The Anxiety Worry Workbook 2nd ed

The Cognitive Behavioral Solution 2nd

Edition David A. Clark
Visit to download the full and correct content document:
https://ebookmeta.com/product/the-anxiety-worry-workbook-2nd-ed-the-cognitive-beh
avioral-solution-2nd-edition-david-a-clark/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

The Anxiety and Worry Workbook : The Cognitive

Behavioral Solution. 2nd Edition David A. Clark

https://ebookmeta.com/product/the-anxiety-and-worry-workbook-the-
cognitive-behavioral-solution-2nd-edition-david-a-clark/

The Anxiety Workbook for Teens Activities to Help You

Deal with Anxiety and Worry 2nd Edition Lisa M Schab

https://ebookmeta.com/product/the-anxiety-workbook-for-teens-
activities-to-help-you-deal-with-anxiety-and-worry-2nd-edition-
lisa-m-schab/

Cognitive Behavioral Treatment for Generalized Anxiety

Disorder From Science to Practice 2nd Edition Melisa
Robichaud

https://ebookmeta.com/product/cognitive-behavioral-treatment-for-
generalized-anxiety-disorder-from-science-to-practice-2nd-
edition-melisa-robichaud/

Treating Later-Life Depression: A Cognitive-Behavioral

Therapy Approach, Workbook (Treatments That Work) 2nd
Edition Ann M. Steffen

https://ebookmeta.com/product/treating-later-life-depression-a-
cognitive-behavioral-therapy-approach-workbook-treatments-that-
work-2nd-edition-ann-m-steffen/
Anxiety Workbook for Men Evidence Based Exercises to
Manage Anxiety Depression and Worry Niblock Ma Lmft
Simon G

https://ebookmeta.com/product/anxiety-workbook-for-men-evidence-
based-exercises-to-manage-anxiety-depression-and-worry-niblock-
ma-lmft-simon-g/

Anxiety & Depression Workbook For Dummies, 2nd Edition

Laura L. Smith

https://ebookmeta.com/product/anxiety-depression-workbook-for-
dummies-2nd-edition-laura-l-smith/

Guide to the psychiatry of old age 2nd ed 2nd Edition

David Ames

https://ebookmeta.com/product/guide-to-the-psychiatry-of-old-
age-2nd-ed-2nd-edition-david-ames/

Thriving in College with ADHD : A Cognitive-Behavioral

Skills Workbook for Students 1st Edition Laura E Knouse

https://ebookmeta.com/product/thriving-in-college-with-adhd-a-
cognitive-behavioral-skills-workbook-for-students-1st-edition-
laura-e-knouse/

The Massachusetts General Hospital Handbook of

Cognitive Behavioral Therapy Current Clinical
Psychiatry 2nd Edition Susan E. Sprich (Editor)

https://ebookmeta.com/product/the-massachusetts-general-hospital-
handbook-of-cognitive-behavioral-therapy-current-clinical-
psychiatry-2nd-edition-susan-e-sprich-editor/
the anxiety and worry workbook
 Also Available

FOR GENERAL READERS

The Mood Repair Toolkit:

Proven Strategies to Prevent the Blues from Turning into Depression
David A. Clark

FOR PROFESSIONALS

Assessment in Cognitive Therapy

Edited by Gary P. Brown and David A. Clark

Cognitive-Behavioral Therapy for OCD and Its Subtypes, Second Edition

David A. Clark

Cognitive-Behavioral Therapy of Addictive Disorders

Bruce S. Liese and Aaron T. Beck

Cognitive Therapy for Adolescents in School Settings

Torrey A. Creed, Jarrod Reisweber, and Aaron T. Beck

Cognitive Therapy of Anxiety Disorders: Science and Practice

David A. Clark and Aaron T. Beck

Cognitive Therapy of Depression

Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery

Cognitive Therapy of Personality Disorders, Third Edition

Edited by Aaron T. Beck, Denise D. Davis, and Arthur Freeman

Group Cognitive Therapy for Addictions

Amy Wenzel, Bruce S. Liese, Aaron T. Beck, and Dara G. Friedman-Wheeler

Intrusive Thoughts in Clinical Disorders: Theory, Research, and Treatment

Edited by David A. Clark

Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions

Aaron T. Beck, Paul Grant, Ellen Inverso, Aaron P. Brinen,
and Dimitri Perivoliotis

Schizophrenia: Cognitive Theory, Research, and Therapy

Aaron T. Beck, Neil A. Rector, Neal Stolar, and Paul Grant
 the
anxiety
and worry
workbook
The Cognitive Behavioral Solution

second edition

David A. Clark, PhD | Aaron T. Beck, MD

The Guilford Press

New York  London
Copyright © 2023 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

All rights reserved

The information in this volume is not intended as a substitute for consultation with
healthcare professionals. Each individual’s health concerns should be evaluated by a
qualified professional.

Purchasers of this book have permission to copy worksheets, where indicated by

footnotes, for personal use or use with clients. These worksheets may be copied from
the book or accessed directly from the publisher’s website, but may not be stored on
or distributed from intranet sites, internet sites, or file-­sharing sites, or made available
for resale. No other part of this book may be reproduced, translated, stored in a
retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, microfilming, recording, or otherwise, without written permission from
the publisher.

Printed in the United States of America

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-­Publication Data is available from the publisher.

ISBN 978-1-4625-4616-9 (paperback) — ISBN 978-1-4625-5192-7 (hardcover)

 contents

a tribute to Aaron T. Beck vii

preface ix

1 a new beginning 1

2 getting started 19

3 when anxiety is helpful 34

4 when anxiety becomes a problem 61

5 living with anxiety symptoms 84

6 transform your anxious mind 110

7 curb anxious behavior 141

8 take control of your worried mind 185

9 defeat the fear of panic 240

10 conquer social anxiety 271

resources 331

references 337

index 341

about the authors 355

Purchasers of this book can download and print

worksheets at www.guilford.com/clark6-forms for personal
use or use with clients (see copyright page for details).

v
 a tribute to Aaron T. Beck
(1921–2021)

V ery few in the medical profession can be said to have changed the course of mental
health treatment. Aaron T. Beck is one of those rare individuals. His six decades
of research, clinical practice, teaching, and training resulted in a new school of psy-
chotherapy called cognitive therapy. His cognitive theory and therapy of psychologi-
cal disorders was one of the first systematic, empirically verifiable forms of psycho-
therapy. As a result Beck’s work has been thoroughly researched to the point where it
is an established, evidence-based form of treatment for a wide variety of psychological
problems even beyond anxiety and depression. The success of cognitive therapy is not
attributable solely to the unusual genius of the man. Dr. Beck had an enthusiasm and
passion for expanding our understanding of the human mind. He had a deep compas-
sion for those struggling with mental health problems. He was truly inspiring in his
vision to raise the quality and effectiveness of mental health treatment on a global
scale.
It has been a great honor and privilege to have learned from and collaborated with
one of the giants of contemporary psychiatry. The personal loss I felt at the death of
my mentor, friend, and collaborator on November 1, 2021, cannot be overstated. He
was in the midst of providing his latest input for the first complete draft of our second
edition of The Anxiety and Worry Workbook just one week before his death. Despite
being deprived of his latest insights, this workbook is infused with the knowledge and
clinical wisdom of probably the most consequential psychiatrist in modern times. It is
my hope that individuals will glimpse the unique wisdom of Aaron T. Beck through
the pages of this workbook.

DAVID A. CLARK

vii
 preface

A nxiety continues to be one of the world’s greatest mental health problems. Since
writing the first edition of this workbook 10 years ago we’ve seen a surge in
anxiety related to the global upheaval caused by the COVID-19 pandemic and its
consequences. The disease itself as well as the various mitigation efforts have directly
impacted the lives of billions around the world. It is within this backdrop of a rising
tide of anxiety that we offer this revised and expanded second edition of The Anxiety
and Worry Workbook.
Like its predecessor, this is a workbook about cognitive behavior therapy (CBT)
for anxiety and its disorders. It is a self-help workbook that shows you how to use the
insights, interventions, and resources of CBT to quell severe and uncontrollable anxi-
ety. Its more than 70 worksheets offer step-by-step guidance in how to apply highly
effective CBT strategies to generalized anxiety, worry, panic, and social anxiety. It
is packed full of case illustrations and examples drawn from our decades of experi-
ence in CBT treatment, research, and teaching. Dr. Aaron T. Beck, my coauthor, is
the originator of cognitive therapy for anxiety. The entire workbook is filled with his
unique and innovative understanding of anxiety and its treatment.
Our second edition is a complete revision and expansion of our original work-
book. There are several changes and upgrades that are noteworthy. We have incorpo-
rated ideas and interventions of recovery-­oriented cognitive therapy (CT-R), a modi-
fication of standard cognitive therapy that Dr. Beck developed for treatment of severe
mental disorders. This perspective was not available when the first edition was pub-
lished. We’ve adapted the CT-R perspective to treatment of problematic anxiety. To
our knowledge this is the first publication of CT-R for anxiety written for the general
public. Based on the CT-R approach, there is a new chapter on helpful forms of anxi-
ety that provides a starting point for revamping one’s approach to more severe, prob-
lematic anxiety. We have reorganized the workbook so that readers are first intro-
duced to the basic CBT interventions used in strategies for difficult anxiety problems
like worry, panic, and social anxiety. Interventions have been broken down into more

ix
x preface

specific, practical steps that make it easier to acquire treatment skills necessary for
genuine anxiety reduction. We have expanded the chapter on behavioral interventions
and introduced more recent innovations in exposure therapy like inhibited learning
theory and behavioral experimentation. A new chapter on anxiety sensitivity has been
added, which is especially important for individuals with panic attacks. Other con-
cepts such as mental control, intolerance of uncertainty, fear of embarrassment, and
postevent processing have been included or expanded to provide a more robust treat-
ment protocol for the various anxiety problems covered in the workbook. Based on
reader feedback, the second edition contains more case examples, illustrations, and
worksheet samples—all based on composites of real people, thoroughly disguised to
protect privacy—so individuals can see how our CBT strategies are applied to real-
world anxiety problems. The chapters on worry and social anxiety provide additional
material that boosts the effectiveness of CBT for anxiety.
This revision would not have been possible without the assistance and encourage-
ment of a host of individuals. Over the years we have learned much about anxiety,
worry, and their treatment from the experiences our patients have shared with us.
Their wisdom and courage in facing such a daunting adversary as anxiety has been
truly inspiring. In addition, numerous researchers, clinicians, and students have con-
tributed to the development of CBT for anxiety. Many we have known personally,
and to them we are grateful for the knowledge and clinical acumen they have brought
to the pages of this workbook. But there are specific individuals who’ve played a criti-
cal role in this revision process. We are especially grateful to Chris Benton for her
insights, energy, practicality, and close attention to details that improved our ability
to communicate ideas and strategies. As in the past we appreciate the positive collabo-
ration of our editor, Kitty Moore, who provided support and encouragement for this
project to move forward. Robert Diforio, our literary agent, is a welcome addition to
the team since our first edition. His deep understanding of the publishing world com-
bined with an enthusiasm for and dedication to this project has been inspirational.
There are also others at The Guilford Press who made a valuable contribution to this
publication: Art Director Paul Gordon, Editorial Project Manager Anna Brackett,
and copy editor Deborah Heimann. Finally, I am grateful for my spouse of 45 years,
Nancy Nason-Clark, who continues to provide unfailing encouragement, advice, and
emotional support in my efforts to communicate through the written word.
the anxiety and worry workbook
 1
a new beginning

