Why We Worry Understanding and Treating and Related Disorders

Presented by

Martin M. Antony, PhD, ABPP Department of Psychology, Ryerson University Website: www.martinantony.com E-mail: [email protected]

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Disclosure Statement: Dr. Antony is the author of several leading books on the topic of anxiety and related problems. In this program, Dr. Antony will recommend a number of books related to anxiety disorders, including some of his own.

COURSE OBJECTIVES Participants completing this program should be able to: 1. List the key features of panic disorder, phobias, , obsessive-compulsive disorders, generalized anxiety, and posttraumatic stress. 2. Describe evidence-based psychological and pharmacological treatments for anxiety and related disorders.

©2014 Martin M. Antony, PhD Professor and Chair, Department of Psychology, Ryerson University, Toronto Director of Research, Anxiety Treatment and Research Center, St. Joseph’s Healthcare, Hamilton

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Outline

. Overview of Anxiety-Based Disorders . Causes of Anxiety-Based Disorders OVERVIEW OF . Medications for Anxiety–Based Disorders . Cognitive-Behavioral Therapy ANXIETY-RELATED . Cognitive Strategies . Exposure-Based Strategies DISORDERS . Acceptance and Mindfulness-Based Treatments . Other Strategies

Recommended Readings Anxiety-Related Disorders

. Antony, M.M., & Norton, P.J. (2009). The . Anxiety Disorders anti-anxiety workbook: Proven strategies . Obsessive-Compulsive and Related to overcome worry, panic, phobias, and Disorders obsessions. New York: Guilford Press. . Trauma- and Stressor-Related Disorders . Antony, M.M., & Stein, M.B. (Eds.) . Somatic Symptom and Related Disorders (2009). Oxford handbook of anxiety and related disorders. New York, NY: Oxford University Press.

2 DSM-5 Anxiety Disorders Definition of . Panic Disorder . Agoraphobia . Period of intense fear or discomfort . Specific Phobia . Peaks within 10 minutes . Social (Social Phobia) . 4 out of 13 symptoms: . Generalized Anxiety Disorder (1) racing or pounding heart, (2) sweating, (3) . Separation Anxiety Disorder trembling or shaking, (4) shortness of breath, (5) . Selective Mutism choking feeling, (6) chest pain or discomfort, (7) . Substance/Medication Induced Anxiety Disorder nausea or abdominal distress, (8) dizzy, unsteady . Anxiety Disorder Due to Another Medical Disorder or faint, (9) feeling unreal or detached, (10) numbness or tingling sensations, (11) chills or hot . Other Specified Anxiety Disorder flushes, (12) fear of dying, (13) fear of going crazy . Unspecified Anxiety Disorder or losing control

DSM-5 Anxiety Disorders DSM-5 Agoraphobia Situations

Panic Disorder Fear or avoidance of 2 or more of the following: . Recurrent unexpected panic attacks, associated with (1) . Using public transportation (e.g., cars, buses, worry about having more attacks or about their trains, ships, planes) consequences, or (2) maladaptive changes in behavior related to the attacks . Being in open spaces (e.g., parking lots, market places, bridges) Agoraphobia . Being in enclosed places (e.g., shops, theaters, . Excessive fear of situations from two of the following cinemas) clusters: (1) public transportation, (2) open spaces, (3) . Standing in line or being in a crowd enclosed places, (4) standing in lines or crowds, (5) . Being outside of the home alone Being outside of the home alone . Fear is related to concern about experiencing panic-like symptoms or other incapacitating symptoms

Recommended Readings DSM-5 Anxiety Disorders . Taylor, S. (2000). Understanding and treating panic disorder: Cognitive and behavioral Specific Phobia approaches. Chichester, UK: Wiley. . Fear and avoidance of specific objects or situations (e.g., animals, heights, blood/needles, driving, enclosed . Antony, M.M., & McCabe, R.E. (2004). 10 simple places), associated with significant distress/impairment solutions to panic: How to overcome panic . Typically lasting 6 months or longer attacks, calm physical symptoms, and reclaim your life. Oakland, CA: New Harbinger Publications. . Barlow, D.H., & Craske, M.G. (2007). Mastery of your anxiety and panic, 4th ed. workbook). New York, NY: Oxford University Press.

3 Recommended Readings Recommended Readings Free download at http://www.martinantony.com/downloads.

.Antony, M.M., & McCabe, R.E. (2005). Overcoming animal . Antony, M.M., Craske, M.G., & Barlow, D.H. (2006). and insect phobias: How to conquer fear of dogs, snakes, Mastering your Fears and Phobias (client rodents, bees, spiders, and more. Oakland, CA: New workbook), second edition. New York, NY: Oxford Harbinger. University Press. .Antony, M.M., & Rowa, K. (2007). Overcoming fear of . Craske, M.G., Antony, M.M., & Barlow, D.H. (2006). heights: How to conquer acrophobia and live a life without limits. Oakland, CA: New Harbinger. Mastering your Fears and Phobias (therapist guide), second edition. New York, NY: Oxford University .Antony, M.M., & Watling, M. (2006). Overcoming medical phobias: How to conquer fear of blood, needles, doctors, and Press. dentists. Oakland, CA: New Harbinger. . Davis, T.E. Ollendick, T.H., & Öst, L.-G. (Eds.) (2012), Intensive one-session treatment of specific phobias. New York, NY: Springer.

DSM-5 Anxiety Disorders Feared Performance Situations . Fear and avoidance of situations involving possible of . Public speaking scrutiny by others (e.g., social interactions, being observed, performing), associated with significant . Performing (e.g., sports, music) distress/impairment . Eating or drinking in front of others . Typically lasting 6 months or longer . Using public restrooms . Crowded places (e.g., malls, subways) . Writing in front of others

Feared Interpersonal Situations Recommended Readings . Antony, M.M., & Rowa, K. (2008). Social anxiety . Initiating or maintaining conversations disorder: Psychological approaches to assessment and treatment. Cambridge, MA: Hogrefe. . Meeting new people or dating . Heimberg, R.G., & Becker, R.E. (2002). Cognitive- . Speaking with authority figures behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York, NY: . Parties Guilford Press. . Meetings . Hofmann, S., & Otto, M.W. (2008). Cognitive- . Interviews behavior therapy of social phobia: Evidence-based and disorder specific treatment techniques. New . Being assertive York, NY: Routledge.

4 Recommended Readings DSM-5 Anxiety Disorders

. Antony, M.M. (2004). 10 simple solutions to shyness: Generalized Anxiety Disorder (GAD) How to overcome shyness, social anxiety, and fear of public speaking. Oakland, CA: New Harbinger. Free . Excessive, uncontrollable worry about a variety of download at life domains (e.g., work, school, health, family), http://www.martinantony.com/downloads. with at least three associated symptoms (e.g., . Antony, M.M., & Swinson, R.P. (2008). The shyness insomnia, muscle tension, irritability, poor and social anxiety workbook: Proven, step-by-step concentration, feeling keyed up), and techniques for overcoming your fear, 2nd edition. distress/impairment Oakland, CA: New Harbinger. . Hope, D.A., Heimberg, R.G., & Turk, C.L. (2010). Managing social anxiety: A cognitive behavioral therapy approach (workbook), 2nd ed. New York, NY: Oxford University Press.

Recommended Readings Recommended Readings

.Dugas, M.J., & Robichaud, M. (2007). Cognitive- .Gyoerkoe, K.L., & Wiegartz, P.S. (2006). 10 behavioral treatment for generalized anxiety simple solutions to worry: How to calm your mind, disorder. New York, NY: Routledge. relax your body, & reclaim your life. Oakland, CA: .Hazlett-Stevens, H. (2008). Psychological New Harbinger. approaches to generalized anxiety disorder: A .Meares, K., & Freeston, M. (2008). Overcoming clinician’s guide to assessment and treatment. worry: A self-help guide using cognitive behavioral New York, NY: Springer. techniques. New York: Basic Books. .Rygh, J.L., & Sanderson, W.C. (2004). Treating generalized anxiety disorder: Evidence-based strategies, tool, and techniques. New York, NY: Guilford Press.

DSM-5 Anxiety Disorders Recommended Readings

Separation Anxiety Disorder .McHolm, A.E., Cunningham, C.E., & Vanier, M.K. (2005). . Developmentally inappropriate and excessive Helping your child with selective mutism: Practical steps anxiety concerning separation from major to overcome a fear of speaking. Oakland, CA: New Harbinger Publications. attachment figures . Duration of 4 weeks or longer (6 weeks in adults) .Eisen, A.R., & Engler, L.B. (2006). Helping your child with separation anxiety: A step-by-step guide for parents. Selective Mutism Oakland, CA: New Harbinger Publications. . Failure to speak in specific social situations in which there is an expectation of speaking, despite speaking in other situations . Duration of 1 month or longer

5 DSM-5 Anxiety Disorders DSM-5 Anxiety Disorders

Substance/Medication-Induced Anxiety Disorder Other Specified Anxiety Disorder . Anxiety secondary to a substance or medication . Used when a clinician chooses to communicate the reason why criteria for a specific anxiety Anxiety Disorder Due to Another Medical Disorder disorder are not met (e.g., GAD duration of only 3 . Anxiety likely the direct pathophysiological months; ataque de nervios) consequence of a medical condition Unspecified Anxiety Disorder . Used when a clinician chooses not to communicate the reason why criteria for a specific anxiety disorder are not met (e.g., in an ER setting where there may not be enough time to diagnose a specific disorder)

OC and Related Disorders Examples of Obsessions

Obsessive-Compulsive Disorder (OCD) . Contamination Obsessions (e.g., germs, bleach, H1N1, AIDS, cancer, etc.) . Obsessions (unwanted thoughts, images, or urges that are resisted and distressing) or compulsions . Doubting Obsessions (repetitive behaviors that occur in response to (e.g., appliances, locks, written work, running over pedestrians) obsessions, are designed to reduce anxiety, or are . Aggressive Obsessions meant to prevent harm) (e.g., stab children, push loved ones into traffic) . Obsessions about Accidentally Harming Others . Specify: (1) good or fair insight, (2) poor insight, or (e.g., contamination, poisoning, starting fires) (3) absent insight or delusional beliefs . Religious Obsessions (e.g., satanic thoughts, blasphemous thoughts) . Sexual Obsessions (e.g., thoughts of having sex with children)

Examples of Compulsions OCD Books for Therapists . Antony, M.M., Purdon, C., & Summerfeldt, L.J. . Washing and Cleaning (Eds.) (2007). Psychological treatment of OCD: . Checking Fundamentals and beyond. Washington, DC: American Psychological Association. . Counting . Clark, D.A. (2004). Cognitive-behavioral therapy for . Repeating Actions or Thoughts OCD. New York, NY: Guilford Press. . Symmetry and Exactness . Wilhelm, S., & Steketee, G.S. (2006). Cognitive . Repeating Words, Phrases, or Prayers to therapy for obsessive-compulsive disorder: A guide Oneself for professionals. Oakland, CA: New Harbinger. . Repeated asking, confessing, or telling

6 OCD Self-Help Workbooks Other OC Related Disorders

. Abramowitz, J.S. (2009). Getting over OCD: . Body Dysmorphic Disorder A 10-step workbook for taking back your life. . Trichotillomania (Hair Pulling Disorder) New York, NY: Guilford Press. . Excoriation (Skin Picking) Disorder . Hyman, B.M., & Pedrick, C. (2010). The OCD workbook: Your guide to breaking free . Hoarding Disorder from obsessive-compulsive disorder (3rd edition). Oakland, CA: New Harbinger.

