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When Panic Attacks

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Published by Harmony on 2007-06-12
Paperback: $17.00
SELF-HELP, HEALTH and FITNESS, FAMILY and RELATIONSHIPS


Are you plagued by fears, phobias, or panic attacks? Do you toss and turn at night with a knot in your stomach, worrying about your job, your family, work, your health, or relationships? Do you suffer from crippling shyness, obsessive doubts, or feelings of insecurity?
What you may not realize is that these fears are almost never based on reality. Anxiety is one of the world’s oldest cons. When you’re anxious, you’re actually fooling yourself. You are telling yourself things that simply aren’t true. See if you can recognize yourself in any of these distortions:
All-or-Nothing Thinking: “My mind will go blank when I give my presentation at work, and everyone will think I’m an idiot.”
Fortune Telling: “I just know I’ll freeze up and blow it when I take my test.”
Mind Reading: “Everyone at this party can see how nervous I am.”
Magnification: “Flying is so dangerous. I think this plane is going to crash!”
Should Statements: “I shouldn’t be so anxious and insecure. Other people don’t feel this way.”
Emotional Reasoning: “I feel like I’m on the verge of cracking up!”
Self-Blame: “What’s wrong with me? I’m such a loser!”
Mental Filter: “Why can’t I get anything done? My life seems like one long procrastination.”
Now imagine what it be like to live a life that’s free of worries and self-doubt; to go to sleep at night feeling peaceful and relaxed; to overcome your shyness and have fun with other people; to give dynamic presentations without worrying yourself sick ahead of time; to enjoy greater creativity, productivity and self-confidence.
Does that sound impossible? The truth is you can defeat your fears. In When Panic Attacks, Dr. Burns takes you by the hand and shows you how to overcome every conceivable kind of anxiety. In fact, you will learn how to use more than forty simple, effective techniques, and the moment you put the lie to the distorted thoughts that plague you, your fears will immediately disappear. Dr. Burns also shares the latest research on the drugs commonly prescribed for anxiety and depression and explains why they may sometimes do more harm than good.
This is not pop psychology but proven, fast-acting techniques that have been shown to be more effective than medications. When Panic Attacks is an indispensable handbook for anyone who’s worried sick and sick of worrying.


(Paperback (Reprint), 2007-06-12)
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ASIN: 076792083X
ISBN: 9780767920834
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Praise for When Panic Attacks “Few truly great books on psychotherapy have been published and this is one of them When Panic Attacks tells you how to deal with all kinds of anxiety and with most other emotional problems It is clearly and charmingly written ” —Albert Ellis Ph D founder of the Albert Ellis Institute and bestselling author of A Guide to Rational Living “Another masterpiece from the author who helped millions help themselves with Feeling Good The New Mood Therapy Dr Burns’s elegant writing style compassion and humor translate powerful psychotherapy methods into accessible practical and helpful tools for the vast number of individuals who struggle with anxiety ” —Henny Westra Ph D Associate Professor and Director of the York University Anxiety Research Clinic “Dr Burns has a truly unique and remarkable ability to present the most current evidence based therapies for anxiety in a way that is engaging compelling easy to read and—most important of all—useful Readers will be able to make immediate practical use of the concepts and strategies Dr Burns presents here I’m sure this book will change many lives ” —Jacqueline B Persons Ph D Director of the San Francisco Bay Area Center for Cognitive Therapy and Associate Clinical Professor at the University of California Berkeley “Besides being well written and accessible with lots of patient narratives to spark in terest When Panic Attacks lays out exactly what readers need to do to feel better ” —Library Journal

Also by David D Burns M D Feeling Good The New Mood Therapy Intimate Connections The Feeling Good Handbook Ten Days to Self Esteem Ten Days to Self Esteem The Leader’s Manual c

cK W H E N Panic A T T A C S The New Drug Free Anxiety Therapy That Can Change Your Life David D Burns M D M o r g a n R o a d B o o k s N e w Yo r k c

Copyright © 2006 by David Burns All Rights Reserved A hardcover edition of this book was originally published in 2006 by Morgan Road Books Published in the United States by Morgan Road Books an imprint of The Doubleday Broadway Publishing Group a division of Random House Inc New York www morganroadbooks com morgan road books and the M colophon are trademarks of Random House Inc Book design by Donna Sinisgalli Library of Congress Cataloging in Publication Data Burns David D When panic attacks the new drug free anxiety therapy that can change your life by David D Burns p cm Includes bibliographical references and index 1 Panic attacks—Treatment 2 Panic attacks—Alternative treatment I Title RC535 B87 2006 616 85'22306—dc22 2005052260 ISBN 978 0 7679 2083 4 1 3 5 7 9 10 8 6 4 2 First Paperback Edition

’ S N O T E The ideas and techniques in this book are not intended as a substitute for consultation or treatment with a qualified mental health professional The names and identities of the people in this book have been disguised to such an extensive degree that any resemblance to any person living or dead is purely coincidental Most of the cases represent composites of many patients with similar problems I’ve done this to protect patient confidentiality However I’ve also attempted to preserve the spirit of the work we did together I hope these stories ring true and resonate with your own personal experience

would like to thank my daughter Signe Burns for her enormous contribu tions to the creation of this book Without Signe’s brilliant editing and spirit this book would have been radically different We worked on it together for over a year—a joyous but sometimes humbling experience because Signe’s feedback was always ruthlessly honest We had tons of fun and spent lots of time giggling uncontrollably just about the time our brains were starting to turn to mush toward the end of the day I also want to thank Amy Hertz for giving me the chance to write this book and to work with her new publishing imprint Morgan Road Books I’ve been knee deep in academic research and clinical teaching at Stanford for more than ten years and there have been many new developments in the treatment of anxiety and depression that I’ve wanted to share with my colleagues and with the general public I’m especially grateful to Marc Haeringer associate editor at Morgan Road Books for his fabulous editing and collaboration in the creation of this manuscript I would also like to acknowledge many gifted colleagues whose creativity and innovation have contributed so greatly to the development and validation of the methods in this book Of course Drs Albert Ellis and Aaron Beck were two of the earliest pioneers but it’s really been a team effort Thousands of

