Anxiety

Fear and its associated reactions (freeze, flight, fight) can be useful responses to a dangerous or threatening situation. However, clients suffering from anxiety disorders experience these reactions too strongly, too often, or in inappropriate situations - and they can be distressing and exhausting. Psychology Tools can help you with CBT for anxiety - our anxiety worksheets are designed to help clients with generalized anxiety disorder (GAD), health anxiety (hypochondriasis), panic disorder, phobias, and social anxiety.

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Links to external resources

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Assessment

  • Oxford - Agoraphobic Avoidance Scale (O-AS) | Lambe, S., Bird, J. C., Loe, B. S., Rosebrock, L., Kabir, T., Petit, A., ... & Freeman, D. | 2023
    • Scale
    • Reference Lambe, S., Bird, J. C., Loe, B. S., Rosebrock, L., Kabir, T., Petit, A., ... & Freeman, D. (2023). The Oxford agoraphobic avoidance scale. Psychological Medicine, 53(4), 1233-1243.
  • Brief Fear of Negative Evaluation Scale | Leary | 1983
  • Severity Measure For Agoraphobia | Craske, Wittchen, Bogels, Stein, Andrews, Lebu | 2013
  • Social Phobia Scale | Mattick, Clarke | 1995
  • Social Phobia Inventory (SPIN) | Connor, Davidson, Churchill, Sherwood, Weisler, Foa | 2000
  • Severity Measure For Specific Phobia | Craske, Wittchen, Bogels, Stein, Andrews, Lebeu | 2013
  • Severity Measure For Social Anxiety Disorder | Craske, Wittchen, Bogels, Stein, Andrews, Lebeu | 2013
  • Severity Measure For Panic Disorder | Craske, Wittchen, Bogels, Stein, Andrews, Lebeu | 2013
  • Severity Measure For Generalized Anxiety Disorder | Craske, Wittchen, Bogels, Stein, Andrews, Lebeu | 2013
  • Spence Children’s Anxiety Scale | Spence | 1998
  • Penn State Worry Questionnaire | Meyer, Miller, Metzger, Borkovec | 1990
    • Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the penn state worry questionnaire. Behaviour Research and Therapy, 28(6), 487-495.
    • Scale archive.org
  • Panic Disorder Severity Scale (PDSS) | Shear, Brown, Barlow, Money, Sholomskas, Woods, Gorman, Papp | 1997
    • Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., … & Papp, L. A. (1997). Multicenter collaborative panic disorder severity scale. American Journal of Psychiatry, 154(11), 1571-1575.
    • Scale
  • Mobility Inventory For Agoraphobia(MIA) | Chambless, Caputo, Jasin, Gracely, Williams | 1985
    • Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behaviour research and therapy, 23(1), 35-44.
    • Scale
  • Liebowitz Social Anxiety Scale (LSAS-SR) | Liebowitz | 1987
  • Health Anxiety Inventory (HAI-18) | Salkovskis, Rimes, Warwick, Clark | 2002
    • Scale
    • Reference Salkovskis, P. M., Rimes, K. A., Warwick, H. M. C., & Clark, D. M. (2002). The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32(05), 843-853.
  • Hamilton Rating Scale For Anxiety (HAM-A) | Hamilton | 1959
    • Hamilton, M. (1959).The assessment of anxiety states by rating. British Journal of Medical Psychology 32, 50-55.
    • Scale
  • Generalized Anxiety Disorder 7-item (GAD-7) | Spitzer, Kroenke, Williams, Lowe | 2006
    • Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.
    • Scale
  • Fear Questionnaire (FQ) (Phobia) | Marks, Matthews | 1979
    • Marks, I. M., & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy, 17(3), 263-267.
    • Scale
  • Brief Fear Of Negative Evaluation Scale | Leary | 1983

Guides and workbooks

  • Anxiety And Substance Use | NDARC: Mills, Marel, Baker, Teesson, Dore, Kay-Lambkin, Manns, Triningham | 2011
  • Specific phobia: patient treatment manual | Clinical Research Unit for Anxiety and Depression (CRUfAD)
  • Working To Overcome Anxiety (Workbook) | Lucock, Noble, Pallister, Horsefield, Padgett, Westley, Atha, Khan | 2015
  • Social Anxiety (An NHS Self-Help Guide) | Lesley Maunder, Lorna Cameron | 2020
  • Phobia Self-Help Booklet | Anne Joice, Jim White | 2006
  • Panic attacks: what they are and how to stop the next one | Glasgow STEPS
  • Coping with panic | Charles Young, Alison Hunte, Jessica Newell, Pat Valian | 2011
  • Health Anxiety – A Self-Help Guide | Maunder, Cameron, Young, Leyland | 2015

