Wiley Concise Guides to Mental Health Anxiety Disorders
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The Wiley
Concise Guides
to Mental Health
Anxiety
Disorders
Larina Kase, PsyD
Deborah Roth Ledley, PhD
John Wiley & Sons, Inc.
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Copyright © 2007 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
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Library of Congress Cataloging-in-Publication Data
Kase, Larina.
Anxiety disorder / by Larina Kase and Deborah Roth Ledley.
p. cm.—(Wiley concise guides to mental health)
Includes bibliographical references.
ISBN-13: 978-0-471-77994-0 (pbk.)
1. Anxiety. I. Ledley, Deborah Roth. II. Title. III. Series.
[DNLM: 1. Anxiety Disorders—therapy—Case Reports.
2. Cognitive Therapy—methods—Case Reports. WM 172 K185a
2007]
RC531.K38 2007
616.85'22—dc22
2006023190
Printed in the United States of America.
10 9 8 7 6 5 4 3 2 1
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To Gary and Jenna
—D.R.L.
To Moraima and John, for fostering my creativity and interest
in writing, and serving as wonderful role models
—L.K.
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CONTENTS
Series Preface ix
Acknowledgments x
Section One: Conceptualization and Assessment
CHAPTER 1 Overview of the Anxiety Disorders 3
CHAPTER 2 CBT for the Anxiety Disorders: Description and
Research Findings 21
CHAPTER 3 Assessment of the Anxiety Disorders 37
CHAPTER 4 Case Conceptualization and Treatment Planning 59
Section Two: Treatment of Anxiety Disorders
CHAPTER 5 Client Psychoeducation 73
CHAPTER 6 Cognitive Tools 87
CHAPTER 7 In Vivo Exposure 99
CHAPTER 8 Imaginal Exposure 115
CHAPTER 9 Other CBT Techniques 131
CHAPTER 10 Termination and Relapse Prevention 145
Section Three: Additional Issues and
Treatment Considerations
CHAPTER 11 Additional Treatment Approaches 161
CHAPTER 12 Treating Children and Adolescents with Anxiety Disorders 173
vii
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viii CONTENTS
CHAPTER 13 Consultation and Collaboration with
Multidisciplinary Professionals 191
CHAPTER 14 Group, Family, and Couples Therapy 203
CHAPTER 15 Supervision 215
CHAPTER 16 Clinician’s Top 10 Concerns and Challenges with
Treating Anxiety 223
APPENDIX Resources for Anxiety Treatment for Clinicians
and Self-Help for Patients 235
Index 237
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SERIES PREFACE
T
he Wiley Concise Guides to Mental Health are designed to provide mental
health professionals with easily accessible overview of what is currently
known about the nature and treatment of psychological disorders. Each
book in the series delineates the origins, manifestations, and course of a com-
monly occurring disorder and discusses effective procedures for its treatment.
The authors of the Concise Guides draw on relevant research as well as their clin-
ical expertise to ground their text both in empirical findings and in wisdom
gleaned from practical experience. By achieving brevity without sacrificing com-
prehensive coverage, the Concise Guides should be useful to practitioners as an
on-the-shelf source of answers to questions that arise in their daily work, and
they should prove valuable as well to students and professionals as a condensed
review of state-of-the-art knowledge concerning the psychopathology, diagnosis,
and treatment of various psychological disorders.
Irving B. Weiner
ix
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ACKNOWLEDGMENTS
W
e would both like to thank, first and foremost, the numerous patients
that we have treated with anxiety disorders. We have enjoyed our work
immensely and have learned something new in our interactions with
each and every patient.
We would also like to thank the entire faculty and staff of the Center for the
Treatment and Study of Anxiety at the University of Pennsylvania where we met,
and both worked. Special thanks to Edna Foa, Shawn Cahill, Kelly Chrestman,
Marty Franklin, Lib Hembree, Jonathan Huppert, Pat Imms, Miles Lawrence,
Kate Muller, Sheila Rauch, Simon Rego, Dave Riggs, and Elna Yadin for their
valuable teaching, clinical insights, and friendships. We were also so lucky at the
CTSA to supervise many fabulous interns—we would like to extend a special
thank you to Joelle McGovern who taught us more than we taught her about
working with kids. More recently, we have also enjoyed peer supervision with
Lynn Siqueland and Tamar Chansky.
