, the exact relationship between the amygdala and the frontal cortex (e.g. prefrontal cortex or the orbitofrontal cortex (OFC)) is not fully understood because there are studies that suggest increased or decreased activity in the frontal cortex in individuals who have GAD. Consequently, because of the tenuous understanding of the frontal cortex as it relates to the amygdala in individuals who have GAD, it’s an open question as to whether individuals who have GAD bear an amygdala that is more sensitive than an amygdala in an individual without GAD or whether frontal cortex hyperactivity is responsible for changes in amygdala responsiveness to various stimuli. Recent studies have attempted to identify specific regions of the frontal cortex (e.g. dorsomedial prefrontal cortex (dmPFC)) that may be more or less reactive in individuals who have GAD or specific networks that may be differentially implicated in individuals who have GAD. Other lines of study investigate whether activation patterns vary in individuals who have GAD at different ages with respect to individuals who do not have GAD at the same age (e.g. amygdala activation in adolescents with GAD).

Treatment

Traditional treatment modalities broadly fall into two (2) categories:

  • Psychotherapeutic; and
  • Pharmacological intervention.

In addition to these two conventional therapeutic approaches, areas of active investigation include complementary and alternative medications (CAMs), brain stimulation, exercise, therapeutic massage and other interventions that have been proposed for further study. Treatment modalities can, and often are utilised concurrently so that an individual may pursue psychological therapy (i.e. psychotherapy) and pharmacological therapy. Both cognitive behavioural therapy (CBT) and medications (such as SSRIs) have been shown to be effective in reducing anxiety. A combination of both CBT and medication is generally seen as the most desirable approach to treatment. Use of medication to lower extreme anxiety levels can be important in enabling patients to engage effectively in CBT.

Psychotherapy

Psychotherapeutic interventions include a plurality of therapy types that vary based upon their specific methodologies for enabling individuals to gain insight into the working of the conscious and subconscious mind and which sometimes focus on the relationship between cognition and behaviour. Cognitive behavioural therapy (CBT) is widely regarded as the first-line psychological therapy for treating GAD. Additionally, many of these psychological interventions may be delivered in an individual or group therapy setting. While individual and group settings are broadly both considered effective for treating GAD, individual therapy tends to promote longer-lasting engagement in therapy (i.e. lower attrition over time).

Psychodynamic Therapy

Psychodynamic therapy is a type of therapy premised upon Freudian psychology in which a psychologist enables an individual explore various elements in their subconscious mind to resolve conflicts that may exist between the conscious and subconscious elements of the mind. In the context of GAD, the psychodynamic theory of anxiety suggests that the unconscious mind engages in worry as a defence mechanism to avoid feelings of anger or hostility because such feelings might cause social isolation or other negative attribution toward oneself. Accordingly, the various psychodynamic therapies attempt to explore the nature of worry as it functions in GAD in order to enable individuals to alter the subconscious practice of using worry as a defence mechanism and to thereby diminish GAD symptoms. Variations of psychotherapy include a near-term version of therapy, “short-term anxiety-provoking psychotherapy (STAPP).

Behavioural Therapy

Behavioural therapy is therapeutic intervention premised upon the concept that anxiety is learned through classical conditioning (e.g., in view of one or more negative experiences) and maintained through operant conditioning (e.g. one finds that by avoiding a feared experience that one avoids anxiety). Thus, behavioural therapy enables an individual to re-learn conditioned responses (behaviours) and to thereby challenge behaviours that have become conditioned responses to fear and anxiety, and which have previously given rise to further maladaptive behaviours.

Cognitive Therapy

Cognitive therapy (CT) is premised upon the idea that anxiety is the result of maladaptive beliefs and methods of thinking. Thus, CT involves assisting individuals to identify more rational ways of thinking and to replace maladaptive thinking patterns (i.e. cognitive distortions) with healthier thinking patterns (e.g. replacing the cognitive distortion of catastrophising with a more productive pattern of thinking). Individuals in CT learn how to identify objective evidence, test hypotheses, and ultimately identify maladaptive thinking patterns so that these patterns can be challenged and replaced.

