858 PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
Treating Anxiety Disorders
Using
Cognitive Therapy
Techniques
S t e p h e n P . M c
harmacotherapy remains the most common
P form of treatment for anxiety disorders in the
United States. As Collins and associates1
wrote, “Most patients who do present for treatment
are managed with pharmacotherapy alone (eg,
rather than with other evidence-based psychothera-
pies). This practice occurs despite numerous
reviews and meta-analyses supporting the efficacy
of psychotherapy compared to no treatment and
placebo control groups.” Even so, patients may
desire, or require, nonpharmacological treatments
for their anxiety disorders.
Dr. McDermott is director of the Cognitive Therapy Insti-
tute, Cognitive Therapy and Research Program, Massa-
chusetts General Hospital, Harvard Medical School,
Boston, MA.
Address reprint requests to: Stephen P. McDermott, MD,
Cognitive Therapy & Research Program, Massachusetts
General Hospital, Psychiatry — WACC 812, Fruit Street,
Boston, MA, 02114.
Dr. McDermott is on the Speakers’ Bureau for Shire US.
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
D e r m o t t , M D
EDUCATIONAL OBJECTIVES
1. Explain the cognitive and behavioral factors
that can maintain or intensify an anxiety
disorder.
2. Discuss the use of basic cognitive and
behavioral techniques to deal with anxiety-
provoking situations.
3. Describe basic techniques to help patients
develop adaptive beliefs that can “inoculate”
them against future anxiety episodes.
Behavioral and cognitive psychotherapies are
the most widely studied psychological interventions
for anxiety disorders.2 Studies suggest cognitive-
behavior therapy (CBT) is effective treatment for
patients with various anxiety disorders, including
panic disorder, social phobia, obsessive-compulsive
disorder, posttraumatic stress disorder and general-
ized anxiety disorder (GAD).3
Some patients do not show adequate intial
859
response to medications for anxiety dis-
orders. CBT can directly address impor-
tant cognitive or behavioral factors of
anxiety disorders, such as agoraphobia
or avoidance, for which medications
alone may be less effective. Some stud-
ies suggest the combination of medica-
tions and a full course of CBT provides
little beyond that offered by CBT alone,
or, as for panic disorder, may result in
quicker relapse.4 For these patients,
CBT may provide a reasonable alterna-
tive to, rather than adjunct for, medica-
tions.
Some patients respond adequately to
medication treatment initially but are
unable to maintain their gains long-
term. Simon and associates5 demon-
strated 46% (n = 36) of 78 patients who
attained a 2-month period of remission
on benzodiazepines relapsed sometime
during the 2-year naturalistic study,
despite continued and adequate phar-
macotherapy. CBT teaches patients
skills necessary to manage their illness-
es long term, and outcome studies gen-
erally show diminished relapse com-
pared with medications alone. In a
meta-analysis of panic disorder treat-
ment outcome studies, Gould and col-
leagues6 note that “on average, treat-
ment effects were maintained at a level
equal to acute treatment effects.”
Patients may have difficulty taking
medications because they have painful
thoughts whenever they think about tak-
ing their medications. They may be anx-
ious about potential medication side
effects, embarrassed about using psy-
chotropic medications, or ashamed of
having a mental illness. These patients
may avoid medications initially or
become noncompliant with them later.
Many patients find CBT to be an accept-
able, and in many cases preferable,
alternative to medications.7 As Otto and
colleagues8 note:
“Although CBT is clearly more
860
effortful than pharmacotherapy ses-
sions and pill taking during the acute
treatment phase, this greater effort
appears to be tolerable to patients and
brings with it the promise of the
elimination of possible medication
side effects, regular office visits, and
the monetary cost of pharmacothera-
py over the long term.”
CBT may be less expensive than
medication management in the long
term for GAD and panic disorder.8,9
Otto et al.8 note there is little informa-
tion to guide the clinician in determin-
ing either the intensity or the modality
of treatment that any particular patient
will require. Some variables, such as
severity of panic and agoraphobia and
degree of comorbidity, tend to predict
poorer outcome, but this occurs regard-
less of the treatment modality (ie, phar-
macotherapy or CBT).
“Consequently, there is no reliable
evidence at present for guiding the
differential referral of patients to
CBT or pharmacotherapy. As a
result, we believe that the available
evidence — suggesting lower cost,
equal or greater acceptability or tol-
erability, and at least equal outcome
— supports the selection of CBT
(particularly lower cost group CBT)
as the initial modality of treatment
for patients with panic disorder. ...
From a cost perspective, combined
treatment with CBT and pharma-
cotherapy is an especially expensive
proposition that may offer no long-
term outcome advantages.”8
Even so, CBT may be unavailable to
patients for a variety of reasons, includ-
ing cost to the patient, insurance limita-
tions, or availability of cognitive-behav-
ior therapists. Less than 20% of the
members of the American Psychological
Association’s Division of Psychothera-
py (Division 29) identify themselves as
practitioners of either behavioral or cog-
nitive therapies.10
There is no indication of how many
of therapists who identify themselves as
cognitive or behavioral therapists are
adequately trained. Becker et al.11 con-
ducted a random survey of U.S. psy-
chologists that revealed only 17% were
utilizing exposure therapy to treat post-
traumatic stress disorder despite “sub-
stantial evidence [that supports its] effi-
cacy.” Even when professionals do pro-
vide evidence-based treatments, these
may not be implemented effectively.
Collins and colleagues1 cite surveys
noting that even when psychologists
report using cognitive behavioral meth-
ods for anxiety treatment in their clini-
cal practice, only about 25% use expo-
sure techniques, which are generally
considered to be a foundation of CBT
anxiety treatment.
“This may result partially from limi-
tations in professional training. The
Society of Clinical Psychology Task
Force on Promotion and Dissemina-
tion of Psychological Procedures
found that training in evidence-based
treatments was somewhat limited
both in doctoral programs and pre-
doctoral internships. At the time of
the survey [published in 1995], only
59% of predoctoral clinical internship
training programs provided supervi-
sion in CBT for depression. A recent
survey of graduate students in psy-
chology programs in the United
States found that 31.4% of students
did not receive any coursework cov-
ering empirically supported treat-
ments. Similarly, both psychiatry res-
idency programs and social work
training neglect to emphasize training
in evidence-based psychotherapy.”1
Thus, psychopharmacology may be
the only evidence-based treatment to
which many patients will have access,
even though medications alone may not
be sufficient treatments for their disor-
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
ders. One option for the psychiatrist fac-
ing this dilemma is to use basic CBT
principles and simple cognitive and
behavioral techniques that may obviate
the need for referral of these patients for
a full course of CBT. As Otto and col-
leagues8 write: “It is clear that some
patients can respond to less than full
treatment interventions for panic disor-
der. … [N]on-specific aspects of treat-
ment (eg, information, support, monitor-
ing, and expectation of benefit) may be
sufficient for some individuals for at
least short-term treatment response.”
