Group Treatment of Anxiety Disorders

    •    There is compelling evidence that adults diagnosed with social phobia
    can be effectively treated with cognitive behavioral group treatment
    (CBGT). Moreover, patients treated in groups improve at the same rate as
    those treated in individual therapy.

    •    There is promising evidence that children and adolescents who are
    treated with CBGT have reliable reduction in social anxiety and depression
    with limited evidence that treatment in a group or individual format
    produce equivalent outcomes.

    •    The dominant group model for treating patients diagnosed with panic
    disorder is CBGT. Improvement in general anxiety, panic symptoms and
    depression results along with improvement in general functioning. 

    •    Exposure and response prevention (ERP) offered in a group format has
    been shown to produce reliable improvement in the primary symptoms of
    obsessive-compulsive disorder (OCD) that are most frequently measured
    by the Yale-Brown Obsessive Compulsive Scale (YBOCS).  More recently,
    ERP has been integrated with CBGT with the greatest effects shown on the
    YBOCS and modest reductions noted in depressive symptoms.

    •    Research into the mechanisms of change responsible for the above
    improvements suggest that more intense treatment can produce the same
    benefits as spaced (weekly) treatment, that comorbid disorders can
    reduce overall improvement and that large improvements can take place
    within a few sessions with some patients (i.e., sudden gains).

Social Anxiety

CBGT dominates the empirical literature for social phobia with Heimberg and colleagues’ protocol (Heimberg and Becker, 2002; Rapee & Heimberg, 1997) being applied most frequently, followed by the Clark and Wells approach (1995).  A recent meta-analysis (Powers, Sigmarsson and Emmelkamp, 2008) demonstrated equivalent outcomes for CBT when it was delivered in a group (d=.68) and individual (d=.69) formats.  The last decade has seen nearly 30 new outcome studies testing CBGT models (Burlingame, Strauss & Joyce, 2013) under a variety of conditions.  For instance, positive effects on standardized measures of anxiety were shown when CBGT was transferred to a private practice setting (Gaston, Abbot, Rapee and Neary, 2006) and when treating patients diagnosed with schizophrenia (Kinsep, Nathan and Neary, 2003).   A recent and promising development is the application of CBGT to children and adolescents suffering from social anxiety.  Although limited in number, these studies suggest results that are similar to adult research when groups are offered in community-based clinics (Baer and Garland, 2005).  There is also support for format equivalence when group and individual formats are experimentally contrasted (Liber, et al., 2008). It is important to note that in virtually every CBGT study there were patients who did not show improvement, spawning consideration of alternate models such as a psychodynamic approach developed by Kapczinski and colleagues (cf. Cordioli, et al; 2003).

Panic Disorder

The CBGT model with the most empirical support for successfully treating panic disorder is the Barlow and colleagues’ protocol (Barlow, Craske, Cerny and Klosko, 1989), followed by Clarke’s (1986) cognitive therapy approach.  The largest and most lasting changes are associated with patients who are simultaneously treated with psychotropic medication, typically SSRIs and tricyclics (e.g., Roy-Byrne, Craske and Stein, 2006).  As with social phobia, recent clinical trials have examined changes in rates of improvement in panic disorder when CBGT is transferred into clinical practice settings.  For example, Austin and colleagues (2008) showed that 85% of patients referred to group treatment by general practitioners accepted and participated in the group, a finding that is quite promising. However, the overall rates of change in anxiety on the Beck Anxiety Inventory were modest (d=.37), suggesting that change in naturalistic settings might be considerably lower than rates of improvement found in clinical trials.  In a related fashion, many referrals to treatment are unable to make the commitment of weekly group sessions given work and family demands.  Accordingly, a group of studies have recently examined if massed versus spaced treatment produces similar rates of improvement. For instance, Bohni and colleagues (2009) examined the same CBGT protocol when it was delivered in a 13-session weekly format versus a 3-week massed format with both conditions receiving 26-hours of treatment.  Both programs were well accepted with no differences in dropout, adherence or satisfaction and improvement rates were equivalent. The massed schedule, however, led to faster recovery, suggesting the importance of considering flexibility in how groups are delivered.

