INTRODUCTION:

According to Freeman, Garcia, et al., 2014¹, cognitive behavioural therapy (CBT) is well regarded as an effective treatment for paediatric mental health illness. McGuire et al., in 2015² found that CBT has moderate-to-large impact sizes on severity, treatment response, and remission over more than two decades of therapy trials. Torp et al in 2015³ found that these advantages extend beyond speciality treatment programmes and into community-based care.

CBT is characterised as "an amalgam of behavioural and cognitive therapies guided by principles of applied science," as Christian Otte et al (2008)^4,5 mentioned. By changing their antecedents and consequences, as well as behavioural practises that result in new learning, behavioural therapies aim to reduce maladaptive behaviours and boost adaptive ones. The cognitive therapies are designed to change maladaptive ideas, self-statements, or cognitions. CBT is known for its problem-focused intervention procedures, which are based on learning theory and cognitive theory concepts. ^4,5 Despite the critical need for treatment of mental illness, the majority of people who satisfy the criteria for a current psychiatric diagnosis (59 percent) have not got their therapy in the previous year (Wang, Berglund, et al., 2005).⁶Furthermore, one out of every seven people with a recent diagnosis received minimum sufficient care (i.e., having any appointments with a psychotherapist, social worker, counsellor, therapist, or mental health nurse in the past year; Wang, Lane, et al., 2005). ⁷

In addition, there is a significant time gap between the onset of illness and the reception of treatment, ranging from 6 to 23 years depending on the disorder.⁸In a worse case, most people do not obtain therapy in a timely manner when they seek for it,⁹ increasing the no-show rate and exacerbating symptom severity¹⁰.Taken into consideration, these findings show that the majority of people with mental illnesses do not receive treatment, and those who do receive treatment do so only after years of suffering with it. Depression is one of the most common mental health disorders¹¹, which commonly starts in youth and can last throughout adulthood if left untreated.¹² It has the fourth highest worldwide burden of disease¹³ and has a higher economic cost to society.¹⁴

CBT and BA (Behavioural Activation) are now widely used as first-line treatments for depression.¹⁵ In the treatment of depression, both CBT and BA have a meta-analytic level evidence.^16,17The most traditional method of delivering CBT and BA has been periodic face-to-face sessions between the therapist and the patient.

1. Attention deficit hyperactivity disorder (ADHD):

It is a common neurodevelopmental disorder that affects 5% of the population of children.¹⁸ ADHD places a significant strain on children, their families, and society as a whole.¹⁹ Comorbid anxiety disorders are common in children with ADHD, which adds to worse performance.²⁰ Treatment of anxiety problems in children with ADHD may enhance their functioning, as well as their overall quality of life.²¹ There is considerable empirical support in the general population for a number of skills-based methods and packages (often referred to as CBT) for the treatment of paediatric anxiety.²²Moderate was discovered in a meta-analysis. Anxiety was relieved in 59 percent of children following CBT treatment, compared to 18 percent of children on the waitlist.²³ Only a few studies have looked at whether CBT is effective in treating anxiety in children with ADHD and comorbid anxiety, and the majority of them were uncontrolled and had small sample sizes.²⁴ A 10-week CBT therapy for children aged 8–12 years with comorbid ADHD and anxiety resulted in immediate improvements in anxiety and ADHD symptom severity.

2. Anorexia nervosa:

Anorexia nervosa is also called as Attention/ restrictive food intake disorder (ARFID). The treatment now being investigated is a novel form of outpatient cognitive-behavioral therapy for ARFID (CBT-AR). CBT-AR is suitable for children, adolescents, and adults aged 10 and above, and it is available in both individual and family-supported forms. It is divided into four stages and takes 20–30 sessions. Only a few randomised controlled studies in young children have been conducted, hence the existing evidence base for ARFID treatment is mostly based on case reports, case series, and retrospective chart reviews.^25,26

Adult studies are lacking, hence family-based treatment and parent training, cognitive-behavioural therapies, hospital-based re-feeding, including tube feeding, and supplementary medication are all ARFID treatments that have recently been documented in the literature. ²⁵ There is currently no evidence-based psychological treatment adequate for all kinds of ARFID, according to Jennifer J. Thomas et al 2018.²⁷ Several groups are actively testing the effectiveness of new psychological treatments for ARFID, particularly family-based and cognitive-behavioural approaches, but the results have yet to be published.