While this format for teaching
patients CBT is less intensive than more
frequent individual or group sessions for
anxiety disorders, it can have the advan-
tage of being better suited to more
longterm treatment of patients in situa-
tions where availability of CBT is limit-
ed.
BASIC PRINCIPLES OF THE
COGNITIVE THERAPY OF ANXIETY
CBT encompasses psychotherapies
ranging from essentially purely behav-
ioral (such as exposure and response
prevention) to primarily cognitive (such
[Cognitive-behavior therapy] encompasses
psychotherapies ranging from essentially
purely behavioral (such as exposure and
response prevention) to primarily
cognitive (such as rational emotive
therapy).However, these distinctions
are often arbitrary at best.
as rational emotive therapy). However,
these distinctions are often arbitrary at
best and are frequently a source of con-
fusion.3 This article will focus primari-
ly on the use of Beck’s cognitive thera-
py (CT),12 which combines cognitive
and emotional theory and techniques
with a strong emphasis on belief
change. A comprehensive conceptual
framework guides the application of
techniques in CT.
Beck’s CT, like many (although not
all) cognitive-behavior therapies, oper-
ates from a basic premise that thoughts,
feelings, and behaviors in a specific sit-
uation affect, and are affected by, each
other. Beck’s CT differs from most
CBT in its emphasis on the role of
beliefs, which cut across many different
(but related) situations. The patient’s
pre-existing beliefs assess or interpret
the situation and give rise to the
thoughts (called automatic
thoughts) that form the basis for
the perception of the situation,
with the resulting behavior and
feelings.
More specifically, anxi-
ety is seen as an overesti-
mation of the danger in a situation, an
underestimation of one’s resources for
dealing with it, or both. A person who
thinks he or she is in a potentially dan-
gerous situation is more likely to feel
anxious. Often, the presence of anxiety
is seen as confirmation that the situation
indeed is dangerous. The assessment of
the situation and confirmatory affect
make more likely behaviors such as
avoidance and help-seeking, which fur-
ther reinforce the perception that the
person is unable to deal with the situa-
tion on his or her own.
Beliefs are patterns of stimuli pro-
cessing based on previous experiences.
Beliefs give rise to specific thoughts,
feelings, and behaviors in a particular
sit-
861
uation by determining how the situation
is perceived. When people repeatedly
perceive themselves to be in situations
they cannot manage alone, they tend to
develop the belief in related situations
that they are relatively helpless. The
greater their belief in their helplessness,
the more likely they are to perceive
themselves to be unable to deal with the
potential danger in relevant situations.
The greater the number of related situa-
tions, the more generalized their anxiety
is likely to be. Thus, beliefs maintain
and promote an anxiety disorder.
IDENTIFYING AUTOMATIC
THOUGHTS
We can best understand the patient’s
assessment of the dangerousness of, and
resources for dealing with, a situation by
having the patient recognize specific,
spontaneous (or “automatic”) thoughts
in situations when anxiety or dysfunc-
tional behaviors, such as excessive reas-
surance seeking or avoidance, are pre-
sent. One common source of helpless-
ness in anxiety is the patient’s percep-
tion that anxiety is occurring “out of the
blue,” with no particular precipitants.
However, cognitive therapists find
that, with training, patients often can
identify anxiety-provoking cognitions
occurring before the appearance of the
anxiety. Although patients may be able
to “push away” these cognitions from
more deliberate attention, the thoughts
have enough presence to be able to “tor-
ment” the patient, producing anxious
affect and dysfunctional behaviors. Yet,
these thoughts are not seen as being
“subconscious” (ie, unable to be
accessed by the patient due to defense
mechanisms). Rather, patients can
quickly learn to recognize these thoughts
when their attention is drawn to them.
Case Example #1
A young female college student sought
862
therapy for GAD. She had been referred remembered becoming tremendously
by her psychopharmacologist but had anxious, which continued until she
been somewhat reluctant to engage in returned home and took the benzodi-
cognitive therapy because, she said, “I’m azepine she had been prescribed to use
just anxious out of the blue. There is noth- as needed.
ing that I’m thinking that makes me anx- The patient was able to step back and
ious.” Her anxiety was quite uncomfort- analyze the accuracy of the painful auto-
able for her but had not affected her matic thoughts. She was doing well in
school performance, al-though she often school, at her part-time job, and social-
worried it might. ly, despite her anxiety. She never had
The patient described an episode in problems functioning at a high level,
which she became anxious “for no rea- although since her current anxiety
son at all” when she went to her local episode occurred, it had been more dif-
laundry to pick up her dry cleaning. ficult for her to maintain her usual high
When she and her therapist looked at the
situation in greater detail, she said she
had not been anxious when she was
going into the laundry, while she was
One commmon source of
helplessness in anxiety is the
patient’s perception that anxiety is
occurring “out of the blue,” with no
particular precipitants.
standing in line, or while she was speak-
ing to the cashier. The young woman
remembered the clerk turning away to
get the clothes. She saw into the hot,
humid back room where several women
washing clothes. The women looked
particularly uncomfortable and unhap-
py, since it was July and the establish-
ment was not air conditioned.
The patient remembered thinking at
that moment, “My life is such a mess.
I’ll never be able to finish school
because of my anxiety. I’ll probably
wind up working for the rest of my
life at the same job those women
are doing.” At that
point, she
productivity. She came from a caring,
well-to-do family who had always
helped her. She realized the thoughts
had been frightening but were extreme-
ly unlikely ever to be true.
Discussion
The automatic thoughts of anxious
patients often come in the form of
images, rather than verbal “self-state-
ments,” which people are more likely
to report when they are asked to catch
their automatic thoughts. It can be
helpful to talk to patients about catch-
ing the “movies in their mind,” which
can be so pervasive that patients aren’t
aware of them until they specifically
look for them.