gifted clinicians and researchers worldwide have worked together to put Cog nitive Behavior Therapy on the map Finally I want to thank the psychiatric residents at Stanford University School of Medicine who have attended my Wednesday evening psychotherapy seminars over the past several years This has been a dynamic personal and professional experience for me and while I’ve been the teacher I’ve also been the student I’ve learned tremendously from all of you every single week Your enthusiasm compassion and zeal have been an incredible gift viii Acknowledgments

Introduction 1 Part I The Basics 1 I Think Therefore I Fear 7 2 Are You Anxious Or Depressed 31 3 Do You Have an Anxiety Disorder 40 4 Placebo Nation The Truth About Antidepressants and Anti Anxiety Medications 47 5 What Would It Be Worth If I Could Show You How to Change Your Life 64 6 The Daily Mood Log 76 Part II The Cognitive Model 7 Uncovering Your Self Defeating Beliefs 99 8 How to Modify a Self Defeating Belief 108 9 The What If Technique 127 10 Compassion Based Technique 133 11 Truth Based Techniques 144 12 Logical and Semantic Techniques 171 13 Quantitative Techniques 191 14 Humor Based Techniques 201 15 Role Playing and Spiritual Techniques 209

16 Motivational Techniques 221 17 Anti Procrastination Techniques 234 Part III The Exposure Model 18 Classical Exposure Taking a Page from the Tibetan Book of the Dead 251 19 Cognitive Exposure The Monster in Your Mind 268 20 Interpersonal Exposure The Fear of People 285 Part IV The Hidden Emotion Model 21 The Hidden Emotion Technique Sweeping Your Problems Under the Rug 313 Part V Selecting the Techniques That Will Work for You 22 The Recovery Circle Failing as Fast as You Can 333 23 Putting It All Together The Woman with the Scar on Her Nose 364 24 Feeling Better versus Getting Better Relapse Prevention Training 389 References 411 Your Anxiety Toolkit 415 Index 437 x Contents

Do self help books actually help anyone During the past fifteen years Dr Forrest Scogin and his colleagues from the University of Alabama Medical Center have conducted a series of innovative experiments designed to answer this question The researchers randomly divided sixty patients seeking treat ment for episodes of major depression into two groups They told both groups of patients that they’d have to wait four weeks to see a psychiatrist In the meantime they gave each patient in one group a copy of my first book Feeling Good The New Mood Therapy and encouraged them to read it during the wait ing period The patients in the second group did not receive the book A re search assistant called all the patients each week and administered two widely used tests that can track changes in depression The researchers were surprised by the results of their study At the end of the four week waiting period two thirds of the patients who read Feeling Good had improved substantially or recovered even though they did not receive any medications or psychotherapy In fact they improved so much that they didn’t need any additional treatment In contrast the patients who did not receive Feeling Good failed to im prove The researchers then gave them a copy of Feeling Good and asked them to read it during a second four week waiting period Two thirds of them recov

ered and did not require any additional treatment Furthermore the patients who responded to Feeling Good have not relapsed but have maintained their gains for up to three years so far These were not fly by night studies but peer refereed studies published in top psychological and medical journals The researchers concluded that Feel ing Good “bibliotherapy” should be the first line of treatment for most patients suffering from depression because it often works faster than drugs or psy chotherapy In addition it’s incredibly cost effective and entirely free of the troublesome side effects of psychiatric medications such as weight gain in somnia sexual difficulties or addiction The therapy I described in Feeling Good is called Cognitive Behavior Ther apy CBT because you learn to change the negative thoughts or “cognitions ” that cause the depression as well as the self defeating behavior patterns that keep you stuck Dr Scogin’s groundbreaking studies clearly show that for many individuals CBT can be very effective in a self help format even without pills or the guidance of a therapist 1 Dozens of published studies have confirmed that CBT is also effective when administered by therapists It’s at least as good as the best antidepressant medications in the short term and is more effective in the long term For ex ample in a recent landmark study conducted at outpatient clinics at the Uni versity of Pennsylvania and Vanderbilt University 240 patients suffering from episodes of moderate to severe depression were randomly assigned to treat ment with CBT paroxetine Paxil or a placebo so the effects of these treat ments could be compared in both the short and the long term The results were recently published in two major papers in the Archives of General Psychiatry the top psychiatric journal 2 The findings confirmed once again that CBT was at least as effective as the antidepressant in the short term but more effective in the long term Dr Robert DeRubeis the chairman of the Department of Psychology at the University of Pennsylvania explained that CBT had more lasting effects because it gave the patients the tools they needed to manage their problems and emotions He concluded that CBT and not pills should be the treatment of choice for patients suffering from moderate to severe depression He stated “Patients with depression are often overwhelmed by other factors in their life 2 Introduction

