The CBT Anxiety Solution Workbook A Breakthrough
Treatment for Overcoming Fear, Worry, and Panic
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The
CBT
Anxiety Solution
WORKBOOK
A BREAKTHROUGH TREATMENT for
OVERCOMING FEAR, WORRY & PANIC
MATTHEW MCKAY, P h D
MICHELLE SKEEN, P sy D
PATRICK FANNING
New Harbinger Publications, Inc.
Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject matter
covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, finan-
cial, legal, or other professional services. If expert assistance or counseling is needed, the services of a compe-
tent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright © 2017 by Matthew McKay, Michelle Skeen, and Patrick Fanning
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Shoup
Acquired by Catharine Meyers
Edited by Susan LaCroix
All Rights Reserved
Library of Congress Cataloging-in-Publication Data on file
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Contents
1 The Anxiety Problem 1
2 The Alarm Response 5
3 Assessment 21
4 Motivation 31
5 Preparation 39
6 The Anxiety Solution 79
7 You Can Face Fear 101
8 Reducing Worry with Defusion 115
9 Correcting Your Anxiety Lens 127
10 Distress Tolerance Skills 145
11 Relapse Prevention 167
Appendix I: Comprehensive Coping Inventory (CCI) 181
Appendix II: Worksheets 185
Appendix III: Depression Anxiety Stress Scales-�21 (DASS-�21) 207
Appendix IV: Interoceptive Exposure 211
Appendix V: Acceptance and Action Questionnaire (AAQ-�II) 219
References 221
CHAPTER 1
The Anxiety Problem
Fear is a natural and valuable emotion. It has great survival value for human beings, preparing
us to fight for survival or run away quickly from a threat. But too much fear in the form of
chronic anxiety is incredibly painful and debilitating.
Anxiety is prolonged fear that persists in the absence of a real threat: after a threat is over,
during situations that aren’t actually very dangerous, or before a potential threat in the future.
When anxiety becomes chronic and dominates your life, it morphs into an anxiety disorder.
Research consistently shows that cognitive behavioral therapy (CBT) is the most effective
anxiety treatment. It works better than drugs, psychoanalysis, hypnosis, and all the other ways
we have tried to treat anxiety over the years.
Broadly speaking, two CBT approaches for treating anxiety have emerged: coping and
exposure. Coping is changing how you think, evaluating threats more accurately, and building
confidence in your ability to handle a threat so that you are gradually less afraid. Exposure is
purposefully experiencing what you are afraid of, disproving your dire predictions of disaster,
until your fear naturally subsides. The most recent data show that both approaches help, but
exposure can work faster and results in larger, longer-lasting reductions in anxiety.
The first two-thirds of this book teach you everything you need to know to apply the latest
and most effective protocol for exposure, called inhibitory learning. It was developed by a team
of therapists and researchers (Craske, Treanor, Conway, Zbozinek, and Vervliet) who pub-
lished their results in 2014. This special exposure process will help you overcome anxiety as
rapidly and completely as possible.
This book also covers the most effective coping strategies used in CBT and related thera-
pies: coping planning, defusion, cognitive flexibility, and distress tolerance. They are research-
tested, highly effective techniques that will augment and strengthen your anxiety recovery
program.
THE CBT ANXIETY SOLUTION WORKBOOK
How to Use This Book
Using this book is simple: continue reading, working through the first six chapters in order.
Do the exercises as you come to them, thoroughly and diligently, before going on to the next
section or skipping ahead. Along the way, you may be advised to also work in chapters 7–10.
Finally, read the final chapter on relapse prevention.
You are about to start a challenging but very rewarding journey. Here is a preview of the
main attractions:
Chapter 2 goes into the details of the alarm response, how we perceive and appraise
threats, the fight/flight reaction, and typical behavioral responses. It allows you to compare
your symptoms to the six most commonly diagnosed anxiety disorders:
1. Generalized anxiety disorder
2. Social anxiety disorder
3. Obsessive-compulsive disorder
4. Panic disorder
5. Specific phobia
6. Post-traumatic stress disorder
You will begin making a list of feared situations that you will carry forward into future
chapters. At the end of the chapter is an exercise to help you identify your particular fear
response and begin to shape your treatment plan.