It is also important to look for specif-
ic automatic thoughts in specific situa-
tions rather than asking the patient a
more general question, “What goes
through your mind when you get anx-
ious?” The answer to such a ques-
tion is more likely to be
deductive guessing on the
part of the patient,
which can lead to a
more intellectualized
understanding of
their situation. It is
usually helpful to
have the patient try to
catch the automatic
thoughts in the pres-
ence of the difficult
emotion. Ideally, this is
done by having a patient
pay attention to the
thoughts in the original
anxiety-provoking situ-
ation. If this is unavail-
able, patients often
can remember spe-
cific automatic
thoughts by
recalling the
situation in
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
enough detail to provoke the dysfunc-
tional emotion again.
Patients may not need any special
training to be able to reality test or
“answer back to” their dysfunctional
thoughts, a process cognitive therapists
call “rational responding.” Patients may
have been unable to respond to their
thoughts in the past simply because
they’ve refused to look at these frighten-
ing, and sometimes painful, cognitions.
Case Example #2
A young man presented for treatment
of his flying anxiety. He had recently
received a promotion at work, and his
new job required him to make a presenta-
tion across the country about 2 weeks
later. The patient generally had been able
to avoid flying in the past, and on the few
occasions in which he was required to fly,
he used a combination of benzodi-
azepines and alcohol, with the result he
described as, “I was still really nervous as
long as I was awake. But the pills and
alcohol made it easier for me to push
aside the anxiety and sleep most of the
trip.” He was looking for another alterna-
tive for the treatment of his flying anxi-
ety, because in his new role at work, he
often would be flying with colleagues
and would be expected to work on the
plane.
The patient had been involved in sev-
eral “fear of flying programs” sponsored
by airlines. Much of the interventions
involved psychoeducation about the rel-
ative safety of airline flight, and com-
mon misunderstandings anxious people
sometimes have about flying, such as,
“The plane will go down like a rock if
there’s trouble with even one engine.”
The patient said he found the program’s
helpful, and somewhat reassuring, but
his anxiety returned whenever he even
thought about flying.
The psychiatrist and the patient
examined his automatic thoughts as he
imagined himself going through each
step of the process for boarding a plane
and flying across the country. In each
part of the image, he could reasonably
describe his feelings, his actions, and
what he imagined he would be thinking
in the situation. For the most part, he
expressed some anxiety, but not a lot of
anxiety, and his thoughts generally were
rational, although most of his concern
centered on the anxiety he predicted he
would have.
The therapist asked the patient to
imagine he was on the plane, and the
flight was going smoothly. The patient
noted he was somewhat anxious, but
found it tolerable. The therapist asked
the patient to imagine that one of the
engines stopped. The patient said he
became more anxious, but remembered
that a plane could easily fly without one
of its engines. The therapist asked the
patient to imagine that all of the engines
on the plane stopped. The patient
became much more anxious but said he
remembered that planes could often
glide into airports even without power.
The therapist then asked the patient to
imagine that the wings fell off the plane.
At this point, the patient said, “Oh, my
God. The plane is going to go down. I
can see myself getting so anxious and
scared that I become as tense as a board
and stop breathing because all of my
muscles are paralyzed with fear.”
As the patient said this, he suddenly
looked surprised. He said, “But that’s
ridiculous. In my spare time, I’m an
emergency medical technician, so I’ve
studied a lot about the body. I know peo-
ple can’t make themselves stop breath-
ing. I guess, when I think about it, the
thing that seems worse than dying from
other causes is suffocating. I’ve always
been afraid of being unable to breathe
since I choked on some food when I was
a little boy.” The patient and his thera-
pist discussed the image further, finding
863
 SIDEBAR.
Self-help Materials for
Patients Learning Cognitive
Therapy Techniques
Burns DD. Feeling Good: The New Mood
Therapy. Revised edition. New York, NY:
Avon: 1999.
Burns DD. The Feeling Good Handbook.
Revised edition. New York, NY: Plume
Books; 1999.
Greenberger D, Padesky CA. Mind Over
Mood: Change How You Feel by Chang-
ing the Way You Think. New York, NY: The
Guilford Press; 1995.
Wright JH, Wright AS, Beck AT. Good
Days Ahead: The Multimedia Program
for Cognitive Therapy. Louisville, KY:
Mindstreet; 2004.
other evidence that refuted the image.
The patient reported feeling much less
anxious about flying and was able to
make his cross-country trip using only a
small amount of benzodiazepines.
Discussion
It is important for patients to be able
to understand that our minds simultane-
ously can assess situations both “emo-
tionally,” which may appear at times as
irrational, illogical, or even foolish, as
well as “rationally,” or logically. They
may worry this makes them appear as
irrational, illogical, or foolish people. It
may be helpful for the clinician to let the
patient know that he or she realizes the
patient “may not really believe” the dys-
functional thoughts but that these cogni-
tions can have a powerful emotional
effect nonetheless.
THE ROLES OF BEHAVIORS AND
BELIEFS
If the primary issue in an anxious
situation is the overestimation of dan-
ger, rational responding or problem
solving may be sufficient to allow the
patient to deal successfully with the sit-
864
uation. Sometimes these two tech-
niques alone don’t work if the primary
issue is not a sense of increased danger,
but rather a belief of an inability to deal
with the danger. That is, the patient
may be making an adequate assessment
of the danger the situation but underes-
timating his or her ability to deal with
the situation or its consequences. For
example, a college student who had
been seriously depressed in the past
might have the thought, “I’m not that
likely to flunk this test, but if I do, I’ll
become depressed again, then flunk out
and want to kill myself.”
These kinds of assessment are often
the result of a “helplessness belief,”
which can be narrow and limited (eg, “I
just can’t handle math classes”) or large
and pervasive (eg, “I’ll never get
through life unless I can find someone
who will always be there for me”).
Helplessness not only predisposes an
individual to cognitive assessments that
can lead to anxiety but also can give rise
to dysfunctional behaviors. Two particu-
larly difficult behaviors are reassurance-
seeking and avoidance.
Reassurance-seeking, and related
“help-seeking” and “neediness,” can
severely limit a person’s ability to func-
tion well. A person may avoid opportu-
nities that could be at all challenging
unless there is ready access to a source
of reassurance. This behavior also can
be problematic in relationships, where it
can place a frustrating burden on even
the most supportive partner.