OC and Related Disorders OC and Related Disorders

Body Dysmorphic Disorder Hoarding Disorder . Preoccupation with one or more perceived defects . Difficulty discarding or parting with possessions, or flaws in physical appearance that are either not regardless of their value, due to a perceived need observable or appear slight to others to save items and distress associated with . Presence of repetitive behaviors (e.g., checking, discarding them reassurance seeking, grooming) or mental acts in . Accumulation of clutter in active living areas response to the appearance concerns . Specify: With excessive acquisition . Specify: With muscle dysmorphia . Specify: (1) good or fair insight, (2) poor insight, or . Specify: (1) good or fair insight, (2) poor insight, or (3) absent insight or delusional beliefs (3) absent insight or delusional beliefs

Hoarding Self-Help Readings Trauma- and Stressor-Related Disorders

. Steketee, G., & Frost, R.O. (2007). Compulsive PTSD hoarding and acquiring (workbook). New York, NY: Oxford University Press. . A person is exposed actual or threatened death, serious injury, or sexual violence, in one or more of . Tompkins, M.A., & Hartl, T.L. (2009). Digging out: the following ways: Helping your loved one manage clutter, hoarding, - Directly experiencing the event and compulsive acquiring. Oakland, CA: New Harbinger. - Witnessing the event in person - Learning about the event in a close family member or friend (event must be violent or accidental) - Repeated exposure to the details of the event (e.g., in first responders)

7 Trauma- and Stressor-Related Disorders Trauma- and Stressor-Related Disorders

PTSD PTSD . At least 1 intrusion symptom (out of 5) . Specify if with dissociative symptoms (e.g., . At least 1 symptom (out of 2) involving avoidance depersonalization, derealization) of trauma-related stimuli . Note that symptoms for children age 6 and . At least 2 symptoms (out of 7) involving changes in younger are slightly different cognition (e.g., distorted cognitions regarding the trauma) and mood (e.g., fear, horror, anger, guilt) . At least 2 symptoms (out of 7) reflecting alterations in arousal and reactivity . Duration of at least 1 month

Trauma- and Stressor-Related Disorders Recommended Readings

.Foa, E.B., & Rothbaum, B.O. (1998). Treating the Acute Stress Disorder trauma of rape: Cognitive behavioral therapy for . Presence of any 9 symptoms from a list of 14 PTSD. New York, NY: Guilford Press. symptoms (e.g., intrusion symptoms, negative .Monson, C.M., & Fredman, S.J. (2012). Cognitive- mood, dissociative symptoms, avoidance behavioral conjoint therapy for PTSD: Harnessing the symptoms, arousal symptoms) healing power of relationships. New York, NY: . Duration of 3 days to 1 month Guilford Press. .Taylor, S. (2006). Clinician’s guide to treating PTSD: A cognitive-behavioral approach. New York, NY: Guilford Press.

Trauma and PTSD Readings Somatic Symptom and Related Disorders

. Hickling, E.J., & Blanchard, E.B. (2006). Overcoming Illness Anxiety Disorder the trauma of your motor vehicle accident: A cognitive-behavioral treatment program (workbook). . Preoccupation with having or acquiring a serious New York, NY: Oxford University Press. illness . Rothbaum, B.O., Foa, E.B., & Hembree, E.A. (2007). . Somatic symptoms are not present or are mild Reclaiming your life from a traumatic experience . High level of anxiety about health; easily alarmed (Workbook). New York, NY: Oxford University Press. about personal health status . Excessive anxiety behaviors (e.g., checking, avoidance) . Present for at last months . Specify: Care-seeking type; Care-avoidant type

8 Somatic Symptom and Related Disorders Health Anxiety

. Abramowitz, J.S., & Braddock, A.E. (2008). Psychological treatment of health anxiety and . One or more somatic symptoms that are distressing or hypochondriasis: A biopsychosocial approach. result in significant disruption in daily life Cambridge, MA: Hogrefe. . Excessive thoughts, feelings, or behaviors related to . Furer, P., Walker, J.R., & Stein, M.B. (2007). somatic symptoms or health concerns: At least one of Treating health anxiety and fear of death: A - Disproportionate and persistent concern about seriousness of practitioner’s guide. New York, NY: Springer. symptoms - High anxiety about health . Taylor, S., & Asmundson, G.J.G. (2004). Treating - Excessive time and energy devoted to symptoms or health health anxiety: A cognitive-behavioral approach. concerns New York, NY: Guilford Press. . Present for at least 6 months . Specify: (1) with predominant pain, (2) persistent

Health Anxiety

. Asmundson, G.J.G., & Taylor, S.. (2005). It’s not all in your head: How worrying could be making you sick – and what to do about it. New York, NY: Guilford Press. CAUSES OF . Owens, K.M.B., & Antony, M.M.(2011). Overcoming health anxiety. Oakland, CA: New ANXIETY Harbinger Publications. DISORDERS

Learning and Anxiety/Fear Absolute vs. Relative Risks

. Media tend to report relative risks of illness, rather than 1. Reinforcement of Anxiety/Avoidance absolute risks. . For example, drinking two alcoholic drinks per day increases a woman’s of certain cancers (e.g., mouth, throat, voice 2. Pathways to Fear (Rachman, 1976) box, esophagus, liver, rectum, breast) by 13%. But what does this mean? . Direct Traumatic Conditioning . Need to know the absolute risk to assess whether the increase in relative risk matters. . Observational Learning . Absolute risk for these cancers is 11.8%. Does that mean that drinking two alcoholic drinks per day increases the risk to . Informational/Instructional Learning 24.8% (13% plus 11.8% = 24.8%)? . In women who consume two drinks per day, we add 13% of 11.8 (i.e., 1.5), so the absolute risk is 13.3%.

http://info.cancerresearchuk.org/healthyliving/introducingcancerprevention/whatisrisk/

9 Cognitive Model of Panic Disorder Cognitive Model of OCD

. Normal intrusive thoughts and obsessions differ in the way they are interpreted by the individual . Individuals with OCD interpret intrusive thoughts as indicating that they are responsible for the occurrence or prevention of harm to self and others (e.g., “I will kill my baby” equals an increased risk of doing so, unless I take steps to prevent it). . Thought suppression and compulsive rituals help to maintain the problem. Clark (1986, 1988)

Biological Factors in Anxiety

Changes in Brain Activity . Increased cerebral blood flow in the prefrontal cortex and basal ganglia in OCD EVIDENCE-BASED Genetic Factors . Based on family, twin, and molecular TREATMENTS FOR genetics studies Altered Neurotransmitter Functioning ANXIETY . Serotonin . Norepinephrine . Gamma Aminobutyric Acid (GABA) . Glutamate

Overview of Treatment Strategies

. Medications . Cognitive Strategies - correcting anxious misperceptions about feared situations MEDICATIONS . Exposure - to the feared situations or sensations . Relaxation - progressive muscle relaxation, breathing retraining FOR ANXIETY . Other Strategies - applied tension, meditation and acceptance-based strategies, skills training (e.g., communication training, problem solving, driving DISORDERS lessons), reinforcement-based strategies

10 Selective Serotonin Selective Serotonin Re-Uptake Inhibitors (SSRIs) Re-Uptake Inhibitors (SSRIs) Effective for: . Paroxetine (Paxil) ─ Panic Disorder with/without Agoraphobia . Sertraline (Zoloft) ─ Social Anxiety Disorder . Fluvoxamine (Luvox) ─ Obsessive Compulsive Disorder . Fluoxetine (Prozac; Sarafem) ─ Posttraumatic Stress Disorder ─ Generalized Anxiety Disorder . Citalopram (Celexa) . Escitalopram (Lexapro; Cipralex) Probably Not Effective for: ─ Specific Phobia

Side Effects for SSRIs Selective Serotonin Re-Uptake Inhibitors (SSRIs) Gastro-Intestinal: nausea, intestinal cramping, diarrhea, vomiting, dry mouth, weight gain . Dosages Central Nervous System: nervousness, . Duration of Treatment headache, tremulousness, insomnia, . Discontinuing Treatment hypersomnia, sedation, anxiety Sexual Symptoms: delayed orgasm, difficulty becoming aroused, reduced interest Skin: allergic reactions, rashes

Side Effects for SSRIs Serotonin and Norepinephrine Re-Uptake Inhibitors (SNRIs) . 38% of patients (from a sample of 700) experienced side effects from SSRIs. . Venlafaxine XR (Effexor XR) . Most common side effects were reduced  Effective for GAD, Panic Disorder, Social Anxiety sexual functioning, sleepiness, weight gain. Disorder, PTSD; Comparable to Paroxetine for OCD . 25% of side effects rated as “very bothersome” (Denys et al., 2003) or “extremely bothersome.” . Duloxetine (Cymbalta) . Only 40% of patients reported their side effects  Controlled studies for GAD only to their prescribing physicians (regardless of . Desvenlafaxine (Pristiq) how bothersome they were).  No controlled studies in anxiety disorders. Cascade et al., 2010

11 Venlafaxine XR in the Treatment of Social Anxiety Disorder Mirtazapine (Remeron)

100 . Norepinephrine and serotonin receptor Placebo (n=138) Venlafaxine (n=133) 90 antagonist . Equivalent to fluoxetine for panic disorder 80 . Superior to placebo for PTSD (small study 70 * by Davidson et al., 2003) * † 60 †

Mean LSAS Mean LSAS total score . Mixed evidence in social anxiety disorder 50 (Muehlbacher et al., 2005; Schutters et al., 0 1 234681012 Venlafaxine dose:75-225 mg/day Time (weeks) 2010) LSAS = Liebowitz Social Anxiety Scale *p<0.05 vs placebo Liebowitz MR, Mangano RM. Int J Neuropsychopharmacol. . Support in open trials for OCD †p<0.01 vs placebo 2002;5(suppl 1):S211. Abstract P.4.W.046.

