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 ANXIETY
Third edition

Anxiety is a complex phenomenon and a central feature of many psychological prob-

lems. This thoroughly revised third edition of Anxiety has been updated to include
astonishing developments in the clinical implementation of knowledge about anxiety.
In particular, this edition updates the reader with:

• a new chapter on health anxiety;

• a fully updated chapter on obsessive-compulsive disorders, including the concept of
mental contamination and the causes of obsessions;
• an account of advances in therapeutic techniques.

Unique in its combination of an introduction to the subject with comprehensive coverage

of the latest developments in research and practice, this book provides an excellent
breadth and depth of coverage, which all practising and trainee clinical psychologists
will find extremely informative.

Stanley Rachman is a clinical researcher, specializing in psychopathology and psy-

chological therapy. He is currently Professor Emeritus at the Institute of Psychiatry,
King’s College London and the University of British Columbia, Vancouver. His other
publications include The Treatment of Obsessions, Fear of Contamination, Panic Disorder
(with Padmal de Silva), and Obsessive–Compulsive Disorder (with Padmal de Silva).
This page intentionally left blank
Anxiety
Third Edition

Stanley Rachman
Third edition published 2013
by Psychology Press
27 Church Road, Hove, East Sussex BN3 2FA
Simultaneously published in the USA and Canada
by Psychology Press
711 Third Avenue, New York, NY 10017
Psychology Press is an imprint of the Taylor & Francis Group, an informa business
© 2013 Stanley Rachman
The right of Stanley Rachman to be identified as author of this
work has been asserted by him in accordance with sections 77
and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilized in any form or by any electronic,
mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any
information storage or retrieval system, without permission
in writing from the publishers.
Trademark notice: Product or corporate names may be
trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.
First edition published by Psychology Press 1998
Second edition published by Psychology Press 2004
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Rachman, Stanley.
Anxiety / Stanley Rachman. – 3rd Edition.
pages cm
1. Anxiety. 2. Anxiety disorders. I. Title.
RC531.R334 2013
616.85'22–dc23
2012042676

ISBN: 978–0–415–69707–1 (hbk)

ISBN: 978–0–415–69708–8 (pbk)
ISBN: 978–0–203–55449–4 (ebk)

Typeset in Palatino
by Keystroke, Station Road, Codsall, Wolverhampton
 Contents

Series preface vii

Introduction to the third edition ix
Introduction to the second edition xi

1 The nature of anxiety 1

2 Fear, anxiety and avoidance 13
3 Influences on anxiety 29
4 Anxiety, attention, perception, memory and emotional
processing 41
5 Theories of anxiety 61
6 Specific phobias and the conditioning theory of fear 77
7 Panic and anxiety 93
8 Agoraphobia 121
9 Obsessions and compulsions 127
10 Health anxiety disorders 149
11 Social anxiety 171
12 Generalized anxiety disorder 183
13 Post-traumatic stress disorder (PTSD) 191

Some concluding remarks 205

Suggested reading 207
References 209
Index 231

v
This page intentionally left blank
 Series preface

Clinical Psychology: A Modular Course was designed to overcome the

problems faced by the traditional textbook in conveying what psycho-
logical disorders are really like. All the books in the series, written by
leading scholars and practitioners in the field, can be read as stand-
alone texts, but they will also integrate with the other modules to form
a comprehensive resource in clinical psychology. Students of psychol-
ogy, medicine, nursing and social work, as well as busy practitioners in
many professions, often need an accessible but thorough introduction
to how people experience anxiety, depression, addiction or other
disorders, how common they are, and who is most likely to suffer
from them, as well as up-to-date research evidence on the causes and
available treatments. The series will appeal to those who want to go
deeper into the subject than the traditional textbook will allow, and
base their examination answers, research, projects, assignments or
practical decisions on a clearer and more rounded appreciation of the
clinical and research evidence.
Chris R. Brewin

Other titles in this series:

