The Treatment Of Anxiety Disorders (2nd Edition, 2003)
Gavin Andrews, Mark Creamer, Rocco Crino, Caroline Hunt, Lisa Lampe and Andrew Page
Clinical Research Unit for Anxiety and Depression, University of New South Wales at St Vincent's Hospital, 299 Forbes St, Darlinghurst, NSW, 2010
This book is about the treatment of anxiety disorders, about helping people with chronic anxiety disorders to become well and stay well. It contains discussions of the nature and treatment of each syndrome; it describes the problems encountered during treatment and outlines some management strategies; and it contains patient treatment manuals for the common anxiety disorders.
Anxiety disorders are not simply about being too anxious, they are about irrational worry and avoidance of situations that are the focus of this worry. Persons with panic disorder worry that their panic will result in personal calamity; those with social phobia worry that their behaviour will result in shame; those with specific phobias fear personal harm; those with obsessive-compulsive disorder (OCD) worry that their obsessions will come true; those with post-traumatic stress disorder (PTSD) worry that their flashbacks will be real; and those with generalized anxiety disorder (GAD) worry that disaster will befall despite their worry.
People with chronic anxiety disorders are very sensitive to stress, become anxious and upset quickly, and are likely to develop a range of symptoms including those of other anxiety and depressive disorders. They know this and commonly think that the seed of their disorder lies within their own nature, personality, or temperament. Perceiving their sensitivity to anxiety and their inability to cope with it, they ignore the stressors that generated the anxiety, they avoid situations that worsen the anxiety, and focus instead on physical symptoms which are part of the anxiety response in an attempt to minimize the meaning of their anxiety. The handicap comes from these avoidance behaviours: the phobic avoidance, the compulsive rituals, the emotional numbing, and the preoccupation with the possibility of physical illness. Treatment should aim to reduce the emotional sensitivity to stress, the worrying thoughts about certain outcomes, and the avoidance behaviours related to specific situations.
The book is written especially for psychiatrists and clinical psychologists to provide detailed knowledge about the process and pitfalls in conducting a comprehensive cognitive behavioural program for the common anxiety disorders. Clinical psychologists and psychiatrists can learn about these techniques during their training, but knowing about something is not equivalent to knowing how to do it. The Patient Treatment Manuals are both the guide book and the journey and hence allow clinicians to make the journey with the patient. In skilled hands these programs comfort, commonly relieve, and quite frequently cure the disorder. These programs can also ameliorate the underlying personality vulnerability to anxiety.
This book contains five detailed Patient Treatment Manuals: for panic disorder and agoraphobia, for social phobia, for specific phobias, for obsessive-compulsive disorder, for generalized anxiety disorder and for Post Traumatic Stress Disorder. The publisher, Cambridge University Press, has agreed that these manuals may be photocopied by the purchaser of the book for the treatment of individual patients. The manuals are designed to be used as workbooks, and most patients annotate and therefore personalize their copy with comments from their clinician that are relevant to their particular disorder. Apart from copies of manuals made by purchasers for their personal use in the treatment of their patients, the manuals - or indeed any other part of the book - may not be copied, distributed, or sold. The standard provisions of copyright listed in the front of the book apply.
Patients with chronic disorders can benefit from simply being given the manual to read. However, most have already struggled to recover, and in these persons significant improvement and the prospect of cure come when a clinician gives the appropriate treatment manual to a patient and then works through the manual with him or her, explaining, supervising, and supporting the process of recovery. In this way, the clinician's expertise enables each patient to understand and put into effect the substance of the treatment. After treatment is concluded, the manuals, usually annotated with notes that the patient made during treatment, are commonly used by patients to reinforce their improvement and inhibit relapse. In this sense they do eventually become valid self-help manuals.