that pills simply cannot solve cognitive therapy succeeds because it teaches the skills that help people cope ”3 CBT has also been shown to be effective in the treatment of anxiety In fact in their review of the world literature Dr Henny Westra from York Uni versity in Toronto Ontario and Dr Sherry Stewart from Dalhousie University in Halifax Nova Scotia concluded that • CBT is the gold standard in the treatment of all forms of anxiety • CBT is more effective than any other type of psychotherapy or medica tion In fact CBT without medications appears to be more effective than CBT with medications 4 My own clinical experience is consistent with these conclusions But here’s the question Will CBT bibliotherapy be effective for anxiety If you’re suffering from shyness chronic worrying panic attacks phobias public speak ing anxiety test anxiety post traumatic stress disorder or obsessive compulsive disorder will this book do you any good Some encouraging studies suggest that the answer may be yes Dr Isaac Marks from the Institute of Psychiatry at the University of London has shown that many individuals can overcome anxiety disorders using CBT techniques without face to face psychotherapy or medications I’m hopeful that this book will prove just as effective for people with anxiety as Feeling Good has been for people struggling with depression However no book technique or pill will work for everyone Some people will need the help of a compassionate and skillful therapist in addition to the meth ods in this book There’s no shame in that When should you seek treatment from a mental health professional There’s no absolute rule but these guide lines may help • How severe is the problem If you feel overwhelmed or hopeless face to face therapy can be extremely helpful • Do you have any suicidal impulses If you have the urge to take your life you should never rely on self help alone Emergency face to face intervention is mandatory If you have a therapist call him or her imme diately and describe how you feel If you have no therapist call 911 or Introduction 3

go to the emergency room of the nearest hospital Your life is too pre cious to play Russian roulette • Do you have any homicidal impulses If you feel enraged and have the urge to hurt or kill other people emergency intervention is manda tory Don’t flirt with these urges • What type of problem do you have Some problems are harder to treat than others and sometimes medications are indicated For example if you have bipolar manic depressive illness with extreme uncontrol lable highs and lows then mood stabilizing medications such as lithium may be necessary • How long have you been suffering If you’ve been working with the tools in this book for three or four weeks but your symptoms haven’t started to improve then professional guidance could help you get on track It’s the same as with anything you’re trying to learn If your tennis serve is off you may have trouble correcting the problem on your own because you can’t quite see what you’re doing wrong But a good coach can quickly diagnose the problem and show you how to correct it I think it’s great news that so many people suffering from depression and anxiety can now be treated quickly and effectively without medications and that the prognosis for complete recovery is so positive Whether you’re seeing a therapist taking psychiatric medications or trying to defeat your fears on your own the techniques in this book can be vitally important The goal is not simply the relief of your symptoms but a profound transformation in the way you think and feel 4 Introduction

The Basics c

Practically everybody knows what it’s like to feel anxious worried nervous afraid uptight or panicky Often anxiety is just a nuisance but sometimes it can cripple you and prevent you from doing what you really want with your life But I have some great news for you You can change the way you feel Powerful new drug free treatments have been developed for depression and for every conceivable type of anxiety such as chronic worrying shyness public speaking anxiety test anxiety phobias and panic attacks The goal of the treatment is not just partial improvement but full recovery I want you to be able to wake up in the morning free of fears and eager to meet the day telling yourself it’s great to be alive Anxiety comes in many different forms See if you can recognize yourself in any of these patterns • Chronic Worrying You constantly worry about your family health career or finances Your stomach churns and it seems as if something bad is about to happen but you can’t figure out exactly what the prob lem is • Fears and Phobias You may be afraid of needles blood heights eleva tors driving flying water spiders snakes dogs storms bridges or getting trapped in closed spaces

• Performance Anxiety You freeze up whenever you have to take a test perform in front of other people or compete in an athletic event • Public Speaking Anxiety You get nervous whenever you have to talk in front of a group because you tell yourself “I’ll tremble and everyone will see how nervous I am My mind will go blank and I’ll make a complete fool of myself Everyone will look down on me and think I’m a total neurotic ” • Shyness You feel nervous and self conscious at social gatherings be cause you tell yourself “Everyone seems so charming and relaxed But I don’t have anything interesting to say They can probably tell how shy and awkward I feel They must think I’m some kind of weirdo or loser I’m the only one who feels this way What’s wrong with me ” • Panic Attacks You experience sudden terrifying panic attacks that seem to come from out of the blue and strike unexpectedly like light ning During each attack you feel dizzy your heart pounds and your fingers tingle You may tell yourself “I must be having a heart attack What if I pass out or die I can’t breathe right What if I suffocate ” You try to hang on for dear life Before long the feelings of panic disappear as mysteriously as they came leaving you bewildered frightened and humiliated You wonder what happened and when it’s going to strike again • Agoraphobia You’re afraid of being away from home alone because you think something terrible will happen—perhaps you’ll have a panic at tack—and there won’t be anyone to help you You may fear open spaces bridges crowds standing in line at the grocery store or taking public transportation • Obsessions and Compulsions You’re plagued by obsessive thoughts that you can’t shake from your mind and compulsive urges to perform superstitious rituals to control your fears For example you may be con sumed by the fear of germs and have the irresistible urge to wash your hands over and over all day long Or you may get up and check the stove repeatedly after you’ve gone to bed just to make sure you didn’t leave the burners on • Post Traumatic Stress Disorder You’re haunted by memories or flash 8 The Basics