Depression, Second Edition

Constance Hammen and Edward Watkins

Stress and Trauma

Patricia A. Resick

Childhood Disorders, Second Edition

Philip C. Kendall and Jonathan S. Comer

vii
 Schizophrenia
Max Birchwood and Chris Jackson

Eating and Weight Disorders

Carlos M. Grilo

Personality Disorders
Paul M. G. Emmelkamp and Jan Henk Kamphuis

Addictions, Second Edition

Maree Teesson, Wayne Hall, Heather Proudfoot and Louisa Degenhardt

viii S E R I E S P R E F A C E
 Introduction to
the third edition

A number of important developments in the study of anxiety have

taken place since the early 2000s, and the findings are being incorpo-
rated into clinical practice. The most remarkable – indeed astonishing
– application of the new knowledge and techniques was undertaken
by the UK government in 2007. Recognizing that the provision of
psychological treatment in the National Health Service (NHS) was
insufficient and unsatisfactory, with long waiting lists and poor
standards, it was decided to adopt the National Institute for Health
and Clinical Excellence (NICE) guidelines for treating anxiety dis-
orders and depression. The treatment recommended for anxiety dis-
orders is cognitive behaviour therapy (CBT), but there was a serious
shortage of trained therapists and therefore an extraordinarily ambiti-
ous training scheme was introduced in 2007. The aim was to reduce the
waiting times for a psychological assessment and possible treatment of
anxiety and depression from six months to two weeks, and improve
the quality of therapy by using the evidence-based treatments recom-
mended by NICE.
A large sum of money was set aside for training 8,000 new
therapists, starting with 3,000 in the first three years. An interim report
on the progress of the programme, Improving Access to Psychological
Therapies (IAPT), was published by a major contributor, Professor
David M. Clark, in 2012. Over 3,600 therapists had been trained by the
midpoint of the programme and ‘more than 300,000 patients are being
treated annually . . . clinical and employment related outcomes are
generally in line with expectation’ (Clark 2012).
On the research side, useful progress has been made in enhancing
our understanding of anxiety disorders, notably post-traumatic stress
disorder (PTSD), social phobia, obsessive compulsive disorders and

ix
 health anxiety. Accordingly, a new chapter (10), on health anxiety
disorders, has been added and Chapter 9 on obsessive-compulsive
disorders has been expanded. Interest in a number of topics included
in the earlier editions has faded and hence they were truncated or
deleted.
Improvements in therapeutic techniques have been deduced from
the prevailing cognitive theories of these disorders, numbers of
controlled treatment trials have been completed and others are under
way. Increased attention is being paid to the dissemination of the new
findings and techniques, and there are many attempts to refine and
shorten the amount of time and effort needed to carry out the treat-
ment procedures.
The improvements in developing and testing refined treatment
techniques and the efforts put into improving dissemination are
welcome, but it is hoped that the need for basic research will not be
neglected by the current emphasis on clinical applications.
S. Rachman
Vancouver, 2013

x INTRODUCTION TO THE THIRD EDITION

 Introduction to
the second edition

Advances in the understanding and treatment of anxiety disorders

have made it necessary to revise and expand this book. During the past
ten years, several new theories of psychopathology have been pub-
lished and eight of them deal with the anxiety disorders. Some of them
are causal theories – unusual in clinical psychology – and all of them
incorporate cognitive concepts. The theories are increasingly specific
and most provide platforms for the derivation of specific methods of
treatment. The evaluation of theories and treatments is an unavoidably
lengthy and demanding process, but several provisional conclusions
are permissible.
The basic science deals with the psychology of anxiety, but the
current emphasis on applied science, on the nature and treatment of
disorders of anxiety, overshadows the basic research. The preoccupa-
tion with anxiety disorders, and the pressure to master these dis-
tressing problems, are understandable, but have tilted the balance from
basic to applied research. However, the interplay between basic and
applied research is a two-way process that benefits both. Advances in
understanding the phenomena and mechanisms of anxiety disorders
help to illuminate fundamental psychological processes. The expan-
sion of understanding of the emotion of fear was largely the result of
clinical research. An excellent example of the interplay is now taking
place in current analyses of the intriguing disturbances of memory that
are so conspicuous in post-traumatic stress disorder (PTSD). Intensive
studies of the clinical phenomena have expanded our conceptions of
memory processes.
S. Rachman
Vancouver, 2003
This page intentionally left blank
 The nature of anxiety 1
The nature of anxiety is defined and illustrated by case examples. The
similarities and differences between anxiety and fear are described.
The main types of fear are set out and the concept of anxiety disorders
is elucidated.
Since the mid-1960s, research on anxiety has accelerated and the
publication of books and journal articles on the subject continues to
increase. Specialized clinics for dealing with anxiety disorders have
been introduced and self-help groups established in many parts of the
world. In England, a momentous expansion of psychotherapy services
for people suffering from anxiety disorders was introduced in 2007.
All of this growth is justified because anxiety is one of the most
troubling and pervasive emotions, and large numbers of people are
distressed by inappropriate or excessive anxiety. In part, the steep
increase in interest was prompted by the decision of the American
Psychiatric Association (APA) committee responsible for preparing a
new diagnostic system in the Diagnostic and Statistical Manual of Mental
Disorders (DSM) to create a separate category for anxiety disorders, and
to introduce clear definitions and criteria for diagnosing these
disorders (Barlow 2002; Norton et al. 1995). The definitions and criteria
are open to some criticism, and hence the manual is revised regularly,
but it is disarming that the total number of ‘mental disorders’ increases
with each revision. The DSM is not an exclusively scientific and
research enterprise, and is used for insurance purposes as well. For
example, in the United States, it is not easy to obtain insurance cover
for the treatment of psychological problems that are not included in the
manual and/or do not have a DSM coding number.
The introduction of the DSM classification system was a major
advance on the chaos that prevailed prior to 1980, but the scheme has