We appreciate our editor, David S. Bernstein, at Wiley. We would also like to
thank the Series Editor of Wiley Concise Guides to Mental Health, Irving B. Weiner,
for his suggestions and enthusiastic support for this book.
Deborah would also like to thank Marty Antony, who first got her interested
in anxiety disorders and Rick Heimberg, who has been an excellent mentor and
collaborator for years. Larina would also like to thank her many wonderful super-
visors, particularly those from her internship, Nancy Talbot, Sharon Gordon,
Deborah King, Dennis Foley, and Mark Larson who encouraged her to pursue her
dream of specializing in the cognitive behavioral treatment of anxiety disorders.
x
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SECTION
ONE
Conceptualization
and Assessment
THE WILEY
CONCISE GUIDES
TO MENTAL HEALTH
Anxiety
Disorders
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C HAPTER
Overview of the Anxiety Disorders
Description of the Anxiety Disorders
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV;
American Psychiatric Association, 1994) includes six anxiety disorders: Panic Dis-
order, Specific Phobia, Social Phobia (also known as Social Anxiety Disorder),
Obsessive-Compulsive Disorder (OCD), Posttraumatic Stress Disorder (PTSD),
and Acute Stress Disorder. In this chapter, these disorders will be described and
a case description of each will be introduced. These cases will be used in later
chapters of the book to demonstrate treatment techniques. The chapter will con-
clude with a discussion of differential diagnosis (how to differentiate one anxiety
disorder from another anxiety disorder, and from other disorders), comorbidity
(which disorders tend to co-occur with each anxiety disorder), and prevalence of
the anxiety disorders.
Panic Attacks, Agoraphobia, and Panic Disorder
Panic Attacks
Panic Disorder is characterized by recurrent, unexpected (“out of the blue”) panic
attacks. Prior to describing panic disorder in more detail, it is important to define
panic attacks. A panic attack is an experience, not a psychiatric disorder. The experi-
ence of panic attacks is most associated with panic disorder, but in fact, panic
attacks are seen across the anxiety disorders. A panic attack is characterized by a
period of fear or discomfort during which a person experiences at least four panic
symptoms. These symptoms come on abruptly and peak within ten minutes. This
does not mean that a panic attack completely goes away within ten minutes; rather,
the symptoms reach their peak severity and intensity very rapidly, and then recede
gradually. The symptoms of panic attacks are listed in Table 1.1. Panic attacks can
include cardiovascular and respiratory symptoms like heart palpitations and short-
ness of breath; gastrointestinal symptoms like nausea or abdominal distress; and
3
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4 CONCEPTUALIZATION AND ASSESSMENT
TABLE 1.1.
Symptoms of Panic Attacks
A discrete period of intense fear or discomfort, in which at least four of the following
symptoms develop abruptly and reach a crescendo within 10 minutes:
1. Racing or pounding heart
2. Sweating
3. Trembling or shaking
4. Shortness of breath
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, or faint
9. Feeling unreal or detached
10. Tingling or numbness (usually in the hands and/or feet)
11. Chills or hot flashes
12. Fear of going crazy or losing control
13. Fear of dying
Source: DSM-IV (American Psychiatric Association, 1994).
cognitive symptoms like fear of losing control or going crazy. For some patients
who experience panic attacks, the main symptom is a sense of derealization (feel-
ings of unreality) or depersonalization (feeling detached from oneself). Clinicians
should be aware that panic attacks can be quite variable from patient to patient
since only four of 13 symptoms are required for a person to be considered to have
panic attacks.
Agoraphobia
Like panic attacks, Agoraphobia is included in the anxiety disorders section of
the DSM, but is not a diagnosable disorder. Agoraphobia is defined as anxiety
about being in particular places or situations where escape might be difficult or
help might not be available, should a panic attack or panic-like symptoms arise.
Commonly feared situations include using public transportation, going to
movie theatres, being away from home, and being in crowds. Agoraphobia leads
to avoidance of these situations, or great distress when in these situations if they
cannot be avoided.
