Why Anxiety Persists

Judith S. Beck, Ph.D. and Robert Hindman, Ph.D.


At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?

Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.

Rob Web

Robert Hindman, PhD

Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.

Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.”  Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”

Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking.  For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers.  For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.

Judith S. Beck, PhD

Judith S. Beck, PhD

Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).

Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.”  The problem with perfectionism is that it’s impossible to be perfect.  When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.

Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.

Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.


Learn more about the upcoming CBT for Anxiety workshop in Chicago. 


CBT for adolescents with anxiety: Mature yet still developing

New Study (1)Abstract

Anxiety disorders are common in adolescents (ages 12 to 18) and contribute to a range of impairments. There has been speculation that adolescents with anxiety are at risk for being treatment nonresponders. In this review, the authors examine the efficacy of cognitive-behavioral therapy (CBT) for adolescents with anxiety. Outcomes from mixed child and adolescent samples and from adolescent-only samples indicate that approximately two-thirds of youths respond favorably to CBT. CBT produces moderate to large effects and shows superiority over control/comparison conditions. The literature does not support differential outcomes by age: adolescents do not consistently manifest poorer outcomes relative to children. Although extinction paradigms find prolonged fear extinction in adolescent samples, basic research does not fully align with the processes and goals of real-life exposure. Furthermore, CBT is flexible and allows for tailored application in adolescents, and it may be delivered in alternative formats (i.e., brief, computer/Internet, school-based, and transdiagnostic CBT).

Kendall, C. P. & Peterman, S. J. (2015). CBT for adolescents with anxiety: Mature yet still developing. The American Journal of Psychiatry, 172(6). pp. 519-530. http://dx.doi.org/10.1176/appi.ajp.2015.14081061

CBT for Perinatal Distress

Amy Wenzel ProfileAmy Wenzel, Ph.D., ABPP

Beck Institute Faculty

Perinatal distress is defined as depression or anxiety experienced by women who are pregnant or who are in the first postpartum year (Wenzel, 2015). Those of you who have attended the Core 2 CBT for Anxiety Workshop at Beck Institute know that I do not include this issue as a part of the curriculum; nevertheless, questions pertaining to work with perinatal women are frequently asked once workshop participants know my background, and lively discussion usually ensues. Thus, we thought it would be of interest to address this topic in this e-newsletter.


On many occasions, I have encountered negative attitudes toward CBT in the community of mental health professionals (the vast majority of whom identify with other theoretical orientations) who treat perinatal women. Examples of these attitudes include:

  • Attention to the therapeutic relationship is paramount, and cognitive behavioral therapists place little, if any, significance on it.
  • Session structure is too rigid and cold for a perinatal woman in substantial distress, who needs to be provided with a “holding environment” (a Donald Winnicott construct) that provides nurturance, reassurance, and a sense of safety.
  • There is no way that a new mom who is frazzled and sleep-deprived can do homework in between sessions.


When I encounter these myths in conversations with colleagues, I treat them as assumptions that should be tested prospectively, rather than factual information that must be followed without critical evaluation in one’s clinical work. When I open up dialogue with these colleagues, they are pleased to learn about the central importance that cognitive behavioral therapists place on the therapeutic relationship and the high-quality research that has been published on the topic in the past decade. They are also surprised to learn that CBT with perinatal women (or with any clients, for that matter) should not be practiced in a mechanistic way, according to a checklist, but instead should proceed in a flexible, collaborative manner that is driven by the individualized case conceptualization and the client’s preferences. In contrast to the experience of some of my non-CBT colleagues, many perinatal women have expressed gratitude for CBT’s session structure and tangible exercises, remarking that it is precisely because they are frazzled and sleep-deprived that they respond well to CBT’s organized approach. Moreover, newer technology such as Mobile phone apps allow perinatal women much flexibility in completing homework; for example, many of my clients have completed the equivalent of a thought record or an activity log while nursing their infants to sleep.