Reassurance-seeking powerfully
reinforces a belief in one’s helplessness,
which, in turn, can cripple a person’s
willingness to confront intimidating
problems. Reassurance often can be
effective in diminishing anxiety in the
short term, but it reinforces the belief
that, without the reassurance, one will
be unable to deal with the anxiety alone.
This makes the reassurance-seeking
even more likely in the future.
Avoidance can become more of a
problem than anxiety. It is a coping
strategy that most anxious patients
eventually “discover.” In fact, avoid-
ance may be so “effective” in preventing
anxiety that the patient presents not with
symptoms of anxiety but with com-
plaints of difficulties tackling specific
problems or being unable to get any-
thing done. As with reassurance-seek-
ing, avoidance demonstrates the self-
reinforcing as-pects of beliefs.
The logical premise behind avoid-
ance is, “That which was avoided must
have been dangerous.” The assumption
of danger is never tested, so each time
the situation is avoided, its “danger” is
accepted, reinforcing the anxiety-induc-
ing perception. Until the patient con-
fronts the feared situation, he or she can-
not know the extent to which the danger
may be overestimated, cannot measure
the effectiveness of personal resources
for dealing with the situation, and can-
not learn how effective strategies for
anxiety control are.
These all lead to a situation in which
the anxiety may not only intensify for
given situation but also the helplessness
which the avoidance reinforces may
lead to generalization of the anxiety,
helplessness, or avoidance to more and
more distantly related situations. This
ultimately may lead from anxiety about
a “feared situation” to “fear of fear (or
other strong emotions) itself,” and there-
fore any situation which may give rise to
powerful affect.
Cognitive therapy views panic disor-
der as a fear of the physical symptoms
of anxiety. Anxiety can be seen as an
internal signal that danger may be pre-
sent. Some individuals look for the dan-
ger outside themselves. When this
becomes pathological, it is referred to as
GAD. Some people, however, look for
the danger within themselves. In panic
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
disorder, anxiety symptoms are inter-
preted as possible signs of an internal
danger. Shortness of breath becomes
“breathing problems.” Chest tightness is
a sign of “heart problems.” Lighthead-
edness can be interpreted as “neurologi-
cal or psychiatric problems.”
The misinterpretation of the anxiety
symptoms amplifies the anxiety. This,
in turn, increases the anxiety symptoms,
which increases the certainty of the
internal danger, ultimately creating a
“catastrophic misinterpretation” of the
symptoms. Thus, shortness of breath
becomes “I’m suffocating,” and chest
tightness, means “I’m having a heart
attack.” For some symptoms, such as
lightheadedness, there may be several
possible catastrophic misinterpreta-
tions, such as “I’m going pass out and
make a fool of myself,” “I’m going to
have a seizure,” or “I’m going crazy.
I’ll lose control and do something
humiliating or dangerous.”
CONCEPTUALIZATION OF THE
PATIENT
The treatment plan in any cognitive
therapy program is driven by the con-
ceptualization of the specific patient’s
problems. When treating a patient with
anxiety disorders, it is important to con-
ceptualize all of the patient’s fears. The
clinician cannot intervene effectively
unless he or she knows the most appro-
priate target; sometimes, the most obvi-
When treating a patient with anxiety
disorders, it is important to conceptualize
all of the patient’s fears.The clinician cannot
intervene effectively unless he or she knows the
most appropriate target; sometimes, the most
obvious fear is not the most potent one.
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
ous fear is not the most potent one. responsible for the dysfunctional
Sometimes, clinicians focus on “real- thoughts, feelings, and behaviors are not
ity-testing” the danger in a situation activated.
without fully understanding the specific Without belief activation, the inter-
peril on which the patient is focusing. ventions often result only in imperma-
The therapist may need to tease out one nent intellectual change. If the affect is
particularly potent perceived danger out too high, the task is more likely to be
of many possible fears. The most impor- avoided, or, if attempted, is less likely to
tant anxiety-provoking issue may not be be effective, because levels of emotion-
apparent until other worries are dealt al arousal that are too high can interfere
with, or until the anxiety is “turned with cognitive techniques (or the pro-
down” (ie, examining it is not so fright- cessing of behavioral techniques). Med-
ening or overwhelming). ications often can be helpful to “turn
This model differs from more behav- down the volume” on the troublesome
iorally based CBT of anxiety disorders,
which stress exposure to the anxi-
ety-provoking stimulus.
Greater intensity of the affect
generally results in a better
response to the exposure.
Beck’s CT, while emphasiz-
ing confronting anxiety-
provoking stimuli, also
places an emphasis on ratio-
nal responding to distorted
automatic thoughts and
belief-change. These process-
es require an “optimal emo-
tional level for interven-
tion.”13 If the level of emo-
tional arousal is too low
when the patient is
attempting an inter-
vention (either
behavioral or cog-
nitive), the beliefs
865

affect, making cognitive and behavioral
interventions more successful, even if
the direct medication effects are only
partially effective.12
Case Example #3
A woman with a history of panic dis-
order was anxious about going to her
daughter’s second grade “class night” at
the school where her ex-husband was a
school district administrator. The patient
had previously undergone CBT, and
based on the ways she learned to cope
with previous anxious situations, she
kept saying to herself, “I know the
teachers won’t be critical of me. Most of
them don’t particularly like my ex-hus-
band, anyway. I still feel anxious about
going, and I don’t know why.”
Instead of using these more formula-
ic responses based on what she deduced
was making her anxious, her psychia-
trist had her imagine she was going into
the school on class night: “I see myself
walking into the school. I’m so worried
someone might react to me negatively, I
get more and more anxious, and eventu-
ally, I have a panic attack.” She and her
clinician then turn the focus their inter-
vention on the improbability of an
attack from the teachers, which is what
she had learned to do in her previous
CBT. Rather, the “dangers” in the situa-
tion were a panic attack and her per-
ception of having few resources for
dealing with it. She noted how
much her anxiety disorder had
improved since starting her pre-
vious treatment. She had not had
a panic attack in more than a year.