Obsessive-compulsive disorder

Behavioral group therapy, specifically, exposure and response prevention (ERP), has the most empirical support for treating obsessive-compulsive disorder.  This treatment appears to be well received with withdrawal rates as low as 6% (Cordioli et al., 2002) and relatively large rates of pre-post improvement on the YBOCS (d=.91-1.74; Fenger, Mortensene, Rasmussen & Lau, 2007; Cordioli et al., respectively). Unfortunately, relapse rates are relatively high for this patient population (e.g., 35%; Braga, Cordioli, Niederauer & Manfro, 2005) with predictors of long-term success being rapid improvement during treatment and full remission by termination. Like panic disorder, there is some evidence that shorter protocols (7- versus 12-session) produce equivalent outcomes arguing for flexibility in how group treatment is delivered. More recently, ERP has been experimentally contrasted with CBGT with some studies reporting equivalent results (Cordioli et al., 2003) and others suggesting a slight advantage for ERP (McLean, Whittal, Thordarson & Taylor, 2001).  Interestingly, two studies (Fals-Stewart et al, 1993; Finerberg, Hughes, Gale & Roberts) that contrasted active treatment to a placebo attention group (i.e., relaxation therapy) found that the common factors associated with group participation led to equivalent outcomes underscoring the importance of paying attention to group dynamics. A recent meta-analysis (Jonsson and Hougaard, 2008) shows support for both ERP and CBGT group protocols in producing large improvements when contrasted with wait list controls (d=1.1).   While one study found an advantage for treatment being delivered in an individual format (McLean, et al., 2001), the collective evidence does not support a difference.

In summary, there is solid to compelling evidence for the effectiveness of group treatments for anxiety disorders.  The majority of studies have employed behavioral or cognitive behavioral protocols.  However, transfer of these protocols to naturalistic practice settings appears to be associated with a reduction in rates of improvement.  Unfortunately, there has been little attention given to diversity considerations since most studies come from North America and Europe.  Finally, there is sufficient evidence to suggest that groups emphasizing group dynamic properties produce similar levels of improvement with certain populations (Burlingame, et al., 2013), arguing for a broad understanding of mechanisms of change.   

References

Austin, S. F., Sumbundu, A. D., Lykke, J., & Oestrich, I. H. (2008). Treating panic symptoms within everyday clinical settings: The feasibility of a group cognitive behavioural intervention. Nordic Journal of Psychiatry, 62(4), 287–293. doi:10.1080/08039480801984016

Baer, S., & Garland, E. J. (2005). Pilot Study of Community-Based Cognitive Behavioral Group Therapy for Adolescents With Social Phobia. Journal of the American Academy of Child & Adolescent Psychiatry, 44(3), 258–264. doi:10.1097/00004583-200503000-00010

Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioral treatment of panic disorder. Behavior Therapy, 20(2), 261–282. doi:10.1016/S0005-7894(89)80073-5

Bohni, M. K., Spindler, H., Arendt, M., Hougaard, E., & Rosenberg, N. K. (2009). A randomized study of massed three-week cognitive behavioural therapy schedule for panic disorder. Acta Psychiatrica Scandinavica, 120(3), 187–195. doi:10.1111/j.1600-0447.2009.01358.x

Braga, D. T., Cordioli, A. V., Niederauer, K., & Manfro, G. G. (2005). Cognitive-behavioral group therapy for obsessive-compulsive disorder: A 1-year follow-up. Acta Psychiatrica Scandinavica, 112(3), 180–186. doi:10.1111/j.1600-0447.2005.00559.x

Burlingame, G., Strauss, B. & Joyce, A (2013). Change mechanisms and effectiveness of small group treatments, In M. J. Lambert (Ed.), Bergin & Garfield’s Handbook of psychotherapy and behavior change, 6th Ed. New York: Wiley & Sons. (pp. 640-689)

Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461–470. doi:10.1016/0005-7967(86)90011-2

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia:  Diagnosis, assessment, and treatment. (pp. 69–93). New York, NY, US: Guilford Press.