AA Alcoholics Anonymous 74 abandonment fear of 323 abuse sexual 275–79 362 acceptance 202 healthy vs unhealthy 216–17 217 acceptance paradox 188 214–20 350 Buddhist principle as basis of 216 359 described 21–22 in relapse prevention 404 407 410 St Paul as example of 22 spiritual traditions as compatible with 216 as tool in role playing 358–59 as weapon against fears 280 334 334n 362 as weapon against self defeating beliefs 377 384–86 achievement addiction 18–20 19 100 101 105 106 406–7 action motivation vs 241 agoraphobia 253 254 case histories of 127–32 129 159–62 267 333 335 defined 8 41 alcohol consumption 74 228–29 Alcoholics Anonymous AA 74 all or nothing thinking 166 197 314 350 397 and addictions 230 on cognitive distortions checklists 16 83–84 136 287 338 353 354 367 368 395 396 as component of mood logs 79 397 as contributing to relapse 391 defined 16 and performance anxiety 171 175 and test anxiety 224 American Psychiatric Association 50 52 60 63 anger 93 179 336 367 399 grief process and 88 as hidden emotion 323–25 post traumatic stress and 66–68 68 resulting from blame 169 398 anger phobia 19 106 316 anti anxiety drugs 47–63 antidepressants 10 47–63 198 placebos vs 53–60 57 and suicidal impulses 59–60 63 See also Paxil Prozac Zoloft anti procrastination techniques for 234–47 334 353 354 360 work sheets 242 243 334 360 Page numbers in italics refer to checklists forms and work sheets

See also procrastination anti shyness techniques See interpersonal exposure techniques Antonuccio David 62 anxiety 33 34–36 40–53 61–63 64 92 181–82 288 313–29 336 367 bibliotherapy for 1–4 as cause of procrastination 234 causes of 10–11 280–81 checklist 41 chemical imbalance theory of 47–53 as common mental health problem 64 depression and 31–32 determining triggers of 410 disorder 40–46 drug treatments for 47–63 environmental factors in 45 62 fainting and 157n forms of 40–42 41 generalized anxiety disorder See generalized anxiety disorder genetic factors in 45 48 62 hidden emotions as cause of 406–10 most common forms of 41 neurotic healthy fear vs 13–14 perception of danger and 31 performance 8 41 101 171 253 315 public speaking 8 41 163 253 254 269 272–74 288 308–9 405 recovery circle vs 333–63 self defeating belief as cause of 19 shame as central feature of 32 signs of 7–9 151–52 as symbolic expression 130 symptoms of 151–52 test 41 67–68 102–5 103 104 107 222 224–26 225 253 as warning signal 325 406 what if technique vs 127 See also Biological Model Cognitive Model Exposure Model Hidden Emotion Model anxiety profile 41 anxious feelings test 33 34–35 34 35 162 anxious physical symptoms test 33 35–36 36 38 approval addiction 19 20 100 105 106 356 377 386 Archives of General Psychiatry 2 49 assertiveness 315 See also Five Secrets of Effective Communication assertiveness training 317 feared fantasy technique vs 280 386 Ativan 10 52 63 attention deficit hyperactivity disorder 51 attitude cost benefit analysis 222 avoidance 10 252–53 266 B Beck Aaron 12 171–72 behavioral or habit cost benefit analysis 222 behavior therapy psychoanalysis vs 251 See also exposure techniques benzodiazepines 52–53 63 “be specific” technique 185–90 357 bibliotherapy 1–4 62 psychotherapy vs 1–2 biological defects 45 Biological Model 10–11 bipolar illness 4 63 rapidly cycling form of 164 See also manic depressive illness blame 100 116 169 anger resulting from 398 on cognitive distortions checklists 16 83–84 136 287 338 353 354 367 368 395 396 as component of mood logs 79 cost benefit analysis of 121 122 defined 16 God as target of 399 See also other blame self blame blood phobia 23–25 48 254–57 255 body dysmorphic disorder BDD 40 42 253 254 269 364–88 369 371 372 388 defined 9 41 borderline personality disorder 177–79 brain chemistry and cognitive behavior therapy 198 438 Index

See also chemical imbalance theory brief mood survey 32 33 34–39 34 63 407 brushfire fallacy 19 20 105 106 356 377 Buddha 390 Buddhism acceptance paradox based on 216 359 and cognitive behavior therapy 23 Burns David D and A E Bennett Award 49 274 blood fear of 23–25 48 evaluation of therapy session form used by 278 flirting rule of 295–96 heights feared by 258–59 405 as Highland Hospital emergency room volunteer 24–25 Mr Cranston and 258–59 266–67 pills or skills prescription of 62–63 public speaking anxiety of 272–74 308–9 405 as shy 299 Burns Mrs 291 300 Burns Signe 300 Burns Rule 295–96 C case studies Alicia 313–15 322 Annemarie 294–98 Betty 275–79 Brent 26–30 Carrie 14 Cassandra 260–64 263 Clarisse blamer 169 Clarisse secretary 304–5 Corey 326–29 David 268 Deborah 163 Diane Martha and Erika 164–67 Eileen 73–74 Emily 145 Helen 364–88 369 371 372 388 Howard 264–66 Jackson 185–89 Jamie 268 Jason 168–69 172–77 173 174 176 337–39 341–47 342 346–47 Jeffrey 15–23 Johanna 222 224–26 225 José 192–96 194 207 Joseph 301–2 June 159–62 333 335 Kim 147–51 148 Kristin and Tom 127–32 129 267 Magdalena 254–57 255 Mandy 206 Marci 321–25 Marie 202 Mark 198–200 Marsha Leslie and Elisa 76–77 80–90 81 85 87 Monica 280–84 Nadine 208 Nate 112–16 115 235 Perry 239–41 Phil 197–98 Rachel 177–79 Rasheed 102–5 103 104 107 Raymond 237–38 Regina 181–82 Roger 289–92 Sam 65–67 Spyder 299 Terri 152–59 154 162 318–21 404 Theresa 269–72 Trevor 69–72 203 205 Walter 134–43 136 141 211–13 Wilson 406–10 Yolanda 242 244 CBT See cognitive behavior therapy chemical imbalance theory 10–11 198 anxiety and 47–53 depression and 47–53 drug companies and 50 panic attacks and 51 serotonin and 47 49–50 272 308 Christianity acceptance paradox as compatible with 22 216 chronic worrying See worrying chronic classical exposure techniques 251–67 253 268 334 353 354 distraction 131–32 254 267 334 361 Index 439