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a behavioural treatment based on acceptance-based models. ACT is designed with the purpose to target three therapeutic goals:

  1. Reduce the use of avoiding strategies intended to avoid feelings, thoughts, memories, and sensations;
  2. Decreasing a person’s literal response to their thoughts (e.g., understanding that thinking “I’m hopeless” does not mean that the person’s life is truly hopeless); and
  3. Increasing the person’s ability to keep commitments to changing their behaviours.

These goals are attained by switching the person’s attempt to control events to working towards changing their behaviour and focusing on valued directions and goals in their lives as well as committing to behaviours that help the individual accomplish those personal goals. This psychological therapy teaches mindfulness (paying attention on purpose, in the present, and in a non-judgemental manner) and acceptance (openness and willingness to sustain contact) skills for responding to uncontrollable events and therefore manifesting behaviours that enact personal values. Like many other psychological therapies, ACT works best in combination with pharmacology treatments.

Intolerance of Uncertainty Therapy

Intolerance of uncertainty (IU) refers to a consistent negative reaction to uncertain and ambiguous events regardless of their likelihood of occurrence. Intolerance of uncertainty therapy (IUT) is used as a stand-alone treatment for GAD patients. Thus, IUT focuses on helping patients in developing the ability to tolerate, cope with and accept uncertainty in their life in order to reduce anxiety. IUT is based on the psychological components of psychoeducation, awareness of worry, problem-solving training, re-evaluation of the usefulness of worry, imagining virtual exposure, recognition of uncertainty, and behavioural exposure. Studies have shown support for the efficacy of this therapy with GAD patients with continued improvements in follow-up periods.

Motivational Interviewing

A promising innovative approach to improving recovery rates for the treatment of GAD is to combine CBT with motivational interviewing (MI). Motivational interviewing is a strategy centred on the patient that aims to increase intrinsic motivation and decrease ambivalence about change due to the treatment. MI contains four key elements:

  • Express empathy;
  • Heighten dissonance between behaviours that are not desired and values that are not consistent with those behaviours;
  • Move with resistance rather than direct confrontation; and
  • Encourage self-efficacy.

It is based on asking open-ended questions and listening carefully and reflectively to patients’ answers, eliciting “change talk”, and talking with patients about the pros and cons of change. Some studies have shown the combination of CBT with MI to be more effective than CBT alone.

Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) is an evidence-based type of psychotherapy that demonstrates efficacy in treating GAD and which integrates the cognitive and behavioural therapeutic approaches. The objective of CBT is to enable individuals to identify irrational thoughts that cause anxiety and to challenge dysfunctional thinking patterns by engaging in awareness techniques such as hypothesis testing and journaling. Because CBT involves the practice of worry and anxiety management, CBT includes a plurality of intervention techniques that enable individuals to explore worry, anxiety and automatic negative thinking patterns. These interventions include anxiety management training, cognitive restructuring, progressive relaxation, situational exposure and self-controlled desensitisation.

Other forms of psychological therapy include:

  • Relaxation techniques (e.g. relaxing imagery, meditational relaxation).
  • Metacognitive Therapy (MCT):
    • The objective of MCT is to alter thinking patterns regarding worry so that worry is no longer used as a coping strategy.
  • Mindfulness based stress reduction (MBSR).
  • Mindfulness based cognitive therapy (MBCT).
  • Supportive therapy:
    • This is a Rogerian method of therapy in which subjects experience empathy and acceptance from their therapist to facilitate increasing awareness.
    • Variations of active supportive therapy include Gestalt therapy, Transactional analysis and Counselling.

Pharmacotherapy

Historically, benzodiazepines (BZs) were used prominently to treat anxiety starting in the 1970s but support for this use attenuated in view of the risk for dependence and tolerance to the medication. BZs can have a plurality of effects that made them a seemingly desirable option for treating anxiety – i.e. BZs have anxiolytic, hypnotic (induce sleep), myorelaxant (relax muscles), anticonvulsant and amnestic (impair short-term memory) properties. While BZs are well appreciated for their ability to alleviate anxiety (i.e. their anxiolytic properties) shortly after administration, they are also known for their ability to promote dependence and are frequently abused. Current recommendations for using BZs to treat anxiety in GAD allow no more than 2-4 weeks of BZ exposure. Antidepressants (e.g. SSRIs/SNRIs) have become a mainstay in treating GAD in adults. First-line mediations from any drug category often include drugs that have been approved by the US Food and Drug Administration (FDA) for treating GAD because these medications have been proven safe and effective for treating GAD.