3. Sleeplessness:

Studies have consistently supported the use of dCBT to treat insomnia, according to Annemarie I. Luik et al 2019²⁸, evidence currently shows strong short-term effects and lesser long-term effects in groups with varied co-occurring health conditions up to 1.5 years following therapy. The impacts are also felt in a variety of aspects of psychological well-being. Mediators and moderators have been investigated in order to better understand how they work and to find new ways to improve efficacy and reduce dropout. Incorporating tailored instruction into dCBT could improve its effectiveness even more. The evidence for dCBT for insomnia is strong, indicating that it is ready for use in mainstream medicine. To ensure that dCBT achieves its full potential, more study, digital innovation, and the development of successful implementation methods are required.²⁹When symptoms of difficulty getting asleep, keeping asleep, or waking up too early persist three or more nights per week, for three or more months, with severe everyday effects, insomnia disorder is diagnosed.³⁰

Insomnia affects a large percentage of the population, with estimates ranging from ten percent for insomnia problem to twenty-five percent for insomnia symptoms. ³¹ Despite the fact that insomnia is a common illness, only 37% of persons who suffer from it say they have sought medical help for their sleep problems.³² The reasons for the low number of people seeking care for insomnia is likely several, but one factor could be that insomnia is frequently treated with medicine.^33,34This goes against American and European standards, which advocate CBT as the first-line treatment for insomnia disorder^35,36 due to its large body of clinical data.³⁷ CBT is a structured therapy for insomnia that consists of various components.^38,39Typically, educational, behavioural, and cognitive components are included in the therapy. Relaxation is typically included as a basic component, and additional techniques such as mindfulness are frequently incorporated.

4. Aspects of autism spectrum disorder (ASD):

According to the American Psychiatric Association, (2013)⁴⁰ people with ASD generally have significant mental health problems in addition to the fundamental symptoms of abnormal social communication and behavioural inflexibility. According to Howes OD et al., 2018⁴¹, between 30% and 50% of children and adolescents with ASD without intellectual disability meet criteria for at least two psychiatric conditions, and 50 percent to 85% have clinically significant emotional difficulties. While anxiety is the most prevalent group of emotional issues having significant overlap in both internalising and externalising symptom presentation.

Mazefsky and White (2014)⁴²hypothesised that impairments in emotion regulation (ER) could explain some of the associated symptomatology. Thompson⁴³ defines emotion regulation as "the extrinsic and intrinsic processes responsible for monitoring, analysing, and adjusting emotional reactions, notably their intense and temporal aspects, to accomplish one's goals." Therefore, it is found that deficiencies in ER are linked to both internalising and externalising difficulties, and these processes lets the adolescents adjust and modulate the strength of their emotional responses in a variety of contexts.

Mental health problems are widespread among people with autism spectrum disorder (ASD), according to Jonathan A. Weiss et al³⁹, and impairments with emotion management mechanisms may be at the root of these problems. In children with ASD, cognitive behaviour therapy (CBT) is thought to be an effective treatment for anxiety. More research is needed to determine the efficacy of a trans-diagnostic treatment strategy, in which the same treatment can be used to address a variety of emotional issues other than anxiety. The goal of this study was to see how effective a 10-session, trans-diagnostic CBT intervention that was manualized and administered individually was at improving emotion regulation and mental health concerns in children with ASD.⁴⁴

5. Obsessive-compulsive disorder (OCD):

It is a common and persistent syndrome that causes significant worldwide disability, according to Dan J. Stein et al 2020⁴⁵. Obsessive–compulsive disorder (OCD) is the most common of the 'obsessive–compulsive and related disorders,' which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, Eleventh Revision, and are frequently underdiagnosed and undertreated. Furthermore, OCD is a prime example of a neuropsychiatric condition for which thorough research on phenomenology, psychobiology, medication, and psychotherapy has aided in better identification, assessment, and outcomes. Despite the fact that OCD is a largely homogeneous condition with similar symptom dimensions around the world, a personalised assessment of symptoms, insight, and comorbidity is required. Several neurobiological mechanisms underlying OCD, including particular brain circuits that underpin OCD, have been identified.