Information Handouts

Information (Professional)

Presentations

  • Cognitive-Behavioral Therapies for Social Anxiety Disorder: Integrating the 3 Waves of Evidence-Based Therapy | Larry Cohen | 2022
  • Why worry? Key cognitive processes that maintain worry and Generalised Anxiety Disorder | Colette Hirsch
  • New developments in exposure therapy for anxiety and related disorders: the inhibitory learning approach | Blakey, Abramowitz | 2018
  • Bringing Specificity to Generalized Anxiety Disorder: Conceptualization and Treatment of GAD using Intolerance of Uncertainty as the Theme of Threat | Robichaud | 2013
  • GAD – a cognitive model and treatment
  • Desirable difficulties: optimizing exposure therapy for anxiety through inhibitory learning | Abramowitz, Jacoby, Blakey | 2018

Self-Help Programmes

Treatment Guide

  • Comprehensive cognitive behavior therapy for social phobia: a treatment manual | Deborah Roth Ledley, Edna B. Foa, Jonathan D. Huppert (in consultation with David M. Clark) | 2005
  • Cognitive behavioral therapy for anxiety: an application of the F.E.A.R. model for adults | Stephen Lenz
  • The CARS cognitive behavioral treatment for anxiety manual | Center for Adolescent Research in Schools | 2014
  • Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders (2014) | Katzman et al | 2014
  • Panic disorder: Manual for Improving Access to Psychological Therapy (IAPT) High intensity CBT therapists. | David Clark, Paul Salkovskis | 2009
  • Comprehensive cognitive behavior therapy for social phobia: a treatment manual | Ledley, Foa, Huppert, Clark | 2006
  • NICE Guidelines For Social Anxiety Disorder | NICE | 2013
  • NICE Guidelines For GAD And Panic | NICE | 2011
  • A brief cognitive-behavioural treatment for social anxiety disorder | Eric P. Morris, David Mensink, and Sherry H. Stewart

Worksheets

Recommended Reading

Health anxiety

  • Walker, J. R., Furer, P. (2008). Interoceptive exposure in the treatment of health anxiety and hypochondirasis. Journal of Cognitive Psychotherapy, 22(4), 366-378

Social Anxiety Disorder

  • Warnock-Parkes, E., Wild, J., Thew, G., Kerr, A., Grey, N., & Clark, D. (2022). ‘I’m unlikeable, boring, weird, foolish, inferior, inadequate’: How to address the persistent negative self-evaluations that are central to social anxiety disorder with cognitive therapy. The Cognitive Behaviour Therapist, 15, E56. doi:10.1017/S1754470X22000496 view
  • Warnock-Parkes, E., Wild, J., Stott, R., Grey, N., Ehlers, A., & Clark, D. M. (2017). Seeing is believing: Using video feedback in cognitive therapy for social anxiety disorder. Cognitive and behavioral practice, 24(2), 245-255. view
  • Veale, D. (2003). Treatment of social phobia. Advances in Psychiatric Treatment, 9, 258-264
  • Wild, Hackmann, Clark (2008). Rescripting early memories linked to negative images in social phobia: a pilot study. Behaviour Therapy, 39(1), 47-56.
  • Moscovitch, D. A. (2009). What is the core fear in social phobia? A new model to facilitate individualized case conceptualization and treatment. Cognitive and Behavioural Practice, 16. 123-134
  • Clark, D. M. (2001). A cognitive perspective on social phobia

Panic disorder

  • Wells, A. (1997). Cognitive Therapy of Anxiety Disorders. Chichester: Wiley.
  • Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J. et al. (2000). Dismantling cognitive-behavioural treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424
  • Huppert, J. D., & Baker-Morissette, S. L. (2003). Beyond the manual: The insider’s guide to panic control treatment.Cognitive and Behavioral Practice,10(1), 2-13.
  • Clark, D. A. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy, 37, S5-S27

Health anxiety

  • Salkovskis, P. M., Warwick, H. M. C., Deale, A. C. (2003). Cognitive-Behavioral Treatment for Severe and Persistent Health Anxiety (Hypochondriasis). Brief Treatment and Crisis Intervention, 3, 353-367 btci.edina.clockss.org
  • Furer, P., Walker, J. R. (2008). Death anxiety: A cognitive behavioural approach. Journal of Cognitive Psychotherapy, 22(2), 167-182
  • Asmundson, G. J. G., Abramowitz, J. S., Richter, A. A., Whedon, M. (2010). Health anxiety: current perspectives and future directions. Current Psychiatry Reports, 12, 306-312