FDA-Approved Medications for Treating GAD

FDA-approved medications for treating GAD include:

  • SSRIs:
    • Paroxetine.
    • Escitalopram.
  • SNRIs:
    • Venlafaxine.
    • Duloxetine.
  • Benzodiazepines (BZs):
    • Alprazolam: Alprazolam is the only FDA-approved BZ for treating GAD.
  • Azapirones:
    • Buspirone.

Non-FDA Approved Medications

While certain medications are not specifically FDA approved for treatment of GAD, there are a number of medications that historically have been used or studied for treating GAD. Other medications that have been used or evaluated for treating GAD include:

  • SSRIs (antidepressants):
    • Citalopram.
    • Fluoxetine.
    • Sertraline.
    • Fluvoxamine (SSRI).
  • Benzodiazepines:
    • Clonazepam.
    • Lorazepam.
    • Diazepam.
  • GABA analogs:
    • Pregabalin (atypical anxiolytic, GABA analog).
    • Tiagabine.
  • Second-generation antipsychotics (SGAs):
    • Olanzapine (evidence of effectiveness is merely a trend).
    • Ziprasidone.
    • Risperidone.
    • Aripiprazole (studied as an adjunctive measure in concert with other treatment).
    • Quetiapine (atypical antipsychotic studied as an adjunctive measure in adults and geriatric patients).
  • Antihistamines:
    • Hydroxyzine (H1 receptor antagonist).
  • Vilazodone (atypical antidepressant).
  • Agomelatine (antidepressant, MT1/2 receptor agonist, 5HT2c antagonist).
  • Clonidine (noted to cause decreased blood pressure and other AEs).
  • Guanfacine (a2A receptor agonist, studied in paediatric patients with GAD).
  • Mirtazapine (atypical antidepressant having 5HT2A and 5HT2c receptor affinity).
  • Vortioxetine (multimodal antidepressant).
  • Eszopiclone (non-benzodiazepine hypnotic).
  • Tricyclic antidepressants:
    • Amitriptyline.
    • Clomipramine.
    • Doxepin.
    • Imipramine.
    • Trimipramine.
    • Desipramine.
    • Nortriptyline.
    • Protriptyline.
  • Opipramol (atypical TCA).]
  • Trazodone.
  • Monamine oxidase inhibitors (MAOIs):
    • Tranylcypromine.
    • Phenelzine.
  • Homeopathic preparations (discussed below, see complementary and alternative medications (CAMs))

Selective Serotonin Reuptake Inhibitors

Pharmaceutical treatments for GAD include selective serotonin reuptake inhibitors (SSRIs).[50] SSRIs increase serotonin levels through inhibition of serotonin reuptake receptors.

FDA approved SSRIs used for this purpose include escitalopram and paroxetine. However, guidelines suggest using sertraline first due to its cost-effectiveness compared to other SSRIs used for GAD and a lower risk of withdrawal compared to SNRIs. If sertraline is found to be ineffective, then it is recommended to try another SSRI or SNRI.

Common side effects include nausea, sexual dysfunction, headache, diarrhoea, constipation, restlessness, increased risk of suicide in young adults and adolescents, among others. Sexual side effects, weight gain, and higher risk of withdrawal are more common in paroxetine than escitalopram and sertraline. In older populations or those taking concomitant medications that increase risk of bleeding, SSRIs may further increase the risk of bleeding. Overdose of an SSRI or concomitant use with another agent that causes increased levels of serotonin can result in serotonin syndrome, which can be life-threatening.

Serotonin Norepinephrine Reuptake Inhibitors

First line pharmaceutical treatments for GAD also include serotonin-norepinephrine reuptake inhibitors (SNRIs). These inhibit the reuptake of serotonin and noradrenaline to increase their levels in the CNS.

FDA approved SNRIs used for this purpose include duloxetine (Cymbalta) and venlafaxine (Effexor). While SNRIs have similar efficacy as SSRIs, many psychiatrists prefer to use SSRIs first in the treatment of GAD The slightly higher preference for SSRIs over SNRIs as a first choice for treatment of anxiety disorders may have been influenced by the observation of poorer tolerability of the SNRIs in comparison to SSRIs in systematic reviews of studies of depressed patients.