Together with her clinician, she
developed coping strategies to
allow her to better deal with
any anxiety she might
have going into
school. She
Case Example #4
A 28-year-old teacher, the mother of
two small children, noted fear of flying
for years. She had been treated in the
past for GAD and had been doing well
for several years without any medica-
tions. She wanted to fly across the coun-
try to be the maid of honor at her best
friend’s wedding. She put off speaking
to her psychiatrist about her anxiety
until 2 weeks before the wedding. Her
psychiatrist suggested she enroll in a
“fear of flying program” at the local air-
port for education about the safety of
flying. He started her on a low dose of a
long-acting benzodiazepine to help her
with her baseline anxiety, which had
risen significantly since she received her
invitation to the wedding.
Upon her return visit 1 week later,
she reported feeling generally more
comfortable, with less anxiety, except
when thinking about her up-coming
flight, when her anxiety rose significant-
ly. She said she found the fear of flying
program reassuring but noted her anxi-
ety had not really diminished when she
thought about flying.
Her psychiatrist asked her to imagine
she was going to the airport to board her
flight. He asked her describe what was

The purpose of therapy is not for the

psychiatrist to treat the patient until all
anxiety is eliminated.Patients need to
understand that anxiety is normal and
that anxiety-provoking stimuli will
occur throughout the rest of their lives.

attended the class that happening to her in the image. He also

night, and later told her
doctor, “I had a good time.
I was only a little nervous
in the beginning.”
asked her to note the level of her anxiety
on a scale of 0 to 10, with 10 as the most
severe anxiety she could imagine). In
her image, her anxiety was increasing as
she approached the airport. She entered

866 PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004

the lobby, and her anxiety approached a
10, a level it never reached before. She
saw herself clutching her chest and
passing out. As she regained conscious-
ness on the floor, she imagined a circle
of people around her. They were all say-
ing themselves how strange she was.
She got up and tried to board the plane,
but the airline refused to let her on
because of her “fainting episode.” She
had to call her friend to explain why she
was missing her wedding; she imagined
her friend saying she would never speak
to her again. At this point during the ses-
sion, she was almost in tears.
The patient and her psychiatrist
looked at the evidence for and against
each of the components in the image.
While she often felt as though she might
faint when she had her anxiety episodes,
in fact, she never had, even when the
anxiety was quite severe. They worked
together on some basic problem-solving
about how she might handle the situa-
tion if she were feeling faint and ways
she could help lessen her anticipatory
anxiety. They also looked at the likeli-
hood that her best friend would never
speak to her again if, for some reason,
she were unable to attend her wedding.
The patient said she found the inter-
vention reassuring but that she still felt
rather anxious about flying. Her psychi-
atrist again led her through an exercise
imagining she was walking through the
airport. This time, her anxiety in the
image was much lower. Her anxiety
increased as she imagined getting on the
plane, but as it took off, she was able to
use some techniques she previously
learned in therapy to help deal with her
anxiety. She imagined herself flying in
the plane, and imagined that she was
“pretty anxious, but it was controllable.”
Her psychiatrist asked her to imagine
looking out the window and seeing an
engine on fire. She reported that her
anxiety shot to “a 10 out of 10”; she sud-
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
denly imagined herself “screaming and
losing control and opening the door of
the plane, causing everyone in the plane
to be sucked out of it.”
Again, she and her psychiatrist
looked at the evidence for and against
her “losing it” on the plane and came up
with coping strategies in the event she
became so anxious on the plane she was
afraid she would go out of control. She
reported feeling much more relieved,but
said she felt still “somewhat nervous”
about her flight.
Her psychiatrist asked her to think
about getting on the plane, which she
could do with minimal anxiety. She
could imagine taking off and flying with
some anxiety, but she found it quite
manageable. She had no worries about
“losing it” or “going crazy.”
Her psychiatrist asked her to imag-
ine hearing a loud bang, seeing an
engine explode, and feeling the plane
tumbling out of control. At that mo-
ment, she reported having the thought,
“I’m going to die. What’s going to hap-
pen to my children? What kind of a
mother would put her children in this
kind of the situation for something as
silly as a wedding?”
GOALS
The purpose of the therapy is not for
the psychiatrist to treat the patient until
all anxiety is eliminated. Patients need
to understand that anxiety is normal, and
indeed healthy, and that anxiety-provok-
ing stimuli will occur throughout the
rest of their lives. Rather, the objective
of the therapy is to teach patients how to
manage their anxiety using the tech-
niques (and the basic conceptualization
behind them) they develop with their
physician. To a large extent, current
problems serve as examples to allow
patients to learn the therapy. They are
not the raison d’être for the therapy.
At the beginning of treatment, the
psychiatrist and the patient should col-
laboratively developed concrete, specif-
ic, behaviorally based goals to guide the
treatment. Behaviorally based goals
start with the assumption that, for
patients feel better, they need to do
something. People who feel helpless
often want to take passive approach, and
have the treatment “done to them” (ie, to
have someone or something lessen their
anxiety for them). Behavioral goals
keep patients participating more active-
ly in their treatment and make it easier
to determine when the goal ultimately is
achieved. An objective such as “I want
to be less anxious,” does not necessarily
make apparent how one is to become
“less anxious” or when one has reached
this endpoint. For an individual with
agoraphobia and social phobia, a more
reasonable goal would be, “I want to be
able to push past my anxiety enough to
be able to go to the store when I need to,
or to be able to go to a party with people
I do not know.”
Behavioral goals assume that the
individual will achieve “less anxiety”
by accomplishing these intimidating
undertaking, and in the process,
decreasing their belief in their helpless-
ness, and increasing their sense of com-
petence. This occurs, not only because
of their improved self-confidence from
tackling a previously frightening task,
but also because, in order to achieve the
assignment, they have to come to a
greater understanding of the issues and
skill deficits which made the chore
daunting in first place. In the process of
achieving their behavioral goal, they
will be improving their skills for deal-
ing with other potentially anxiety-pro-
voking situations.
Behavior-based goals also are impor-
tant because anxious patients often focus
on lessen their anxiety as their primary,
or perhaps sole, reason for being in treat-
ment. Being able to go to the grocery
867
store whenever necessary or to go to
unfamiliar places can add significantly
to the quality of their lives. Instead, anx-
ious patients often see these chores as
things that could aggravate their anxiety
and therefore work against their primary
goal of “being less anxious.” Their lives
may become less anxious while they still
have minimal improvement in the quali-
ty of their lives.
Behavioral goals for problems such
as “I’m anxious” and “I’m depressed”
may not be intuitively obvious. It is
often helpful to have the patient answer
the questions, “What you want to do that
you’re not doing now? What you want
to stop doing that you are doing now?”