flooding 254 258–64 334 361 gradual See gradual exposure technique response prevention 195 254 264–67 334 361 372–73 claustrophobia 69 269 cognition defined 2 10 12 cognitive behavior therapy CBT 2–3 171 314 327 407 and brain chemistry 198 drugs vs 2 61–63 198 psychiatrists and 283 spiritual traditions as compatible with 22–23 216 359 techniques used sequentially 364–88 theory behind 12 99 158 285 truth as cornerstone of 144 221 334 353 354 356–57 vs Paxil 2 See also chemical imbalance theory cognitive cost benefit analysis 222 cognitive distortions 176 187 286 314 337–38 343 350 368 372 395 396 398 checklists of 16 83–84 135 136 172 174 193 194 286 287 337 338 349 353 367 368 395 396 as component of daily mood logs 77 defined 14–15 See also specific cognitive distortions cognitive exposure techniques 253–54 253 255 268–84 334 350 353 354 361–62 cognitive flooding 255 269–72 275 334 361 404 feared fantasy 217 269 279–84 297 334n 350 358 362 377 384–86 404 407 410 image substitution 269 272–75 334 361 405 memory rescripting 269 275–79 334 362 See also Exposure Model Cognitive Model 11–23 99–247 333 336 367 anti procrastination techniques of 234–47 334 353 354 360 compassion based technique of 133–43 334 353 354 356 397 defined 10 humor based techniques of 201–8 334 353 354 358 logical and semantic techniques of 171–90 334 353 354 375 motivational techniques of 221–33 334 350 353 354 359 397 398 quantitative techniques of 191–200 334 353 354 357–58 relapse and 392–404 role playing and spiritual techniques of 209–20 334 self defeating beliefs vs 99–126 truth based techniques and See truth based techniques what if technique of See what if technique Cognitive Specificity Theory 12–13 cognitive therapy See cognitive behavior therapy Common Cause theory of depression 32 communication training 324 compassion based technique 133–43 334 353 354 356 397 compulsions 192–93 195–96 253 372 case histories of 76–77 80–90 81 85 87 264–66 defined 8 41 264 conflict phobia 19 100 106 316 408 409 contamination fear of 193 326–29 cost benefit analysis CBA 66–67 116 123 221–29 350 380–81 381 397 398 407 410 attitude 222 behavioral or habit 222 cognitive 222 defined 66 emotion 222 paradoxical form of 73–74 221 222 226–29 234 334 performance perfectionism 109 111 relationship 222 self defeating beliefs modified by 108–12 359 straightforward 222–26 440 Index

work sheets 68 109 111 117 118 119 120 121 122 194 223 225 227 381 Cranston Mr 258–59 266–67 D daily mood logs 72–74 76–95 101–2 107 127 134–35 138 140 147 153 164 172 186 193 197 201 209–10 211 213 275 335 339 343 344 345 355 365–67 used in relapse prevention 393–401 394 397 400–1 work sheets 78–79 81 85 87 103 141 148 154 173 339 341 344 346–47 348–49 366 388 394 397 400–1 danger perception of 31 David Letterman technique 288 303–9 334n 345 358 363 405 defectiveness feelings of 185–89 as trigger of depression 32 186 188 212 215–16 217 367 demandingness 19 deMello Anthony 221 denial 230 326 depression 19 33 38–39 92 350 anxiety as related to 31–32 bibliotherapy as effective in 1–4 borderline personality disorder form of 177–79 case histories of 73–74 280–84 as cause of procrastination 234 Common Cause theory of 32 as common mental health problem 64 defectiveness feelings and 32 186 188 212 215–16 217 367 determining triggers of 410 drug treatments for 2 47–63 genetic factors in 45 48 62 hidden emotions as cause of 406–10 isolation as trigger of 32 as melancholia 48 recovery circle vs 333–63 sense of tragedy as characteristic of 31 severity range of 37 symptoms of 38 test for 37 38–39 162 theory of chemical imbalance and 10–11 47–53 198 depression test 37 38–39 162 DeRubeis Robert 2–3 devil’s advocate technique 230–33 234 334 334n 358 359 Diagnostic and Statistical Manual of the American Psychiatric Association DSM IV 40 42 44 diagnostic labeling 40 42–46 dialogues See externalization of voices role playing disarming technique 303 304 305 306 309 363 See also Five Secrets of Effective Communication discounting the positive 84 224 230 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 16 distraction technique 131–32 254 267 334 361 double blind studies 58–59 double standard technique 86 133–43 211 372 397 404 410 as one of “40 Ways to Defeat Your Fears ” 334 334n 356 358 downward arrow technique 101–2 104 105 107 127 186–87 350 374–76 377 404 407 410 as one of “40 Ways to Defeat Your Fears ” 334 356 drinking See alcohol consumption driving fear of 147–51 148 280–84 drug companies chemical imbalance theory and 50 conference sponsorship by 60 misleading drug studies results and 58–59 drugs 47–63 cognitive behavior therapy vs 2 61–63 198 See also specific drugs DSM IV 40 42 44 Index 441