A nxiety is not your enemy! This may sound like an unusual way to begin an anxiety
workbook. No doubt you’ve been drawn to this workbook because anxiety and
worry feel like uncontrollable forces in your life. Maybe you can think back to a time
when feeling anxious was no different than any other fleeting emotion, like feeling
sad, angry, or frustrated. But anxiety has come to play a much bigger role in your life
than you’d like. It now causes you considerable personal distress and it’s interfering in
your daily life. It’s taken the joy out of living and your self-­confidence has been shat-
tered. Your world may be shrinking, as you avoid more and more places, people, and
experiences because of anxiety. Clearly, anxiety and worry are a serious problem and
you’re searching for answers.
Whether your problem with anxiety and worry occurred recently or has been
present for years, you’ll find in this workbook step-by-step instruction in how to use
the cognitive behavior therapy approach to lighten the burden of your emotional dis-
tress. Cognitive behavior therapy (CBT) is a scientifically supported treatment that is
effective in reducing a variety of anxiety problems. CBT was founded by Dr. Aaron
T. Beck (second author), and The Anxiety and Worry Workbook is based on our
collective research and clinical experience in offering CBT to hundreds of individu-
als. You’ll find in its pages numerous exercises and worksheets that present the most
potent and innovative treatment strategies for anxiety and worry based on the funda-
mental tenets of CBT.
Our approach in this workbook differs from other CBT resources in two fun-
damental ways. First, we spend considerable time explaining how the anxious mind
operates and what you’ll want to work on to achieve lasting change. We believe it’s
important to understand the psychology of anxiety to get maximum benefit from
CBT interventions. And second, we introduce a new form of CBT called recovery-­
oriented cognitive therapy (CT-R). This approach recognizes that negative emotions
like anxiety can be helpful in reaching cherished goals and aspirations. It assumes
that everyone has strengths that can be harnessed to deal with problems like anxiety

1
2 The Anxie t y and Worry Workbook

and worry. Several exercises in the workbook focus on discovering your strengths and
abilities when feeling anxious.
Maybe you’ve been focused on eliminating your anxiety and worry by reading
self-help books and inspirational material, taking motivational seminars, trying medi-
cation, and the like, but the harder you try, the more anxious and worried you feel.
Have you considered whether you’re focusing on the wrong outcome? The truth is
we can’t eliminate anxiety or worry by trying harder. Wouldn’t it be wonderful if we
could abolish all distress and be calm and confident all the time? But this isn’t pos-
sible because negative and positive emotions are an intrinsic part of our psychological
makeup. In fact, negative emotions, including anxiety, are necessary for our very sur-
vival. When they’re tolerable, they motivate us to deal with problems in our life and
to prepare for the future. But anxiety and worry are not always tolerable. They can
become very uncomfortable, disrupting important aspects of our life. This workbook
is about dialing back problematic anxiety so you can live a happy and productive life.
There are many ways that our experiences with anxiety differ from one another.
Anxiety can vary from a slight, barely noticeable feeling of being keyed up to an
intense surge of apprehension. Panic attacks and elevated generalized anxiety are
examples of severe anxiety experiences. The intensity of our anxious feelings can
change quickly or remain elevated for hours, depending on the situation. A little anxi-
ety can be healthy. But when anxiety becomes too severe, persistent, and out of pro-
portion to the situation, it becomes unhealthy. It is this type of anxiety that causes us
to seek relief from its distressing and disruptive qualities. Anxiety can be measured on
an emotional gauge as illustrated in Figure 1.1.
We can use numbers ranging from 0 to 100 to represent various levels of anxiety.
When anxiety is mild to moderately intense (0–50), we feel physically aroused, tense,
alert, focused, and concerned. This is a healthy level of anxiety that can help us deal
with life’s challenges. When anxious feelings become more intense (50–100), we feel
agitated, nervous, frightened, hyperaroused, and out of control. Anxiety has now

50

25 75

0 10 0

F I G U RE 1.1. The anxiety gauge.

 a new beginning 3

become severe. It’s a highly distressing state that interferes in our ability to function.
It’s difficult to tolerate anxiety in this range, so we seek immediate relief. This work-
book introduces you to interventions shown to increase anxiety tolerance, which has
the effect of dialing down its intensity. But before delving into severe anxiety, take a
moment to consider your experience of mild anxiety.

Mild Anxiety
In your struggle with severe anxiety and worry, you may have forgotten that many
times your anxiety experiences are brief, mild, and even helpful in specific situations.
Mild anxiety involves:

„ A noticeable feeling of apprehension and unease

„ An increase in physical arousal and tension
„ Thoughts of a possible negative outcome for you or your loved ones

Mild anxiety is often triggered by anticipating specific situations, such as taking

an important exam, attending a social event involving unfamiliar people, speaking up
at a meeting, performing in front of others, going to an impending job interview, rais-
ing an important issue with your partner, or traveling alone to an unfamiliar place.
Hardly a day goes by without each of us experiencing some mild anxiety or appre-
hension. It’s usually brief and reasonably well tolerated or managed. Even if you have
many episodes of severe anxiety, you, like others, probably handle these mild inci-
dents well. In fact, you probably harness that anxiety, so you cope with the situation
much better than if you were too relaxed and overly confident. Have you forgotten all
the times you tolerated milder anxiety and used it to your advantage? Throughout this
workbook we’ll show you how you can take what you do with mild anxiety and apply
it to more severe episodes. To get started we encourage you to take a few minutes to
complete the following exercise.

E VA L U AT ION EXER C I S E  Remembering Mild Anxiety

Here is an opportunity to take a closer look at your strengths and abilities to deal with
mild to moderately intense anxiety. You might even discover that you’re able to tolerate a
greater range of anxiety than you realized. In Worksheet 1.1 you’re asked to recall situa-
tions that caused only mild anxiety. Think about how your response to these situations kept
your anxiety low.
W ORK SHEE T 1.1

My Mild Anxiety Experiences

Instructions: Think back to three or four experiences of mild anxiety (from 0 to 50 on the anxiety gauge). In
the first column, note the situation that triggered your anxiety, and in the second column, describe how the
anxiety felt (physical sensations, emotions, thoughts). In the third column, briefly describe how you reacted
to the anxiety and how feeling a little anxious or worried might have been beneficial. Did the anxiety/worry
help you deal with a difficult problem? The first row provides an example that illustrates how to complete
the worksheet.

Situation (trigger) How the mild anxiety felt How the anxiety helped
Example: I felt a knot in my stomach; I did a review of my finances before I heard
I have an older car, and tense; I had difficulty back from the dealer and came up with a limit
while driving to work I hear sleeping; I kept thinking on what I’d spend in repairing my old car.
a knocking sound in the about an expensive car I made an appointment with the dealer.
engine. repair and how would I pay I thought of ways to deal with my
for it. transportation needs other than owning a car.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can pho-
tocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

4
 a new beginning 5

 Troubleshooting Tips: Recording Mild Anxiety

If you’re having difficulty recalling past experiences of mild anxiety, ask your partner
or family member for help. Also, you could use the worksheet to write down your mild
anxiety experiences over the next two weeks.

Were you surprised to learn that you can use mild anxiety to deal with problems?
Looking back at your entries, is there anything you did in these situations that you
could apply to times of severe anxiety? Keep this worksheet handy because we’ll come
back to it in Chapter 3. For now let’s consider your experience of severe anxiety.

Severe Anxiety
Episodes of severe anxiety feel much different than their milder form. When the anxi-
ety dial is turned up into the 80–100 range, the anxiety becomes much harder to
manage. There are several features of severe anxiety that make it especially difficult
to tolerate.

„ We experience more symptoms with greater intensity and persistence.

„ Our feelings are disproportionate (excessive) to the everyday situations that
trigger them.
„ Our thinking becomes more extreme by focusing on the worst possible out-
come (catastrophe).
„ We’re more narrowly focused on danger and threat as well as personal helpless-
ness.
„ We hold strong beliefs that anxious feelings are intolerable and must be elimi-
nated.
„ Escape and avoidance become our modus operandi.

Chapter 4 explains how these features are related to each other, making severe
anxiety a problem that interferes in daily living. In the meantime, consider the follow-
ing three illustrations of people who experience various forms of problematic anxiety.