Furthermore, laboratory models have shown how cellular and molecular dysfunction underlying repetitive stereotyped behaviour and the genetic architecture of OCD is becoming better understood. Serotonin reuptake inhibitors and cognitive–behavioral therapy are effective therapies for OCD, as are neurosurgery for patients with severe symptoms. Integration of global mental health and translational neuroscience approaches could help researchers learn more about OCD and enhance patient outcomes.⁴⁶ Obsessions and/or compulsions are present in people with OCD. Obsessions are intrusive and undesired thoughts, visions, emotions, or urges that occur repeatedly and persistently. They are frequently related with anxiety. Compulsions are compulsive behaviours or mental activities that a person feels compelled to engage in in response to an obsession or to achieve a sense of 'completeness.'

Obsessions may be difficult for children to notice or describe, but most adults can recognise the existence of both obsessions and compulsions. Obsessions frequently cause an increase in anxiety or a sense of discomfort, according to cognitive–behavioral theories, and compulsions are commonly committed in response to obsessions. However, some data suggests that compulsive behaviour is primary, and obsessions develop as a post-hoc rationalisation of these behaviours, however this view needs further research.⁴⁷ The majority of OCD sufferers are acutely aware that their compulsive symptoms are excessive and wish they had greater control over them.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) have each added a chapter to their respective international classifications of mental disorders. While there are many similarities between OCD and the other OCRDs⁴⁸ such as intersecting comorbidities and familial history^49,50, there are also significant variances in their biology, assessment, and treatment. The epidemiology and assessment of OCD, its pathophysiology and underlying mechanisms, and clinical management are all covered in this primer.^51,52In addition, this Primer highlights OCD-related quality of life (QOL) difficulties as well as major unanswered research questions. Despite increased emphasis to the prevention and early intervention of mental diseases, such issues in OCD have received very little attention.⁵³ Psychoeducation and the lowering of familial accommodation in high-risk persons with subclinical or no symptoms could be main preventive targets, whereas early detection and management of clinical OCD could be secondary prevention targets.⁵⁴

According to Dan J. Stein et al. 2020,⁴⁵ the treatment of OCD consists of several components, beginning with establishing a therapeutic alliance with the patient and providing psychoeducation, then moving on to psychological and/or pharmacological approaches, and finally, for patients with treatment-resistant OCD, neuro-modulation and neurosurgery. Alternative approaches have also irked attention, but more proof is needed.⁵⁵ Although generic management principles exist, they must be adjusted to each individual. Some comorbid illnesses, such as depression, respond well to first-line OCD pharmacotherapies, but others, such as bipolar disorder, may require extra treatment^.56 Although similar pharmacotherapies and psychotherapies are utilised across the lifespan,^57-58when treating children and adolescents, essential adjustments are required; however, a complete discussion is beyond the scope of this Primer.

6 Anxiety disorders:

Excessive dread and consequent avoidance are symptoms of anxiety disorders, which occur in response to a specific object or circumstance in the absence of genuine threat. Anxiety disorders are very common, with a high frequency of anxiety disorders. A 12-month rate of around 18% and lifetime rates of around 29% are expected.^59,60

Figure 1 Average odd ratios of acute treatment response to cognitive-behavioral therapy as compared with placebo. *, P<0.05, **, P<0.01

Adapted from⁶³: Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008; 69: 621-632. Copyright © Physicians’ Postgraduate Press, 2008

The gold standard in the psychotherapeutic treatment of anxiety disorders is cognitive behavioural therapy (CBT), and various meta-analyses and reviews of these meta-analytic findings about CBT have been published. In recent years, studies on the efficacy and effectiveness of CBT have been published. 61-67 These CBT strategies are weighted differently during therapy depending on the unique anxiety issue. A slew of studies has looked into the effectiveness of CBT for adults with anxiety problems. In addition, multiple meta-analyses have been undertaken to quantify the evidence of CBT for anxiety disorders. 62, 68, 69 Treatment efficacies are measured in terms of an effect size in meta-analysis. The magnitude of an observable effect in a standard unit of measurement is expressed as an effect size. It's crucial to note, however, that multiple types of effect sizes might be utilised to assess the evidence.

