Cognitive Therapy of Anxiety Disorders: Science and Practice

641 Pages·2009·4.54 MB·English

by  David A. Clark Phd

Cognitive therapy
of anxiety DisorDers

Cognitive Therapy
of Anxiety Disorders
Science and Practice
D a. C
aviD lark
a T. B
aron eCk
THE GUILFORD PRESS
New York London
© 2010 The Guilford Press
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Last digit is print number: 9 8 7 6 5 4 3 2 1
These materials are intended for use only by qualified mental health professionals.
The Publisher grants to individual purchasers of this book nonassignable permission
to reproduce all materials for which photocopying permission is specifically granted
in a footnote. This license is limited to you, the individual purchaser, for personal
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Library of Congress Cataloging-in-Publication Data
Clark, David A., 1954-
Cognitive therapy of anxiety disorders: science and practice / David A. Clark
and Aaron T. Beck.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60623-434-1 (hardcover: alk. paper)
1. Anxiety disorders—Treatment. 2. Cognitive therapy. I. Beck, Aaron T. II. Title.
[DNLM: 1. Anxiety Disorders—therapy. 2. Cognitive Therapy—methods.
WM 172 C592c 2010]
RC531.C535 2010
616.85′22—dc22
2009027597
To my wife, Nancy, and our daughters,
Natascha and Christina, with sincere love
for your steadfast interest, support, and understanding
D. A. C.
To my wife, Phyllis,
our children, Roy, Judy, Daniel, and Alice,
and our grandchildren,
Jodi, Sarah, Andy, Debbie, Eric, Ben, Sam, and Becky,
with love
A. T. B.
About the Authors
David A. Clark, PhD, is Professor of Psychology at the University of New Brunswick,
Canada. He has published seven books, including Intrusive Thoughts in Clinical Disor-
ders: Theory, Research, and Treatment; Cognitive- Behavioral Therapy for OCD; and
Scientific Foundations of Cognitive Theory and Therapy of Depression, as well as over
100 articles and chapters on various aspects of cognitive theory and therapy of depres-
sion and anxiety disorders. Dr. Clark is a Fellow of the Canadian Psychological Asso-
ciation, a Founding Fellow of the Academy of Cognitive Therapy, and a recipient of the
Academy’s Aaron T. Beck Award for significant and enduring contributions to cognitive
therapy. He is an Associate Editor of the International Journal of Cognitive Therapy
and maintains a private practice.
Aaron T. Beck, MD, is University Professor Emeritus of Psychiatry, School of Medicine,
University of Pennsylvania, and the founder of cognitive therapy. He has published 21
books and over 540 articles in professional and scientific journals. Dr. Beck is the recipi-
ent of numerous awards, including the Albert Lasker Clinical Medical Research Award
in 2006, the American Psychological Association Lifetime Achievement Award in 2007,
the American Psychiatric Association Distinguished Service Award in 2008, and the
Robert J. and Claire Pasarow Foundation Award for Research in Neuropsychiatry in
2008. He is President of The Beck Institute for Cognitive Therapy and Research and
Honorary President of the Academy of Cognitive Therapy.
vi
Preface
T
he intricacies of anxiety have continued to capture the attention of some of the world’s
greatest scientists, scholars, and critical thinkers. In 1953 Rollo May stated in Man’s
Search for Himself that the “middle of the twentieth century is more anxiety- ridden
than any period since the breakdown of the Middle Ages” (p. 30). If this statement char-
acterized the last century, is it not even more applicable to the dawn of the 21st century
with all the social, political, and economic threats that besiege us? Despite an end to
the cold war, an era of relative global stability and cooperation, and an unprecedented
rise in economic prosperity and technological advances, many in the Western world live
in a state of perpetual threat and uncertainty. According to the National Institute of
Mental Health (2003) approximately 40 million American adults (18%) suffer from an
anxiety disorder, with serious mental illness, including the anxiety disorders, costing
an estimated $193 billion in lost personal earnings (Kessler et al., 2008). No wonder
the search for highly effective and accessible treatments for the anxiety disorders has
become a major health initiative for most developed countries.
Twenty-five years ago, coauthor Aaron T. Beck published Anxiety Disorders and
Phobias: A Cognitive Perspective with Gary Emery and Ruth Greenberg. In the first
part of that book, Beck introduced a cognitive model of anxiety disorders and phobias
that represented a significant reconceptualization of the etiology, nature, and treatment
of anxiety (Beck, Emery, & Greenberg, 1985). At that time, research on the cognitive
features of anxiety was scant, and so much of the theoretical scaffolding was, by neces-
sity, based on clinical observation and experience. Since key aspects of the cognitive
model of anxiety had not yet been investigated, some of the treatment recommendations
described in the second half of the book have not stood the test of time. However, the
last 20 years has witnessed a virtual explosion in basic information- processing research
on the cognitive model of anxiety, the development of disorder- specific cognitive mod-