Rebekah’s Story: Haunted by What-Ifs

Rebekah can’t sleep. In the past five years since being promoted to store manager,
this 38-year-old mother of two school-age daughters has been fraught with apprehen-
6 The Anxie t y and Worry Workbook

sion, nervousness, and worries over her work, her children’s safety, her aging parents’
health, personal finances, and her husband’s job insecurities. Her mind generates an
endless list of possible catastrophes—she won’t be an effective manager at work, she’ll
fail to meet monthly sales projections, her younger daughter will get injured at school
or her older daughter will be teased by friends, her parents will be disappointed if
she doesn’t visit regularly, she won’t have enough money left over after paying bills
to contribute to their retirement savings plan, her husband could lose his job any day
. . . the list goes on. Rebekah has always been a worrier, but it has become almost
unbearable in the last few years. In addition to sleepless nights, Rebekah is almost
constantly agitated, shaky, “rattled,” unable to relax, and irritable, with occasional
anger outbursts. She breaks down in tears for no apparent reason. The worries are
relentless and impossible to control. Despite her best efforts at distraction and reas-
suring herself that everything will be fine, she has a sick feeling in her stomach that
“trouble is just around the corner.”

Todd’s Story: A Body of Fears

Todd is losing control—at least that’s what it feels like. As a recent college graduate
starting a new sales job, Todd had just moved to a new city and for the first time
had his own apartment. He was making friends; he had a steady girlfriend, and he
was making great progress in his new occupation. His initial performance evalua-
tions were extremely positive. Life was good; but all this suddenly changed on a cool
November day while he was driving home from work. His job had been somewhat
stressful, with Todd working extra hours to finish a large client project on time. He
had gone to the gym afterward to do his cardio routine and work off the day’s stress.
On his way home a strange and unexpected feeling overtook Todd. Suddenly his chest
tightened, and his heart started pounding rapidly. He felt lightheaded, almost dizzy,
as if he was about to faint. He pulled off to the side of the road, turned off the car,
and gripped the wheel. By now he was feeling tense and started to shake and tremble.
He felt extremely hot and started gasping for breath, convinced he was suffocating.
Instantly, Todd wondered whether he was having a heart attack, just like his uncle
had had three years earlier. He waited a few minutes until the symptoms settled down
and then drove to the hospital emergency department. A thorough examination and
medical tests revealed no physical problems. The attending physician called it a panic
attack, gave Todd medication, and told him to see his family doctor.
That first attack happened nine months ago, and since then Todd’s life has
changed dramatically. He now has frequent panic attacks and is almost constantly
worried about his health. Any unexpected physical sensation can trigger a cycle of
severe anxiety. He’s cut back on social activities and now finds he’s afraid to go places
 a new beginning 7

for fear of having another attack. He restricts himself to work, his girlfriend’s apart-
ment, and his own place, afraid to venture into new or unfamiliar territory. Todd’s
world has shrunk, dominated by fear and avoidance.

Isabella’s Story: Dying of Embarrassment

Isabella is a shy single woman in her mid-40s. Since childhood she’s felt anxious
around other people and so avoids social interaction as much as possible. It seems
like just about everything to do with people makes her anxious—­carrying on a con-
versation, answering the phone, speaking up in a meeting, asking a store clerk for
assistance, even eating in a restaurant or walking up the aisle of a movie theater. All
these situations make her feel tense, anxious, and self-­conscious as she worries about
blushing and coming across as awkward. She’s convinced that people are looking at
her and wondering what’s wrong with her. On several occasions she has had panic
attacks and felt incredibly embarrassed by her behavior in social settings. As a result,
Isabella avoids social and public situations as much as possible. She has only one close
friend and spends most weekends with her parents. Although very competent in her
job as an office clerk, she has been overlooked for promotion because of her awkward-
ness around others. Isabella is caught in her own little world, feeling depressed, lonely,
and unloved—­trapped by her fears and anxiety over people.
Rebekah, Todd, and Isabella have considerable personal distress and limitations
in their daily living because of severe and persistent anxiety. Do any of these stories
sound familiar? Are you struggling with severe anxiety that is like Rebekah’s worry,
Todd’s panic attacks, or Isabella’s self-­consciousness around others? The next exercise
gives you an opportunity to write about your experience of severe anxiety.

E VA L U AT ION EXER C I S E  Remembering Severe Anxiety

You can probably remember several instances of severe anxiety or worry. It’s important
that you take a look at these past experiences because they have likely had a big influ-
ence on your present tolerance for anxious feelings. Worksheet 1.2 will be an important
resource for you throughout the remainder of the workbook.

Was it easier to recall occasions when anxiety was severe than when it was mild?
Compare your entries on Worksheets 1.1 and 1.2. Do you notice any similarities
between your mild and severe anxiety? Are there specific symptoms of severe anxiety
that make it intolerable? Are there coping strategies you use with mild anxiety that
could reduce the harmful effects of severe anxiousness? We believe there is much you
W ORK SHEE T 1. 2

My Severe Anxiety Experiences

Instructions: Think back to three or four experiences of intense and persistent anxiety that felt intolerable at
the time (anxiety gauge 80–100). In the first column, note the situation that triggered your anxiety. It could be
a situation, a physical sensation, or an unwanted thought. Describe how the anxiety felt in the second column
(physical sensations, emotions, thoughts), and in the third column briefly describe how you reacted to the
anxiety and any consequences or problems caused by the anxiety. The first row provides an example that
illustrates how to complete the worksheet.

Situation (trigger)
Example:
I feel nauseous, tired,
and generally unwell
How the severe anxiety felt
I feel weak, unsteady, lightheaded;
my breathing becomes more rapid
and shallow; my heart rate increases.
I can’t explain why I feel so bad; I
wonder if I should call the doctor; I
think about the people I know who’ve
had cancer and wonder if I could
have stomach cancer.
How you reacted/its consequences
I called my mother to seek reassurance
that I’m not seriously ill.
I stayed home from work and didn’t
leave the house because I didn’t feel well.
The anxiety was so severe; I couldn’t
stand it any longer, so I took my
medication.
I lay down and tried to rest to see if I
could calm down.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can pho-
tocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

8
 a new beginning 9

You’re Not Alone

You’re not alone in your struggle against severe anxiety. Globally, 1 in 9 people experience an
anxiety disorder in any given year,1 and approximately 65 million U.S. adults will experience
a clinically significant anxiety condition sometime in their life, making it the most common
mental health problem.2 Think of it this way. Over one-­quarter of your friends, colleagues,
and neighbors will experience severe anxiety, even if the majority don’t seek professional
help. Some well-known and successful people have struggled with anxiety, including Selena
Gomez, Lady Gaga, Nicolas Cage, Kim Kardashian, and Marcus Morris,3 as well as historical
figures like Winston Churchill and Abraham Lincoln. So, there is no reason to be embar-
rassed or to blame yourself for your fears and anxiety. Many people have lived very success-
ful lives despite their bouts of severe anxiety. The good news is you don’t have to struggle
alone. Research over the last several decades has taught us a lot about anxiety and the most
effective way to treat it.

can learn from how you deal with mild anxiety. We’ll be returning to this theme time
and again throughout the workbook, showing you how to learn from your experi-
ences of tolerable anxiety. But for now, let’s put aside your experience with anxiety
and introduce you to our approach to anxiety.

What’s Different about This Workbook?

Hundreds of self-help books, as well as numerous internet gurus, life coaches, moti-
vational speakers, and mental health professionals, offer insights and approaches that
they claim produce breakthroughs in dealing with anxiety. For many of you this is
not your first workbook on anxiety. Possibly your therapist has recommended other
resource materials, but they’ve failed to live up to their promise. So why should you
invest more time and effort in this workbook? What makes our approach different
from others?
The Anxiety and Worry Workbook drills deep into the CBT approach to anxi-
ety. It doesn’t mix in other interventions with less proven effectiveness. It teaches the
CBT understanding of anxiety and shows what needs to change in our thinking and
behavior to reduce anxiety. The first seven chapters teach the fundamental skills of
CBT, which are then tailored and refined in later chapters to deal with specific anxiety
problems like worry, panic attacks, and social anxiety. This is also the first workbook
on anxiety to include elements of CT-R. Throughout you will find case examples,
illustrations, exercises, and worksheets that enhance the workbook’s practical utility.
To give you a better idea of what to expect, we start with a brief overview of CBT
and CT-R.
10 The Anxie t y and Worry Workbook

Cognitive Behavior Therapy

Cognitive behavior therapy (CBT) asserts that the way we think and how we act has a
significant effect on how we feel. If we think an impending event might result in a neg-
ative outcome, we’ll consider it threatening. Anticipated threat often leads to escape
and avoidance actions because we are seeking safety and comfort. The thoughts of
threat and avoidance behavior have the unintended effect of raising the intensity of
anxious feelings. In CBT changing the way we think about threat and danger is con-
sidered critical to anxiety reduction. It’s an organized, systematic psychological treat-
ment that teaches people how to dial down their anxiety by changing their thoughts,
beliefs, and behavior. Figure 1.2 illustrates the basic CBT model.
One of us (Aaron T. Beck) pioneered CBT in the late 1960s and 1970s for depres-
sion and then anxiety. Together we published an updated and comprehensive treat-
ment manual of CBT for anxiety in 2010 called Cognitive Therapy of Anxiety Dis-
orders: Science and Practice.4 The first edition of The Anxiety and Worry Workbook
was a client version based on that manual. Readers can find a more detailed explana-
tion of the CBT perspective on anxiety, its research support, and treatment strategies
in the 2010 clinician manual.
Today CBT is practiced by mental health practitioners worldwide. Hundreds of
research studies demonstrate the effectiveness of CBT for anxiety.5,6 Sixty to eighty
percent of people with an anxiety problem who complete a course of CBT (10–20 ses-
sions) will experience a significant reduction in their anxiety, although only a minor-
ity (25–40%) will be completely symptom-free.7,8 This is equivalent to or better than
the effectiveness of medication alone, with some studies showing that CBT produced
longer-­lasting improvement than was produced by medication only.9 At the very least,
CBT is substantially more effective than doing nothing or getting basic supportive

Thought Behavior Feeling

Trigger
+ (perception, + (coping = (tense,
(trigger)
interpretation) response) anxious)

“I have no clue Pace around Feel nervous,

Waiting for job what to say; the room; tense, butterflies
interview they’ll think drink coffee in stomach
I’m an idiot.”