Affect tends to bias one’s percep-
tion of the current situation and mem-
ories of the past. This can make it dif-
ficult for patients to see the “big pic-
ture” of the progress of their treatment.
Instead, they focus on what they can-
not yet do. For some patients, the mere
presence of anxiety episodes suggests
“nothing has improved.”
Patients with anxiety and mood dis-
orders often have difficulty perceiving
and remembering small but significant
changes to their affect on a daily basis.
Rather, they tend to make more global
assessments of the state of their affec-
tive disorder which can be negatively
biased (eg, "I'm just not getting better").
Patients benefit from documenting regu-
lar measures of their affect frequently
(ie, several times per day). These mood
logs can demonstrate to patients that,
while they may still be having episodes
of anxiety, the episodes are occurring
less frequently and are less intense than
before treatment. Mood logs might also
show that their anxiety is no longer gen-
eralized but rather their anxious
episodes may tend to correlate with par-
ticular times or activities. Similarly, reg-
ular, frequent documentation of a
patient's endeavors (activity logs) may
868
show the psychiatrist that, although the
patient's anxious symptoms have
decreased, she is still avoiding social sit-
uations which might make her feel less
lonely and isolated, but which she sees
as unquestionably inciting her anxious.
Rating scales, particularly those that
are patient administered (eg, Beck14 or
Burns15) can show the patient and psy-
chiatrist not only overall patient
improvement but also relative areas of
strength and difficulty in the treatment.
For example, a patient with panic disor-
der might demonstrate decreased anxiety
physical symptoms but continue to show
a high level of apprehension, suggesting
he may not yet fully comprehend the
improvement in his panic disorder.
Rating scales also can be helpful to
assess related conditions such as depres-
sion16 or hopelessness,17 which may
coincide with anxiety disorders but not
be as apparent because of the intensity of
the anxiety. Rating scales and logs can
also be useful for documenting the effec-
tiveness of the treatment for managed-
care or risk-management purposes.
However, rating scales and logs should
not be used to “tell” patients that they are
getting better (or worse) because the
scores on their scales or logs are going
up or down. Rather, psychiatrists and
patients should discuss apparent “dis-
crepancies” between a patients’ percep-
tion of various aspects of their treatment
progress and more objective (but not
necessarily more accurate) measures.
BEHAVIORAL TECHNIQUES
Once the patient and the clinician
have agreed on behaviorally based
goals, it is important to track the
patient’s progress towards achieving
them. Large, overwhelming goals can be
made more manageable through the use
of graduated task assignments. In this
system, the final goals are broken down
into intermediate steps. As patients
accomplish the smaller, more manage-
able steps, they became more confident,
and in the process confront their help-
less or hopeless beliefs.
It is important to build steps in grad-
uated task assignments of the appropri-
ate level of difficulty. A step that is too
difficult makes it more likely for the
patient to “fail” the assignment and
become even more demoralized. A step
that is too easy can be seen by the
patient as a sign that the psychiatrist has
little faith in the patient’s abilities, or as
an indication that achieving the goal
will take too long. Cognitive therapists
generally use the rule of a difficulty
level of 70%. That is, the patient is
asked to rate on a scale from 0 to 100 the
likelihood of their completing their task
(where 0% is no likelihood all and 100%
is guaranteed completion). The task is
adjusted until the patient’s perception of
the likelihood of achievement is about
70%. This means the patient believes
the task is more likely than not to be
completed but is not such a “sure thing”
that the achievement seems meaning-
less.
It is important that these tasks be set
up as win–win situations. If patients
complete their assignments, they should
give themselves praise for successfully
achieving something they thought was
difficult. If patients cannot complete
their tasks, however, they should under-
stand that, merely by tackling the task,
they have pushed past their hopeless-
ness and avoidance and have taken an
important step towards achieving their
goal. If they observe what interfered
when they attempted the undertaking —
such as lack of preparation or anxious or
self-critical thoughts with overwhelm-
ing anxiety or hopelessness — then they
can work with their doctors on over-
coming these impediments and moving
further towards the goal.
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
COGNITIVE TECHNIQUES
Patients may discount their small
achievements as being reached through
luck, or because of their therapists’
interventions, rather than through their
own strength, perseverance, and skills.
It is important to teach patients to give
themselves substantial praise for under-
takings that were previously seen as
extremely difficult or undoable.
Frequently, when patients attempt to
praise themselves, they are bombarded
with negative, often self-deprecating
thoughts, such as, “Why should I praise
myself for that? I should have been
doing that long ago. Anyone else could
do it. I’m starting to sound like my doc-
tor. She only says these things because
she has to.” Patients should write down
these negative automatic thoughts and
rationally respond (or “talk back”) to
them on their own, then go over them
with their clinicians at their next visit.
Teaching patients how to respond to
rationally their automatic thoughts is a
cornerstone of Beck’s CT. While a dis-
cussion of the methods of rationally
responding is beyond the scope of this
article, there are many good resources
for therapists18 and patients. Some par-
ticularly useful self-help materials for
patients learning cognitive therapy are
listed in the Sidebar (see page 864).
Here are some cognitive techniques
that can be particularly useful for anxi-
ety disorders:
Assessing the costs and benefits of
reassurance seeking. Patients come to
understand not only the short-term ben-
efit of decreased anxiety but also the
long-term costs of continuing the
anxiety and helplessness.
Time projection. Patients
learn to look past the initial period of
anxiety in a situation and instead to
think about the positive results once the
situation is over. For example, instead of
focusing on catastrophic images of
plummeting into the water while driving
over a bridge, the patient can focus on
what he or she will be doing when she
gets to her final destination.
Fear of fear. Patients learn the dis-
tinction between being afraid of the sit-
uation and being afraid of the anxiety
the situation may engender, as in the
example of the woman going to her
child’s class night discussed previously.
Analyzing the worst, best, or most
realistic outcome. Anxiety-provoking
situations bring up anxious thoughts and
affect, even when patients avoid think-
ing directly about the situation. Address-
ing the thoughts is the first step in bring-
ing about an adequate resolution, but
confronting the thoughts directly almost
invariably increases patients’ anxiety (at
least initially), which also makes prob-
lem solving difficult. This technique
helps patients focus on the anxiety-pro-

Patients may discount their small

achievements as being reached through
luck, or because of their therapists’
interventions, rather than their own
strength, perseverance, and skills.

