Davi D a. Clark
aaron T. BeCk
Preface
The 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
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
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.
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aaron T. BeCk
Preface
The 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
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
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.
http://adf.ly/N7b7M
or
http://adf.ly/N7bGr