Placebo Response Tricyclic Antidepressants

One meta-analysis of antidepressant trials run Imipramine (Tofranil) between 1980 and 2005 found that the . Effective for: Panic Disorder, PTSD, GAD placebo effect accounted for 68% of the . Not effective for: OCD, Social Anxiety effects found in people with depression being Disorder, Specific Phobia treated with medications. Clomipramine (Anafranil) . Effective for: Panic Disorder, OCD Rief et al. (2009) Journal of Affective Disorders . Not effective for: Specific Phobia . Unknown efficacy: Social Anxiety Disorder, PTSD, GAD

Other Antidepressants Benzodiazepines

Bupropion (Wellbutrin) Alprazolam (Xanax) and Clonazepam (Klonapin . Dopamine uptake inhibitor or Rivotril) . Negative trials with panic disorder, OCD, PTSD. – Panic Disorder with/without Agoraphobia Found to be equivalent to escitalopram in one GAD study (Bystritsky et al., 2008). – Social Anxiety Disorder Vilazodone (Viibryd) Diazepam (Valium) and Lorazepam (Ativan) . a combined serotonin specific reuptake inhibitor – Generalized Anxiety Disorder (SSRI) and 5-HT1A receptor partial agonist Limited Effectiveness for . Approved by the FDA and released in the US in 2011 . No studies in anxiety yet. – Specific Phobia – Obsessive-Compulsive Disorder Note: Sedating, difficult to discontinue

12 Anticonvulsants Glutamatergic Agents

Gabapentin (Neurontin): Support for social Topiramate (Topamax): An anticonvulsant that anxiety disorder (Pande et al., 1999) and panic augments the effects of GABA, and also inhibits the disorder (Pande et al., 2000) effects of glutamate. Support for treating PTSD (Yeh et al., 2011) and for augmenting the effects of SSRIs Lamotrigine (Lamictal): May augment the effects in treatment-resistant OCD (Berlin et al., 2011; of SSRIs for OCD (Bruno et al., 2012) Mowla et al., in press). Pregabalin (Lyrica): Effective for GAD treatment N-Acetylcysteine: A glutamate-modulating agent that (Boschen, 2011; Wensel et al., 2012); effective appears to be useful for augmenting the effects of for treating and preventing relapse in social SSRIs in treatment resistant OCD (Afshar et al., anxiety disorder (Feltner 2011; Greist et al., 2012). Also effective as a monotherapy for 2011) trichotillomania (Grant et al., 2009)

Adjunctive Antipsychotics Adjunctive Antipsychotics

. OCD – Placebo controlled studies have examined . PTSD – mixed evidence for adjunctive olanzapine and adjunctive use of risperidone (Risperdal), adjunctive risperidone (e.g., Krystal et al., 2011; Pae et haloperidol (Haldol), olanzapine (Zyprexa), al., 2008). Support for olanzapine monotherapy (Carey quetiapine (Seroquel), aripiprazole (Abilify), and et al., 2012) ziprasidone (Geodon). Overall, findings are mixed, . GAD – mixed evidence for adjunctive antipsychotics (e.g., but a recent meta-analysis supports combining SRIs olanzapine, risperidone, quetiapine) (Samuel et al., and antipsychotics for treatment resistant OCD (Dold 2011). Meta-analysis suggests no differences from et al., 2011), though consistent findings were only placebo (LaLonde & Van Lieshout, 2011). Evidence supporting quetiapine monotherapy (e.g., Bandelow et found for risperidone (Dold et al., 2013). al., 2010; Khan et al., 2011), but concerns about adverse . OCD – Fluoxetine + clomipramine more effective effects. than fluoxetine + quetiapine (Diniz et al., 2011) . Social Anxiety Disorder– Mixed evidence for adjunctive ziprazidone (e.g., Lohoff et al., 2010)

Other Medications FDA Indications and Anxiety

Buspirone (Buspar) Celexa: Depression . Effective for GAD only Lexapro: Depression, GAD Luvox: Depression, OCD Beta Blockers Paxil: Depression, Panic Disorder, OCD, – Atenolol (Tenormin) Social Anxiety Disorder, GAD, – Propranolol (Inderal) PTSD . Useful for stage fright, but not generalized social phobia Prozac: Depression, OCD, Bulimia . Not effective for treating anxiety disorders Zoloft: Depression, Panic Disorder, OCD, Social Anxiety Disorder, PTSD

13 FDA Indications and Anxiety FDA Indications and Anxiety Ativan: Anxiety Disorders Cymbalta: Depression, GAD, Pain Klonapin: Seizure Disorder Pristiq: Depression Valium: Anxiety Disorders Xanax: Panic Disorder, GAD, Anxiety Disorder Effexor: Depression, GAD, Social Anxiety Buspar: Anxiety Disorders and Symptoms Disorder Keppra Seizure disorders Anafranil: OCD Lyrica: Pain after Shingles, Diabetic Nerve Tofranil: Depression Pain, fibromyalgia Viibryd: Depression Neurontin: Pain after Shingles, Seizure Disorder Wellbutrin: Depression

FDA Indications and Anxiety Recommended Readings . Bezchlibnyk-Butler, K.Z., Jeffries, J.J., Abilify: Schizophrenia, Bipolar Disorder, Procyshyn, R.M., & Virani, A.S. (Eds.) (2014). Depression (adjunctive treatment) Clinical handbook of psychotropic drugs, 20th Geodon: Schizophrenia, Bipolar Disorder edition. Boston, MA: Hogrefe. Haldol: Schizophrenia, TourettesDisorder . Elbe, D., Bezchlibnyk-Butler, K.Z., & Virani, A.S (2014). Clinical handbook of psychotropic drugs Risperdal: Schizophrenia, Bipolar Disorder, for children and adolescents, 3rd edition. Boston, Autistic Disorder MA: Hogrefe. Seroquel: Schizophrenia, Bipolar Disorder, Depression (adjunctive treatment) Zyprexa: Schizophrenia, Bipolar Disorder

Complementary and Alternative Treatments

. A 2002 survey found that 62% of American adults had used COMPLEMENTARY alternative treatments in the past year for a health concern (Barnes et al., 2002). . A 2012 survey found that 50% of college students had used AND ALTERNATIVE 1 of 9 herbal products for anxiety in the past year (Birkett, 2012). . Popular alternative treatments for anxiety include: TREATMENTS acupuncture, acupressure, Bach flower remedies (e.g., rescue remedy), biofeedback, color therapy, herbal remedies, homeopathy, hydrotherapy, hypnotherapy, massage, meditation, nutrition and diet therapy, prayer and spirituality, reflexology, reiki, vitamins and supplements, therapeutic touch, yoga. www.holisticonline.com

14 Herbs and Supplements Herbs and Supplements

. Chamomile: superior to placebo for GAD on . Inositol: Panic (comparable to some measures (Amsterdam et al., 2009) fluvoxamine), OCD (superior to placebo) . Oral Lavender Oil (Silexan): Equivalent to . Kava: (1) mixed group of anxiety disorders, lorazepam in a 6-week treatment study for GAD including agoraphobia, specific phobia, GAD (Woelk & Schläfke, 2010) (controlled); (2) three negative controlled . Galphimia glauca: equivalent to lorazepam in trials in GAD (Connor et al., 2006). one study of GAD (Herrera- et al., 2007), . Silybum marianum (Marian Thistle): found and superior to lorazepam in another (Herrera- to be equivalent to fluoxetine (30 mg) in an Arella et al., 2012) 8-week OCD study (Sayyah et al., 2010) . . Ginkgo biloba special extract EGb 761: Preliminary support for GAD (Woelk et al., 2007) . Omega-3 Fatty Acids: Not supported in a controlled study for OCD (Fux et al., 2004).

Herbs and Supplements Herbs and Supplements

. Passionflower: As effective (with less work . St. John’s Wort: Controlled studies found impairment) as oxazepam for treatment of GAD negative results in OCD and social anxiety (though ozazepam worked more quickly) disorder (Akhondzadeh et al., 2001) . Homeopathic Remedies: equal to placebo for . Valerian root: Preliminary support in 8-week GAD; no support for anxiety (Davidson et al., placebo-controlled study for OCD (Pakseresht et 2011) al., 2011) . Aromatherapy: Not supported in controlled . Xiao-Tan-Jie-Yu-Fang (XTJYF; a Chinese herbal studies (Wiebe, 2000; Muzzarelli et al., 2006) formula) was found to be more effective than placebo for reducing global anxiety and depression symptoms in earthquake survivors with PTSD (Meng et al., 2012)

Herbs and Supplements Herbs at a Glance

. Rescue Remedy: Not supported in controlled . Fact sheets published by the National studies on test anxiety (Walach et al., 2001). For Center for Complementary and Alternative a review on Bach Flower Remedies, see Ernste, Medicine, National Institutes of Health 2002. . S-Adenosyl methionine (SAM-e): No studies in . Provides reviews on more than 45 herbal anxiety disorders. products . Cannabidiol: Reduces anxiety during a speech . Updated regularly in social anxiety disorder (Queiroz et al., 2011). . http://nccam.nih.gov/health/herbsataglance. htm

15 Other Alternative Treatments Other Alternative Treatments

. Meditation: Emerging evidence from controlled trials . Acupuncture: Preliminary evidence for GAD supporting mindfulness meditation for GAD, OCD, and PTSD (Pilkington et al., 2010), but studies and other anxiety disorders (Hanstede et al., 2008; are flawed (small sample sizes, poorly Roemer & Orsillo, 2007). controlled). . Aerobic Exercise: Preliminary research supports the use of aerobic and nonaerobic exercise in a . Massage: Led to improvements in GAD, but no variety of anxiety-based problems. For reviews, see more than control conditions (thermotherapy; Jayakody et al. (2014, British Journal of Sports relaxing room therapy) (Sherman et al., 2010). Medicine) and Asmundson et al. (2013, Depression Also evidence that massage reduces state and and Anxiety). trait anxiety (Rich, 2010). . Yoga: Some promising results, but studies have . Meridian Tapping: Not effective for the significant methodological limitations (Kirkwood et al., treatment of OCD (Moritz et al., 2011) 2005).