1
 shortcomings. It encourages the unfortunate idea that all problems
with anxiety are pathological, are indeed mental disorders. The full title
of the DSM scheme is The Diagnostic and Statistical Manual of Mental
Disorders.
This book is a description and psychological analysis of the phe-
nomena of anxiety. The therapeutic implications of current knowledge
and theorizing are analysed because anxiety is a central feature of
many psychological problems, including those that were formerly
called ‘neuroses’.
Anxiety disorders are distressing, often disabling and costly. Large-
scale surveys carried out in the United States in recent years led to the
conclusion that ‘anxiety disorders represent the single largest mental
health problem in the country’ (Barlow 2002: 22). If they are left
untreated, anxiety disorders can become chronic. Affected people
require and use many specialized services, and affected men are four
times as likely as non-sufferers to be chronically unemployed (Leon et
al. 1995). The rates of alcoholism and drug abuse are elevated among
sufferers.
The study of anxiety was invigorated by the infusion of cognitive
concepts and analyses. One of the earliest and most influential contri-
butions was made by A. T. Beck (Beck 1976, 2005; Beck and Emery
1985), whose writings on depression in the 1970s were timely and very
important. Paradoxically, the extension of cognitive ideas into the
study of anxiety and its disorders has been even more successful and
more quickly successful than the original work on depression. The
introduction of the cognitive theory of panic by Clark (1986) and the
cognitive analysis of obsessive-compulsive disorders by Salkovskis
(1985) spawned a profusion of new ideas and applications. Virtually all
contemporary psychological discussions of anxiety incorporate the
cognitive view.
Anxiety is an intriguing and complex phenomenon that lends itself
to cognitive analyses because it involves the interplay of vigilance,
attention, perception, reasoning and memory – the very meat of
cognitive processing. Moreover, many of these operations take place at
a non-conscious level.
Psychologists have an excellent reason for pursuing their interest
in anxiety because it turns out that they are ‘good at it’, and have
developed demonstrably effective techniques for reducing unadaptive,
distressing anxiety. It is one of the major achievements of modern
clinical psychology.
Advances in understanding anxiety have led to important changes
in the larger subject of psychopathology, and have given rise to the

2 ANXIETY
development of effective methods of treatment. In all of this, the
mighty debate about the relative importance of biological and psy-
chological influences on anxiety rumbles on.

Defining anxiety
Anxiety is a tense unsettling anticipation of a threatening but form-
less event; a feeling of uneasy suspense. It is a negative affect (feeling)
so closely related to fear that in many circumstances the two terms
are used interchangeably. Fear also is a combination of tension and
unpleasant anticipation, but distinctions can be made between the
causes, duration and maintenance of fear and of anxiety. Strictly, the
term fear is used to describe an emotional reaction to a perceived
danger, to a threat that is identifiable, such as a poisonous snake. Most
fear reactions are intense and have the quality of an emergency. The
person’s level of arousal is sharply elevated. However, feelings of
anxiety persist for lengthy periods and can nag away ‘at the back of
one’s mind’ for days, weeks or months.
Fear has a specific focus. Typically, it is episodic and recedes or
ceases when the danger is removed from the person, or the person
from the danger. In this sense, fear is determined by perceivable events
or stimuli. The perceived source of the danger may be accurately or
inaccurately identified; or correctly identified, but wrongly evaluated.
The fear may be rational or irrational. Intense but irrational fears are
termed phobias, as in claustrophobia (intense fear of enclosed spaces),
snake phobia, and so on.
When feeling anxious, the person has difficulty in identifying the
cause of the uneasy tension or the nature of the anticipated event or
disaster. The emotion can be puzzling for the person experiencing it. In
its purest form, anxiety is diffuse, objectless, unpleasant and persistent.
Unlike fear, it is not so obviously determined. Usually it is unpredict-
able and uncontrollable. The rise and decline of fear tends to be limited
in time and in space, whereas anxiety tends to be pervasive and per-
sistent, with uncertain points of onset and offset. It seems to be present,
as if in the background, almost all of the time. ‘I constantly feel as if
something dreadful is going to happen.’ Anxiety is a state of height-
ened vigilance rather than an emergency reaction. Fear and anxiety are
marked by elevated arousal – subjective and/or physiological arousal.
Fear is more likely to be intense and brief; it is provoked by triggers
and is circumscribed. Anxiety tends to be shapeless, grating along at a