voking situation, then put it in better

perspective, by looking at the exaggerat-
ed extremes of possible good and bad
outcomes. This allows patients to come
up with a more balanced perspective
and then decide how they want to deal
with it.

Case Example #5

869
 A patient had missed work for 2 days
because he had been feeling depressed.
He left a message for his boss telling her
he was not feeling well and that he was
having a difficult time with his mood as
well. He missed a few days of work
approximately 2 years before when he
was depressed but had discussed it with
his boss, who been very supportive.
When he returned to his office, he
found a note from his boss asking him to
meet with her. He became anxious but
tried not to think about the meeting.
Instead, he busied himself with work,
although it was difficult to focus on it.
He noticed his anxiety was growing as
the day went on, so he decided to deal
with his anxiety directly. He asked him-
self the following three questions:
What’s the worst that could happen?
He imagined his boss calling him into
her office, and telling him she was “fed
up with his constantly missing work
because of his depression, which merely
showed he was a weak person who was
unfit to be an employee in anyone’s
company,” She said she was not only fir-
ing him, she was going to make sure he
no longer worked for any company in
their field or in their region of the coun-
try.
What’s the best that could happen?
He imagined his boss calling him into
her office and telling him she felt bad
that he was having a difficult time, and
that he was the most valuable employee
in the company. She said she assumed
the company must have been at least
partly responsible for his problems, so
she was giving him a month off with pay.
What’s most realistic thing that could
happen? He imagined his boss calling
him into her office and asking him if
there was anything she could do to help
them during his difficult time. He imag-
ined they discussed ways to temporarily
ease his workload until his depression
improved, when he would resume his
870
full workload. She assured him he was
an important and productive member of
her team, and she knew he would be
“back to his usual good self in no time.”
He felt fairly confident of this last
scenario, as it was very similar to when
he spoke to her 2 years before. Memories
of that time did not come to him earlier
in the day because he had been avoiding
thinking at all about his current situation.
As he thought back to the events of the
past 2 years, he realized that he was,
indeed, one of the most productive mem-
bers of the team. He felt more relieved
and competent when he went into their
meeting later that afternoon.
BELIEF-CHANGE
Ultimately, Beck’s CT aims to
change patients’ underlying belief sys-
tems to create more permanent, positive
change in the way they think, feel and
behave. In the cognitive therapy of anx-
iety disorders, patients aim to shift from
maladaptive (dysfunctional) beliefs,
such as “I can’t cope with this problem,”
to adaptive (health-promoting) beliefs,
such as, “I can deal with it well enough”
— not “It won’t make me anxious.”
Patients need to learn that anxiety is not
only normal but also a useful and impor-
tant part of life that they need to learn
how to manage.
Often, the desire to totally eliminate
anxiety stems from the all-or-nothing
belief that “if I have any anxiety, it will
go out of control, and I won’t be able to
deal with it.” This belief often can inter-
fere with the pharmacologic treatment
of anxiety disorders because patients
may have the unexpressed goal of the
complete elimination of anxiety. Any
anxiety may in turn become a stimulus
for even more anxiety (ie, “becoming
anxious about being anxious”). The fail-
ure to achieve the complete absence of
anxiety may indicate to the patient that
“the meds aren’t working well enough,”
leading to demands for higher levels of
medication, with resulting higher levels
of side effects.
Through belief-change techniques,
patients learn they can deal with their
fears by confronting them and respond-
ing rationally to the automatic thoughts
that occur. By repeatedly answering
back to dysfunctional thoughts in many
different situations, patients weaken the
dysfunctional beliefs from which the
thoughts arise.
Belief-change can only occur when
the dysfunctional beliefs are “activated”
(or “turned on”), which occurs best
when patients put themselves into
feared situations. Rational responding to
automatic thoughts may become primar-
ily an intellectual exercise when the
individual does it in an emotionally-
neutral setting (such as the relative safe-
ty of the clinician’s office). If the ratio-
nal responding cannot occur in the orig-
inal anxiety-provoking situation, the
underlying negative beliefs can be acti-
vated in therapy by having the patient
describe the situation in enough detail to
provoke at least some of the upsetting
affect.
Belief-change involves more than
just weakening dysfunctional beliefs,
however. Patients build self-confidence,
which “inoculates” them in future
potential anxiety-provoking situations
by building up positive beliefs that com-
pete with dysfunctional beliefs for inter-
pretation of potentially anxiety-inducing
situations. It is important for the clini-
cian to keep drawing patients’ attention
to what they’re doing right instead of
focusing only on their challenges. This
will allow patients to build confidence
in their skills and abilities to deal with
their feared situations instead of
attributing their improvement to more
transient, external forces, such as luck
or the skills of their clinician.
One way to increase patients’ atten-
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004

tion on their not-so-obvious strengths is
to have patients keep “strength logs.”
Several times a day, patients note in the
log examples of the positive attributes
their clinician is helping them try to
appreciate in themselves.
Case Example #6
A young man with a history of learn-
ing disabilities had difficulty seeing
himself as a competent individual. His
peers saw him as quite charismatic and a
natural leader, but whenever he had to
perform in new situations, he always
became anxious because he assumed he
would “screw it up, just like I have all
the other times in the past, and prove to
everyone how incompetent I really am.”
He agreed to keep a log several times a
day of even the slightest things he did
that showed he was a competent person.
Two weeks later, the young man
returned to his psychiatrist’s office. He
apologized profusely for having written
nothing in his log. He said, “I really
tried to do this assignment. I just didn’t
do anything competent. I tried so hard, I
even went up to the local beach several
nights last week and walked up and
down the shoreline, hoping I might see
someone drowning in the water, so I
could save them and prove I was com-
petent.” The young man in his psychia-
trist discussed how few people in the
world could ever claimed the competent
if the only measure competency was
saving a drowning person. This allowed
the young man to see the extreme stan-
dards he held for himself, and he was
better able, during the session, to
remember smaller things he had done
that were competent. He returned to his
clinician’s office 2 weeks later with a
more extensive list of examples of his
competency, and a greater sense of self-
confidence. He continued to log for the
following month.