6.1 Post-traumatic stress disorder (PTSD):

The DSM-IV includes criteria for (i) the traumatic experience; (ii) re-experiencing; (iii) avoidance of relevant stimuli and numbness; and (iv) heightened arousal in the classification of post-traumatic stress disorder (PTSD). CBT for PTSD usually consists of three parts: (i) Psychotherapy on the nature of fear, anxiety, and PTSD; (ii) controlled, long-term exposure to traumatic event cues; and (iii) cognitive therapy. Maladaptive beliefs/appraisals may be restructured, processed, or challenged. The controlled effect size in six randomised placebo-controlled efficacy trials of CBT in PTSD was 0.62 (95 percent confidence interval 0.28-0.96), indicating a medium effect.⁷⁰

A recent Cochrane review of psychological treatment for PTSD⁷¹ backed up these findings, showing that trauma-focused treatment is effective. Treatment as usual or waiting list control were both less effective than CBT. Six research looked at the effectiveness of CBT in the treatment of depression.⁶² and discovered an uncontrolled pre-to-post-treatment effect size of 2.59. (95 percent CI 2.06-3.13). For the principal continuous anxiety measure (dark blue bars) and depression measures, average effect size estimations and corresponding 95 percent confidence intervals of the acute treatment efficacy of cognitive-behavioural therapy as compared to placebo on the various anxiety disorders (light blue bars).

6.2 Social anxiety disorders:

Dread of performance, excessive fear of scrutiny, and fear of acting in an embarrassing way are all symptoms of social anxiety disorder (or social phobia). Although they believe their anxieties are overblown and out of proportion, most patients are very sensitive to others' supposed opinions and have low self-esteem. When confronted with dreaded events, or even anticipating them, most people experience bodily symptoms such as sweating, shaking, or blushing, which might act as a trigger for worrying about social consequences on their own. CBT for social phobia usually focuses on cognitive restructuring and in-person exposure to the feared situation. in a social environment.⁶³

Patients are taught to recognise and question their beliefs about their social competence and the likelihood of unfavourable social appraisal and repercussions. In vivo exposures give you a better idea of what you're reaching into opportunities to address and practise social skills in situations that are feared or avoided. The effectiveness of CBT in social anxiety disorder was 0.62 (95 percent CI 0.39-0.86, Figure 1) in seven randomised placebo-controlled treatment studies, showing a medium effect. The uncontrolled pre- to post-treatment acute treatment effect size was 1.27.⁵⁸ in a separate meta-analysis. The efficiency of The uncontrolled pre-to-post-treatment effect size was 1.04 in eleven efficacy studies (95 percent 0.79-1.29).⁶³

6.3 Panic disorders:

Panic attacks, according to Christian Otte in 2011,⁷² are sudden bouts of unidentified feelings that include palpitations, chest pains, sweating, shortness of breath, feeling of choking, trembling, nausea, dizziness, paresthesias, chills or hot flushes, depersonalization or derealisation, and fear of dying or losing control. Additional criteria for a diagnosis of panic disorder include at least one unanticipated episode followed by at least one month of terrified anticipation or concern about the attack's effects. Panic disorder is commonly followed or accompanied by agoraphobia, which is described as the fear of being in places or situations where escape is impossible or help is unavailable; these situations are avoided or endured with great distress, or the patient requires a companion. CBT for panic disorder usually includes education about the nature and physiology of the panic response, cognitive therapy techniques to correct catastrophic misinterpretations of panic symptoms and their consequences, and graduated exposure to panic-related body sensations (interoceptive exposure) and avoided situations. The efficacy of CBT in panic disorder was investigated in five researches in a placebo-controlled randomised trial.⁵⁵ The effect size was 0.35 (95 percent confidence interval: 0.04-0.65), indicating that the effect was minor to medium (Figure 1). A different Meta analysis that assessed uncontrolled pre- to post-treatment effect sizes shows how vital it is to consider the type of effect size when assessing the amount of effect^.58The effect size for CBT in panic disorder was 1.53 in that meta-analysis. The effectiveness of CBT in panic disorder has been studied in several researches.⁶⁵ For panic attacks, the computed uncontrolled pre-to-post treatment effect size was 1.01 (95 percent CI 0.77-1.25) and for avoidance, it was 0.83 (95 percent CI 0.60-1.06).