CBT and Fluoxetine for SAD

45 RESEARCH ON 40 35 PBO FLU 30 CCBT CBT VS CCBT + PBO 25 CCBT + FLU

20

MEDICATION Score BSPS Total 15 04814 Assessment Point (Weeks)

Davidson, Foa et al. (2004). Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Archives of General Psychiatry, 61, 1005-1013

CBT and Imipramine for PD CBT and Clomipramine for OCD

30 70

60 25

50 20

40 15

30 10 20 5 10

Mean YBOCS Total Score Mean YBOCS Total 0 Percent Responders (PDSS) 0 CLP ERP ERP + CLP Placebo CBT Alone IMI Alone PLA Alone CBT + IMI CBT + PLA 0 Weeks 12 Weeks Post-Tx 1-Yr Follow up RESPONDER = 40% reduction on the PDSS; based on intent to treat analyses. Note: CLP = clomipramine Foa, Liebowitz, et al. (2005). Randomized, placebo-controlled trial of exposure and ritual Barlow DH, Gorman JM, Shear MK, Woods SW (2000). Cognitive-behavioral therapy, imipramine, prevention, clomipramine, and their combination in the treatment of obsessive-compulsive or their combination for panic disorder: A randomized controlled trial. JAMA, 283, 2529-2536. disorder. American Journal of Psychiatry, 162, 151-161.

16 Augmenting SSRIs CBT and the Brain 30 . A study using proton magnetic resonance 25 spectroscopic imaging found that after 4 weeks of 20 intensive CBT for OCD, treatment response was 15 associated with changes in glutamate metabolites (O’Neill et al., 2013). 10 . Levels of inositol (a marker of glial activity) in the 5 orbitofrontal cortex are predictive of CBT response

Mean YBOCS Total Score YBOCS Mean Total 0 in OCD (Zurowski et al., 2012) Risperidone EX/RP Placebo

0 Weeks 8 Weeks Note: EX/RP = Exposure + Response Prevention

Simpson, Foa, Liebowitz, et al. (2013). Cognitive-Behavioral Therapy vs Risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: A randomized controlled trial. JAMA Psychiatry, Published online Sept 11, 2013.

D-Cycloserine (DCS; Seromycin)

. Best known as a treatment for tuberculosis (500- 1000 mg per day) . Side effects: mostly CNS (e.g., irritability, headache) . A partial agonist at the N-methyl-D-aspartate D-CYCLOSERINE (NMDA) glutamatergic receptor . DCS is a cognitive enhancer - it improves extinction learning (fear reduction during exposure) in rodents . NMDA antagonists seem to prevent fear learning and extinction . Question - Does DCS improve outcomes in exposure-based treatments for anxiety?

DCS and Height Phobia D-Cycloserine (DCS) and Anxiety

. 28 Participants with height phobia received two . DCS enhances exposure-based treatment for social sessions of virtual-reality exposure for height anxiety disorder (Hofmann et al., 2006; Guastella et phobia. al., 2008) and specific phobia (Ressler et al., 2004) . 1 pill (50 mg DCS, 500 mg DCS, or placebo) was . Several studies in OCD and panic disorder suggest taken 2 to 4 hours before each session. that DCS may speed up the effects of exposure early . DCS was associated with reduced symptoms (fear, in treatment (though exposure without DCS catches up over time). avoidance, skin conductance) relative to placebo, at 1-week posttreatment and 3 months later . DCS is supported in a meta-analytic study (Norberg et al., 2008). . No effects of dosage . Mixed evidence in PTSD (de Kleine et al., 2012; Litz et al., 2012). Ressler, Rothbaum, et al., 2004

17 D-Cycloserine (DCS) and Anxiety

. DCS (50 mg) does not appear to be effective for enhancing VR exposure for height phobia when applied immediately INTRODUCTION after each of two sessions (Tart et al., 2013) . DCS (50 mg) enhances outcomes of VR exposure for height phobia when provided after a successful exposures, TO COGNITIVE- and appears to have detrimental effects when provided after an unsuccessful exposures (Smits et al., 2013). . DCS (50 mg) combined with a single session of exposure BEHAVIORAL for snake phobia leads to long lasting changes in ventromedial and other prefrontal cortex responses to phobic stimuli that are not seen in exposure without DCS THERAPY (Nave et al., 2012).

CBT for Anxiety Disorders Presenting the Treatment Rationale Basic Assumptions . The Nature of Fear and Anxiety . Treatment is relatively brief. . Survival Value of Fear and Anxiety . Therapy focuses on identifying and changing cognitive and behavioral factors . Three Components of Fear and Anxiety that currently maintain the problem, rather – Physical component than factors that may have initially caused – Cognitive component the problem. – Behavioral component . Treatment procedures based in research. . Overview of Treatment Strategies . Homework is assigned between sessions.

CBT “Apps” for Smartphones (e.g., iPhone)

CBT Referee . http://www.cbtreferee.com/ CBT Applications COGNITIVE . http://www.cbtapps.com/ iCouch CBT STRATEGIES . http://itunes.apple.com/us/app/icouch- cbt/id446115508?mt=8

18 Structure of a Typical Education Cognitive Therapy Session

1. Setting the agenda for the session . Provide information or evidence to 2. Discussion of the patient’s functioning in the help counter anxiety- provoking previous week 3. Review of the patient’s homework for the beliefs. previous week 4. Psychoeducation (e.g., relationship between thoughts and feelings) 5. Application of cognitive therapy techniques (e.g., examining the evidence, behavioral experiments, etc.). 6. Assigning new homework

Cognitive Reappraisal Types of Anxious Thinking

. It is important that everyone likes me Probability Overestimations . If I make a mistake at work, I will get fired . Overestimating the chance of something . If my heart skips a beat, it means I am having bad happening a heart attack . I cannot cope with thinking about my past . Examples: trauma - People will think I am an idiot . Having a panic attack in public is - I will have a heart attack unmanageable . I need to suppress negative thoughts about - The dog will bite me others Countering Probability Overestimations . Examine the Evidence

Types of Anxious Thinking Cognitive Reappraisal Catastrophic Thinking . Overestimating how bad a particular . Pie Chart Technique outcome would be . Examples: - It would be awful if someone didn’t like me - I could not handle panicking Countering Catastrophic Thinking . Ask “What is the worst thing that can happen?”

19 Cognitive Reappraisal Behavioral Experiments

Questions to Challenge Thoughts . Set up experiment to test out the validity of a target cognition vs. an alternative cognition. . Are my thoughts necessarily true? . Be sure to operationalize predictions (e.g., what . Are my thoughts consistent with the does “check out a symptom” mean?) evidence? . Consider whether to disclose the expected outcomes or rationale to the client in advance. . Are there other ways of thinking . Report on the outcome (results). about the situation? . Reflect on the outcome and what conclusions can be made.

Behavioral Experiments Behavioral Experiments

Variables to Manipulate . Target Cognition: If I don’t check out a . Testing the effects of exposure to a feared symptom with my physician, I will get sick thought, symptom, object, or situation and die. . Testing the effects of preventing safety . Alternative Perspective: If I don’t check behaviors out a symptom with my physician, it will go . Testing the effects of using safety away. behaviors (e.g., distraction) or avoiding . Experiment: ??

Behavioral Experiments Perspective Shifting . Target Cognition: If I lose my train of thought during my presentation, it would be . Involves considering the event from a unmanageable. different perspective. . Alternative Perspective: I could manage Examples: losing my train of thought if it happens. . What would you tell a loved one who . Experiment: ?? was having the same thought as you? . What might someone without anxiety be thinking in this situation?

20 Coping Statements Summary of Cognitive Strategies

. Coping statements may be useful in . Education moments of high distress, when it may be . Thought Records difficult to step back from one’s thoughts and consider the evidence. . Behavioral Experiments Examples . Pie Chart Technique . “It’s okay if some people don’t like me” . Perspective Shifting . “the worst thing that will happen during a . Coping Statements panic attack is that I will be uncomfortable”

Exposure-Based Treatments

Methods EXPOSURE- . In-Vivo Exposure . Imaginal Exposure BASED . Interoceptive (Symptom) Exposure . Prevention of Safety Behaviors TREATMENTS . Virtual Reality Exposure

VR for Anxiety Disorders Virtual Reality for SAD

. VR is well established for specific . 97 participants with public speaking phobias of heights and flying fears received 8 sessions of VR . Preliminary evidence supporting VR exposure, exposure group therapy, or for other specific phobias (e.g., waitlist (no treatment). spiders, claustrophobia), combat- . Both active treatments were equivalent, related posttraumatic stress disorder, and superior to “no treatment.” and public speaking fears . Gains maintained at 1 year follow up

Anderson et al. (2013)

21 Virtual Reality for SAD Principles of Effective Exposure

30 . Predictability and perceived control 25 . Graduated exposure versus flooding 20 . Longer exposure practices work best

15 Pre . Exposures should be spaced closely Post . Eliminate subtle avoidance strategies 10 . Vary the context of the exposure 5 practices

Personal Report of Confidence as a Speaker Reportof Confidence Personal 0 . Do not fight the fear VR Group Exposure Waitlist

VR = Virtual Reality. From Anderson et al. (2013)

Exposure Hierarchy for Social Anxiety

Item (Fear 0-100)

1. Have a party and invite everyone from work. 99 2. Go to Christmas party for 1 hour without drinking. 90 3. Invite Cindy to have dinner and see a movie. 85 4. Go for a job interview. 80 5. Ask boss for a day off work. 65 6. Ask questions in a meeting at work. 65 7. Eat lunch with coworkers. 60 8. Talk to a stranger on the bus. 50 9. Talk to cousin on the telephone for 10 minutes. 40 10. Ask for directions at the gas station. 35 Abramowitz (2009)

Practical Issues Eliminating Safety Behaviors

. Setting of session Social Anxiety Disorder . Role of modeling by the therapist . Wearing a turtleneck or make-up to hide . Ensuring safety during exposure blushing . Using technology to facilitate . Avoiding eye contact treatment . Memorizing a presentation . Including a family member in the . Avoiding certain topics of conversation treatment . Having several glasses of wine . Dimming the lights at dinner . Filling out a check before arriving at a store

22 Symptom Exposure Imaginal Exposure

. Shake head from side to side (30 sec.) . Used in PTSD, OCD, GAD, and other . Spin around in a swivel chair (60 sec.) problems where people fear images, . Hyperventilate (shallow breathing at a rate thoughts, memories, or other mental stimuli of about 100-120 breaths per min.) (60 . Can involve mental exposure, exposure to sec.) verbal descriptions, or written exposure . Breathe through a narrow, small straw (plug . Imagery should include visual, auditory, nose if necessary) (2 min.) tactile, and other senses, when relevant . Stare at a small dot (about the size of a . Record sessions and listen to them for dime) posted on the wall (3 min.) homework . Run on the spot (or run up and down stairs) (60 sec.)