Panic Disorder
With panic attacks and Agoraphobia defined, it is appropriate to return to the
diagnostic criteria for Panic Disorder—the disorder most associated with these
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Overview of the Anxiety Disorders 5
experiences (see Table 1.2 for a summary of the diagnostic criteria). Panic Disor-
der is characterized by recurrent, unexpected panic attacks. The DSM defines
“recurrent” as two or more unexpected panic attacks. When patients have had
panic attacks for quite some time, they might deny the experience of unexpected
attacks. This is because unexpected attacks usually happen early on in a patient’s
experience with the disorder. Gradually, patients come to associate panic attacks
with specific situations. For example, a patient might have an “out of the blue”
panic attack at the supermarket and then come to fear having additional panic
attacks at the supermarket. This expectation can actually bring on attacks, as
patients enter a situation already feeling anxious and being hypervigilant to their
internal, physical state. Often, by the time a patient presents for treatment, he
will report that all of his panic attacks are cued or expected (e.g., “I always have
panic attacks in line at the supermarket and the bank.”). The clinician should
inquire if they ever experienced an “out of the blue” attack—particularly when
they first started experiencing panic. Most will report that their first few attacks
were indeed unexpected or surprising.
The DSM also requires that at least one panic attack has been accompanied
by one month or more of concern about having additional attacks, worry about
the consequences of having attacks (e.g., worrying about having a heart attack
or going crazy), or change in behavior due to the attacks (e.g., avoiding the
supermarket). Some of these behavioral changes can be subtle, like no longer
drinking caffeine, having sex, or watching scary movies simply because they
bring on the same physical sensations as those experienced during a panic
attack.
TABLE 1.2
Summary of the Diagnostic Criteria for Panic Disorder
• Defining characteristic: Recurrent, unexpected panic attacks (see Table 1.1)
AND:
• One of the following (for one month or more):
— Worry about having additional attacks.
— Worry about the implications of having attacks (e.g., having a heart attack,
going crazy).
— Change in behavior related to the attacks (e.g., will not exercise, see scary
movies, have sex, drink caffeinated beverages, etc.).
• Not due to organic factors (e.g., medical problems, substance use).
• Not better accounted for by another disorder.
Source: DSM-IV (American Psychiatric Association, 1994).
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6 CONCEPTUALIZATION AND ASSESSMENT
It is also essential to rule out any physiological cause for panic symptoms.
Panic symptoms can be brought on by various medical problems, like hyperthy-
roidism, or by the use of substances, like caffeine or marijuana. Particularly for
patients who have never had problems with anxiety, it is advisable that they see
their physician for a thorough medical evaluation to rule out any medical prob-
lems. When patients with panic disorder present for an evaluation by a mental
health professional, it is often the case that they have already undergone med-
ical evaluation—typically many times. Since patients often think that they are
having a heart attack when they first experience panic attacks, it is not unusual
for them to first present to emergency rooms. Once cardiac problems have been
ruled out, many savvy physicians will suggest that anxiety might be the cause
of the patients’ difficulties and will recommend that they see a mental health
professional.
Panic Disorder can be diagnosed with or without Agoraphobia. Clinicians
should keep in mind that Panic Disorder with Agoraphobia would be diagnosed
if (a) patients avoid situations because of their fear of having a panic attack while
in them; (b) endure such situations with a great deal of distress; and/or (c) enter
such situations but only with a safe person or by engaging in some other safety
behavior such as carrying anti-anxiety medication, sitting near exits, or always
having a cell phone available. Not surprisingly, most patients with Panic Disor-
der have at least mild Agoraphobia (White & Barlow, 2002).
Case Example: Panic Disorder with Agoraphobia
Susan was a 30-year old mother of a baby boy. She experienced her first panic
attack a few months after her baby was born. She was alone at home with him
at the time, and it was a particularly stressful day. The baby was inconsolable
and would not eat or sleep. Susan was exhausted, frustrated, and worried. She
suddenly became very dizzy, felt her heart racing, and experienced chest pain
and pressure. She was terrified that she was “going crazy.” Her brother was
schizophrenic and she worried that she was developing the disorder too. Susan
called her husband at work, and he came home and took her to the emergency
room. After a thorough workup, Susan was deemed healthy. It was recom-
mended that she cut back on caffeine and smoking (she was drinking many pots
of tea and smoking up to two packs of cigarettes per day) and try to get some
more rest and help around the house.
About a week later, Susan took the baby to the supermarket. She found the
fluorescent lights to be very annoying and she started to feel anxious. Before
she knew it, she was having another panic attack and had to leave her cart of
food and rush from the store. Over the next few months, Susan had panic