“I’m well prepared Relax while sitting; Feel calm,

Waiting for job for this interview; read Facebook confident,
interview I should be able to make postings and safe
a good impression.”

F I G U RE 1. 2 . The basic cognitive behavioral model of anxiety.

 a new beginning 11

counseling. It’s now a recommended first-­choice treatment for anxiety by many psy-
chiatric and mental health provider organizations worldwide.10,11

Recovery-­Oriented Cognitive Therapy

CT-R is a new perspective in CBT that views human change in terms of recovery and
not simply the alleviation of personal distress. A recovery approach focuses on strate-
gies that help people capitalize on their interests, capabilities, aspirations, problem-­
solving ability, effective communication, and resilience over stress.12 CT-R recognizes
that we all have “at our best” moments when our thoughts, emotions, and actions
work together in pursuit of cherished goals, values, and aspirations. Beck and col-
leagues refer to this as the adaptive mode. A mode is a tendency or way of acting that
involves beliefs, attitudes, feelings, motivation, and behavior.13 In CT-R we consider
any response adaptive if it helps you reach important personal goals and values. We
usually experience positive feelings when we respond adaptively. When you manage
anxiety and, on occasion, turn it into a sense of accomplishment, you are operating
in the adaptive mode.
In CT-R we don’t simply work on negative thoughts and beliefs that cause distress,
we also help individuals discover more positive ways of thinking that promote a more
meaningful life.14 So the CT-R therapist and client work together on ways of think-
ing that might interfere in the person’s ability to achieve a goal. For example, imagine
you’re coming to the end of a medical leave from work due to anxiety and stress.
You’re very anxious and worried about the return-to-work plan created by HR. You’re
convinced you’re going to fail and your anxiety will return with a vengeance. The
traditional CBT therapist would focus on your anxious thoughts and how you could
reduce your work anxiety. The CT-R therapist would also target anxiety reduction but
would go beyond this focus to include discovering how you could promote a greater
sense of fulfillment and goal attainment at work. If you’re maximizing your capabili-
ties at work, progressing toward cherished goals, and developing greater resilience to
stress, your work anxiety will be more tolerable, even adaptive, rather than severe and
debilitating. Throughout this workbook we emphasize what you can learn from your
experiences of mild anxiety and worry that helps you attain greater life satisfaction.

What to Expect
The first seven chapters of The Anxiety and Worry Workbook delve into core psy-
chological processes responsible for making anxiety a problem. In these chapters we
tackle the nuts and bolts of the anxious mind, such as threat interpretation bias,
underlying beliefs about anxiety, heightened anxiety sensitivity, avoidance and safety-­
12 The Anxie t y and Worry Workbook

seeking behavior, and intolerance of uncertainty. Psychologists often call these pro-
cesses transdiagnostic because they are found in different types of anxiety problems.
You’ll learn how to use specific treatment strategies designed to alter these core fea-
tures of the anxious mind.
The remaining three chapters focus on three anxiety problems: worry, panic
attacks, and social-­evaluative anxiety. You’ll find CBT treatment protocols tailored
to the unique features of each anxiety problem. Even if your anxiety fits closely with
one of these problems, we recommend that you work through the first seven chapters
before focusing on one of the specific later chapters. The early chapters provide foun-
dational skills necessary to get the most from the later chapters. Table 1.1 presents an
overview of the skills you’ll learn in each chapter.
We wrote this workbook with you in mind. Its organization, style, and content
are intended for individuals like you who desire a better life, a life of tolerable anxi-
ety experienced in a way that enriches life rather than threatens your joy, peace, and
comfort. No one who picks up a self-help workbook is looking for the easy way out.
You know it will take commitment, time, and effort to overcome your usual ways of
dealing with anxiety. It is our desire to work with you, providing a new way to under-
stand your anxiety and more effective strategies so you can better tolerate and cope
with a range of anxiety experiences.

How to Use the Workbook

There may be unique aspects to your anxiety, but if you can see elements of your
anxiety in the case examples of Rebekah, Todd, and Isabella, then this workbook is
for you. It’s been written as a stand-alone self-help resource. This means you can use
it on your own, regardless of the level or type of anxiety you experience.
Others might find it more helpful to use the workbook as a companion to treat-
ment, with a therapist assigning specific chapters, special sections, or certain exercises.
This will be true if your anxiety is severe, you’re avoiding activities that are important
to daily living because they make you anxious, or you’re having difficulty identifying
your anxious thinking. A therapist can also advise you on which CBT skills to empha-
size and how they might be modified to address unique features of your anxiety, and
can assign workbook exercises in a more strategic fashion. Often people find they
need the accountability of structured therapy to encourage commitment to the change
process. If you’ve worked with a CBT therapist in the past and found the treatment
helpful, you’ll be able to use the workbook to sharpen your CBT skills.
Dropping old habits, learning new strategies, and practicing greater tolerance for
fear, anxiety, and uncertainty takes courage and determination. Even if your anxiety
is in the moderate range, using the workbook on your own may be too demanding.
 a new beginning 13

TA B L E 1.1. What You’ll Learn from This Workbook

Chapters What you’ll learn Key exercises

Chapter 2, Getting • That practice is key to treatment • Complete the Beliefs about Practice
Started effectiveness Assignments worksheet
• What beliefs undermine motivation and • Evaluate whether you’re getting the
how to correct them most from your practice experiences
• How to get the most benefit from the
workbook

Chapter 3, When • How anxiety can be helpful • Track mild, helpful anxiety
Anxiety Is Helpful • How to recognize how anxiety helps • Discover your Adaptive Anxiety Profile
you cope
• Your level of anxiety resilience

Chapter 4, When • How to identify problematic anxiety • Catch anxious thoughts

Anxiety Becomes • What an anxious mind is • Keep an anxiety log
a Problem • How to develop an individualized • Create an Anxiety Symptom Profile
treatment plan for your anxiety
problem.

Chapter 5, Living with • Whether anxiety sensitivity (AS) is
Anxiety Symptoms driving your problematic anxiety
• Your tolerance for specific anxiety
symptoms
• How to use CBT interventions to
increase your anxiety tolerance and
lower AS
• Evaluate your symptom sensitivity
• Complete the Anxiety Sensitivity
Beliefs worksheet
• Practice detached observation and
other CBT interventions

Chapter 6, Transform • How erroneous threat predictions
Your Anxious Mind drive anxiety
• How to create a unique map of your
anxious mind
• How to use evidence gathering and
other CBT interventions to reduce
anxiety
• How to conduct a mental audit to
discover less anxious ways of thinking
• Discover your threat predictions
• Create your anxious mind map
• Use evidence gathering and cost/
benefit forms to practice CBT skills
• Use the Alternative Perspective Form
to generate healthier ways of thinking

Chapter 7, Curb • How to rediscover your courage over
Anxious Behavior anxiety
• How to recognize the effects of the
self-­protective mode on anxiety
• Which anxiety beliefs are responsible
for its persistence
• How safety-­seeking can be self-­
defeating
• How to use systematic exposure to
overcome anxiety
• Complete the Self-­Protective Response
worksheet
• Fill-in the Beliefs about Anxiety Scale
• Discover problematic safety-­seeking
with the Safety-­Seeking Response
Form
• Use the Recovery-­Oriented
Exposure Plan to enhance treatment
effectiveness
        (continued )
14 The Anxie t y and Worry Workbook

Chapters What you’ll learn Key exercises

Chapter 8, Take Control • How to distinguish harmful from
of Your Worried Mind helpful worry
• The mental processes that drive the
worried mind
• How to determine your worry profile
• How to use problem solving, de-­
catastrophizing, directed worry
exposure, and other interventions to
overcome harmful worry
• How to build worry resilience through
heightened tolerance of uncertainty
• Identify unhelpful ways of thinking that
create harmful worry
• Complete the Worry Beliefs Checklist
• Track your worry with the Worry Diary
• Construct your individualized Worry
Profile
• Evaluate control and responsibility
with the Control Pie Chart
• Record your interventions with
the Worry Exposure Form, Daily
Uncertainty Record, and Tolerance
Fitness Form

Chapter 9, Defeat • How to know what makes panic and its
the Fear of Panic fear a problem
• How to identify hypersensitivity and
catastrophic misinterpretations of
physical symptoms
• How the panic-­stricken mind operates
• How to assess your panic episode
• How to use CBT strategies like
panic reappraisal, panic rescripting,
symptom induction, and safety-­seeking
removal to counter panic attacks
• Complete the Panic Self-­Diagnostic
Checklist
• Self-­monitor your anxiety with the
Weekly Panic Log
• Create your unique Panic Profile
• Use the Antipanic Symptom
Interpretation Record to counter
catastrophic misinterpretations

Chapter 10, Conquer • How to recognize the three pillars of
Social Anxiety social anxiety
• How to break down your anxiety into
the three phases of social anxiety
• The CBT way to assess and
conceptualize your social anxiety
• How to use CBT interventions to
reduce debilitating anticipatory anxiety
• Strategies that promote better
management of anxiety and improve
social skills
• How to stop anxious rumination and
postevent processing of recent social
interactions
• Complete the Social Anxiety Checklist
• Identify your social change goals
• Maintain a social anxiety log
• Create your Social Anxiety Profile
• Construct a social exposure plan
• Strengthen social skills with the
Prosocial Cognitive Skills Form and
the Behavioral Retraining Guide
• Confront a fear of embarrassment with
the Cost of Embarrassment Form
• Practice reevaluation of past social
performance to reduce rumination

You may make better progress if you receive professional treatment, because genuine
change depends on knowing what to do and then applying this knowledge to your
everyday experience of anxiety. Whether using the workbook alone or with a thera-
pist, you’ll only get as much from the workbook as you put into it. We suggest you
schedule 20 minutes each day to read The Anxiety and Worry Workbook and plan on
which exercises and worksheets you’ll complete next.
 a new beginning 15

As you read through the workbook, keep asking yourself “How does this apply to
my anxiety?” Take your time and do as many exercises as possible. Don’t get too hung
up on trying to do all the exercises and worksheets perfectly. You’ll find some more
helpful than others, and so you’ll want to spend more time on the helpful worksheets.
Remember, the workbook is meant to be a practical guide, not a textbook. You’ll gain
new insights into your anxiety, but more importantly, we’re hoping you’ll learn new
skills that you can apply to your everyday experience of anxiety. Before we get started,
take a few moments to consider what you’d like to achieve from spending time with
The Anxiety and Worry Workbook.