elevator phobia 260–64 263 Ellis Albert 180 203–4 299 embarrassment 92 emotional perfectionism 19 106 316 emotional reasoning 146 224 353 354 379 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 14–15 16 emotion cost benefit analysis 222 emotions 77 78 81 85 87 89 92–93 197–98 See also specific emotions “emotophobia ” 19 106 316–17 empathy See Five Secrets of Effective Communication empirical validation of treatments 42 entitlement 19 100 106 116 121 122 environmental factors 45 62 evaluation of therapy session form 278 examine the evidence technique 144–46 147 170 213 221 334 341 344 356 379–80 407 experimental technique 144 146–47 149–53 155–63 170 333 334 335 355 356 381–83 404 410 Exposure Model 11 23–25 251–309 334 392 404–5 defined 10 See also cognitive exposure techniques exposure techniques 11 30 266–67 270–71 333 336 405 accidental exposure vs 260 classical See classical exposure techniques cognitive See cognitive exposure techniques interpersonal See interpersonal exposure techniques as part of “40 Ways to Defeat Your Fears ” 360–63 psychoanalysis vs 260–61 research on recovery with 266 selecting 253 theory behind 72 externalization of voices 166 209–14 399 402–3 407 feared fantasy technique vs 284 as one of “40 Ways to Defeat Your Fears ” 334 358 359 pitfalls to avoid with 213–14 See also role playing F failure fear of 15–23 102 105 107 fainting 156–57 254 fantasies 269 aggressive 276–78 279 feared fantasy technique and 280 FDA Food and Drug Administration 55–56 59–60 fear 7–30 253 280 of abandonment 323 of blindness 192–93 195–96 of blood 23–25 48 254–57 255 of contamination 193 326–29 David D Burns and 23–25 48 258–59 defined 7 41 of driving 147–51 148 280–84 of failure 15–23 102 105 107 of flying 145–46 148 149–51 280 282 of heights 258–59 405 irrational as common 183 laughter vs 200–1 of lightning 268 of looking foolish 202–5 neurotic anxiety vs healthy 13–14 of people 285–309 of public speaking 8 41 163 253 254 269 272–74 288 308–9 405 of rejection 19 20 106 377 See also phobias feared fantasy techniques 280 See also cognitive exposure techniques fantasies fear hierarchy 255–57 255 258 263 263 360 feeling better vs getting better 384 389–410 Feeling Good The New Mood Therapy Burns 1–2 153 260 442 Index

Feeling Good Handbook The Burns 112 feelings relationship between thoughts and 77 88 Five Secrets of Effective Communication 303–9 305 disarming technique 303 304 305 306 309 363 EAR empathy assertiveness respect 304 305 “I feel” statements 304 305 306 inquiry 304 305 306 363 stroking 304–5 305 306 309 363 thought empathy and feeling empathy 303–4 305 306 363 flirting case histories of 208 294–98 definitions of 293–94 See also interpersonal exposure techniques flooding technique 25 48 132 163 classical exposure 254 258–64 334 361 cognitive 255 269–72 275 334 361 404 flying fear of 145–46 148 149–51 280 282 Food and Drug Administration FDA 55–56 59–60 foolish looking 202–5 fortune telling 146 224 230–31 235 237 350 353 354 on cognitive distortions checklists 16 79 84–85 136 287 338 367 368 395 396 defined 14 16 “40 Ways to Defeat Your Fears ” 333–63 334 334n 356–63 367 410 frustration 92 low tolerance of 19 106 G generalized anxiety disorder GAD 40 42–46 defined 41 See also worrying chronic genetics as factor in anxiety and depression 45 48 62 getting better vs feeling better 384 389–410 God blaming problems on 399 gradual exposure technique 162–63 254–57 258–59 263 as one of “40 Ways to Defeat Your Fears ” 334 360 grief 88–89 90 guilt 82 83 88–90 92 169 179 199 208 234 H habit cost benefit analysis 222 Hamilton Rating Sale for Depression 56 Healey David 60 health concerns exaggerated See hypochondriasis healthy vs unhealthy acceptance 216–17 217 heights fear of 258–59 405 Hidden Emotion Model 10–11 25–30 313–29 334 392 defined 10 and relapse prevention 405–10 hidden emotion techniques 11 30 132 333 336 353 354 367 368 373 374 404 as one of “40 Ways to Defeat Your Fears ” 334 363 See also Hidden Emotion Model hidden “should” statements 179–80 Highland Hospital 24–25 homicidal impulses 4 hopelessness feelings of 19 38–39 92 106 201 217 Horney Karen and “The Tyranny of the Shoulds ” 180 humor based techniques 201–8 334 353 354 358 humorous imaging 206–8 334 358 hyperventilation 155 319 hypochondriasis 36 38 192–93 194 195–96 207 253 315 defined 9 41 I “I feel” statements 304 305 306 Index 443

See also Five Secrets of Effective Communication image substitution See cognitive exposure techniques inadequacy feelings of 112–16 115 208 235 408 inferiority feelings of 19 20 38 92 106 179 227–28 333 409 inquiry 304 305 306 363 See also Five Secrets of Effective Communication insanity feelings of 26–30 insomnia 52 53 interpersonal exposure techniques 253–54 253 285–309 350 353 354 David Letterman technique and 288 303–9 334n 345 358 363 405 flirting training of 288 292–99 334 334n 345 358 362 as part of “40 Ways to Defeat Your Fears ” 334 334n 362–63 rejection practice of 288 299–300 334 345 362 self disclosure and 288 290–303 334 345 363 410 smile and hello practice of 288–92 298 334 345 362 381–83 405 irrational fears as common 183 isolation 217 as trigger of depression 32 J judgments by others assuming See mind reading jumping to conclusions 165 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 368 395 396 defined 16 146 K Kirsch Irving 55–56 L labeling 23 179–85 314 353 354 397 “be specific” technique vs 185–90 357 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 15 16 diagnostic 40 42–46 “let’s define terms” and 182–85 334 357 problems with diagnostic 42 laughter 217 vs fear 200–1 laws of the universe shoulds 181 legal shoulds 181 “let’s define terms ” labeling and 182–85 334 357 Letterman David 207 289 See also David Letterman technique lightning fear of 268 little steps for big feats technique 234 238–41 334 360 logical and semantic techniques 171–90 334 353 354 375 logic based techniques 334 357 397 loneliness 92 294–95 loss 89 90 love addiction to 19 100 101 106 116 117 118 See also self love low frustration tolerance 19 106 L tryptophan 49 M magical thinking 19 66 106 magnification 21 353 354 on cognitive distortions checklists 79 83–84 136 287 338 367 368 395 396 defined 14 16 paradoxical 205–6 334 358 377 379 mania 49 manic depressive illness 4 164 166–67 See also bipolar illness manipulation 177 320 marital therapy 324 Marks Isaac 3 Mascola Anthony 254–57 “masochistic solution ” 130 444 Index