Generalized Anxiety Disorder

  • Roemer, L., Salters, K., Raffa, S. D., & Orsillo, S. M. (2005). Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model.Cognitive Therapy and Research,29(1), 71-88.
  • Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance‐based approaches with existing cognitive‐behavioral models.Clinical Psychology: Science and Practice,9(1), 54-68
  • Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. (2002). Applying an emotion regulation framework to integrative approaches to generalized anxiety disorder.Clinical Psychology: Science and Practice,9(1), 85-90
  • Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Ritter, M. (2013). Emotion regulation therapy for generalized anxiety disorder.Cognitive and Behavioral Practice,20(3), 282-300 nih.gov
  • Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder.Behavioural and cognitive psychotherapy,23(3), 301-320
  • Hjemdal, O., Hagen, R., Nordahl, H. M., & Wells, A. (2013). Metacognitive therapy for generalized anxiety disorder: Nature, evidence and an individual case illustration.Cognitive and Behavioral Practice,20(3), 301-313.
  • Hjemdal, O., Hagen, R., Nordahl, H. M., & Wells, A. (2013). Metacognitive therapy for generalized anxiety disorder: Nature, evidence and an individual case illustration.Cognitive and Behavioral Practice,20(3), 301-313
  • Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder.Generalized anxiety disorder: Advances in research and practice,2004.
  • Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model.Behaviour research and therapy,36(2), 215-226.
  • Milne, S., Lomax, C., & Freeston, M. H. (2019). A review of the relationship between intolerance of uncertainty and threat appraisal in anxiety. the Cognitive Behaviour Therapist, 12.
  • Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching cognitive behavior therapy for generalized anxiety disorder from a cognitive process perspective. Frontiers in psychiatry, 10, 796.
  • Bottesi, G., Ghisi, M., Carraro, E., Barclay, N., Payne, R., & Freeston, M. H. (2016). Revising the Intolerance of Uncertainty Model of Generalized Anxiety Disorder: Evidence from UK and Italian Undergraduate Samples.Frontiers in psychology,7, 1723
  • Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23, 1011-1023

General

  • Clark, D. M. (1999). Anxiety disorders: why they persist and how to treat them. Behaviour Research and Therapy, 37, S5-S27
  • Task concentration training and fear of blushing | Bögels, Mulkens, De Jong | 1997

What Is Anxiety?

Signs and Symptoms of Anxiety Disorders

Different anxiety disorders are characterized by various foci of concern.In addition to disorder-specific cognitive content, individuals experiencing anxiety disorders are likely to experience physical symptoms of anxiety including:

  • palpitations or accelerated heart rate

  • sweating

  • trembling or shaking

  • dry mouth

  • difficulty breathing

  • a feeling of choking

  • nausea or abdominal discomfort

  • dizziness

  • derealization or depersonalization

  • fear of losing control or passing out

  • fear of dying

  • hot flushes or cold chills

  • numbness or tingling

  • blushing

  • fear of vomiting

  • urgency or fear of urination or defecation

Psychological Models and Theories of Anxiety

One broad conceptualization of anxiety can be summarized by an ‘anxiety equation’ (Beck, Emery, & Greenberg, 1985; Salkovskis, Forrester, & Richards, 1998):
Anxiety = (perceived probability of therapy × perceived cost or awfulness of danger)÷ (perceived ability to cope + perceived ‘rescue factors’)
Disorder-specific ‘CBT for anxiety’ cognitive models have been developed for all of the anxiety disorders. These are helpful in that they direct the therapist’s attention toward key interpretations and behaviors that act to perpetuate the anxiety disorders. For example, the critical mechanism that Clark identified in the cognitive model of panic (1986) is that body sensations are misinterpreted catastrophically as signs of danger, with concomitant effects upon emotions, behavior, and secondary cognitions.

Evidence-Based Psychological Approaches for Working with Anxiety

Cognitive behavior therapy has a strong evidence base for treating all of the anxiety disorders. Key components of CBT for anxiety interventions include exposure to the feared situations or stimulus, and an experimental approach to test the accuracy of beliefs.

Resources for Working with Anxiety

Psychology Tools resources available for working therapeutically with anxiety may include:

References

  • Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

  • Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461–470.

  • Salkovskis, P. M., Forrester, E., & Richards, C. (1998). Cognitive–behavioral approach to understanding obsessional thinking. The British Journal of Psychiatry, 173(S35), 53–63.

  

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