Eye Movement Desensitization Eye Movement Desensitization and Reprocessing (EMDR) and Reprocessing (EMDR)

. Imaginal exposure combined with bilateral sensory Role of Eye Movements (EMs) stimulation (usually eye movements), as well as other . Controversy regarding the role of eye movements since EMDR was first developed. strategies (e.g., alternating tones). . Early studies (public speaking fear, panic disorder, anxiety . Tones are less effective than eye movements in PTSD in healthy controls, test anxiety) showed that exposure images with and without EMs led to similar reductions in treatment (e.g., van den Hout et al., 2012). symptoms, but dismantling studies for PTSD are lacking. . Supported for PTSD, but not other anxiety disorders . Some studies suggest that EMs tax working memory, thus (e.g., panic disorder, phobias). rendering the negative images less vivid and less emotional. . One study found EMDR and citalopram to be equally . Effects of EM on negative memories (in healthy controls) effective for OCD (Nazari et al., 2011). are identical to the effects of attentional breathing (van den . Evidence is lacking for theory underlying EMDR (e.g., Hout et al., 2011). Samara et al., 2011). . Recent reviews on the role of EMs in EMDR: Jeffries & Davis, 2013; Lee & Cuijpers, 2013

If Preventing Rituals is Impossible Principles of Ritual Prevention

. Eliminate behavioral and mental . Eliminate certain rituals first (based rituals on location, time of day, ritual content) . Solicit support from others . Delay the ritual . Complete vs. Gradual Ritual Prevention . Shorten the ritual . Do the ritual differently

23 Managing Overwhelming Urges Recommended Readings

. Engage in other activities (e.g., go for a . Abramowitz, J.S., Deacon, B.J., & Whiteside, walk; watch television) S.P.H. (2011). Exposure therapy for anxiety: Principles and practice. New York, NY: Guilford . Seek social support (e.g., call a friend) Press. . Contact therapist . Breathing retraining or relaxation exercises

Managing Realistic Anxiety

. Reducing risk (e.g., exercise to reduce risk of heart attack; carrying bag in case of vomiting; moving STRATEGIES FOR from a dangerous neighborhood) . Problem solving REALISTIC . Relaxation-based treatments . Mindfulness and acceptance-based approaches . Supportive psychotherapy ANXIETY . Medication to reduce anxiety . CBT strategies to deal with excessive anxiety

Steps in Case Formulation

. List patient’s main problems (e.g., anxiety, physical sensations, etc.). . Develop hypotheses about the predisposing, precipitating, perpetuating, and protective CASE factors, based on cognitive and behavioral principles. . Assess factors to confirm or disconfirm FORMULATION hypotheses (e.g., functional analysis). . Develop a treatment plan based on case formulation.

Adapted from Taylor & Asmundson (2004)

24 Components of Case Formulation Example of Case Formulation

. Triggers and cues . Learning history (e.g., father’s heart attack, being . Anxious thoughts and interpretations teased in childhood) . Dysfunctional core beliefs . Work stress (long hours; difficult coworkers) . Life experiences, observations, etc. . Belief that a racing heart is dangerous . Proneness to panic attacks, fainting, or other . Belief that one must always make a positive physical reactions (and origins of unexplained body impression on others sensations) . Hypervigilance for physical arousal symptoms . Use of anxiety-reducing behavior . Hypervigilance for negative reactions from others . Other contributing factors . Maladaptive coping behaviors (e.g., avoidance of exertion, avoidance of social situations, reassurance . Environmental reinforcers seeking, etc.) . Family factors Adapted from Abramowitz & Braddock (2008)

Treatment Plan Based on Formulation

. Strategies for managing work stress (e.g., relaxation or mindfulness) . Cognitive strategies for changing anxious beliefs (e.g., about physical arousal sensations, social situations) ANXIETY AND . Exposure to feared sensations and situations . Prevention of safety behaviors THE FAMILY

Family Accommodation and OCD Family Accommodation and OCD (Calvocoressi et al., 1995) (Calvocoressi et al., 1995) Examples of Accommodation Percent of Family Members Reporting: . Participation in OC compulsions No Accommodation 11.8% . Providing items for OC rituals Mild Accommodation 50% . Assisting with or participating in patient Moderate Accommodation 29.4% avoidance Severe Accommodation 8.8% . Modifying family routine . Doing things for the patient . Modifying work or leisure schedule

25 Family Accommodation and OCD Possible Family Predictors of (Albert et al., 2010) Poor Treatment Response

Percent of family members engaging in three . Excessive accommodation common types of accommodation on a daily . Critical interactions and negative basis: communication among family members Providing reassurance 47% . Excessive pressure to confront feared Participating in rituals 35% situations Assisting with avoidance 43% . Excessive attention paid to symptoms . Accommodation is most frequent when the patient . Lack of empathy has prominent contamination concerns, or when the family member has an anxiety disorder history.

Insomnia and Anxiety . Develop regular times for going to sleep and waking INSOMNIA . Avoid napping . Use the bed only for sleep and sex AND ANXIETY . Avoid liquid intake close to bedtime . Avoid caffeine in the evenings . Don’t “try” to fall asleep . Use relaxation and breathing exercises

Definition of Mindfulness MINDFULNESS AND . Deliberately paying attention to experiences as they are, in the ACCEPTANCE- present and without evaluation BASED TREATMENTS

26 Acceptance-Based Treatments Acceptance and Commitment Therapy

. Dialectical behavior therapy . Goal 1: to foster acceptance of unwanted thoughts and feelings – . Mindfulness-based stress reduction especially those that cannot be . Mindfulness-based cognitive therapy controlled by the individual . Acceptance and commitment therapy . Goal 2: To foster commitment and action toward living a rich, fulfilling life, consistent with one’s core values

Acceptance-Based Behavior Therapy Acceptance-Based Behavior Therapy Randomized Controlled Trial in GAD . Informed by ACT, MBCT, DBT, CBT . Goal 1: Cultivate an expanded awareness and . 81 Participants with generalized a compassionate and decentered stance toward anxiety disorder (GAD) randomly internal experiences assigned to 16 sessions of ABBT (n = . Goal 2: Increase acceptance of (willingness to 40) or Applied Relaxation (n = 41) have) internal experiences . Goal 3: Encourage mindful engagement in personally meaningful behaviors

Roemer, Orsillo, & Hayes-Skelton, 2012 Roemer, Orsillo, & Hayes-Skelton, 2012

Acceptance and Mindfulness- Effects of ABBT and AR Based Treatment for GAD on GAD Clinical Severity

Components of Treatment 6 5 . Psychoeducation 4 Pre . Experiential exercises 3 Post . Between-session assignments (homework) 2 6 Mo 1

. Use of metaphors (0-8) GAD of Severity 0 ABBT AR ABBT = Acceptance-based behavior therapy AR = Applied relaxation Roemer et al., 2008 GAD Clinical Severity Rating (CSR), p < .001 Roemer et al., 2012

27 Effects of ABBT and AR Effects of ABBT and AR on Hamilton Anxiety Rating Scale on Penn State Worry Questionnaire

25 80 70 20 60 50 15 Pre Pre 40 Post Post 10 30 6 Mo 6 Mo 20 5 10 0 0 Hamilton Anxiety Anxiety Rating Hamilton Scale ABBT AR ABBT AR Penn State Worry QuestionnairePenn StateWorry ABBT = Acceptance-based behavior therapy ABBT = Acceptance-based behavior therapy AR = Applied relaxation AR = Applied relaxation Hamilton Anxiety Rating Scale, p < .001 Roemer et al., 2012 Penn State Worry Questionnaire, p < .001 Roemer et al., 2012

Effects of ABBT and AR Effects of ABBT and AR on Beck Depression Inventory on Quality of Life Inventory

25 2.5

20 2

15 Pre 1.5 Pre Post Post 10 1 6 Mo 6 Mo 5 0.5

0 0 Quality of Life Inventory of Life Quality

Beck Depression Inventory Beck Depression ABBT AR ABBT AR ABBT = Acceptance-based behavior therapy ABBT = Acceptance-based behavior therapy AR = Applied relaxation AR = Applied relaxation Beck Depression Inventory, p < .001 Roemer et al., 2012 Quality of Life Inventory, p < .001 Roemer et al., 2012

Percentage of Participants Achieving Is Acceptance Anything New? Clinically Significant Improvement . Accepting the presence of anxiety is crucial ABBT = Acceptance-based behavior therapy . The patient usually wants to avoid or fight anxiety AR = Applied relaxation 82 symptoms. In cognitive therapy, he is encouraged 80 instead to accept his symptoms 78 . Paradoxically, by giving up the idea of control, the 76 patient can be taught to control his anxiety Post 74 6 Mo . Acceptance is allowing what exists at the moment to 72 be as it is. Acceptance is acknowledging the 70 existence of an event without placing a judgment or 68 label on it (right/wrong, good/bad, safe/dangerous)

% Clinically Significantly Improved Significantly Clinically % ABBT AR . The patient is encouraged to stop "value-judging" his Clinically significantly improved = within normative range on 3 of 5 anxiety measures (Newman et al., 2011) anxiety