Chapter 3 is all about assessment. You will begin an inventory of your feared situations,
your level of distress for each, and which of several safety behaviors you tend to use:
• Avoiding what’s making you anxious
• Seeking reassurance from others
• Distraction
• Procrastination
• Checking and double-checking
• Overpreparing for stressful encounters
• Perfectionism
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The Anxiety Problem
• Ritual thoughts or actions
• List making to avoid forgetting and uncertainty
• Using drugs or alcohol to take the edge off
By far the most common safety behavior is avoidance. The chapter concludes with a check-
list to find out which types of avoidance you favor: avoiding certain situations, avoiding certain
thoughts, or avoiding certain physical sensations.
Chapter 4 is where you will work to build motivation for facing your feared situations.
You’ll assess the costs of your avoidance and other safety behaviors in nine domains:
1. Friendships
2. Family
3. Parenting
4. Work/education
5. Self-care/health
6. Pleasure/recreation
7. Life goals
8. Service to others
9. Romantic relationships
You will also identify and rate your positive values in these domains and list the activities
and accomplishments you have been missing because of chronic anxiety. Finally, you will
consider the importance of willingness when facing situations you have been avoiding.
Chapter 5 is the planning chapter in which you will list various ways you plan to stop your
safety behaviors and expose yourself to the situations, feelings, and thoughts you have been
avoiding. For each of your planned exposures you will predict the worst possible outcome and
set a percentage probability for the outcome happening as predicted. After consulting many
detailed examples of inventories composed by people suffering from all the different anxiety
disorders, you will arrive at the end of the chapter with your own detailed exposure
inventory.
Chapter 6 guides you through the actual exposure process: when to do it, what to experi-
ence first, how to prepare for exposures, evaluating your results, how often to do exposures,
and so on.
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THE CBT ANXIETY SOLUTION WORKBOOK
Chapter 7 is the first of the supplemental coping chapters. It explains how to increase your
sense of efficacy by developing a coping plan for your worst-case scenario.
Chapter 8 teaches the cognitive skill of defusion, a technique for coping with fearful
thoughts, adapted from acceptance and commitment therapy.
Chapter 9 corrects your anxiety lens by teaching you how to appraise threats more
accurately.
Chapter 10 works on increasing your distress tolerance, using techniques from dialectical
behavior therapy, such as mindfulness, self-soothing, and relaxation.
Chapter 11 guides you in crafting a plan for relapse prevention, so that you can deal with
any anxiety that crops up in the future.
Appendices contain all the worksheets in one place for ease of photocopying, extra
instructions for panic disorder, and some useful standard measures for mental health profes-
sionals to use.
4
CHAPTER 2
The Alarm Response
In this chapter you will learn about the alarm response to threats, identify your type of anxiety,
and begin to plan your treatment.
Chronic anxiety is like having an alarm sound in your mind and body that won’t turn off.
It just keeps ringing and warning you of danger. Everyone has a hardwired alarm system
designed for survival. It helps you survive by mobilizing you to deal with threats. To under-
stand how this valuable alarm response gets stuck in the “On” position, we first have to see
how the mechanism works. There are four steps in the alarm response:
1. Perception of threat—the alarm sounds.
2. Appraisal of threat—you assess how serious the danger is and whether you have the
resources to cope.
3. Physiological and emotional responses—you experience a cascade of physical sensations
preparing you to deal with danger, and the emotion of fear.
4. Behavioral response—you do something to feel safer, such as avoiding the threat, post-
poning the threat until later, distracting yourself from the threat, and so on.
Perception of Threat
There are three kinds of threats we are always alert for. The first is external. You’re out in the
woods and notice a bear lumbering in your direction. Or your boss frowns and says she’s con-
cerned about your performance. Or your partner seems withdrawn and disconnected. Whether
the threat is physical injury, loss of your job and livelihood, or a possible rejection, the danger
is that something bad will happen to you via outside forces.
