ANXIETY Third edition Anxiety is a complex phenomenon and a central feature of many psychological prob- lems. This thoroughly revised third edition of Anxiety has been updated to include astonishing developments in the clinical implementation of knowledge about anxiety. In particular, this edition updates the reader with: • anew chapter on health anxiety; • a fully updated chapter on obsessive-compulsive disorders, including the concept of mental contamination and the causes of obsessions; • an account of advances in therapeutic techniques. Unique in its combination of an introduction to the subject with comprehensive coverage of the latest developments in research and practice, this book provides an excellent breadth and depth of coverage, which all practising and trainee clinical psychologists will find extremely informative. Stanley Rachman is a clinical researcher, specializing in psychopathology and psy- chological therapy. He is currently Professor Emeritus at the Institute of Psychiatry, King’s College London and the University of British Columbia, Vancouver. His other publications include The Treatment of Obsessions, Fear of Contamination, Panic Disorder (with Padmal de Silva), andObsessive–Compulsive Disorder (with Padmal de Silva). This page intentionally left blank Anxiety Third Edition Stanley Rachman Third edition published 2013 by Psychology Press 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USAand Canada by Psychology Press 711 Third Avenue, New York, NY10017 Psychology Press is an imprint of the Taylor & Francis Group, an informa business ©2013 Stanley Rachman The right of Stanley Rachman to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice:Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Psychology Press 1998 Second edition published by Psychology Press 2004 British Library Cataloguing in Publication Data Acatalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Rachman, Stanley. Anxiety / Stanley Rachman. – 3rd Edition. pages cm 1. Anxiety. 2. Anxiety disorders. I. Title. RC531.R334 2013 616.85'22–dc23 2012042676 ISBN: 978–0–415–69707–1 (hbk) ISBN: 978–0–415–69708–8 (pbk) ISBN: 978–0–203–55449–4 (ebk) Typeset in Palatino by Keystroke, Station Road, Codsall, Wolverhampton Contents Series preface vii Introduction to the third edition ix Introduction to the second edition xi 1 The nature of anxiety 1 2 Fear,anxiety and avoidance 13 3 Influences on anxiety 29 4 Anxiety, attention, perception, memory and emotional processing 41 5 Theories of anxiety 61 6 Specific phobias and the conditioning theory of fear 77 7 Panic and anxiety 93 8 Agoraphobia 121 9 Obsessions and compulsions 127 10 Health anxiety disorders 149 11 Social anxiety 171 12 Generalized anxiety disorder 183 13 Post-traumatic stress disorder (PTSD) 191 Some concluding remarks 205 Suggested reading 207 References 209 Index 231 v This page intentionally left blank Series preface Clinical Psychology: AModular Course was designed to overcome the problems faced by the traditional textbook in conveying what psycho- logical disorders are really like. All the books in the series, written by leading scholars and practitioners in the field, can be read as stand- alone texts, but they will also integrate with the other modules to form acomprehensive resource in clinical psychology. Students of psychol- ogy, medicine, nursing and social work, as well as busy practitioners in many professions, often need an accessible but thorough introduction to how people experience anxiety, depression, addiction or other disorders, how common they are, and who is most likely to suffer from them, as well as up-to-date research evidence on the causes and available treatments. The series will appeal to those who want to go deeper into the subject than the traditional textbook will allow, and base their examination answers, research, projects, assignments or practical decisions on a clearer and more rounded appreciation of the clinical and research evidence. Chris R. Brewin Other titles in this series: Depression, Second Edition Constance Hammen and Edward Watkins Stress and Trauma Patricia A. Resick Childhood Disorders, Second Edition Philip C. Kendall and Jonathan S. Comer vii Schizophrenia Max Birchwood and Chris Jackson Eating and Weight Disorders Carlos M. Grilo Personality Disorders Paul M. G. Emmelkamp and Jan Henk Kamphuis Addictions, Second Edition Maree Teesson, Wayne Hall, Heather Proudfoot and Louisa Degenhardt viii SERIES PREFACE Introduction to the third edition Anumber of important developments in the study of anxiety have taken place since the early 2000s, and the findings are being incorpo- rated into clinical practice. The most remarkable – indeed astonishing –application of the new knowledge and techniques was undertaken by the UK government in 2007. Recognizing that the provision of psychological treatment in the National Health Service (NHS) was insufficient and unsatisfactory, with long waiting lists and poor standards, it was decided to adopt the National Institute for Health and Clinical Excellence (NICE) guidelines for treating anxiety dis- orders and depression. The treatment recommended for anxiety dis- orders is cognitive behaviour therapy (CBT), but therewas a serious shortage of trained therapists and therefore an extraordinarily ambiti- ous training scheme was introduced in 2007. The aim was to reduce the waiting times for a psychological assessment and possible treatment of anxiety and depression from six months to two weeks, and improve the quality of therapy by using the evidence-based treatments recom- mended by NICE. A large sum of money was set aside for training 8,000 new therapists, starting with 3,000 in the first three years. An interim report on the progress of the programme, Improving Access to Psychological Therapies (IAPT), was published by a major contributor, Professor David M. Clark, in 2012. Over 3,600 therapists had been trained by the midpoint of the programme and ‘more than 300,000 patients are being treated annually ... clinical and employment related outcomes are generally in line with expectation’ (Clark 2012). On the research side, useful progress has been made in enhancing our understanding of anxiety disorders, notably post-traumatic stress disorder (PTSD), social phobia, obsessive compulsive disorders and ix