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004
Discussion
To strengthen their positive self-
beliefs, patients may need to act as if
they were more confident, secure, lik-
able, and so on. While behavioral
change often follows belief change,
belief change can also follow behavioral
change. Changing behaviors before
belief change often can give rise to self-
critical or doubting thoughts in difficult
situations, such as, “It doesn’t matter
that I was able to force myself to go to
this party. I was only faking feeling
more confident, so it doesn’t really
count. I’m really just a weak person
inside.” While it is often best for
patients to respond rationally to such
thoughts by looking at their inaccuracy,
it may be easier initially for them to dis-
miss the thoughts by focusing on how
they interfere with the patients achiev-
ing their ultimate goals.
Some patients fear that, if they have
some anxiety in their lives, their anxi-
ety will “control them” as before, or
that they are unable to totally eliminate
their anxiety because the are weak and
helpless. Their logic is often similar to
this: “I’m feeling anxious. I have an
anxiety disorder. Therefore, I must be
feeling anxious because an anxiety dis-
order. ‘Normal’ people don’t have an
anxiety disorder, so a ‘normal’ person
wouldn’t be feeling anxious right now.
This just proves I’m abnormal, weak,
and helpless.”
Patients need to “normalize” their
anxiety — that is, they need to under-
stand the difference between the patho-
logical anxiety disorder they had before
treatment and the normal anxious
moods that all people have. This is a
crucial step for patients to feel comfort-
able continuing treatments to manage
their anxiety disorders. Some patients
who successfully manage their psychi-
atric disorders discontinue their treat-
ments as a way of proving to themselves
that they no longer have the disorder and
therefore can avoid the stigma of having
a psychiatric disorder. Their logic may
be something like this: “I have to take
my medicine/complete my cognitive
therapy techniques because I have an
anxiety disorder. I’m weak because I
have an anxiety disorder. If I didn’t take
my medicine or do my cognitive therapy
techniques and I did okay, this would
prove I don’t have an anxiety disorder
and I’m no longer weak.”
It can be useful to discuss with
patients that many of the skills they
learn in cognitive therapy are skills that
other people use intuitively. Their anxi-
ety disorder prevented them from
acquiring these abilities in the past, but
they have learned them in their treat-
ment, and they need to do them as rou-
tinely as everyone else to keep their anx-
iety disorder in check.
It may be helpful to ask patients if
they know of “strong” people who take
medications, particularly “strong” peo-
ple with anxiety disorders. They may be
able to get examples on the Internet or
from anxiety support groups in their
communities. It can also be useful to ask
a patient to imagine his or her best
friend had a problem like an anxiety dis-
order and felt weak because of needing
to take medications or use special tech-
niques. What would the patient say to
their best friend?
Most patients can easily come up
with several meaningful, supportive
statements that they might find difficult
to believe about themselves, such as,
“Being able to do all you have in your
life, with an anxiety disorder on top of
it, means you’re stronger than most peo-
ple, not weaker.” Would they believe
this if they said it to the friend? Why
wouldn’t it be just as applicable for
them? What would the best friend say if
he or she knew the patient felt this way?
Finally, many patients have to “cope
with the cure” of the anxiety disorder.
871
That is, they may now be able to do
things they never thought possible,
which can make them grieve what was
lost due to the anxiety disorder in their
past — things they now know might
have been possible.
Case Example #7
A man with severe panic disorder had
a complete remission of his panic
attacks on high-dose benzodiazepines. A
few months later, he returned to his psy-
chiatrist saying he had been feeling
“kind of depressed” for several weeks.
He had several neurovegetative signs
but did not meet full criteria for a major
depression. His doctor discussed the
possible use of an antidepressant but the
patient said he “did not want to be on
another pill.” The patient agreed to pay
attention to the thoughts going through
his mind when he noticed feeling
“down,” and he agreed to meet again the
following week.
On his return, the patient and his psy-
chiatrist noted a common theme running
through the thoughts he had collected. He
frequently was thinking about what his
life might have been had he not had panic
disorder. For example, he had been in the
premedical curriculum in college but had
to drop out because he couldn’t stand
feeling “trapped” in lectures. He became
a laboratory technician at his local hospi-
872
tal instead. The psychiatrist and the
patient discussed the normal process of
grieving and ways to get support through
this process. The patient was asked to try
to rationally respond to his automatic
thoughts (after going through several
examples) before their next meeting. The
psychiatrist also suggested several self-
help books to assist him.
The patient returned 2 weeks later
and said he felt “fine.” He said he had
tried to respond rationally to his auto-
matic thoughts using one of the work-
books the doctor suggested. He found it
helpful with some thoughts but still felt
somewhat down.
The patient also had not told his wife
about his “feeling down” before the ini-
tial visit because he “didn’t want her to
worry about me getting depressed.”
After speaking to the psychiatrist, how-
ever, he decided to tell his wife about his
“grieving” as a way of getting her sup-
port. The two of them talked about what
he could and couldn’t change about his
life now that his panic attacks were con-
trolled. She suggested they focus on
what he could change “and not worry
about the rest for now.”
He said he had always regretted how
his panic disorder had affected his rela-
tionship with his wife, saying, “Even
from the beginning, we could never do
some of the things ‘normal couples’ did
when they were dating.” They decided
this was something from their past they
could change by beginning to court
again. He said his wife was thrilled with
the idea. “All her friends are envious.
Last night, we went out to a restaurant for
the first time as a couple. It was great.”
The psychiatrist and the patient made
a follow-up appointment for several
months later.
SUMMARY
Cognitive-behavior therapy can pro-
vide significant improvement in patients
with anxiety disorders, either in combi-
nation with, or as an alternative to, med-
ications. Yet many patients do not have
access to CBT. The general psychiatrist
can use the cognitive model of anxiety
disorders to apply basic cognitive,
behavioral, and belief-change tech-
niques to treat patients with anxiety dis-
orders who may not need, or may not
have access to, a full course of CBT.
REFERENCES
1. Collins KA, Westra HA, Dozois DJ, Burns
DD. Gaps in accessing treatment for anxiety
and depression: Challenges for the delivery of
care. Clin Psychol Rev. 2004;24(5):583-616.
2. Barlow DH. Anxiety and Its Disorders: The
Nature and Treatment of Anxiety and Panic.
2nd ed. New York, NY: Guilford Press; 2002.
3. Deacon BJ, Abramowitz JS. Cognitive and
behavioral treatments for anxiety disorders: a
review of meta-analytic findings. J Clin Psy-
PSYCHIATRIC ANNALS 34:11 | NOVEMBER 2004