Cordioli, A. V., Heldt, E., Bochi, D. B., Margis, R., de Sousa, M. B., Tonello, J. F., … Kapczinski, F. (2002). Cognitive-behavioural group therapy in obsessive-compulsive disorder: A clinical trial. Revista Brasileira de Psiquiatria, 24(3), 113–120. doi:10.1590/S1516-44462002000300004

Cordioli, A. V., Heldt, E., Bochi, D. B., Margis, R., de Sousa, M. B., Tonello, J. F., … Kapczinski, F. (2003). Cognitive-behavioral group therapy in obsessive-compulsive disorder: A randomized clinical trial. Psychotherapy and Psychosomatics, 72(4), 211–216. doi:10.1159/000070785

Fals-Stewart, W., Marks, A. P., & Schafer, J. (1993). A comparison of behavioral group therapy and individual behavior therapy in treating obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 181(3), 189–193. doi:10.1097/00005053-199303000-00007

Fenger, M. M., Mortensen, E. L., Rasmussen, J., & Lau, M. (2007). Group therapy with OCD: Development and outcome of diagnosis specific treatment of patients with OCD in groups. Nordic Psychology, 59(4), 332–346. doi:10.1027/1901-2276.59.4.332

Fineberg, N. A., Hughes, A., Gale, T. M., & Roberts, A. (2005). Group cognitive behaviour therapy in obsessive-compulsive disorder (OCD): A controlled study. International Journal of Psychiatry in Clinical Practice, 9(4), 257–263. doi:10.1080/13651500500307180

Gaston, J. E., Abbott, M. J., Rapee, R. M., & Neary, S. A. (2006). Do empirically supported treatments generalize to private practice? A benchmark study of a cognitive-behavioural group treatment programme for social phobia. British Journal of Clinical Psychology, 45(1), 33–48. doi:10.1348/014466505X35146

Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia:  Basic mechanisms and clinical strategies. New York, NY, US: Guilford Press.

Jónsson, H., & Hougaard, E. (2009). Group cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 119(2), 98–106. doi:10.1111/j.1600-0447.2008.01270.x

Kingsep, P., Nathan, P., & Castle, D. (2003). Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophrenia Research, 63(1-2), 121–129. doi:10.1016/S0920-9964(02)00376-6

Liber, J. M., Van Widenfelt, B. M., Utens, E. M. W. J., Ferdinand, R. F., Van der Leeden, A. J. M., Van Gastel, W., & Treffers, P. D. A. (2008). No differences between group versus individual treatment of childhood anxiety disorders in a randomised clinical trial. Journal of Child Psychology and Psychiatry, 49(8), 886–893. doi:10.1111/j.1469-7610.2008.01877.x

McLean, P. D., Whittal, M. L., Thordarson, D. S., Taylor, S., Söchting, I., Koch, W. J., … Anderson, K. W. (2001). Cognitive versus behavior therapy in the group treatment of Obsessive-Compulsive disorder. Journal of Consulting and Clinical Psychology, 69(2), 205–214. doi:10.1037/0022-006X.69.2.205

Powers, M. B., Sigmarsson, S. R., & Emmelkamp, P. M. G. (2008). A meta-analytic review of psychological treatments for social anxiety disorder. International Journal of Cognitive Therapy, 1(2), 94–113. doi:10.1521/ijct.2008.1.2.94

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756. doi:10.1016/S0005-7967(97)00022-3

Roy-Byrne, P. P., Craske, M. G., & Stein, M. B. (2006). Panic disorder. The Lancet, 368(9540), 1023–1032. doi:10.1016/S0140-6736(06)69418-X

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