Foreword. Anxiety disorders are common, serious, yet eminently treatable

Anxiety disorders are common, serious, yet eminently treatable. Progress in the treatment of anxiety disorders over the past thirty years is nothing short of remarkable. Each of the conditions responds to cognitive behavioral interventions tailored specifically for the problems at hand. This is truly outstanding news for patients suffering from these debilitating disorders, for therapists looking for ways to help patients presenting with these problems, and for the public health of this country and the world more broadly. The Dialectical Behavior Therapy Skills Workbook for Anxiety represents a welcome addition to the armamentarium available for clinicians looking to provide optimal care for their patients.

Conceived as a workbook for patients undergoing an active learning approach to the treatment of their disorder, this book is in fact far more. It provides people a context for understanding their recovery from the disabling features of anxiety. Understanding the context is helpful in encouraging people to move forward in treatment. They are not alone. For instance, in treating people who develop post-traumatic stress disorder (Keane, Marshall, and Taft 2006), we’ve learned that simply providing information on the diagnosis that characterizes their suffering presents a huge relief to the individual. Knowing that others have responded to traumatic life events in similar ways appears to represent a major advance for them.

Over the past twenty years, we’ve learned that the dialectical approaches stemming from Buddhist philosophies, when integrated with scientifically validated treatments (Linehan 1993), yield an augmentation of treatment effects. This improvement was initially visible with patients who suffered from personality disorders, but now we can say convincingly that these integrated treatments are enhancing the care of people with many different disorders, but in particular those that carry a major anxiety component. This workbook will contribute to a higher standard of care for patients, whether they use it on their own, with a therapist, or in a clinic.

How does one recover from panic, fear, phobias, PTSD, and a propensity to worry so much that it impedes one’s ability to enjoy life? The process involves developing a sense of where you are in the recovery process, recognizing that there’s more you want from your life, and refusing to be deterred from pursuing recovery. Psychologists call this self-efficacy: the capacity to see your way through the challenges before you.

Perhaps the most important concept in this workbook is mindfulness. A simple strategy conceptually, its effective use in your life becomes the architecture of recovery. Related to meditation, it offers a way of staying in the present when past, ineffective coping strategies foster looking toward the future. Mindfulness provides a coping strategy that facilitates positive present-moment performance and promotes a feeling of confidence beyond that which is customary. The key to strengthening mindfulness is practice. Beginning with the most elementary skills, one is quickly able to progress to applying mindfulness-based skills to the most complex and challenging experiences and settings. The rewards for applying the skills successfully are improvements in one’s perspective on what is possible in life. Once these skills are mastered, you’ll learn that you can do the things you think you cannot do.

What does the future hold for people who can learn to use dialectical skills in conjunction with other cognitive behavioral skills? The future is indeed bright. While today you are using a workbook for guiding your care, soon there will be internet-based facilitation of your treatment. The presence of the World Wide Web will permit the delivery of treatment on the spot and precisely when you need it. Smartphone-based applications are already available for some psychological conditions. More are under development. The present workbook, in its next iteration, will likely be available on the omnipresent smartphone so that reminders, lessons, and skills will be instantly available when you want them and when you might need them. This is the future of behavioral health care: therapy sessions that will work directly with you in your own home, work, and social environments. Social support will be delivered in person and electronically as one progresses systematically in overcoming obstacles to the enjoyment of life, pursuing goals, and gaining a firm sense of accomplishment.

As you explore The Dialectical Behavior Therapy Skills Workbook for Anxiety, you’ll recognize that the book progresses in steps that are manageable for all those who are concerned that they can never overcome their anxiety. Drs. Chapman, Gratz, and Tull are clearly accomplished clinicians who are sensitive to the needs of their patients and are talented in organizing treatment hierarchically so that the skills appear in a sensible order, build on one another, and result in the availability of a balanced portfolio of skills to be used across situations, circumstances, and environments. Their work represents state-of-the-art care across the anxiety disorders and those conditions that occur concomitantly. Patients, clinicians, and health care more broadly will benefit from the careful attention to detail they’ve brought forward in this workbook.

—Terence M. Keane, PhD director, Behavioral Science Division, National Center for Posttraumatic Stress Disorder professor of psychiatry and psychology, Boston University

Chapter 1

Anxiety and Anxiety Disorders

Since you are reading this book, it is likely that you or someone you know struggles with anxiety. And, if this is the case, it is important for you to know that you are not alone. Anxiety problems are such a common experience for people that research on anxiety disorders has grown exponentially in the past three decades. Yet, despite how much we have learned about anxiety disorders, what causes them, and how to successfully treat them, people continue to struggle with the experience of anxiety. For example, a survey of almost ten thousand people across the United States found that with the exception of substance-­use disorders, anxiety disorders are the most common mental health diagnosis. In fact, almost one-­third of people surveyed had experienced at least one anxiety disorder at some point in their lives (Kessler et al. 2005).

So, why are anxiety disorders so common in our society? Well, it is difficult to identify one specific factor that explains why so many people struggle with anxiety disorders. It is likely that a number of different factors work together to explain why anxiety disorders are so common. Genetics (or inherited traits), experience and learning, stressful or traumatic events, and the basic uncertainty of life are all thought to play a role in the development of anxiety disorders (Barlow 2002b). However, another reason why anxiety disorders are so common may have to do with the fact that anxiety is such a common experience in everyday life.

Did you know that many of the anxiety disorders are actually more severe variants of common experiences? It’s true. Take panic disorder, for example. Panic disorder is an anxiety disorder in which a person experiences frequent, out-­of-­the blue panic attacks (or episodes of intense fear and terror). Many people with panic disorder believe during a panic attack that they are dying or may be at risk of dying, and as a result, they may try to avoid the situations or activities that could trigger a panic attack, such as exercise. The large survey previously mentioned found that approximately 5 percent of people in the United States have had panic disorder at some point in their lifetimes (Kessler et al. 2005). However, what this survey doesn’t tell us is that the experience of panic attacks is a very common one. Around 11 percent of people have experienced a panic attack in the past year, and 28 percent of people say that they have had a panic attack at some point in their lives (Kessler et al. 2006).

And this isn’t just the case for panic attacks. Many other symptoms of common anxiety disorders are also common experiences among the general population. For example, worry (or thoughts about future stressful or anxiety-­provoking situations), which is one of the main symptoms of generalized anxiety disorder, and checking and ordering behavior, a symptom of obsessive-­compulsive disorder, are also quite common experiences (Tallis, Eysenck, and Mathews 1992; Radomsky and Rachman 2004).

Now, before you can understand what an anxiety disorder is, you need to first understand what anxiety is. In this chapter, we are going to take you through the basics of anxiety, including the symptoms of anxiety and how the normal, everyday experience of anxiety can turn into an anxiety disorder. We’ll also describe some common unhealthy behaviors and mental health disorders that often go along with anxiety disorders. The goal of this chapter is to help you develop an understanding and awareness of your anxiety so we can better target it with the skills that we present later in this book. Let’s get started.