% Clinically Significantly Improved, p < .001 Roemer et al., 2012 Quotes from Beck & Emery (1985), Cognitive Therapy for Anxiety Disorders

28 Recommended Readings Mindfulness and Cognitive Therapy

. Eifert, G.H., & Forsyth, J.P. (2005). Acceptance & Definition of Mindfulness commitment therapy for anxiety disorders: A practitioner's . Mindfulness is “paying attention in a particular treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: way: on purpose, in the present moment, and New Harbinger. nonjudgmentally” (Kabat-Zinn, 1994) . Forsyth, J.P., & Eifert, G.H. (2007). The mindfulness and acceptance workbook for anxiety: A guide to breaking free Acceptance in Cognitive Therapy from anxiety, phobias, and worry using acceptance and . “Acceptance is allowing what exists at the commitment therapy. Oakland, CA: New Harbinger. moment to be as it is. Acceptance is . Orsillo, S.M., & Roemer, L. (2011). A mindful way through acknowledging the existence of an event anxiety: Break free from chronic worry and reclaim your life. New York, NY: Guilford Press. without placing a judgment or label on it” (Beck & Emery, 1985)

29 after Anxiety (0–100) conclusions Evidence and realistic realistic and Evidence predictions Alternative thoughts and Alternative before Anxiety (0–100) ­ Anxiety Workbook by Martin M. Antony and Peter Norton. J. Copyright 2009 by The Guilford Press. Anxiety Thought Record Thought Anxiety

provoking thoughts ­ provoking and predictionsand Anxiety- Situation time Day and and Day form 4.1 Copyright 2009 by Martin M. Antony and Peter Norton. J. Reprinted with permission The Anti- in

30 Recent Books by the Presenter

1. Egan, S.J., Wade, T.D., Shafran, R., & Antony, M.M. (in press). Cognitive-behavioral treatment of perfectionism. New York, NY: Guilford Press. To be published September 2014. 2. Antony, M.M., & Roemer, L. (2011). Behavior therapy. Washington, DC: American Psychological Association. ISBN: 978-1-43380-984-2. 3. Owens, K.M.B., & Antony, M.M. (2011). Overcoming health anxiety: Letting go of your fear of illness. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-838-0. 4. Antony, M.M., & Barlow, D.H. (Eds.) (2010). Handbook of assessment and treatment planning for psychological disorders, 2nd ed. New York, NY: Guilford Press. ISBN: 978-1-60623-868-4. 5. Antony, M.M., & Norton, P.J. (2009). The anti-anxiety workbook: Proven strategies to overcome worry, phobias, panic, and obsessions. New York, NY: Guilford Press. ISBN: 978-1-59385-993-0. 6. Antony, M.M., & Stein, M.B. (2009). Oxford handbook of anxiety and related disorders. New York, NY: Oxford University Press. ISBN: 978-0-19530-703-0. 7. Antony, M.M., & Swinson, R.P. (2009). When perfect isn’t good enough: Strategies for coping with perfectionism, 2nd edition. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-559-4. 8. Antony, M.M., & Rowa, K. (2008). Social anxiety disorder: Psychological approaches to assessment and treatment. Cambridge, MA: Hogrefe. ISBN: 978-0-88937-311-2. 9. Antony, M.M., & Swinson, R.P. (2008). Shyness and social anxiety workbook: Proven, step-by-step techniques for overcoming your fear, 2nd edition. Oakland, CA: New Harbinger Publications. ISBN: 978-1- 57224-553-2. 10. Antony, M.M., Purdon, C., & Summerfeldt, L.J. (2007). Psychological treatment of OCD: Fundamentals and beyond. Washington, DC: American Psychological Association. ISBN: 978-1-59147-484-5. 11. Antony, M.M., & Rowa, K. (2007). Overcoming fear of heights: How to conquer acrophobia and live a life without limits. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-456-6. Available as free download at http://www.martinantony.com/downloads. 12. Antony, M.M., Craske, M.G., & Barlow, D.H. (2006). Mastering your Fears and Phobias (client workbook), second edition. New York, NY: Oxford University Press. ISBN: 978-0-19518-918-6. 13. Antony, M.M., & Watling, M. (2006). Overcoming medical phobias: How to conquer fear of blood, needles, doctors, and dentists. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-387-3. Available as free download at http://www.martinantony.com/downloads. 14. Bieling, P.J., McCabe, R.E., & Antony, M.M. (2006). Cognitive behavioral therapy in groups. New York, NY: Guilford Press. ISBN: 978-1-60623-404-4. 15. Craske, M.G., Antony, M.M., & Barlow, D.H. (2006). Mastering your Fears and Phobias (therapist guide), second edition. New York, NY: Oxford University Press. ISBN: 978-0-19518-917-9. 16. Antony, M.M., Ledley, D.R., & Heimberg, R.G. (2005). Improving outcomes and preventing relapse in cognitive behavioral therapy. New York, NY: Guilford Press. ISBN: 978-1-59385-197-2. 17. Antony, M.M., & McCabe, R.E. (2005). Overcoming animal & insect phobias: How to conquer fear of dogs, snakes, rodents, bees, spiders & more. Oakland, CA: New Harbinger Publications. ISBN: 978-1- 57224-388-0. Available as free download at http://www.martinantony.com/downloads. 18. Antony, M.M., & McCabe, R.E. (2004). 10 simple solutions to panic: How to overcome panic attacks, calm physical symptoms, and reclaim your life. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224- 325-5. 19. Antony, M.M. (2004). 10 simple solutions to shyness: How to overcome shyness, social anxiety, and fear of public speaking. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-348-4. Available as free download at http://www.martinantony.com/downloads. 20. Bieling, P.J., & Antony, M.M. (2003). Ending the depression cycle: A step-by-step guide for preventing relapse. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-333-0. 21. Antony, M.M., Orsillo, S.M., & Roemer, L. (Eds.) (2001). Practitioner’s guide to empirically-based measures of anxiety. New York, NY: Springer. ISBN: 978-0-30646-582-6. 31 Video Resources

Panic Disorder With and Without Agoraphobia AnxietyBC (2010). Effectively managing panic disorder (DVD). Vancouver, BC: Author. May be ordered from anxietybc.com. Clark, D.M. (1998). Cognitive therapy for panic disorder (DVD). Washington, DC: American Psychological Association. Dobson, K.S. (2010). Cognitive therapy over time (DVD). Washington, DC: American Psychological Association. Jongsma, A.E., & Bruce, T.J. (2010). Evidence-based treatment planning for panic disorder (DVD). Hoboken, NJ: John Wiley and Sons. Olatunji, B.O. (2011). Cognitive-behavioral therapy for clients with anxiety and panic (DVD). Washington, DC: American Psychological Association. Rapee, R.M. (1999). Fight or flight? Overcoming panic and agoraphobia (DVD). New York, NY: Guilford Press.

Social Phobia Albano, A.M. (2006). Shyness and social phobia (DVD). Washington, DC: American Psychological Association. Jongsma, A.E., & Bruce, T.J. (2010). Evidence-based treatment planning for social anxiety disorder (DVD). Hoboken, NJ: John Wiley and Sons. Rapee, R.M. (1999). I think they think…Overcoming social phobia (DVD). New York, NY: Guilford Press. Wenzel, A. (2013). Cognitive behavioral therapy for social anxiety. (DVD). Washington, DC: American Psychological Association.

Obsessive-Compulsive Disorder and Related Problems Antony, M.M. (2009). Behavioral therapy over time (DVD on Compulsive Hoarding). Washington, DC: American Psychological Association. Jongsma, A.E., & Bruce, T.J. (2010). Evidence-based treatment planning for obsessive-compulsive disorder (DVD). Hoboken, NJ: John Wiley and Sons. Turner, S.M. (1998). Behavior therapy for OCD (DVD). Washington, DC: American Psychological Association. Wilson, R. (2012). Cognitive therapy for obsessions. (DVD). Mill Valley, CA: Psychotherapy.net. Wilson, R.R. (2005). Obsessive-compulsive disorder (DVD). Washington, DC: American Psychological Association.

Perfectionism Antony, M.M. (2008). Cognitive behavioral therapy for perfectionism over time (DVD). Washington, DC: American Psychological Association.

Anxiety Disorders, Phobias and Cognitive Behavior Therapy (Miscellaneous) Dobson, K.S. (2011). Cognitive-behavioral therapy strategies (DVD). Washington, DC: American Psychological Association. Padesky, C. Guided discovery using Socratic dialog (DVD). May be ordered from www.padesky.com. Padesky, C. Testing automatic thoughts with thought records (DVD). May be ordered from www.padesky.com. Tompkins, M.A. (2013). Cognitive-behavioral therapy for specific phobias. (DVD). Washington, DC: American Psychological Association (exposure therapy for a client with a cat phobia). Wilson, R. (2012). Exposure therapy for phobias. (DVD). Mill Valley, CA: Psychotherapy.net (exposure therapy for a client with claustrophobia).

Anxiety Disorders in Children AnxietyBC (2009). Separation anxiety: A parent’s guide to helping your child (DVD). Vancouver, BC: Author. May be ordered from anxietybc.com. AnxietyBC (2011). Obsessive compulsive disorder: A parent’s guide to helping your child (DVD). Vancouver, BC: Author. May be ordered from anxietybc.com.