7. Psychosis:

The technique with the longest history and the most evidence base is cognitive behaviour therapy for psychosis (CBTp)^73-76. CBTp combines components from behavioural therapy and the so-called "second" or "cognitive wave" of CBT, as well as aspects from the "third wave" of CBT^.77The weight and execution of these parts vary each manual. Nonetheless, the National Institute for Health and Care Excellence (NICE) guidelines⁷⁸ outline basic elements on which there is agreement: (i) re-evaluating patients' perceptions, beliefs, or reasoning related to the symptom; (ii) monitoring thoughts, feelings, or behaviours related to symptoms; and (iii) promoting alternative ways of coping with symptoms, reducing distress, and improving functioning.

CBT also takes a metacognitive approach, in which therapists and patients talk about and question problematic thoughts and beliefs. CBT teaches metacognitive knowledge, such as the need of treating thoughts as thoughts rather than facts. Furthermore, CBT demonstrates that there is no one-size-fits-all emotional response to a given scenario (for example, failing an exam); situations/events can be assessed and dealt with in a variety of ways. Many national guidelines, including the British NICE guidelines⁷⁸, the German Society of Psychologists guidelines (DGPs)⁷⁹, and the German Society of Psychiatrists (DGPPN) guidelines, highly support CBTp in all stages of psychotic diseases.⁸⁰

Metacognitive therapy aims to improve cognitive flexibility, change metacognitive beliefs, and lower CAS (eg, reduction of dysfunctional coping strategies). Experiential strategies (e.g., practising detached mindfulness, i.e., letting go of an experience rather than trying to change or control it and knowledge-based techniques are two types of strategies (eg, challenging metacognitive beliefs). According to Steffen Moritz⁸¹, the Australian Psychiatric Association and the German Psychiatric Association (DGPPN) metacognitive training is well thought-out as a treatment for psychosis.

CONCLUSION:

For the purposes of frugality and to enable discussion of this diverse set of treatments, in this article the authors group the cognitive and behavioural therapies under the umbrella term “CBT” while acknowledging that the relative emphasis of cognitive vs behavioural techniques differs across treatment programs. Cognitive therapy focuses on changing cognitions, which is proposed to change emotions and behaviours. The terms cognitive therapy, behavioural therapy, and cognitive-behavioural therapy have emerged. CBT has been associated with improvements in quality of life in all the mental health disorders. CBT approach to treatment aimed at reducing emotional distress and increasing adaptive behaviour in patients with a host of mental health and adjustment problems. Cognitive behavioural therapists deliver interventions in a strategic manner, such that interventions emerge from the customized case formulation of the patient’s clinical presentation; delivered in a collaborative manner with the patient; designed to move patients forward and directly towards meeting their treatment goals. It has been shown to be effective for a wide variety of mental health disorders, including anxiety disorders, Attention deficit/ hyperactivity disorders (ADHD), obsessive-compulsive disorder (OCD), insomnia, avoidant/restrictive food intake disorder (ARFID), social anxiety, autism, depression in children and adolescents. CBT is typically conceptualized as a short-term, skills-focused treatment aimed at altering maladaptive emotional responses by changing the patient’s thoughts, behaviours, or both. It is the combination of one’s thoughts, feelings and behaviours.

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Received on 10.01.2022 Modified on 29.01.2022

Research J. Pharm.and Tech 2022; 15(3):1330-1336.

DOI: 10.52711/0974-360X.2022.00222