els and treatment protocols for the major anxiety disorders, and dozens of treatment
outcome studies demonstrating the efficacy of cognitive therapy of anxiety. In light of
the unprecedented advances in our understanding and treatment of the cognitive basis
of anxiety, a comprehensive, updated, and reformulated presentation of the cognitive
vii
viii Preface
model of anxiety was needed so the model could be understood within the context of
contemporary research findings. This book, then, was born out of this necessity. In
addition, we believe that a single volume containing a detailed comprehensive treatment
handbook for cognitive therapy is timely in order to encourage greater use by clinicians
of evidence-based psychotherapy for the anxiety disorders.
The book is divided into three parts. Part I consists of four chapters on the refor-
mulated cognitive model of anxiety and its empirical status. Chapter 1 discusses the dis-
tinctions between fear and anxiety and provides a rationale for taking a cognitive per-
spective on anxiety. Chapter 2 presents a reformulation of the generic cognitive model
of anxiety based on the original model (Beck et al., 1985) that was later refined by Beck
and Clark (1997). Twelve key hypotheses of the model are presented in Chapter 2, and
the vast empirical research relevant to these hypotheses is critically reviewed in Chap-
ters 3 and 4. The literature review spans hundreds of studies conducted in key research
centers in Western Europe and North America, confirming our perception that the main
tenets of the cognitive model of anxiety have achieved a broad basis of empirical sup-
port.
The cognitive therapy approach has been applied to a wide range of psychiatric
and personality conditions. Thus, Part II consists of three chapters that explain how
the basic elements of cognitive therapy are used to alleviate anxiety. Chapter 5 reviews
several standardized measures of anxious symptoms and cognition that are useful for
assessment and treatment evaluation and provides a detailed explanation for produc-
ing a cognitive case formulation of anxiety. Chapters 6 and 7 present a step-by-step
description for implementing various cognitive and behavioral intervention strategies
for reduction of anxious symptoms. Case illustrations, suggested therapy narratives,
and clinical resource materials are provided in all three chapters as training tools in
cognitive therapy.
The final section, Part III, consists of five chapters that present disorder- specific
adaptations of cognitive therapy for panic disorder, social phobia, generalized anxiety
disorder, obsessive– compulsive disorder, and posttraumatic stress disorder. We excluded
specific phobias because there have been fewer developments on the cognitive aspects
of phobia since its presentation in Beck et al. (1985), and exposure-based treatment is
still considered the main treatment approach for reduction of phobic responses. Each of
the disorder- specific chapters presents a cognitive model tailored to that disorder and a
review of the empirical research that addresses key hypotheses of each model. In addi-
tion, the chapters offer disorder- specific case conceptualizations and cognitive therapy
strategies that target unique symptom features of each disorder. In essence, Part III
consists of five minitreatment manuals for complex anxiety disorders.
To assist therapists in explaining cognitive concepts and strategies to their clients,
we are in the process of developing a companion client workbook that will match the
organization and themes of the present book and will offer explanations for key aspects
of the therapy, homework exercises, and record-keeping forms.
We are indebted to a large contingent of renowned experts in the anxiety disorders
whose theoretical contributions, innovative and rigorous research, and clinically astute
treatment insights are responsible for the significant advances that we have presented in
this volume. In particular we acknowledge the notable contributions to cognitive the-
ory and therapy of anxiety of Drs. Martin Antony, Jonathan Abramowitz, David Bar-
low, Thomas Borkovec, Brendan Bradley, Michelle Craske, David M. Clark, Meredith
Preface ix
Coles, Michel Dugas, Edna Foa, Mark Freeston, Randy Frost, Richard Heimberg,
Stefan Hofmann, Robert Leahy, Colin MacLeod, Andrew Mathews, Richard McNally,
Karen Mogg, Christine Purdon, Stanley Rachman, Ronald Rapee, John Riskind, Paul
Salkovskis, Norman Schmidt, Robert Steer, Gail Steketee, Steven Taylor, and Adrian
Wells. Furthermore, we wish to acknowledge with gratitude the tenacity and meticu-
lousness of Michelle Valley, who laboriously revised and validated all the references,
and to past and current graduate students, Mujgan Altin, Anna Campbell, Gemma
Garcia-Soriano, Brendan Guyitt, Nicola McHale, Adriana del Palacio Gonzalez, and
Adrienne Wang for their research and thoughtful discussions on cognitive aspects of
anxiety. We also appreciate the partial financial support for publication costs from the
University of New Brunswick Busteed Publication Fund. Finally we are grateful for the
encouragement, guidance, advice, and support of the staff at The Guilford Press, espe-
cially Jim Nageotte, Senior Editor, and Jane Keislar, Assistant Editor.