Side effects common to both SNRIs include anxiety, restlessness, nausea, weight loss, insomnia, dizziness, drowsiness, sweating, dry mouth, sexual dysfunction and weakness. In comparison to SSRIs, the SNRIs have a higher prevalence of the side effects of insomnia, dry mouth, nausea and high blood pressure. Both SNRIs have the potential for discontinuation syndrome after abrupt cessation, which can precipitate symptoms including motor disturbances and anxiety and may require tapering. Like other serotonergic agents, SNRIs have the potential to cause serotonin syndrome, a potentially fatal systemic response to serotonergic excess that causes symptoms including agitation, restlessness, confusion, tachycardia, hypertension, mydriasis, ataxia, myoclonus, muscle rigidity, diaphoresis, diarrhoea, headache, shivering, goose bumps, high fever, seizures, arrhythmia and unconsciousness. SNRIs like SSRIs carry a black box warning for suicidal ideation, but it is generally considered that the risk of suicide in untreated depression is far higher than the risk of suicide when depression is properly treated.

Pregabalin and Gabapentin

Pregabalin (Lyrica) acts on the voltage-dependent calcium channel to decrease the release of neurotransmitters such as glutamate, norepinephrine and substance P. Its therapeutic effect appears after 1 week of use and is similar in effectiveness to lorazepam, alprazolam and venlafaxine but pregabalin has demonstrated superiority by producing more consistent therapeutic effects for psychic and somatic anxiety symptoms. Long-term trials have shown continued effectiveness without the development of tolerance and additionally, unlike benzodiazepines, it does not disrupt sleep architecture and produces less severe cognitive and psychomotor impairment. It also has a low potential for abuse and dependency and may be preferred over the benzodiazepines for these reasons. The anxiolytic effects of pregabalin appear to persist for at least six months continuous use, suggesting tolerance is less of a concern; this gives pregabalin an advantage over certain anxiolytic medications such as benzodiazepines.

Gabapentin (Neurontin), a closely related medication to pregabalin with the same mechanism of action, has also demonstrated effectiveness in the treatment of GAD, though unlike pregabalin, it has not been approved specifically for this indication. Nonetheless, it is likely to be of similar usefulness in the management of this condition, and by virtue of being off-patent, it has the advantage of being significantly less expensive in comparison. In accordance, gabapentin is frequently prescribed off-label to treat GAD.

Complementary and Alternative Medicines Studied for Potential in Treating GAD

Complementary and alternative medicines (CAMs) are widely used by individuals who suffer GAD despite having no evidence or varied evidence regarding efficacy. Efficacy trials for CAM medications often suffer from various types of bias and low quality reporting in regard to safety. In regard to efficacy, critics point out that CAM trials sometimes predicate claims of efficacy based on a comparison of a CAM against a known drug after which no difference in subjects is found by investigators and which is used to suggest an equivalence between a CAM and a drug. Because this equates a lack of evidence with the positive assertion of efficacy, a “lack of difference” assertion is not a proper claim for efficacy. Moreover, an absence of strict definitions and standards for CAM compounds further burdens the literature regarding CAM efficacy in treating GAD. CAMs academically studied for their potential in treating GAD or GAD symptoms along with a summary of academic findings are given below. What follows is a summary of academic findings. Accordingly, none of the following should be taken as offering medical guidance or an opinion as to the safety or efficacy of any of the following CAMs.