meditation as related to self monitoring 196–97 melancholia 48 melanin 48 memory rescripting See cognitive exposure techniques mental filter 84 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 16 mental health professionals consulting of 3–4 39 62 279 mind reading 146 167 197 350 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 14 16 minimization 21 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 16 moods survey of See brief mood survey moral “shoulds ” 181–82 moral superiority 398–99 motivation action vs 241 motivational techniques 221–33 334 350 353 354 359 397 398 “musterbation ” 180 N National Institute of Mental Health 55 178 272 274 NATO Advanced Study Institute on Metabolic Compartmentation in the Brain 272 Navajos 216 necessary condition 88 94–95 175–76 355 370 needle phobia 254–57 255 negative thoughts 99 133 226 333 335 375–76 mood logs and 77 80 83–84 86 88–95 102 panic attacks as caused by 320–21 in role playing 210 212 215 399 402–3 self defeating beliefs vs 101 niceness 130 316–17 374 409 as cause of anxiety 10 25–26 316 317 319–20 322 O obsessions 192–93 195–96 206 263 264 372 406–7 defined 8 41 obsessive compulsive disorder OCD 253–54 315 320 333 350 case histories of 192–96 194 207 264–66 269–72 326–29 defined 41 264 slowness as 326–29 Oedipal complex 318 320 one minute drill therapy 324–25 other blame 169 228 353 354 398 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 16 19 other directed “should” statements 179 outcome process vs 176–79 334 357 overeating 228 overgeneralization 185 187 189–90 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 16 P panic attacks 52 317–21 case histories of 26–30 152–62 154 313–15 318–21 322 333 335 404 406–10 chemical imbalance as possible cause of 51 defined 8 emotional symptoms of 92 fainting fear and 156–57 157n hyperventilation induced 155 memories as triggers of 275 negative feelings as cause of 320–21 physical symptoms test for 36 Index 445

relapse and 409 source of 152 symptoms of 151–52 thoughts as triggers of 152 treatment techniques for 253 254 333 350 404 406 panic disorder PD 153 280–84 defined 41 paradoxical cost benefit analysis 73–74 221 222 226–29 234 334 paradoxical habit cost benefit analysis 227–29 359 paradoxical magnification 205–6 334 358 377 379 paradoxical techniques 198 233 267 paradoxical thought cost benefit analysis 227–28 passive aggressive behavior 320 Paul Saint 22 Paxil 10 47 52 60 cognitive behavior therapy vs 2 Peale Norman Vincent 61 Pennsylvania University of Affective Disease Research Unit at 60 CBT study of 2 perceived narcissism 19 20 100 106 perceived perfectionism 18 19 100 105 106 116 119 120 356 377 386 performance anxiety 101 171 253 315 defined 8 41 performance perfectionism 18 19 100 105 108 110 112–16 237–38 376 cost benefit analysis of 109 111 personality 339 phobias agoraphobia 8 41 127–32 129 159–62 253 254 267 333 335 anger 19 106 316 blood 23–25 48 254–57 255 claustrophobia 69 269 conflict 19 100 106 316 408 409 contamination 193 326–29 defined 7 41 elevator 260–64 263 “emotophobia” and 19 106 316–17 needle 254–57 255 public transportation 275–79 sweating 69–72 203 205 See also fear “Pills or Skills Dr Burns’s Prescription ” 62–63 placebo effects 50 53–60 antidepressants vs 57 pleasing others 19 20 106 316 pleasure perfectionism balance sheets 113–14 115 pleasure predicting sheets 124 125 126 235 236 237 334 360 technique 234–38 polypharmacy 63 positive thoughts 339 341 343 344 mood logs and 77 86 88 94–95 in role playing 210 212 215 399 402–3 post traumatic stress disorder PTSD 65 253 254 268–69 350 anger and 66–68 68 case histories of 65–67 268 defined 8–9 41 Power of Positive Thinking The Peale 61 problem solution list 245 246 246 334 360 technique 235 244–47 process vs outcome 176–79 334 357 procrastination 229 231–32 234–47 anxiety as cause of 234 case histories of 239–41 242 244 depression and 234 See also anti procrastination Prozac 10 47 52 53 56 58 59 60 psychiatrists cognitive behavior therapy and 283 See also Archives of General Psychiatry psychoanalysis 337 behavior therapy vs 251 exposure techniques vs 260–61 psychotherapy bibliotherapy vs 1–2 traditional model of 91 PTSD See post traumatic stress disorder public speaking anxiety 163 253 254 269 272–74 288 308–9 405 446 Index