Interestingly, unlike the literature on CBT for a host of adult mental health problems, there is mixed evidence for CBT’s efficacy with perinatal women (with postpartum depression being the perinatal mental health problem that has received the vast majority of the attention). Authors of meta-analyses on this subject generally conclude that there is strong evidence for the efficacy of interpersonal psychotherapy (IPT) and weak to moderate evidence for the efficacy of CBT for this population. However, in my recent comprehensive review of psychotherapy for perinatal mental health problems (Wenzel, 2016), I concluded that a true “Beckian” approach to CBT—one in which the case conceptualization lies at the heart of the treatment and informs intervention in a flexible, individualized, and collaborative manner—has not yet been evaluated with perinatal women. The majority of the “CBT” treatment packages evaluated to date are heavily focused on psychoeducation and specific techniques (e.g., relaxation) delivered at prescribed times throughout the course of treatment. Although these packages are thoughtfully designed and often theoretically driven, in many instances they did not fare better than usual care in outcome analyses. Thus, I recently published a manual that describes a case conceptualization-driven approach to CBT with perinatal women (Wenzel, 2015), and I look forward to empirical research that evaluates this approach to treating perinatal distress. I will also call your attention to an excellent article written by Arch, Dimidjian, and Chessick (2012) that refutes myths about the dangers of exposure therapy with pregnant women and provides guidelines for conducting exposures with this population in a safe but effective manner.


Arch, J. J., Dimidjian, S., & Chessick, C. (2012). Are exposure-based cognitive behavioral therapies safe during pregnancy? Archives of Women’s Mental Health, 15, 445–457.

Wenzel, A. (2015; with K. Kleiman). Cognitive behavioral therapy for perinatal distress. New York, NY: Routledge.

Wenzel, A. (2016). Psychotherapy for psychopathology during pregnancy and the postpartum period. In A. Wenzel (Ed.), Oxford handbook of perinatal psychology (pp. 341-365). New York, NY: Oxford University Press.

Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial

New Study (1)Abstract

Importance:  Generalized anxiety disorder (GAD) is common in older adults; however, access to treatment may be limited, particularly in rural areas.
Objective:To examine the effects of telephone-delivered cognitive behavioral therapy (CBT) compared with telephone-delivered nondirective supportive therapy (NST) in rural older adults with GAD.

Design, Setting, and Participants:Randomized clinical trial in the participants’ homes of 141 adults aged 60 years and older with a principal or coprincipal diagnosis of GAD who were recruited between January 27, 2011, and October 22, 2013.

Interventions: Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping.

Main Outcomes and Measures: Primary outcomes included interviewer-rated anxiety severity (Hamilton Anxiety Rating Scale) and self-reported worry severity (Penn State Worry Questionnaire-Abbreviated) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Mood-specific secondary outcomes included self-reported GAD symptoms (GAD Scale 7 Item) measured at baseline and 4 months’ follow-up and depressive symptoms (Beck Depression Inventory) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Among the 141 participants, 70 were randomized to receive CBT and 71 to receive NST.

Results: At 4 months’ follow-up, there was a significantly greater decline in worry severity among participants in the telephone-delivered CBT group (difference in improvement, -4.07; 95% CI, -6.26 to -1.87; P?=?.004) but no significant differences in general anxiety symptoms (difference in improvement, -1.52; 95% CI, -4.07 to 1.03; P?=?.24). At 4 months’ follow-up, there was a significantly greater decline in GAD symptoms (difference in improvement, -2.36; 95% CI, -4.00 to -0.72; P?=?.005) and depressive symptoms (difference in improvement, -3.23; 95% CI, -5.97 to -0.50; P?=?.02) among participants in the telephone-delivered CBT group.

Conclusions and Relevance: In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD.

Brenes G. A., Danhauer S.C., Lyles M.F., Hogan P.E. & Miller M.E. (2015) Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015 Aug 5. doi: 10.1001/jamapsychiatry.2015.1154.

Worry and Worriers

Judith S. Beck, PhD

Judith S. Beck, Ph.D.

Worry, as defined by Clark and Beck (2012) is “a persistent, repetitive, and uncontrollable chain of thinking that mainly focuses on the uncertainty of some future negative or threatening outcome in which the person rehearses various problem-solving solutions but fails to reduce the heightened sense of uncertainty about the possible threat.”

This certainly describes the thinking of Stacy, a client I recently treated who suffered from Generalized Anxiety Disorder. She is a 44 year old woman, the mother of three children. And she worries constantly. “What if my boss doesn’t like my work?” “What if my kids get rejected at school?” “What if my husband falls in love with someone else?” “What if this cough I have is really throat cancer?” “What if the bus I’m on crashes?”