This book also contains separate Clinician Guides for the treatment of each of these disorders. These guides contain advice about the structures and settings in which these programs have been shown to work, about patient characteristics and behaviours that will require special skills if the progress of therapy is to continue, and about critical issues in the therapeutic process. The guides are about the art of therapy for patients with these disorders. The Clinician Guides are for clinicians' eyes only and, like other material in the book that is intended for clinician use, are printed in a double column format, whereas the Patient Treatment Manuals are printed in single column format.
These Patient Treatment Manuals and the Clinician Guides are new, and are certainly without precedent in the therapy literature. They comprise three-quarters of the book. The remaining quarter is much more conventional: an account of the scientific knowledge needed for clinicians to understand the nature of the disorders affecting their patients and to evaluate the treatment options available. There is no treatment manual for post-traumatic stress disorder because we decided to review stress-related anxiety and other secondary anxiety separately. While standardized patient treatment manuals are unlikely to be widely used for such disorders, advice to the clinician about their nature, evidence for treatment effectiveness, and management strategies are needed and are included in those two chapters.
It is our experience that when a clinician sees a patient with, say, agoraphobia, and after a discussion of the alternatives it is decided that a cognitive behaviour therapy program is to be the treatment of choice, the clinician: Completes an assessment of symptoms and level of handicap, using appropriate rating scales and questionnaires, and then has patients identify and rate the extent to which their main problem interferes with their life activities.
Explains the treatment to the patient using words like, "I am going to teach you how to control your panics, enter feared situations, and master your worrying thoughts. Here is a manual that describes the program. I want you to take the manual home and look through it. Do remember to bring it to your next session when we will begin to work through it together."
The patient is seen often, usually more than once per week, and at each session a segment of the manual is worked through, the clinician modifying it as appropriate for the patient's understanding and level of disorder. Homework exercises are then set and arrangements for the next session are made.
Treatment proceeds quickly with most patients improving their panic control by session three, being able to travel by session six, and mastering worrying thoughts by session ten. Treatment should conclude within 20 sessions with the clinician, the patient having spent an additional 40-60 hours on homework during this time. The homework is focused on hyperventilation control, relaxation practice, on confronting feared situations, and on identifying and combating dysfunctional cognitions.
When treatment concludes, the assessment measures made at the beginning are repeated. Areas in which the patient needs to continue to make gains or to consolidate are identified both from the therapy sessions and from the pattern of scores on these measures. Patients are encouraged to continue their own therapy by using both the manual, now embellished with the additional information and techniques provided by the clinician, and by periodic follow-up sessions with the clinician.
Clinicians of varying levels of expertise will use the rest of the book in different ways. Those new to the field, before treating a patient with, say, agoraphobia, should read Chapters 2 and 3, the general overview and the general advice about treatment, and then proceed to Chapters 4 and 5 to review the scientific knowledge about the nature and treatment of agoraphobia. Finally, they should read Chapter 6, the Clinician Guide, specifically about treating patients with agoraphobia, reading that in conjunction with the Patient Treatment Manual for panic disorder and agoraphobia. Thus, when they begin to work with the patient, they will be familiar both with the course of treatment outlined in the Patient Treatment Manual and with the necessary background information an experienced clinician needs. Experienced and busy clinicians may initially have to skip the review chapters but should still find the general advice about treatment and the Clinician Guide to agoraphobia essential, especially when difficulties arise during treatment. In fact the Clinician Guides will be useful even when the Patient Treatment Manual is not the principal treatment being used. That is, these treatment and clinician guide chapters will also be of use to many clinicians even when imipramine or other drugs are the treatments being used, simply because many of the same difficulties will arise and most of the strategies described will prove useful. In general, clinicians using drugs as their main treatments will find the chapters reviewing the syndromes and those reviewing treatments to be of use, for patients invariably ask about their disorder and expect their clinician to be conversant with the literature.
This book is for practicing clinicians. It provides most of the information needed for the successful treatment of patients with anxiety disorders.
Edited by Gavin Andrews MD, UNSW, 2007
©2007 CRUfAD