defined 8 41 public transportation phobia 275–79 Q quantitative techniques 191–200 334 353 354 357–58 R rage 52 65 67 68 68 275 rape 277 362 reattribution technique 144 167–70 334 357 recovery getting better vs feeling better 384 389–410 and “My Blueprint for Recovery ” 410 recovery circle 333–63 367 370 386 as relapse prevention tool 403–4 work sheets 340 342 351–52 369 371 rejection 134–43 136 141 211–13 fear of 19 20 106 377 rejection practice See interpersonal exposure techniques relapse relapse prevention Cognitive Model and 392–404 daily mood log for 393–401 394 397 400–1 defined 389–90 Exposure Model for 404–5 Hidden Emotion Model for 406–10 as inevitable 391–92 recovery circle for 403–4 relapse prevention training and 62 384 389–410 suicidal impulses and 393 relationship cost benefit analysis 222 resentment 169 179 resistance 65–74 301–2 respect See Five Secrets of Effective Communication response prevention 195 254 264–67 334 361 372–73 role playing 135 137–40 166 187–89 209–20 231 232 280 281–84 307 353 354 378–80 385–86 399 402–3 407 as one of “40 Ways to Defeat Your Fears ” 334 358 359 362 techniques 209–14 334 S sadness 89 142 St John’s wort 55 337 schizophrenia 45 63 Scogin Forrest 1–2 62 SDBs See self defeating beliefs selecting exposure techniques 253 Selecting Techniques Based on the Distortions in Your Negative Thought 353 396 Selecting Techniques Based on the Problems You’re Working On 354 selective serotonin reuptake inhibitors SSRIs 49–50 60 self blame 19 86 106 167 168 169 350 353 354 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 15 16 See also self criticism self criticism 82 142–43 171 201 209 211 386 case histories of 185–89 198–200 critical voice in 207–8 See also self blame self defeating beliefs SDBs 359 386 cognitive behavior therapy for evaluation of 222 Cognitive Model vs 99–126 common 19 106 406 cost benefit analysis and 108–12 downward arrow technique and 375–77 experiment technique for testing of 146 381 individual 99–100 interpersonal 100–1 listed 18–20 modifying of 108–26 359 negative thoughts vs 101 “niceness” as a result of 316–17 pleasure predicting sheet for testing of 360 Index 447

revising of 110 112 testing of 112–14 115 116 uncovering techniques for identifying of 356 See also specific self defeating beliefs self defense paradigm 214–15 280 284 362 self destructive behavior 177 See also suicidal impulses self directed “should” statements 179 self disclosure See interpersonal exposure techniques self esteem 38 99 112–16 115 187 200 215 216 217 235 300 407 self help and importance of doing assignments 72 See also bibliotherapy self love 209–10 218 self monitoring 131–32 191–98 334 357 chart 196 as related to meditation 196–97 self pity 398–99 semantic method 179–82 334 343 344 350 353 354 357 397 serotonin 47 49–50 272 308 as happiness molecule 49 L tryptophan supplementation of 49 theory of deficiency in 49 See also SSRIs sexual abuse 275–79 362 shame 69–72 89 90 92 179 275 367 as basis of shyness 302 as central feature of anxiety 32 shame attacking exercises 70–72 147 202–5 334 358 383–84 as interpersonal exposure technique 288 “should” statements 136 179–81 343 350 353 354 357 on cognitive distortions checklists 16 79 83–84 136 287 338 367 368 395 396 defined 15 16 hidden 179–80 and laws of the universe shoulds 181 and “legal shoulds ” 181 and “moral shoulds ” 180–81 as “musterbation ” 180 other directed 179 self directed 179 and “The Tyranny of the Shoulds ” 180 shy bladder syndrome 253 defined 41 shyness 40 92 179 181 253 254 269 285–93 300–2 333 343 350 anti shyness techniques See interpersonal exposure techniques case histories of 168–69 172–77 173 174 176 208 280–84 289–92 294–98 299 301–2 337–39 341–45 342 346–47 David D Burns and 299 defined 8 41 and fear of people 285–93 nature vs nurture origin of 293 shame as basis of 302 See also social anxiety disorder slowness 326–29 as obsessive compulsive disorder 326–29 smile and hello practice See interpersonal exposure techniques Smucker Merv 277 social anxiety disorder 40 42 47 48 280–81 defined 41 See also shyness spiritual techniques 334 350 353 354 359 See also Cognitive Model spiritual traditions and cognitive behavior therapy 22–23 216 359 See also acceptance paradox spotlight fallacy 19 105 106 377 SSRIs selective serotonin reuptake inhibitors 49–50 60 See also serotonin Stanford psychiatric clinic 365 405 Stanford University Hospital 201 Stewart Sherry H 3 61 straightforward cost benefit analysis 222–26 448 Index

David D Burns M D is an Adjunct Clinical Professor of Psychiatry and Be havioral Sciences at the Stanford University School of Medicine and has served as Visiting Scholar at Harvard Medical School Dr Burns has been a pioneer in the development of Cognitive Behavioral Therapy a drug free treatment for depres sion and anxiety which has become the most widely used and extensively re searched form of psychotherapy in history Dr Burns has won numerous research teaching and media awards but is best known for his successful self help books including Feeling Good and the Feeling Good Handbook which have sold more than 5 million copies in the United States alone In a national survey of American mental health professionals Dr Burns’s Feeling Good was the top rated book from a list of 1 000 self help books for patients suffering from depression In addition American and Canadian mental health professionals prescribe Feeling Good for their patients more often than any other self help book In recent years more than 50 000 mental health professionals have attended his training programs throughout the United States and Canada More than 100 articles about his work have appeared in magazines such as Reader’s Digest Psychology Today and others He has been interviewed by numerous radio and television personalities including Oprah Winfrey Mike Wallace Charlie Rose Maury Povich and Phil Donahue

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