  • Kava Kava (Piper methysticum) extracts:
    • Meta analysis does not suggest efficacy of Kava Kava extracts due to few data available yielding inconclusive results or non-statistically significant results.
    • Nearly a quarter (25.8%) of subjects experienced adverse effects (AEs) from Kava Kava extracts during six (6) trials.
    • Kava Kava may cause liver toxicity.
  • Lavender (Lavandula angustifolia) extracts:
    • Small and varied studies may suggest some level of efficacy as compared to placebo or other medication; claims of efficacy are regarded as needing further evaluation.
    • Silexan is an oil derivative of Lavender studied in paediatric patients with GAD.
    • Concern exists regarding the question as to whether Silexan may cause unopposed oestrogen exposure in boys due to disruption of steroid signalling.
  • Galphimia glauca extracts:
    • While Galphima glauca extracts have been the subject of two (2) randomised controlled trials (RCTs) comparing Galphima glauca extracts to lorazepam, efficacy claims are regarded as “highly uncertain.”
  • Chamomile (Matricaria chamomilla) extracts:
    • Poor quality trials have trends that may suggest efficacy but further study is needed to establish any claim of efficacy.
  • Crataegus oxycantha and Eschscholtzia californica extracts combined with magnesium:
    • A single12-week trial of Crataegus oxycantha and Eschscholtzia californica compared to placebo has been used to suggest efficacy.
    • However, efficacy claims require confirmation studies.
    • For the minority of subjects who experienced AEs from extracts, most AEs implicated gastrointestinal tract (GIT) intolerance.
  • Echium amoneum extract:
    • A single, small trial used this extract as a supplement to fluoxetine (vs using a placebo to supplement fluoxetine); larger studies are needed to substantiate efficacy claims.
  • Gamisoyo-San:
    • Small trials of this herbal mixture compared to placebo have suggested no efficacy of the herbal mixture over placebo but further study is necessary to allow definitive conclusion of a lack of efficacy.
  • Passiflora incarnata extract:
    • Claims of efficacy or benzodiazepam equivalence are regarded as “highly uncertain.”
  • Valeriana extract:
    • A single 4-week trial suggests no effect of Valeriana extract on GAD but is regarded as “uninformative” on the topic of efficacy in view of its finding that the benzodiazepine diazepam also had no effect.
    • Further study may be warranted.

Other Possible Modalities Discussed in Literature for Potential in Treating GAD

Other modalities that have been academically studied for their potential in treating GAD or symptoms of GAD are summarised below. What follows is a summary of academic findings. Accordingly, none of the following should be taken as offering medical guidance or an opinion as to the safety or efficacy of any of the following modalities.

  • Acupuncture:
    • A single, very small trial revealed a trend toward efficacy but flaws in the trial design suggest uncertainty regarding efficacy.
  • Balneotherapy:
    • Data from a single non-blinded study suggested possible efficacy of balneotherapy as compared to paroxetine.
    • However, efficacy claims need confirmation.
  • Therapeutic massage:
    • A single, small, possibly biased study revealed inconclusive results.
  • Resistance and aerobic exercise:
    • When compared to no treatment, a single, small, potentially unrepresentative trial suggested a trend toward GAD remission and reduction of worry.
  • Chinese bloodletting:
    • When added to paroxetine, a single, small, imprecise trial that lacked a sham procedure for comparison suggested efficacy at 4-weeks.
    • However, larger trials are needed to evaluate this technique as compared to a sham procedure.
  • Floating in water:
    • When compared to no treatment, a single, imprecise, non-blinded trial suggested a trend toward efficacy (findings were statistically insignificant).
  • Swedish massage:
    • When compared to a sham procedure, a single trial showed a trend toward efficacy (i.e. findings were statistically insignificant).
  • Ayurvedic medications:
    • A single non-blinded trial was inconclusive as to whether Ayurvedic medications were effective in treating GAD.
  • Multi-faith spiritually-based intervention:
    • A single, small, non-blinded study was inconclusive regarding efficacy.

Lifestyle

Lifestyle factors including: stress management, stress reduction, relaxation, exercise, sleep hygiene, and caffeine and alcohol reduction can influence anxiety levels. Physical activity has shown to have a positive impact whereas low physical activity may be a risk factor for anxiety disorders.

Substances and Anxiety in GAD

While there are no substances that are known to cause GAD, certain substances or the withdrawal from certain substances have been implicated in promoting the experience of anxiety. For example, even while benzodiazepines may afford individuals with GAD relief from anxiety, withdrawal from benzodiazepines is associated with the experience of anxiety among other adverse events like sweating and tremor.

Tobacco withdrawal symptoms may provoke anxiety in smokers and excessive caffeine use has been linked to aggravating and maintaining anxiety.

Comorbidity

Depression

In the National Comorbidity Survey (2005), 58% of patients diagnosed with major depression were found to have an anxiety disorder; among these patients, the rate of comorbidity with GAD was 17.2%, and with panic disorder, 9.9%. Patients with a diagnosed anxiety disorder also had high rates of comorbid depression, including 22.4% of patients with social phobia, 9.4% with agoraphobia, and 2.3% with panic disorder. A longitudinal cohort study found 12% of the 972 participants had GAD comorbid with MDD. Accumulating evidence indicates that patients with comorbid depression and anxiety tend to have greater illness severity and a lower treatment response than those with either disorder alone. In addition, social function and quality of life are more greatly impaired.