32 Relevant Associations

Anxiety and Depression Association of America (ADAA) 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910, USA Tel: 240-485-1001; Fax: 240-487-1020; Web Page: www.adaa.org

Association for Behavioral and Cognitive Therapies (ABCT) 305 Seventh Avenue, 16th Floor, New York, NY 10001-6008, USA Tel: 212-647-1890 or 800-685-2228; Fax: 212-647-1865; Web Page: www.abct.org

International Obsessive-Compulsive Disorder Foundation 112 Water Street, Suite 501, Boston, MA 02119 USA Tel: 617-973-5801; Fax: 617-973-5803; Web Page: www.ocfoundation.org

Anxiety Disorders Association of Canada (ADAC) P.O. Box 117, Station Cote St. Luc, Montreal, QC H4V 2Y3 Tel: 514-484-0504 or 888-223-2252; Fax: 514-484-7892; Web Page: www.anxietycanada.ca

Canadian Association of Cognitive and Behavioural Therapies (CACBT) Department of Psychology, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4 Web Page: www.cacbt.ca

Recommended Readings

Anxiety, Stress, CBT, and Related Topics Hackman, A., Bennett-Levy, J., & Holmes, E.A. (2011). Oxford guide to imagery in cognitive therapy. Oxford, UK: Oxford University Professional Readings Press. Abramowitz, J.S., & Braddock, A.E. (2011). Hypochondriasis and Kuyken, W., Padesky, C.A., & Dudley, R. (2009). Collaborative case health anxiety. Göttengen, Germany: Hogrefe. conceptualization: Working effectively with clients in cognitive- Abramowitz, J.S., Deacon, B.J., & Whiteside, S.P.H. (2011). Exposure behavioral therapy. New York, NY: Guilford Press. therapy for anxiety: Principles and practice. New York, NY: Guilford Newman, C.F. (2013). Core competencies in cognitive behavioral Press. therapy: Becoming a highly effective and competent cognitive Antony, M.M., & Barlow, D.H. (Eds.) (2010). Handbook of assessment behavioral therapist. New York, NY: Routledge. nd and treatment planning for psychological disorders, 2 ed. New Stott, R., Mansell, W., Salkovskis, P., Lavender, A., Cartwright-Hatton, York, NY: Guilford Press. S. (2010). Oxford guide to metaphors in CBT: Building cognitive Antony, M.M., & Stein, M.B. (2009). Oxford handbook of anxiety and bridges. Oxford, UK: Oxford University Press. related disorders. New York, NY: Guilford Press. Taylor, S., & Asmundson, G.J.G. (2004). Treating health anxiety: A Antony, M.M., Ledley, D.R., & Heimberg, R.G. (Eds.) (2005). cognitive-behavioral approach. New York, NY: Guilford Press. Improving outcomes and preventing relapse in cognitive behavioral Westra, H.A. (2012). Motivational interviewing in the treatment of therapy. New York, NY: Guilford Press. anxiety. New York, NY: Guilford Press. Antony, M.M., Orsillo, S.M., & Roemer, L. (Eds.) (2001). Practitioner’s Wilhelm, S., Phillips, K.A., & Stekettee, G. (2013). Cognitive- guide to empirically-based measures of anxiety. New York, NY: behavioral therapy for body dysmorphic disorder: A treatment Springer. manual. New York, NY: Guilford Press. Barlow, D.H. (Ed.) (2008). Clinical handbook of psychological Wright, J.H., Basco, M.R., & Thase, M.E. (2006). Learning cognitive- disorders, 4th edition. New York, NY: Guilford Press. behavior therapy: An illustrated guide. Washington, DC: American Bennett-Levy, J., Butler, G., Fennell, M., & Hackman, A. (Eds.) (2011). Psychiatric Press. Oxford guide to behavioural experiments in cognitive therapy. Self-Help Readings Oxford, UK: Oxford University Press. Abramowitz, J.S. (2012). The stress less workbook: Simple strategies Bernstein, D.A., Borkovec, T.D., & Hazlett-Stevens, H. (2000). New to relieve pressure, manage commitments, and minimize conflicts. directions in progressive relaxation training: A guidebook for New York, NY: Guilford Press. helping professionals. Westport, CT: Praeger. Antony, M.M., & Norton, P.J. (2009). The anti-anxiety workbook: Butler, G., Fennell, M., & Hackman, A. (2008). Cognitive-behavioral Proven strategies to overcome worry, phobias, and obsessions. therapy for anxiety disorders; Mastering clinical challenges. New New York, NY: Guilford Press. York, NY: Guilford Press. Antony, M.M., & Swinson, R.P. (2009). When perfect isn’t good Bieling, P.J., McCabe, R.E., & Antony, M.M. (2006). Cognitive enough: Strategies for coping with perfectionism, 2nd edition. behavioral therapy in groups. New York, NY: Guilford Press. Oakland, CA: New Harbinger Publications. Clark, D.A., & Beck, A.T. (2010). Cognitive therapy of anxiety Asmundson, G.J.G., & Taylor, S.. (2005). It’s not all in your head: How disorders: Science and practice. New York, NY: Guilford Press. worrying could be making you sick – and what to do about it. New Franklin, M.E., & Tolin, D.F. (2007). Treating trichotillomania: York, NY: Guilford Press. Cognitive-behavioral therapy for hair pulling and related problems. Burns, D.D. (1999). The feeling good handbook, Revised Edition. New New York, NY: Springer. York, NY: Plume. Furer, P., Walker, J.R., & Stein, M.B. (2007). Treating health anxiety Forsyth, J.P., & Eifert, G.H. (2007). The mindfulness and acceptance and fear of death: A practitioner’s guide. New York, NY: Springer. workbook for anxiety: A guide to breaking free from anxiety,

33 phobias, and worry using acceptance and commitment therapy. Oakland, CA: New Harbinger Publications. Obsessive-Compulsive Disorder and Hoarding Greenberger, D., & Padesky, C.A. (1995). Mind over mood: Change Professional Readings how you feel by changing the way you think. New York, NY: Guilford Press. Abramowitz, J.S. (2006): Obsessive-compulsive disorder. Göttingen, Germany: Hogrefe. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, Abramowitz, J.S. (2006): Understanding and treating obsessive- NY: Dell Publishing. compulsive disorder: A cognitive behavioral approach. Mahwah, NJ: Erlbaum. Keuthen, N.J., Stein, D.J., & Christenson, G.A. (2001). Help for hair pullers: Understanding and coping with trichotillomania. Oakland, Antony, M.M., Purdon, C., & Summerfeldt, L.J. (2007). Psychological CA: New Harbinger Publications. treatment of obsessive-compulsive disorder: Fundamentals and beyond. Washington, DC: American Psychological Association. McKay, M., Davis, M, & Fanning, P. (2009). Messages: The communications skills book, third edition. Oakland, CA: New Bratiotis, C., Schmalisch, C.S., & Steketee, G. (2011). The hoarding Harbinger Publications. handbook: A guide for human service professionals. New York, NY: Oxford University Press. Orsillo, S.M., & Roemer, L. (2011). A mindful way through anxiety: Break free from chronic worry and reclaim your life. New York, NY: Clark, D.A. (2004). Cognitive-behavioral therapy for OCD. New York, Guilford Press. NY: Guilford Press. Foa, E.B., Yadin, E., & Lichner, T.K. (2012). Exposure and response Owens, K.M.B., & Antony, M.M. (2011). Overcoming health anxiety: (ritual) prevention for obsessive-compulsive disorder, therapist Letting go of your fear of illness. Oakland, CA: New Harbinger nd Publications. guide (2 ed.). New York: Oxford University Press. Wilhelm, S. (2006). Feeling good about the way you look: A program Steketee, G., & Frost, R.O. (2014). Treatment for hoarding disorder (therapist guide), 2nd ed. New York, NY: Oxford University Press. for overcoming body image problems. New York, NY: Guilford Press. Wilhelm, S., & Steketee, G.S. (2006). Cognitive therapy for obsessive- compulsive disorder: A guide for professionals. Oakland, CA: New Panic Disorder With and Without Agoraphobia Harbinger Publications. Professional Readings Self-Help Readings Craske, M.G., & Barlow, D.H. (2007). Mastery of your anxiety and Abramowitz, J.S. (2009). Getting over OCD: A 10-step workbook for panic, 4th ed. therapist guide). New York, NY: Oxford. taking back your life. New York, NY: Guilford Press. Baer, L. (2012). Getting control: Overcoming your obsessions and Taylor, S. (2000). Understanding and treating panic disorder: rd Cognitive and behavioral approaches. New York, NY: John Wiley compulsions, 3 ed. New York, NY: Plume. and Sons. Challacombe, F., Oldfield, V.B., & Salkovskis, P. (2011). Break free Self-Help Readings from OCD: Overcoming obsessive compulsive disorder with CBT. London, UK: Vermilion. Antony, M.M., & McCabe, R.E. (2004). 10 simple solutions to panic: How to overcome panic attacks, calm physical symptoms, and Grayson, J. (2004). Freedom from obsessive-compulsive disorder: A reclaim your life. Oakland, CA: New Harbinger Publications. personalized recovery program for living with uncertainty. New York, NY: Berkley Publishing Group. Barlow, D.H., & Craske, M.G. (2007). Mastery of your anxiety and th Hyman, B.M., & Pedrick, C. (2010). The OCD workbook: Your guide to panic, 4 ed. workbook). New York, NY: Oxford University Press. rd rd breaking free from obsessive-compulsive disorder (3 edition). Wilson, R. (2009). Don’t panic: Taking control of anxiety attacks, 3 ed. Oakland, CA: New Harbinger Publications. New York, NY: HarperCollins Purdon, C., & Clark, D.A. (2005). Overcoming obsessive thoughts: How to gain control of your OCD. Oakland, CA: New Harbinger Social Phobia Publications. Professional Readings Steketee, G., & Frost, R.O. (2014). Treatment for hoarding disorder Antony, M.M., & Rowa, K. (2008). Social anxiety disorder: (workbook), 2nd ed. New York, NY: Oxford University Press. Psychological approaches to assessment and treatment. Yadin, E., Foa, E.B., & Lichner, T.K. (2012). Treating your OCD with Cambridge, MA: Hogrefe. exposure and response (ritual) prevention for obsessive- Heimberg, R.G., & Becker, R.E. (2002). Cognitive-behavioral group compulsive disorder, workbook (2nd ed.). New York: Oxford therapy for social phobia. New York, NY: Guilford Press. University Press. National Collaborating Centre for Mental Health (2013). Social anxiety disorder: The NICE guideline on recognition, assessment, and Generalized Anxiety Disorder treatment. London, UK: British Psychological Society and Royal Professional Readings College of Psychiatrists. Bernstein, D.A., Borkovec, T.D., & Hazlett-Stevens, H. (2000). New Hope, D.A., Heimberg, R.G., & Turk, C.L. (2010). Managing social directions in progressive relaxation training: A guidebook for anxiety: A cognitive behavioral therapy approach (therapist guide), helping professionals. Westport, CT: Praeger. 2nd ed. New York, NY: Oxford University Press. Dugas, M.J., & Robichaud, M. (2007). Cognitive-behavioral treatment Self-Help Readings for generalized anxiety disorder. New York, NY: Routledge. Antony, M.M. (2004). 10 simple solutions to shyness: How to Hazlett-Stevens, H. (2008). Psychological approaches to generalized overcome shyness, social anxiety, and fear of public speaking. anxiety disorder: A clinician’s guide to assessment and treatment. Oakland, CA: New Harbinger Publications. New York, NY: Springer. Antony, M.M., & Swinson, R.P. (2008). The shyness and social anxiety Heimberg, R.G., Turk, C.L., & Mennin, D.S. (Eds.) (2004). workbook: Proven, step-by-step techniques for overcoming your Generalized anxiety disorder: Advances in research and practice. fear, second edition. Oakland, CA: New Harbinger Publications. New York, NY: Guilford Press.. Hope, D.A., Heimberg, R.G., & Turk, C.L. (2010). Managing social Marker, C.D., & Aylward, A.G. (2012). Generalized anxiety disorder. anxiety: A cognitive behavioral therapy approach (workbook). New Göttingen, Germany: Hogrefe. York, NY: Oxford University Press. Rygh, J.L., & Sanderson, W.C. (2004). Treating generalized anxiety Monarth, H., & Kase, L. (2007). The confident speaker: Beat your disorder: Evidence-based strategies, tool, and techniques. New nerves and communicate at your best in any situation. New York, York, NY: Guilford Press. NY: McGraw-Hill.