T H E N AT U R E O F A N X I E T Y 3
 lower level of intensity; its onset and offset are difficult to time, and it
lacks clear borders. Anxiety is not a lesser and pale form of fear; and
in many instances, it is more difficult to tolerate than fear. It is
unpleasant, unsettling, persistent, pervasive and draining. Intense and
prolonged anxiety can be disabling and even destructive.
It is illustrated by these two examples of people suffering from
anxiety, and one of a person suffering from a phobia. Anne complained
of being tense, edgy and apprehensive. She awoke each morning with
a feeling that something awful but elusive was about to happen. This
feeling of dread usually persisted into the late morning, accompanied
by uncomfortable bodily sensations such as tremors, nausea, fast pulse
and shallow breathing. It was unsettling and tiring. In the first weeks
of her experience of this anxiety, she spent a lot of time and energy
trying to understand why she was feeling so poorly, struggling to
identify what was troubling her. The elusive and puzzling quality of
her dread was an added source of discomfort.
Anne made a clear distinction between this daily anxiety and the
fear she had experienced when encountering a snake in the country-
side. Her reaction to the snake was sharp, intense and focused, but
quickly subsided when the snake scurried away into the undergrowth.
She experienced strong bodily sensations, especially a rapidly racing
heart, but recognized the threat and felt no puzzlement.
Brian worried incessantly about his health, constantly scanning his
body for external or internal signs of trouble, and frequently sought
medical advice. He dreaded the possibility of illness or injury, and
often felt that ‘something’ was seriously wrong. Brian was careful to
avoid sources of real or imagined infection, restricted his diet, and
lifted or carried objects with deliberate care. He recognized that he had
an excellent health record, and was all the more puzzled by this intru-
sive and disturbing anxiety about his well-being. Brian was unable
to dampen or stifle the continuing feelings of dread. He described
episodes of fear, such as his intense but circumscribed and brief
reactions to near-accidents on the road, and made a clear distinction
between these fearful events and his pervasive anxiety about his
health.
A young horticulturalist sought help because her intense, circum-
scribed fear of spiders was interfering with her work. She was so
frightened of encountering spiders that she was unable to work alone
in the gardens. The fear was so intense and disabling that it qualified
for the term phobia. She had no other fears, anxiety or psychological
problems. The fear had a specific identifiable focus and was episodi-
cally evoked by contact with the threatening stimulus.

4 ANXIETY
 It is easier to distinguish between fear and anxiety in theory than in
practice. Distinctions between fear and anxiety based on the focus of
threat can be blurred in clinical conditions. For example, episodes of
acute fear, such as panic, tend to be followed by a mixture of the fear
and prolonged anxiety. Episodes of panic leave a residue of anxiety.
There is no distinct transition from fear to anxiety, and at times it is not
possible to distinguish between the two. Although panic is one of the
purest expressions of fear, the triggers of episodes of panic are not
always immediately discernible. The relationships between fear and
anxiety can be complex. Anxiety often follows fear (as in the anxiety
that one might panic again and lose control), but repeated experiences
of anxiety can in turn generate fears.
Clinicians and patients devote considerable time and effort to
unravelling the cause or causes of the person’s anxiety, precisely
because of the uncertainty or indeterminacy of the sources of the

TABLE 1.1
Similarities between fear and anxiety

• Elevated arousal
• Negative affect
• Accompanied by bodily sensations
• Tense apprehensiveness
• Uneasiness

TABLE 1.2
Differences between fear and anxiety

Fear Anxiety

• Specific focus of threat • Source of threat is elusive

• Understandable connection • Uncertain connection between
between threat and fear anxiety and threat
• Usually episodic • Pervasive uneasiness
• Persistent • Can be objectless
• Circumscribed tension • Cues for anxiety can be elusive
• Identifiable threat • Persistent
• Provoked by threat cues • Uncertain offset
• Declines with removal of threat • Without clear borders
• Offset is clear • Threat seldom imminent
• Circumscribed focus of threat • Tension, but no sense of emergency
• Imminent threat • Bodily sensations of vigilance
• Quality of an emergency • Puzzling qualities
• Bodily sensations of an emergency
• Rational quality