Some amount of worry is normal and can be productive when individuals think through a potential problem and come up with a way to prevent it, cope with it if it does arise, or lessen its impact.  But Stacy’s worry is pervasive and unproductive. Why does she keep worrying when it’s clearly dysfunctional? Why does she have so little control over it? A number of factors account for why she worries so incessantly (while another client of mine, an adolescent, fails to worry in situations in which at least a little anxiety is warranted and would be productive).

Stacy’s safety behaviors include the following:

  • She tries as hard as she can to predict problems. “If my boss could possibly be displeased with me, I should anticipate that and know how to respond.”
  • She is constantly trying to gain certainty that a given difficulty won’t occur. “If I think through every option thoroughly, I’ll be able to avoid the problem.”
  • She tries to figure out the optimal solution. “If I just keep thinking about it, maybe I can figure out the perfect thing to do.”
  • She avoids situations she deems risky. “The weather is bad; I better cancel my doctor’s appointment because I might get into a car accident.”
  • She tries to reassure herself and frequently asks for reassurance from others. “I can only feel better if I’m 100% sure that nothing bad will happen.”

Other contributing factors include the following:

  • She catastrophizes, automatically considering only the worst outcomes of a situation. “If my child is late, maybe it means she’s been in an accident.”
  • She misreads her physiological arousal. “I’m so on edge. There must be something bad going on.”
  • She lacks confidence about her ability to handle problems. “I won’t be able to handle it if the problem does arise.”
  • She holds positive beliefs about the worry process. “It’s good to worry because worrying can keep me safe.”
  • She has negative beliefs about worry. “I can’t control my worry. There’s nothing I can do about it.” “I’m going to worry so much that I’ll go crazy!”
  • She tries to stop worrying. But her attempt to suppress worry-related thoughts often rebounds and leads to more unwanted thoughts, which then triggers her positive worry beliefs and the worry process begins again.
  • She doesn’t realize that, most of the time, she can’t solve a given problem and therefore feel relief—because the problem hasn’t happened yet.
  • At the bottom of all this are her underlying negative beliefs about threat and uncertainty, and a sense of helplessness.

Rather than evaluating Stacy’s automatic thoughts (because successfully evaluating one worry-related automatic thought will often be replaced by another worry-related automatic thought), we focused on modifying her dysfunctional beliefs about worry itself (it helps me stay safe), reducing her safety behaviors (seeking reassurance) and attempts to control her worry (thought suppression), using functional problem solving when indicated, identifying when she was thinking catastrophically and mindfully refocusing her attention, facing her worst fear, and accepting and building her tolerance for uncertainty. Although she described having been “a worrier” her whole life, she was able to overcome her excessive worry. She gained a sense of competence and much improved peace of mind.



Clark, D., & Beck, A. (2012). The Anxiety and Worry Workbook: The Cognitive Behavioral Solution. New York: Guilford Press.

Workshop Participant Spotlight – Pablo Alonso

As a therapist in Madrid, Pablo knew he wanted to improve his skills and, after reading many of both Drs. Beck’s books, he decided to come to Philadelphia for our Core 2: CBT for Anxiety course. “Part of being a great therapist is constantly working to improve your skills, and the best way is to go directly to the source.”

DSC_0138Pablo works in a clinic at the University of Madrid where he is a therapist, researcher, and supervisor of final-year students. He also works at the Deyre Medical Clinic, where he provides therapy to trauma patients. His clients are mainly adults and adolescents with depression, anxiety, and substance use disorders.

“When I grow up as a therapist I want to be just like Amy,” referring to Dr. Wenzel, who instructed the 3 day course on CBT for Anxiety. Roleplays were his favorite part of the workshop, because that’s when he got to see Dr. Wenzel “in action.”

On having the opportunity to meet Dr. Aaron Beck, “I have seen so many videos on YouTube, it was like I met him a long time ago.” 

His favorite lesson from the workshop was that “CBT is eclectic, it’s not a rigid therapy where you have to do A, B, then C. It’s fluid.”

No trip to Philadelphia is complete without a history tour and a cheese steak, which Pablo enjoyed and said,”I’m going to have to repeat that!”

Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between veteran and community participants

New Study (1)Abstract:

Cognitive–behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

Barrera, T. L., Cully, A. J., Amspoker B. A., Wilson, L. N., Kraus-Schuman, C., Wagener, D. P., Calleo, S. J., Teng, E. J., Rhoades, H. M. & Mosozera, N. (2015)9. Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants  Journal of Anxiety Disorders, Volume 33, Issue null, Pages 72-80

Ethical considerations in exposure therapy with children

New Study (1)Abstract:

Despite the abundance of research that supports the efficacy of exposure therapy for childhood anxiety disorders and OCD, negative views and myths about the harmfulness of this treatment are prevalent. These beliefs contribute to the underutilization of this treatment and less robust effectiveness in community settings compared to randomized clinical trials. Although research confirms that exposure therapy is efficacious, safe, tolerable, and bears minimal risk when implemented correctly, there are unique ethical considerations in exposure therapy, especially with children. Developing ethical parameters around exposure therapy for youth is an important and highly relevant area that may assist with the effective generalization of these principles. The current paper reviews ethical issues and considerations relevant to exposure therapy for children and provides suggestions for the ethical use of this treatment.

Gola, A. J., Beidas, S. R., Antinoro-Burke, D., Kratz, E. H. & Fingerhut, R. (2015). Ethical considerations in exposure therapy with children.  Cognitive and Behavioral Practice. doi:10.1016/j.cbpra.2015.04.003

Protocol: Reducing Suicidal Ideation Among Turkish Migrants in the Netherlands and in the UK: Effectiveness of an Online Intervention

New Study (1)Abstract
Background: The Turkish community living in Europe has an increased risk for suicidal ideation and attempted suicide. Online self-help may be an effective way of engagement with this community. This study will evaluate the effectiveness of a culturally adapted, guided, cognitive behavioural therapy-based online self-help intervention targeting suicidal ideation for Turkish adults living in the Netherlands and in the UK.
Methods and design: This study will be performed in two phases. First, the Dutch online intervention will be adapted to Turkish culture. The second phase will be a randomized controlled trial with two conditions: experimental and waiting-list control. Ethical approval has been granted for the trials in London and Amsterdam. The experimental group will obtain direct access to the intervention, which will take 6 weeks to complete. Participants in the waiting-list condition will obtain access to the modules after 6 weeks. Participants in both conditions will be assessed at baseline, post-test and 3 months post-test follow-up. The primary outcome measure is reduction in frequency and intensity of suicidal thoughts. Secondary outcome measures are self-harm, attempted suicide, suicide ideation attributes, depression, hopelessness, anxiety, quality of life, worrying and satisfaction with the treatment.
Read More: http://informahealthcare.com/doi/abs/10.3109/09540261.2014.996121

Written by 2013 Student Scholarship Recipient: Ozlem Eylem:

Eylem, O., van Straten, A., Bhui, K., & Kerkhofl, J.F.M. (2015). Protocol: Reducing suicidal
ideation among Turkish migrants in the Netherlands and in the UK: Effectiveness of an online intervention. International Review of Psychiatry, 27(1), 72-81. doi:

CBT for Insomnia & Related Anxiety & Depression in Cancer Patients

CBT studyAbstract Objectives: This secondary analysis of data from a randomised controlled trial explores associations between common symptom clusters and evaluates pre-treatment to post-treatment changes in clinical levels of these symptoms following cognitive behaviour therapy for insomnia (CBT-I).

Methods: Baseline data from 113 participants with insomnia were explored to establish rates of and associations between clinical levels of fatigue, anxiety and depression across the sample. Effects of CBT-I on this symptom cluster were also explored by examining changes in pre-treatment to post-treatment levels of fatigue, anxiety and depression.

Results: At baseline, the most common symptom presentation was insomnia + fatigue, and 30% of the sample reported at least three co-morbid symptoms. Post-CBT, the number of those experiencing clinical insomnia and clinical fatigue decreased. There were no changes in anxiety rates from baseline to post-treatment in the CBT group and modest reductions in rates of those with clinical depression. Seven individuals (9.6%) from the CBT group were completely symptom free at post-treatment compared with 0% from the treatment as usual condition. Chi-square analysis revealed a significant relationship between group allocation and changes in symptoms of insomnia and fatigue. No such relationship was found between group allocation and mood variables.

Conclusions: These findings confirm the high rate of symptom co-morbidities among cancer patients and highlight strong associations between sleep and fatigue. CBT-I appears to offer generalized benefit to the symptom cluster as a whole and, specifically, is effective in reducing fatigue, which exceeded clinical cut-offs prior to implementation of the intervention. This has implications for the diagnosis/management of common symptoms in cancer patients.

Fleming, L., Randell, K., Harvey, C., & Espie, C. A. (2014). Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients? Psycho-Oncology, 23, 6, 679-684.