My Anxiety-­Reduction Goals

What do you want to get from the workbook? What are your goals when it comes
to dealing with anxiety? This next exercise gives you an opportunity to think more
deeply about your anxiety and how better coping skills might contribute to a more
fulfilling life.

E VA L U AT ION EXER C I S E  Stating Your Workbook Goals

Like most people, you’ve probably tried to make improvements in some area of your life,
like physical exercise, diet, time management, sleep, and the like. You know that having a
goal is critical to maintaining your motivation and commitment. The same is true for The
Anxiety and Worry Workbook. You need specific goals to keep yourself motivated to apply
the knowledge and do the workbook exercises. Worksheet 1.3 presents a process you can
use to discover specific ways that your life would be improved if your anxiety was less
intense and more tolerable. You’re asked to come up with specific goals that refer to practi-
cal ways your life would be better if your anxiety was more manageable.

 Troubleshooting Tips: Other Ways to Establish Anxiety-­Reduction Goals

In CBT, therapists work closely with clients to help them create reasonable and effective
treatment goals. Most people need some help with this task. If you’re doing this exercise
alone, setting goals for change can be especially difficult. We’ve listed some additional
strategies you can follow when creating your anxiety-­reduction goals.

„ Think of some specific ways your performance would improve in each life domain if
you had little or no anxiety.
„ Consider how you functioned in each domain before anxiety became a problem. Your
goal might be to get back to that same way of functioning.
W ORK SHEE T 1.3

My Anxiety-­Reduction Goals
Instructions: Daily living involves several primary concerns that are listed below. Review your entries in
Worksheet 1.2 and consider how anxiety is having a negative effect in each life concern. Next, imagine spe-
cific ways you’d be more successful or effective in each life domain if your anxiety was mild (tolerable) rather
than severe (intolerable). In the right-hand column, list specific ways in which you would function better
within that domain if you were less anxious. These will become your anxiety-­reduction goals; that is, what
you’d like to achieve by improving your tolerability and management of anxiety. An example is provided for
each life concern.

Life domains Specific anxiety-­reduction goals or targets

Work Example: I’d express my opinion more often in the weekly department
meetings.
(How would mild,
tolerable anxiety make
me more successful at 1.                                 
work?)

2.                                 

3.                                 

Family/partner Example: I’d take trips with my family and attend family gatherings rather than
use my anxiety as an excuse to stay home alone.
(How would I be a
better parent, spouse,
sibling, or son/ 1.                                 
daughter if my anxiety
was milder, more
tolerable?) 2.                                 

3.                                 

Friendships Example: I’d go out more with friends rather than make up excuses for turning
them down.
(How would milder
anxiety affect my
social life?) 1.                                 

2.                                 

3.                                 

(continued)
From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can pho-
tocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

16
W ORK SHEE T 1.3 (continued)

Life domains Specific anxiety-­reduction goals or targets

Health/physical fitness Example: I’d take a reasonable wait-and-see approach when I have an
unexpected ache or pain rather than immediately googling the symptoms or
(How could more
making a doctor’s appointment.
tolerable anxiety
improve my health?)
1.                                 

2.                                 

3.                                 

Leisure/recreation
(How could milder
anxiety lead to more
fun in my life?)
Example: I’d engage in more hobbies, sports, arts, or other enjoyable activities
rather than wait until I felt like it.
1.                                 

2.                                 

3.                                 

Community/citizenship Example: I’d read more about important political/social issues and seek ways
to become more politically engaged in my community.
(How might tolerable
anxiety increase my
level of community 1.                                 
engagement?)

2.                                 

3.                                 

Spirituality Example: Be more present minded and grateful; that is, more aware of the
blessings in my life.
(How would better
anxiety tolerance
enhance my spiritual 1.                                 
awareness?)

2.                                 

3.                                 

17
18 The Anxie t y and Worry Workbook

„ Do you have a friend or family member who you think is a great parent, has a suc-
cessful career, maintains their physical fitness, or in some other way seems success-
ful? Anxiety doesn’t interfere in their life. What do you admire about them? Could
that characteristic or quality become your anxiety-­reduction goal?
„ Make sure your goal refers to a specific way of thinking or responding. It should be
a way of thinking or responding that is consistent with your personality and skills.
For example, a goal like “be the life of the party” would be inappropriate if you are a
more serious introvert by nature.

Were you able to list specific ways you’d act, think, or feel better with less anxi-
ety? You can think of these as goals or aspirations for how you’d like to function if
you had better management of your anxiety. Maybe these are ways you used to be
when anxiety was less intense, and now you’d like to get back to your previous way
of being. If you can see how your life would be better with milder anxiety, this can
motivate you to do the work presented in the following chapters.
As you work your way through the chapters, you may want to come back to
Worksheet 1.3 and revise your goals. Also, you can use your goals to evaluate how the
CBT approach to anxiety has improved your quality of life. We all need encourage-
ment to keep going, and if you can see progress through the goals you’ve achieved,
you’ll be motivated to keep working on your anxiety.

The Next Chapter

This chapter is all about determining whether the workbook is right for you. If you
completed Worksheets 1.1 and 1.2, you may have already decided the workbook is
relevant for your distress. At the very least you have enough curiosity to read on. You
may be wondering what CT-R can add to the standard CBT approach to anxiety. The
next chapter shows you how to get started with the workbook. You’ll learn about the
importance of practice assignments in CBT and how to improve your engagement
with the workbook.
 2
getting started

W hen you think about fitness and staying healthy, no doubt diet and physical exer-
cise come to mind. You try your best to eat well and get regular exercise because
you know they’re important to life satisfaction and well-being. But it’s hard to “stay
the course.” Our busy schedules and the pressing demands of daily living easily knock
us off our healthy routines. When this happens, it’s important to take stock and renew
our commitment to healthy living.
Mental health is a lot like physical health. In fact the term mental fitness has been
used in reference to a healthy mind. Psychologists define mental fitness as thriving
in this life by using our skills and resources to flexibly adapt to the challenges and
advantages that come our way.15 Excessive anxiety and worry undermine mental fit-
ness. They interfere in our ability to deal with challenges and reach our potential. If
problematic anxiety and worry are blocking your path to mental fitness and whole-
ness, we’ll show you how to use CBT to clear the path for better mental fitness.
It’s well known that physical fitness can be achieved only through a regular exer-
cise program that keeps our bodies strong, agile, and resilient. The same is true for the
mind. We can become psychologically and emotionally stronger by engaging in daily
cognitive (thinking) and behavioral exercises. These exercises are designed to reduce
the damaging impact of anxiety on our lives just as physical exercises counteract the
modern sedentary lifestyle. But the benefits of all exercise, whether physical or men-
tal, depend on regular practice. And that’s the rub for most of us!
Maintaining regular exercise and eating a balanced diet is challenging. You may
start out strong, but soon your enthusiasm wanes, schedules collapse, resolve crum-
bles, and excuses start to sound more and more reasonable. Even the most die-hard
fitness enthusiasts find regular exercise tough. Fortunately, those who make some
effort to stick with it find that the benefits—both short- and long-term—become so
important that they miss exercising when they let their regimen lapse. We believe
you’ll discover the same when you devote your energy to the exercises in this work-

19
20 The Anxie t y and Worry Workbook

book. That’s why this chapter is important: Arming yourself with the mental tools
you’ll need to keep working at reducing your anxiety will give you a chance to make
the CBT approach work for you.

Different Starting Points

Each of us starts at a different point on the pathway to mental fitness and wholeness.
Because of previous life adversities, childhood difficulties, family history, biological
predispositions, and other factors, some people may have to work harder at mental
fitness than others. But everyone can improve their emotional health. The fact that
you’re reading this workbook is the first step toward committing yourself to better
mental health. First steps are a critical part of change, so we commend you for starting
this journey with us. We’ve designed exercises to help you make long-term changes,
just as CBT has been shown to have long-term beneficial effects on anxiety. Are you
ready to take the next step by practicing the CBT skills explained in this workbook?
Before you begin, consider the following ways you can make the workbook a
more positive, satisfying experience.

„ Keep your expectations realistic. We all have different starting points for anxi-
ety and worry that affect how much we can lower our anxiety. For example, in Chap-
ter 5 you’ll learn that we have different sensitivities to anxiety symptoms. If you’re
highly reactive to anxious feelings, you may not get your anxiety down to the same
level as a person less sensitive to anxiousness.

„Make time for yourself. If you ever start questioning whether you can afford
to take the time to do CBT, stop and consider how much time you are wasting now
because of anxiety. Have you ever sat down and figured out how much time you spend
each day worrying, feeling tired because of insomnia, being stressed out, or being
unproductive because of avoidance? Now compare this to how much time you’ll need
with the workbook. Would an investment in anxiety reduction now cause a net loss
or gain in time and productivity in the coming months?

„Start low and work up. You’ve heard the saying “Rome wasn’t built in a day.”
This certainly applies to CBT for anxiety. If you are very sensitive to anxiety symp-
toms (see Chapter 5), it’s important not to overwhelm yourself by trying to do too
much. It’s much better to start with something that causes only mild or moderate
anxiety and then gradually work up to more severe anxiety situations.

„Pace yourself. If you’ve ever done a road race, you’ll know that keeping a good
steady pace is key to finishing the race. The same is true for your CBT program. It’s
 getting started 21

better to do a little each day and every day than to do nothing for a few days and then
do something for a couple of hours on the weekend. Read a little of the workbook
each day and make sure you are spending some time on the exercises.