T H E N AT U R E O F A N X I E T Y 5
 threat. It is assumed by both patient and therapist that there are
identifiable causes of anxiety to be found and that these causes are
likely to be of considerable significance. Insofar as they are successful
in identifying the cause of the patient’s apprehensiveness, the defini-
tion should change from anxiety to fear, from an unknown source to a
focused trigger.
Matters are complicated by the fact that fear/anxiety can be caused
by external cues of danger or by internal threats, which tend to be
particularly elusive. Furthermore, qualifiers are often introduced when
describing different types of anxiety, such as generalized anxiety,
unconscious anxiety, free-floating anxiety, and so forth. Earlier hopes
that fear and anxiety could be teased apart by physiological analyses
of the two states have not been fulfilled, and even the types of
behaviour associated with fear and with anxiety (especially avoidance)
are not easily distinguishable. Fear and anxiety are both accompanied
by bodily sensations, notably muscle tightness, pounding heart, and so
forth, but there are some differences in the sensations and subjective
discomfort experienced in the two states. The bodily sensations most
frequently reported in dangerously frightening military contexts are
pounding heart, sweating, a dry mouth and trembling; and the
sensations frequently reported by patients with anxiety disorders are
dizziness, chest pain and faintness (McMillan and Rachman 1988).
The differences between fear and anxiety are most evident in
extreme cases. Sharp and brief fearful reactions to a poisonous snake
are different from the pervasive and persistent uneasiness experienced
as a result of a disturbed personal relationship. Leaving aside extreme
illustrations, however, fear and anxiety often blend in everyday
language as in clinical practice. For example, the terms social anxiety
and social phobia are used interchangeably to refer to the same psy-
chological problem – intense discomfort when under social scrutiny,
and the subsequent avoidance of social gatherings. The term anxiety is
also used to describe problems such as public speaking anxiety, and
sexual anxiety, even though the focus of the concern is identifiable. The
use of the terms fear and anxiety is not always consistent with the
definitional distinction made between fear, which has a specific focus;
and anxiety, in which there is no such focus.
A number of common assumptions made about the distinctions
between fear and anxiety repay consideration. Although psycho-
analytic and academic writers differ on almost all important aspects of
emotion, many of them share the view that useful distinctions can be
made between fear and anxiety. An assumption common to many
different points of view, but not necessarily correct, is the idea that

6 ANXIETY
anxiety is potentially reducible to fear. If the cause of the anxiety is
potentially knowable and the focus is identifiable, then by diligent
work, therapeutic or not, it should be possible to convert puzzling
anxiety into clear-cut fear. Associated with this assumption, and
sometimes contingent on it, is the idea that fear is more manageable
than anxiety. Hence it is often assumed that reducing a state of anxiety
to a state of fear is a progressive step. Also associated with the idea that
anxiety is theoretically reducible to fear is the notion that anxiety is not-
fear simply by reason of default; that is, we have anxiety when the
focus of fear is elusive.
There is no universally accepted definition of ‘anxiety’ (Barlow
2002) and some dissatisfaction with the way in which the term is used.
In addition to the several meanings of anxiety in technical language,
the word also has several meanings in common language, ranging
from dread to endeavour or eagerness. For example, ‘I am anxious to
go to the new production of the opera.’
At least two of the commonly recognized features of fear/anxiety,
a state of elevated arousal and negative affect, require comment. In
most circumstances, these features are indisputably part of a fear
reaction, but fear can also have a positive and desirable quality in
exceptional instances. People even seek it out, try to provoke it, as they
do in dangerous sports, riding on roller coasters, attending frightening
movies, and other curious diversions. These exceptions should be
noted, but need not obscure the major and common features of fear.
Elevated arousal is one such common feature, but some findings
suggest that although elevated arousal is typical of fear, it is less
evident in anxiety (Brewin 1996; Rapee 1996).
There is a long-standing debate about the precise meaning of the
term angst, a concept of particular importance in psychoanalysis. This
German term is often taken to mean anxiety, but Lewis (1980) argued
that this can be misleading. The disagreement about this term among
German writers has been compounded by problems of translation, and
in the English literature the term anxiety cannot be taken to mean
angst.
The term anxiety itself appears to have been derived from the Greek
root angh, which means tightness or constriction. Related words such
as anguish and anger come from the same root, but are rarely confused
with anxiety, even though they are often used to describe related
psychological states or reactions (see Barlow [2002] for a full discussion
of these terms).
In order to avoid confusion, for the remainder of this book, the
terms used by the original writers, clinicians and research workers will

T H E N AT U R E O F A N X I E T Y 7
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