For many, the symptoms of both depression and anxiety are not severe enough (i.e. are subsyndromal) to justify a primary diagnosis of either major depressive disorder (MDD) or an anxiety disorder. However, dysthymia is the most prevalent comorbid diagnosis of GAD clients. Patients can also be categorised as having mixed anxiety-depressive disorder, and they are at significantly increased risk of developing full-blown depression or anxiety.

Various explanations for the high comorbidity between GAD and depressive disorders have been suggested, including genetic pleiotropy, meaning that GAD and nonbipolar depression might represent different phenotypic expressions of a common aetiology.

Comorbidity and Treatment

Therapy has been shown to have equal efficacy in patients with GAD and patients with GAD and comorbid disorders. Patients with comorbid disorders have more severe symptoms when starting therapy but demonstrated a greater improvement than patients with simple GAD.

Pharmacological approaches i.e. the use of antidepressants must be adapted for different comorbidities. For example, serotonin reuptake inhibitors and short acting benzodiazepines (BZDs) are used for depression and anxiety. However, for patients with anxiety and substance abuse, BZDs should be avoided due to their abuse liability. CBT has been found an effective treatment since it improves symptoms of GAD and substance abuse.

Compared to the general population, patients with internalising disorders such as depression, GAD and post-traumatic stress disorder (PTSD) have higher mortality rates, but die of the same age-related diseases as the population, such as heart disease, cerebrovascular disease and cancer.

GAD often coexists with conditions associated with stress, such as muscle tension and irritable bowel syndrome.

Patients with GAD can sometimes present with symptoms such as insomnia or headaches as well as pain and interpersonal problems.

Further research suggests that about 20% to 40% of individuals with attention deficit hyperactivity disorder have comorbid anxiety disorders, with GAD being the most prevalent.

Those with GAD have a lifetime comorbidity prevalence of 30% to 35% with alcohol use disorder and 25% to 30% for another substance use disorder. People with both GAD and a substance use disorder also have a higher lifetime prevalence for other comorbidities. A study found that GAD was the primary disorder in slightly more than half of the 18 participants that were comorbid with alcohol use disorder.

Epidemiology

GAD is often estimated to affect approximately 3-6% of adults and 5% of children and adolescents. Although estimates have varied to suggest a GAD prevalence of 3% in children and 10.8% in adolescents. When GAD manifests in children and adolescents, it typically begins around 8 to 9 years of age.

Estimates regarding prevalence of GAD or lifetime risk (i.e. lifetime morbid risk (LMR)) for GAD vary depending upon which criteria are used for diagnosing GAD (e.g. DSM-5 vs ICD-10) although estimates do not vary widely between diagnostic criteria. In general, ICD-10 is more inclusive than DSM-5, so estimates regarding prevalence and lifetime risk tend to be greater using ICD-10. In regard to prevalence, in a given year, about two (2%) percent of adults in the United States and Europe have been suggested to suffer GAD. However, the risk of developing GAD at any point in life has been estimated at 9.0%. Although it is possible to experience a single episode of GAD during one’s life, most people who experience GAD experience it repeatedly over the course of their lives as a chronic or ongoing condition. GAD is diagnosed twice as frequently in women as in men and is more often diagnosed in those who are separated, divorced, unemployed, widowed or have low levels of education, and among those with low socioeconomic status. African Americans have higher odds of having GAD and the disorder often manifests itself in different patterns. It has been suggested that greater prevalence of GAD in women may be because women are more likely than men to live in poverty, are more frequently the subject of discrimination, and be sexually and physically abused more often than men. In regard to the first incidence of GAD in an individual’s life course, a first manifestation of GAD usually occurs between the late teenage years and the early twenties with the median age of onset being approximately 31 and mean age of onset being 32.7. However, GAD can begin or reoccur at any point in life. Indeed, GAD is common in the elderly population.

  • US: Approximately 3.1% of people age 18 and over in a given year (9.5 million).
  • UK: 5.9% of adults were affected by GAD in 2019.
  • Australia: 3% of adults
  • Canada: 2.5%.
  • Italy: 2.9%
  • Taiwan: 0.4%.