„ Catch the thoughts. When doing CBT exercises, focus your attention on how
you are thinking. If you’re feeling anxious, write down thoughts of exaggerated threat
and danger (catastrophic thinking). Are there errors or distortions in your thinking?
Are you convinced you’re helpless or can’t stand the anxiety? Are you thinking about
escape or relying on a false sense of safety? Becoming more aware of your anxious
thinking and learning to correct it (see Chapter 6) is an important strategy for reduc-
ing anxiety.

„ Be patient and don’t run. When anxiety is building and the anxious mind takes
over, our instinct is to run! Although this is entirely understandable, it’s important to
stick with the exercise. Don’t leave the situation or give up. Break time into small units
and focus on reaching the next goal (“I’ll stay for 10 more minutes, and once that is
reached, I’ll stay for another 10 minutes, and so on”). This is how runners finish a race
when they are tired, aching, and want to give up.

„ Celebrate success and problem-solve barriers. Many people who begin a CBT
program see improvements in their anxiety right away. It is important to recognize
your achievements and celebrate the progress you’ve made in overcoming anxiety.
After all, you’re the one who is making the changes, and so you need to encourage
yourself. At the same time, expect setbacks and disappointments. Instead of giving
up, take a close look at why the assignment did not go well. Take a problem-­oriented
approach and see what changes you can make to break through the failed attempt.

„ Don’t fight anxiety; let it flow. Anxiety is like being entangled in a net; the
more you fight it, the worse the entanglement. Take note of whether you are trying to
control your anxiety when doing the practice exercises. Fighting for control will make
your anxiety worse. Instead, focus on accepting your anxious state and allowing the
anxiety to decline naturally.

„ Be kind to yourself. Changing how we think and react to strong emotions like
anxiety is difficult. You’ll get a lot further with the workbook if you exercise self-­
compassion rather than self-­criticism.

How Our Approach Can Work for You

There are three types of exercises and associated worksheets in this workbook.
Approximately half of the exercises are evaluative. They are designed to give you new
22 The Anxie t y and Worry Workbook

insight into your anxiety and worry. They provide assessment information that shows
you how to apply intervention strategies to reduce your anxiety.
Most of the remaining exercises present CBT intervention strategies. These are the
therapeutic exercises designed to reduce your anxiety and worry. They will help you
progress toward the anxiety reduction goals you listed in the first chapter. It’s impor-
tant that you complete both types of exercises because they build on each other. Occa-
sionally you’ll encounter a quiz. This type of exercise helps you determine whether
you understand a core tenet of the CBT approach to anxiety.
Regardless of the type of exercise, you’ll find the worksheets more helpful in
reducing your anxiety if you follow these tips.

„ Always fill out the worksheets on your own so that you’re capturing your per-
spective on anxiety and worry.
„ Follow the exercise instructions that tell you how to complete the worksheet.
„ Don’t spend a lot of time worrying about whether your entries on the work-
sheets are highly detailed and complete. You’ll get better at doing this type of
work as time progresses.
„ Avoid being a perfectionist. Your worksheets don’t have to be perfect, but
always consider them a “work in progress”—an opportunity to learn.
„ Try to complete the worksheets as close to an anxiety experience as possible.
If you wait until hours or days later, you’ll forget a lot of valuable information
about your experience.
„ Resist the temptation to go back and change your entries to worksheets already
completed. Your first, immediate response on a worksheet is probably the best.
„ The worksheets in this book are available to download and print from www.
guilford.com/clark6-forms. If you choose to print out worksheets from the
website, be sure to keep your completed forms handy; you’ll need to refer to
many of them as you proceed through the book.

What Have You Heard about CBT?

You probably wouldn’t have gotten this far in the book if you had serious doubts
about the CBT approach to anxiety. But if you’ve been exposed to the following mis-
conceptions, they could weaken your confidence in CBT and undermine your motiva-
tion to do the workbook exercises. Let’s put them to rest once and for all:
 getting started 23

: M Y T H : CBT is overly intellectual and does not deal with feelings.

; F A C T: It is true that CBT focuses a lot on how we think and behave. But the
thoughts and beliefs important in CBT are emotional—they deal with our emo-
tions and not our intellect. CBT is all about changing emotions, and in this
workbook we continually ask people to observe, record, and understand “how
they feel.”

: M Y T H : Only well-­educated or highly intelligent people can benefit from CBT.

; F A C T: The ability to observe your thinking, evaluate it, and consider alterna-
tive ways of thinking is more important to the success of CBT than how far you
went in school or your IQ.

: M Y T H : Because it’s very rigid, CBT can’t take into account the unique needs
and circumstances of individuals.
; F A C T: CBT is always applied to the unique features of your anxious experi-
ence.

: M Y T H : CBT is superficial, dealing only with symptoms and not addressing the
root cause of anxiety.
; F A C T: CBT considers automatic thoughts and beliefs about threat and helpless-
ness, basic elements of anxiety. By addressing these cognitive “root causes,”
CBT has often shown enduring benefits for reducing anxiety.

: M Y T H : You can’t benefit from CBT if you’re taking medication for anxiety.
; F A C T: Research studies and our own clinical experience have shown that peo-
ple on medication for anxiety can benefit significantly from CBT.

: M Y T H : You have to be well organized and disciplined to benefit from CBT.

; F A C T: There is no research evidence that a well-­organized and disciplined per-
sonality type benefits more from CBT than anyone else.

: M Y T H : CBT completely ignores the influence of a person’s past.

; F A C T: CBT does focus on the present, but past difficult experiences and child-
hood adversities may be considered when they have an important influence on
your anxiety and worry.
24 The Anxie t y and Worry Workbook

: M Y T H : CBT is effective only with mild or moderate anxiety.

; F A C T: Research studies that formally evaluated CBT have shown that individu-
als with severe anxiety symptoms can achieve significant symptom improve-
ment.

: M Y T H : CBT is only “talk therapy” in which people “talk themselves out of

being anxious.”
; F A C T: Behavior change is a very important part of CBT. Although changing
how you think about anxiety is critical, it is just as important to change your
behavior in response to your anxiety problem.

: M Y T H : CBT emphasizes the “power of positive thinking” to trick people into

being less anxious.
; F A C T: CBT emphasizes the importance of “realistic thinking” and not “posi-
tive thinking.” You’ll learn to replace unrealistic, exaggerated thinking with
more accurate, realistic evaluations of threat in ordinary daily activities. This is
a core skill you’ll use repeatedly to reduce the intensity of your anxiety.

: M Y T H : Cognitive behavior treatment for anxiety is slow and can take many
weeks before real benefits are seen.
; F A C T: Many of the significant effects of CBT are seen in the first few sessions.
You can expect to see some improvement within the first four to six weeks of
therapy.

: M Y T H : It is rare to see sudden anxiety reductions in CBT.

; F A C T: People in formal CBT can experience a sudden reduction in anxiety
from one week to the next. It is unknown whether these sudden changes occur
when using CBT workbooks alone.

 Tips for Success: Staying Motivated for Change

If you hit a point in this workbook where you feel stalled or unmotivated, come back to this
list and see if you’re still subscribing to any of these myths. If so, remind yourself of the
facts. Or maybe you believe one of these myths and it’s preventing you from committing
to the workbook program. If this is the case, consider whether you can suspend judgment
about the CBT approach until you’ve given it a try. You could select some aspect of your
anxiety experiences and use one or two exercises in Chapter 6 or 7 over a two- to three-
 getting started 25

week period. Observe what effect it’s had on your anxiety. Is it worth continuing? The best
way to stay motivated is to experience some progress in reducing your anxiety or worry.
If you’re working with a CBT therapist, discuss your concerns about slow treatment prog-
ress.

Practice Makes “Perfect”

The phrase “practice makes perfect” may not quite apply to anxiety reduction, but its
basic message is relevant. The more you practice CBT skills, the better you’ll get at
applying them to your anxiety and worry problems. You may never reach perfection,
but the more you use the workbook exercises and worksheets, the greater their
anxiety-­reducing effects. Research has shown that individuals who engage in practice
assignments between therapy sessions experience greater improvements in anxiety
and depression than do individuals who don’t engage.16,17
In CBT, practice exercises are tailored
to address unique aspects of your anxi- In this workbook, practice exercises are
ety experience. Here are some examples. defined as any specific, clearly defined
Darrell avoids public places because he structured activity that is carried out in
believes being in them causes his panic a person’s home, work, or community to
attacks. His practice exercises focused observe, evaluate, or modify the faulty
on demonstrating to him that it is not the cognitions and maladaptive behaviors
places that triggered anxiety but his ten- that characterize anxiety.
dency to misinterpret his increased heart
rate as a sign of a possible heart attack.
Aaliyah constantly worries about almost every aspect of her life—the health of her
daughters, the viability of her marriage, the future of her aging mother, and so on.
Her exercises tested her beliefs that worrying prepared her for the worst. Phoebe felt
extremely anxious in anticipation of all social situations because she was convinced
she was the only person who felt this level of anxiety and that embarrassing herself
was inevitable. Her exercises focused on showing her not only that many people felt
some level of social anxiety but also that they performed well even while anxious.

Do You Have Doubts about Doing CBT Exercises?

Maybe you’re thinking that this sounds good but it’s a lot easier said than done.
You may bring to this book (or to therapy) a lot of preconceived notions about the
effectiveness of practice exercises and about CBT strategies in general. By doing the
26 The Anxie t y and Worry Workbook

exercises you’ll see that CBT tools and techniques have been crafted meticulously to
anticipate stumbling blocks and help you chip away at the negative effects of anxiety
in your life. But if you’ve got doubts that keep you from diving in, now is the time to
clear away any preconceived notions that are standing in your way. We’ve found that
when people have trouble completing practice exercises, either as self-help or with a
therapist’s guidance, the problem often lies in preconceived ideas about this work.
You might feel eager to tackle your anxiety and believe you’re entering this program
with an open mind, but little doubts and questions often lurk in the back of people’s
minds, ready to pop up and sabotage their efforts when they least expect it. Exposing
these hobgoblins to the light of day and addressing them now will help you get the
most out of the work you do in this book and/or in therapy. The bottom line: You’ll
get a lot more from this workbook if you have an open mind about doing the exercises
and filling out the worksheets.