34 Self-Help Readings Rothbaum, B.O., Foa, E.B., & Hembree, E.A. (2007). Reclaiming your Gyoerkoe, K.L., & Wiegartz, P.S. (2006). 10 simple solutions to worry: life from a traumatic experience (Workbook). New York, NY: Oxford How to calm your mind, relax your body, & reclaim your life. University Press. Oakland, CA: New Harbinger Publications. Williams, M.B., & Poijula, S. (2013). The PTSD workbook: Simple, nd Meares, K., & Freeston, M. (2008). Overcoming worry: A self-help effective techniques for overcoming traumatic stress symptoms (2 guide using cognitive behavioral techniques. New York, NY: Basic ed). Oakland, CA: New Harbinger Publications. Books. Depression Specific Phobia Self-Help Readings Addis, M.E., & Martell, C.R. (2004). Overcoming depression one step Professional Readings at a time. The new behavioral activation approach to getting your Davis, T.E. Ollendick, T.H., & Öst, L.-G. (Eds.) (2012), Intensive one- life back. Oakland, CA: New Harbinger Publications session treatment of specific phobias. New York, NY: Springer. Bieling, P.J., & Antony, M.M. (2003). Ending the depression cycle: A Craske, M.G., Antony, M.M., & Barlow, D.H. (2006). Mastering your step-by-step guide for preventing relapse. Oakland, CA: New Fears and Phobias (therapist guide), 2nd edition. New York, NY: Harbinger Publications. Oxford University Press. Williams, M., Teasdale, J., & Segal, Z. (2007). The mindful way Öst, L.-G., & Skaret, E. (2013). Cogntive behavior therapy for dental through depression. New York, NY: Guilford Press. phobia and anxiety. Hoboken, NJ: Wiley-Blackwell. Wright, J.H., & McCray, L.W. (2012). Breaking free from depression: Self-Help Readings Pathways to wellness. New York, NY: Guilford Press.

Antony, M.M., Craske, M.G., & Barlow, D.H. (2006). Mastering your Fears and Phobias (client workbook), second edition. New York, NY: Oxford University Press. Child Anxiety Disorders Antony, M.M., & McCabe, R.E. (2005). Overcoming animal and insect Professional Readings phobias: How to conquer fear of dogs, snakes, rodents, bees, Chorpita, B.F. (2007). Modular cognitive-behavioral therapy for spiders, and more. Oakland, CA: New Harbinger Publications. childhood anxiety disorders. New York, NY: Guilford Press. Available for free download at Grills-Taquechel, A.E., & Ollendick, T.H. (2012). Phobic and anxiety http://www.martinantony.com/downloads. disorders in children and adolescents. Göttingen, Germany: Antony, M.M., & Rowa, K. (2007). Overcoming fear of heights: How to Hogrefe. conquer acrophobia and live a life without limits. Oakland, CA: Kearney, C.A. (2005). Social anxiety and social phobia in youth: New Harbinger Publications. Characteristics, assessment, and psychological treatment. New http://www.newharbinger.com/bookstore/productdetails.cfm?PC=1 York, NY: Springer. 693 March, J.S., & Mulle, K. (1998). OCD in children and adolescents. Antony, M.M., & Watling, M. (2006). Overcoming medical phobias: New York, NY: Guilford Press. How to conquer fear of blood, needles, doctors, and dentists. Oakland, CA: New Harbinger Publications. Available for free Rapee, R.M., Wignall, A., Hudson, J.L., & Schniering, C.A. (2000). download at http://www.martinantony.com/downloads. Treating anxious children and adolescents: An evidence-based approach. Oakland, CA: New Harbinger Publications. Posttraumatic Stress Disorder Self-Help Readings / Readings for Parents Professional Readings Eisen, A.R., & Engler, L.B. (2006). Helping your child with separation anxiety: A step-by-step guide for parents. Oakland, CA: New Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Harbinger Publications. Cognitive behavioral therapy for PTSD. New York, NY: Guilford Press. Kearney, C.A. (2011). Silence is not golden: Strategies for helping the shy child. New York, NY: Oxford University Press. Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged exposure therapy for PTSD: emotional processing of traumatic March, J.S., & Benton, C.M. (2007). Talking back to OCD: The experiences (therapist guide). New York, NY: Oxford University program that helps kids and teens say “no way” – and parents say Press. “way to go.” New York, NY: Guilford Press. Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). McHolm, A.E., Cunningham, C.E., & Vanier, M.K. (2005). Helping your Effective treatments for PTSD: Practice guidelines from the child with selective mutism: Practical steps to overcome a fear of International Society for Traumatic Stress Studies, 2nd ed. New speaking. Oakland, CA: New Harbinger Publications. York, NY: Guilford Press. Rapee, R.M., Spence, S.H., Cobham, V., & Wignall, A. (2008). nd Hickling, E.J., & Blanchard, E.B. (2006). Overcoming the trauma of Helping your anxious child: A step-by-step guide for parents (2 your motor vehicle accident: A cognitive-behavioral treatment ed.). Oakland, CA: New Harbinger Publications. program (therapist guide). New York, NY: Oxford University Press. Tompkins, M.A., & Martinez, K. (2010). My anxious mind: A teen’s Monson, C.M., & Fredman, S.J. (2012). Cognitive-behavioral conjoint guide to managing anxiety and panic. Washington, DC: therapy for PTSD: Harnessing the healing power of relationships. Magination Press. New York, NY: Guilford Press. Wagner, A.P. (2000). Up and down the worry hill: A children’s book Taylor, S. (2006). Clinician’s guide to treating PTSD: A cognitive- about obsessive-compulsive disorder and its treatment. behavioral approach. New York, NY: Guilford Press. Rochester, NY: Lighthouse Press.

Zayfert, C., & Becker, C.B. (2007). Cognitive-behavioral therapy for PTSD: A case formulation approach. New York, NY: Guilford Press. Mindfulness Meditation CDs Self-Help Readings Kabat-Zinn, J. (2002). Guided mindfulness meditation, Series 1. Lexington, MA: Stress Reduction CDs and Tapes. May be ordered Follette, V.M., & Pistorello, J. (2007). Finding life beyond trauma: Using through www.mindfulnesscds.com. acceptance and commitment therapy to heal from post-traumatic stress and trauma-related problems. Oakland, CA: New Harbinger Kabat-Zinn, J. (2002). Guided mindfulness meditation, Series 2. Publications. Lexington, MA: Stress Reduction CDs and Tapes. May be ordered through www.mindfulnesscds.com. Hickling, E.J., & Blanchard, E.B. (2006). Overcoming the trauma of your motor vehicle accident: A cognitive-behavioral treatment Kabat-Zinn, J. (2005). Guided mindfulness meditation, Series 3. program (workbook). New York, NY: Oxford University Press. Lexington, MA: Stress Reduction CDs and Tapes. May be ordered through www.mindfulnesscds.com.

35 IBP programs are designed to be based on the best available evidence from current scientific research. However, the interpretation of evidence-based research may vary among researchers. The views and opinions expressed in this program are those of the presenter and do not necessarily reflect the views and opinions of IBP.

Why We Worry Martin M. Antony, PhD, ABPP Self‐Test

1. Which of the following is no longer an anxiety disorder, since the publication of DSM‐5? a. Social anxiety disorder b. Specific phobia c. Panic disorder d. Obsessive‐compulsive disorder

2. According to the cognitive model of panic disorder… a. Unexpected panic attacks are often triggered by feared physical sensations. b. Unexpected panic attacks are often triggered by changes in neurotransmitter levels. c. Unexpected panic attacks are often triggered by feared situations. d. People should try to suppress their anxious thoughts using distraction and other techniques.

3. Increased cerebral blood flow in the prefrontal cortex and basal ganglia is a feature of… a. Panic disorder b. Obsessive‐compulsive disorder c. Specific phobia d. Social anxiety disorder

4. Which of the following is an example of catastrophic thinking, as defined in the seminar? a. “People will think I am an idiot if I make a mistake.” b. “I will have a heart attack” c. “The dog will bite me” d. “It would be awful if someone didn’t like me.”

5. Each of the following is an evidence‐based treatment for anxiety‐related disorders, except for… a. Cognitive therapy b. Rescue remedy c. Exposure therapy d. Antidepressant medication

6. Which of the following is an acceptance‐based therapy? a. Dialectical behavior therapy b. Mindfulness‐based stress reduction c. Mindfulness‐based cognitive therapy d. All of the above 7. Which of the following medication seems to enhance learning during exposure therapy? a. D‐Cycloserine b. Alprazolam c. Paroxetine d. Venlafaxine

8. Virtual reality has been found to be an effective method for delivering… a. Hypnosis b. Eye movement desensitization and reprocessing c. Exposure therapy d. None of the above

9. Exposure therapy works best when… a. Practices are delivered in an unpredictable way b. Practices are infrequent c. Clients have a sense of control over what occurs during the practice d. Practices are brief

10. Which of the following is not a type of exposure therapy? a. Interoceptive exposure b. Imaginal exposure c. In‐vivo exposure d. Mindfulness exposure