THE CBT ANXIETY SOLUTION WORKBOOK
Internal threats originate with sensations in your own body. Any kind of physical pain is
an example of an internal threat. A surprising, unfamiliar sensation can be threatening, as are
sensations associated with danger, such as rapid heartbeat, shortness of breath, or light-
headedness.
The third type of threat is a conditioned threat, or phobia. This is an object, a situation, or
even an internal experience that’s not very dangerous itself, but has become associated with
the expectation of harm. This process, based on classical conditioning, is how phobias are
formed. Most of us experience very little sense of danger getting in a car. But if your car gets
linked in your mind to a terrible accident you witnessed, or a scary near-collision you experi-
enced, something may change. Your car changes from a neutral, non-frightening stimulus into
a conditioned, threatening stimulus. You now have the same fearful response to driving your
car as you had to the accident or scary near-collision.
When these learned linkages occur, almost anything can become a conditioned stimulus/
threat. You’re probably aware of some of these phobias—heights, tight spaces, freeways, hypo-
dermics, elevators, airplanes, public places, dizzy feelings, bees, feeling hot, darkness, thunder,
rodents, dogs, spiders, and so on.
Appraisal of Threat
Once the alarm has gone off, your mind kicks in, trying to determine how much danger you
face. First, there is an assessment of the level of threat. How big is the bear? Is it moving toward
you? Does it look aggressive? In the case of conditioned threats (phobias) the evaluation of
danger may be near instantaneous, and largely depends on how close you are to the feared
object or situation.
Appraisal of the level of threat can run the gamut from accurate to utterly wrong. Your
evaluations of conditioned threats, because they’re driven by a learned relationship between a
neutral stimulus and grave danger, will usually be distorted. Inaccurate or distorted assess-
ments of danger are called misappraisals, and two components of the treatment program in this
book will help you overcome them.
In addition to appraising the immediate threat, your mind will also try to predict out-
comes. What bad things might happen in five minutes, tomorrow, in a month? This fortune-
telling response to threat is natural. Assessing possible catastrophic outcomes has helped us
survive as a species. But when your mind locks onto threats and won’t let go, when you can’t
stop preparing for all the harmful things that could happen, a normal mental process has gone
awry. Instead of protecting you, this worry/rumination response can drive anxiety to over-
whelming levels. This treatment program includes a component called defusion that will help
you deal with ruminative thoughts.
6
The Alarm Response
The third appraisal in response to threat is an assessment of your ability to cope. Do you
feel strong enough to face it? Do you have the resources to withstand the pain or stress this
threat might bring? The appraisal of your ability to cope, if it is high, leads to self-efficacy—
confidence that you can deal with difficult things. If it is low, you may experience distress
intolerance—a sense that you can be quickly overwhelmed by painful events. Distress intoler-
ance is a major contributor to chronic anxiety, and there are two components of this treat-
ment program that target it.
Here is an outline of the typical threat appraisal process, teased apart and slowed down so
that you can clearly see the three types of appraisals that determine whether your response
will be a decline in anxiety or escalating anxiety and avoidance:
Perception of Threat: The alarm sounds: Danger!
Appraisals:
1. Big Danger?
No—Alarm stops, anxiety/arousal declines.
Yes—Alarm continues: Danger!
2. Catastrophic possibilities?
No—Alarm stops, anxiety/arousal declines.
Yes—Alarm continues: Danger!
3. More than I can cope with?
No—Alarm stops, anxiety/arousal declines.
Yes—Alarm continues: Danger!
Notice that the alarm bell shuts off if your appraisal of the threat or future danger is low.
Likewise, the alarm diminishes or stops if you determine that you have the coping resources
to face the threat. Only if the current or future danger seems high and you lack the ability to
cope does the alarm continue, triggering both anxiety/fear and physiological arousal.
Avoidance behaviors typically occur only after anxiety/fear and arousal have been trig-
gered. The decision to avoid is often automatic and unconscious, unless you have a strong
reason to face the threat (for example, avoidance would trigger dire negative consequences, or
there is something you value about facing this particular fear). You will learn, in this treatment
program, how to consciously and deliberately make the decision to face threats and the anxiety
they trigger.