E VA L U AT ION EXER C I S E  Problematic Beliefs about Practice

Are you fully aware of the beliefs you hold about CBT practice exercises? Take a few min-
utes and rate yourself on the belief statements in Worksheet 2.1.
How did you do? We don’t have data that will tell you reliably what ratings indicate
being ready for CBT. But you can use the checklist more informally by looking over the
belief statements for which you checked off “Agree” or “Strongly agree.” All of these state-
ments reflect ideas that might interfere with your ability to commit to this program.

IN T ER V EN T ION EXER C I S E  Challenge Unhelpful Practice Beliefs

You don’t have to remain stuck in your negative beliefs and biases against practicing CBT
strategies. You can use the CBT approach to evaluate your beliefs about practice assign-
ments and adopt a more positive perspective that will boost your engagement in the work-
book. Review your answers to Worksheet 2.1 and write down statements that you marked
“Agree” and “Strongly agree” on a piece of paper. For each statement you listed, evaluate
the accuracy of that belief statement by doing the following:

„ Question the accuracy of these beliefs. Does the belief apply to all your experiences
of doing physical or mental exercises to improve yourself? Have you had any experi-
ences that contradict the belief? What are the consequences for you of holding these
beliefs?
„ Substitute the term physical fitness or lack of physical fitness for anxiety in your
belief statement (for example, “I can overcome my lack of physical unfitness without
practice”). Would you believe this statement if it referred to getting physically fit?
If it is untrue for physical fitness, how can it be true for mental fitness? You could
W ORK SHEE T 2.1

My Beliefs about Practice Assignments

Instructions: Please read each statement and circle the number that best corresponds with how much you
agree or disagree with each belief about self-help exercises.

Strongly Strongly
Belief statement disagree Disagree Agree agree

1. Doing these assignments will make my anxiety worse. 1 2 3 4

2. There is no point in trying; nothing can help me. 1 2 3 4

3. I should not have to practice skills to overcome my

1 2 3 4
anxiety.

4. I am too anxious to do homework tasks right now. 1 2 3 4

5. My anxiety has been pretty good; I don’t want to risk

1 2 3 4
making things worse by doing self-help exercises.

6. I don’t believe these exercises are an effective approach

1 2 3 4
for reducing anxiety.

7. I am a procrastinator; I’ve always had trouble motivating

1 2 3 4
myself to do extra work.

8. I’m not getting any better, so why bother doing these

1 2 3 4
exercises?

9. I’m too tired or stressed to do self-help exercises. 1 2 3 4

10. These tasks are trivial; I don’t see how this will help me
1 2 3 4
beat anxiety.

11. I’m too busy and don’t have time for daily mental self-help
1 2 3 4
exercises.

12. Anxiety is a medical condition; I shouldn’t have to go to all

1 2 3 4
this effort to get rid of it.

(continued)
From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can pho-
tocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

27
W ORK SHEE T 2.1 (continued)

Strongly Strongly
Belief statement disagree Disagree Agree agree

13. Other people overcome anxiety without putting this much

1 2 3 4
work into it.

14. There is a deep-­seated root to my anxiety that needs to

be discovered; I don’t see how these exercises can be 1 2 3 4
effective.

15. What if I don’t do these exercises correctly and they

1 2 3 4
make my anxiety worse?

16. I hate writing things down; I’ve never been a person to

1 2 3 4
keep records.

17. I lack the motivation and discipline to do this kind of

1 2 3 4
therapy.

18. This is too hard; there must be an easier way to

1 2 3 4
overcome anxiety.

19. Doing even a little homework is better than doing nothing

1 2 3 4
at all.

20. Even if I don’t do the self-help exercises, going to therapy

sessions or reading about anxiety should be somewhat 1 2 3 4
helpful.

21. I’ve always hated doing homework, even as a child. 1 2 3 4

22. I don’t like following rigid programs; I prefer to do things

1 2 3 4
my own way.

23. I can overcome my anxiety without practice. 1 2 3 4

24. I’ve made progress on my anxiety in the past without

doing self-help exercises; therefore I shouldn’t need to do 1 2 3 4
them now.

25. These exercises are too demanding; I just don’t see how
1 2 3 4
they are going to help me overcome anxiety.

28
 getting started 29

discuss with friends how they overcame the same negative beliefs about physical
fitness training.
„ Take action by doing something small that might test or correct the belief (if you
believe you lack the discipline to do self-help assignments [item 17], you could start
by engaging in a brief, limited self-help exercise that takes only a few minutes each
day).

 Troubleshooting Tips: Still Skeptical about Practice Exercises

If you still have some doubts about your readiness to do the exercises in this workbook,
and you are in therapy, you should discuss these doubts with your therapist, because
they could also be a roadblock to your therapy progress. If you are reading the work-
book on your own, talk to others who overcame anxiety through therapy. What role did
exercises play in their recovery? Also, we are not asking you to do all the exercises all
the time. Instead we are asking you to set aside 30 minutes on most days and focus on
one exercise at a time. Do you recall the old Chinese saying “Every journey begins with
the first step”? That’s our outlook in CBT. You have already taken the first step by get-
ting this far in the workbook. Are you ready to continue the journey toward recovery?

Maximizing Your Workbook Success

CBT is most effective when people practice anxiety-­reduction strategies rather than
just read about them. You’ve been introduced to barriers that can hinder your engage-
ment with this workbook. It’s also important to remember that our practice exercises
are generic so they can be applied to a wide range of anxiety experiences. Even with
instructions and recommendations, it is up to you to decide how to use the exer-
cises and apply CBT strategies to your anxiety experiences. It is possible to use these
exercises in an effective manner or an ineffective manner. Consider the following
examples.
For many years Sebastian, age 44, had severe anxiety caused by upsetting, intru-
sive thoughts of harm or injury to loved ones. For example, he had thoughts of a
friend being in a car accident and then became anxious that this might really happen,
or he would think of a family member having a serious illness and then worry that
his relative might actually become seriously sick. Sebastian experienced these ter-
rible thoughts many times throughout the day and tried to distract himself from the
thoughts or reassure himself that everything would be all right.
To overcome the anxiety caused by these worrisome thoughts, it was important
for Sebastian to engage in exercises that exposed him to situations that trigger the
worry, practice correcting his automatic thoughts of danger (such as “if I have this
worry about harm, maybe something bad will happen to people”), and prevent efforts
30 The Anxie t y and Worry Workbook

to control the worry. Sebastian, however, was never very keen on doing these home-
work tasks. He was quite happy to attend therapy sessions and talk about his anxiety,
but he had great difficulty finding the time to apply the therapy. Sebastian tried to
do some of the things his cognitive behavior therapist recommended, but they never
worked for him. He was afraid the exercises would make him feel more anxious.
He was impatient with the pace of therapy and felt like the exercises were trivial
and unimportant. He refused to keep a written account of the exercises and would
do them only once or twice a week for a few minutes. He said he was too busy and
didn’t have enough time. When he did an exercise, he would stop it as soon as he felt
a little anxious. In the end, the whole process was frustrating and unproductive for
Sebastian. Despite faithfully attending his therapy sessions, Sebastian was unable to
overcome his anxious, worrisome thoughts.
What went wrong? Sebastian wasn’t sure of the benefits he stood to gain from
doing the exercises assigned by his therapist, he didn’t stick with the tasks and work
his way up gradually, he refused to keep a written record of his exercise experiences,
he didn’t practice regularly, and he never tried to determine what had gone wrong
and how he might rectify the problems. There were many problems with Sebastian’s
approach to practice assignments. To turn his therapy around and make it effective,
he’d need to truly believe in the benefits of practice exercises. He would need to be
more systematic in how he did the exercises, keep a written record of his experiences,
and practice the exercises repeatedly over several days.
Belinda, age 32, who wanted to address intense social anxiety, took advantage of
all the arrows in the CBT quiver. Belinda felt conspicuous when around others and
believed that people could see she was anxious and therefore would conclude that she
must have an emotional problem. Her practice exercises exposed her to increasingly
more severe anxiety-­provoking social situations. She practiced these exercises on a
daily basis and recorded her progress in structured diaries and rating forms. If she had
trouble with a particular exercise, she wrote the challenges down on her evaluation
form and then problem-­solved the issues. She also used the exercises as an opportu-
nity to practice correcting her exaggerated thoughts of fear and danger and to refine
her coping responses to anxiety. After several weeks of daily structured exercises,
Belinda found she was much less anxious in a variety of common social situations,
and she felt much more confident in her social skills.
The people you met at the beginning of this chapter—­Darrell, Aaliyah, and
Phoebe—used exercises that helped them too.
Darrell’s exercises involved going into the supermarket in the morning when only
a few people were shopping. He would stay close to the front of the store, near the
exit, and monitor his anxiety level, note any physical symptoms, and identify any
anxious thoughts or interpretations of the symptoms. He then generated alternative,
Another random document with
no related content on Scribd:
oblique incision, made between the lower rib and the upper margin
of the pelvis, its centre about four inches from the spine, extending in
either direction two inches or more, in order to afford sufficient
access. It is carried down until the abdominal aponeurosis and
muscles are exposed. These are then divided and the perirenal fat,
which is sometimes excessive in amount, is exposed. The deep
opening should now be stretched to a size to permit the introduction
of a hand, and exploration made for the identification and retraction
of the kidney. Much aid may be afforded in this effort by the use of
the other hand upon the outside of the patient’s abdomen, which
should all have been protected and sterilized to permit such free
manipulation. Sometimes it is easy to find such a kidney, at other
times and in persons of certain build it is a difficult matter. It lies
behind the peritoneum, and this should never be opened during the
effort. More or less of the perirenal fat may be cleared away. The
more or less elusive kidney being identified, it should be seized with
tenaculum forceps, which should secure only its capsule and not
injure its substance. With these it is drawn up at least to the wound,
or in some methods, it is withdrawn through it and delivered upon the
surface of the body. If sutures alone are to be depended upon they
may be placed after any one of a number of different methods. The
older method was to place the kidney as nearly as possible in its
normal relations and then unite the deep margins of the wound to the
capsule, and perhaps the cortex of the kidney, by a series of two or
three sutures on either side, either of chromic gut or of silk. The
theoretical objections which prevail against passing sutures through
the renal cortex are hardly well founded, and stitches may be so
placed, if desired, but they should not be drawn too tightly (Fig. 636).
Senn and others have endeavored to induce the formation of
dense adhesions by packing around the kidney with gauze, left in
situ for several days, whose presence should provoke the formation
of granulation tissue. In theory this works well, but in practise the
presence of the gauze is painful, its removal especially so, and the
wound must be left more or less open for the purpose. Since I have
learned of the harmlessness and the advantages of decortication I
have made a practise of decapsulating almost every kidney thus
exposed, and of endeavoring to utilize a portion of the capsule for
the purpose of support, as by cutting it into strips, which are
threaded into a needle, and then passed through the tissues, thus
utilizing the capsule for suture material, or by fastening it with
sutures which are not passed through the kidney substance. All in all
I have had best results from a combination of some such method as
this with one of suspension, for which purpose tapes or gauze are
used and passed beneath the kidney—one above the hilum and one
below it—after it has been delivered well into the wound, by which it
is, first of all, lowered into the position in which it is intended to hold it
and then maintained there, the ends being left hanging out of the
wound, where they are tied over a roll of gauze or something similar.
This provides the smallest amount of gauze, whose presence may
provoke granulation tissue, at the same time proving an efficient
means of support, and leaving trifling strips to remove when the time
for their removal has come. I have usually left them in place for nine
or ten days, by which time they are comfortably loosened by the
presence of granulations around them, and consequent moisture, so
that they are easily withdrawn, with a minimum of discomfort to the
patient. Da Costa has suggested an improvement on this by sewing
the ends of strips of gauze with chromic gut and letting these sewed
ends be placed beneath the kidney. In the course of time, as the
catgut softens, the union is separated, and the strips are easily
withdrawn. If there be a tendency in these tapes to slip from their
desired position, they may be attached to the capsule by a single
suture of catgut, which will have softened and disappeared before
the time for their withdrawal has arrived. Again in many of these
instances the capsule which has been stripped off, or more or less
detached, may be utilized for the purpose of fixation by suture with
its own tissue.
Nearly all of these operations are without mortality, although they
are not yet as satisfactory as could be desired, the trouble inhering
partly in the fact that the kidney is not fastened as high up as it
should be, or else not in quite the same relative position, so that
there is some strain upon its vessels or upon its ureter. Every effort
should be made to imitate the original position as accurately as
possible. Methods theoretically more perfect, yet more complicated
and but little more advantageous, include fixation of the kidney to the
twelfth rib, by suture passing through the capsule and then around
the rib. No matter what method be adopted, it is necessary to keep
the patient in bed for several weeks after these operations, in order
that adhesions may not only form but may not be stretched by too
early change of posture.