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THE CBT ANXIETY SOLUTION WORKBOOK
Physiological and Emotional Responses
The physiological response to threat has been labeled the fight-or-f light reaction (Cannon,
1915), and more recently the fight, flight, freeze reaction (Clark, 2011). As soon as you decide
there is a significant threat, your body reacts with a rapid sequence of protective responses.
Your sympathetic nervous system triggers the pituitary gland to produce the stress hormone
ACTH, and your adrenal gland to release the neurotransmitter epinephrine. Ultimately this
results in:
• a boost in blood pressure
• accelerated heart rate
• more rapid breathing
• slowing or stopping of digestion
• constriction of blood vessels in your skin (to minimize bleeding)
• dilation of blood vessels in your big muscles (to help you run or fight)
• dilation of pupils (to see better)
• tunnel vision
• shaking
All of these autonomic reactions prepare you to survive a threat in the best possible way
by (1) running away, (2) fighting and defending yourself, or (3) freezing and playing dead. Your
brain decides which of these to do in just a few seconds.
Meanwhile, as your body reacts, the hypothalamus and the limbic areas of your brain are
beginning an emotional response—fear (a threat is right in front of you) or anxiety (a threat
may occur sometime in the future). The emotion of fear/anxiety creates a painful level of
arousal that makes you want to do something to stop it. While fear is adaptive, motivating you
to avoid danger, false alarms trigger fear-driven avoidance that makes you run from what isn’t
dangerous.
Behavioral Responses
All emotions share a single function—to organize and motivate behavior that helps you
survive. Anger, for example, drives aggressive behavior to protect you from attacks. Sadness
8
The Alarm Response
pushes you to withdraw so you can reevaluate following a loss or failure. And fear urges you to
resist or avoid whatever scares you. So embedded in every emotion is an innate, hardwired
urge to take action that helps to keep us alive.
The urge triggered by fear or anxiety is to seek safety. The most common safety behavior
is avoidance—the flight part of the fight-or-f light reaction. Avoidance can take three forms:
avoiding certain situations, avoiding certain thoughts, or avoiding certain sensations. Or
instead of immediate avoidance, you might try to determine whether you are safe by checking
for danger or seeking reassurance to ascertain whether the threat is as dangerous as you feared.
If a threat is unavoidable, you might perform certain mental or physical rituals like invoking
divine help or hand washing to feel safer. Safety behaviors can take many forms.
• Example: Sheila’s Alarm Response
Several hours after getting home from a baseball game where Sheila ate two ballpark
franks, she started to have sharp stomach pain. The threat led to an immediate
appraisal of the level of danger.
Sheila’s mother had died of cancer several years before, and had endured a great
deal of pain. As a result, Sheila had begun to recognize physical pain as something
dangerous, something alarming. What would turn out to be a bad hot dog was
misappraised as highly dangerous and perhaps life threatening.
Sheila began trying to predict the future. Perhaps this was cancer, and she’d need
surgery and chemotherapy. Like her mother, she might not survive. How would she
provide for her two teenage boys, given that her ex-husband was a lunatic and would
damage her sons if he got his hands on them? How would she keep a roof over her
head if she couldn’t work anymore? Sheila worried, or ruminated, about cancer until
she threw up. Because she’d had a number of stomach upsets lately, she started
thinking that maybe she also had irritable bowel disease.
As she struggled with the weight of catastrophic possibilities, Sheila wondered how
she would cope. Her mother had “given up” at the end, and maybe she would, too.
Sheila suspected that the stress would be overwhelming and that she couldn’t cope.
The misappraisal, worry/rumination, and distress intolerance were taking a toll.
Sheila could feel her heart beginning to race. Her face and chest felt hot. She was
light-headed. When she stood up, her legs felt shaky and weak. Now the alarm
response began merging with growing anxiety. Both her body and her emotions were
screaming “Danger!” Sheila noticed all this and thought, I’m in real trouble.
Half an hour later Sheila indulged in a common safety behavior—seeking
reassurance. She went online to read about stomach and colon cancer as well as