TUMORS OF THE KIDNEY.

The kidney is the site of an occasionally benign and frequently of a
malignant tumor of some of the known varieties. The simplest forms,
like the fatty and the fibrous, are uncommon and deserve no special
consideration here. There is a so-called adenoma of the kidney,
which does not deserve this expression any more than does the so-
called adenoma of the thyroid, in that it is not built up of the normal
type of secreting gland, but represents something more or less
similar to it, perhaps only undergoing multicystic degeneration, its
commonest expressions being of congenital origin. The
consequence is the production of the so-called congenital adenoma
or cystic or multicystic or polycystic kidney, in which may be seen a
conversion of original renal tissue into a mass of cysts, surrounded
by degenerated kidney tissue, all semblance to the original being
lost, and the whole constituting a partial or complete invasion of the
organ, by which sometimes its proportions are enormously
increased. The condition is essentially of congenital origin, although
its serious clinical expressions may not occur for years. The result is
to destroy the renal function, to produce a growing mass, and to
constitute an essentially surgical condition to be relieved only by
nephrectomy. (See Fig. 637.) I recall one child of twenty-three
months with a tumor of this character, of such size and extent that it
could only stand erect when wearing from its neck a sort of
suspensory in which the lower part of the abdomen was contained. I
removed this kidney by abdominal section, the child recovering, and
being at that time the youngest case that had ever survived a
nephrectomy. A number of years later a similar condition developed
in the other kidney, of which the child finally died, it having passed
during the last thirteen days of its life not more than an ounce or two
of urine.
 Of the solid tumors of the kidney both carcinoma and sarcoma
occur, the former usually as a secondary growth, the latter usually as
primary, although any form may be met. The sarcomas are more
frequent in early life and in general more common. On account of the
kidney having a well-marked capsule metastasis is not so common,
in the early stages, as from some other organs. These malignant
tumors may attain great size; some grow regularly in shape, others
constitute most irregular masses. The entire organ may be involved
or only a part.
There are no indicative symptoms of renal cancer that may not be
met in other conditions; the development of tumor, perhaps its
displacement, pain, and hematuria, though late, and, in proportion to
the rapidity of growth, enlargement of superficial veins and general
cachexia. When the tumor is large enough to press upon the vena
cava or upon one of the common iliacs there will be edema of one or
both lower extremities. The veins of the external genitals are more
likely to suffer early rather than late (Figs. 638, 639).

Fig. 637

Congenital cystic kidney; exterior and internal appearance; patient forty-two years
of age. (Schmidt.)
 Fig. 638

Cancer of kidney, intramural, as seen after dividing the organ. (Israel.)

Hypernephroma.—There is one peculiar variety of solid tumor of

the kidney which deserves special mention, the
so-called hypernephroma. These tumors consist essentially of
adrenal tissue, although when they develop within the kidney their
occurrence there is due to the presence of aberrant rests of the
original suprarenal tissue. Gravitz, in 1883, was the first to recognize
their real character. Supernumerary adrenal rests have been met
with in many parts of the body, not alone in the kidney and
perinephric tissue, but in the broad ligament, along the spermatic
vessels, in the sexual glands of both sexes, in the liver, the
mesentery, and even the solar and renal plexuses. Their occurrence
in these localities may be explained by the close relationship
between the mesonephros and the origins of these various organs.
Hypernephroma has no pathognomonic signs or symptoms. It is
usually a single tumor, although both kidneys have been affected.
When the organ is not so involved as to mask all its original features
the tumor will be found beneath the capsule, varying in size from that
of a pea to that of a child’s head, its outer surface lobulated by
depressed bands of capsule, its color lighter than that of the
surrounding kidney texture, while projecting portions will be soft and
almost cystic. When met with in other parts of the body its gross
characteristics are essentially the same. Metastasis is very common,
the tumor often extending along the walls of the veins, or even more
often partially filling them than the lymphatics. A common method of
extension also is by implantation within the peritoneal cavity; for the
secondary implantation occurs most often along some portion of the
urinary tract—e. g., the bladder.[66]
[66] It may assist in the recognition of hypernephromatous tissue, after
removal, to remember that adrenal tissue has the property of decolorizing
starch which has been turned blue by the addition of iodine. Crofton has
shown how there may be put into a test-tube a 1 per cent. starch solution
colored with a drop of weak tincture of iodine. If to this solution
hypernephromatous tissue be added the blue color changes gradually to a
pink and then fades out.
 Fig. 639

Infiltrating form of cancer of the kidney. (Israel.)

Hematuria and renal colic are the most conspicuous features

connected with the growth of these tumors. The former often occurs
during sleep, and blood is passed in almost pure form, perhaps for a
considerable period of time, after which spontaneous recovery
apparently takes place, the trouble recurring at intervals.
There is but one method of treating hypernephromas, like other
solid tumors, namely, by complete extirpation, i. e., nephrectomy.
Even this may be too late, but should be undertaken, except in the
most unpromising instances. If the existence of metastatic
involvement can be determined even nephrectomy may be
considered useless. (See chapter on Cysts and Tumors.)

HYDRONEPHROSIS.
 This term refers to a more or less permanent distention of the
kidney cavity by retention of urine, due to partial or intermittent
obstruction to its escape. An intermittent form is common, which,
however, at almost any time may lead to some degree of
enlargement, while when the obstruction is permanent the resulting
tumor becomes practically a thin-walled cyst, which may contain an
enormous amount of fluid, more or less altered urine, which will
contain, in addition to the ordinary urinary elements, cholesterin
crystals and other adventitious products. Hydronephrosis, then, may
be congenital or acquired in origin, intermittent or permanent in
character, and unilateral or bilateral in location. Among the acquired
causes are strictures of any portion of the urinary tract below, either
in the ureter, the prostate, or the urethra; tumors of any kind making
pressure; movable kidney which permits of kinking; tuberculous
diseases which lead to chemosis of the mucosa and consequent
obstruction; renal calculi which plug the ureter; foreign bodies, blood
clot, and the like (Figs. 640 and 641).
 Fig. 640 Fig. 641

Hydronephrosis from obliteration of Hydronephrosis in first stage of

ureter by tuberculous disease. (Tuffier.) development. (Rayer.)
 Fig. 642

Operative treatment of hydronephrosis or pyonephrosis. (Hartmann.)

Until the infectious or suppurative element be added the urine is in

these cases but little changed. When infection is added the case
becomes one of pyohydronephrosis, and perhaps finally one of
distinct pyonephrosis. The symptoms produced at first are not very
pronounced and will vary with the exciting cause. If the result of
acute obstruction, renal colic is perhaps the most significant. When
this is accompanied by tumor in the region of the kidney the
interpretation of the phenomenon is easy. Sudden decrease in size
of such tumor, with unusually great escape of urine, is also
pathognomonic of intermittent hydronephrosis. The discovery and
the history of a gradually increasing tumor in which, when large,
fluctuation can be determined, and in which fluid is easily found with
the aspirating needle, will permit a differentiation of these
pseudocysts from solid tumors of the kidney. They are to be
distinguished from ovarian cysts, from general ascitic accumulations
within the abdomen, and from perinephritic and spinal abscesses.
Their location, which corresponds so closely with that of the kidney,
especially while they are small, their gradual growth, the
displacement of the abdominal viscera forward and to their inner
side, their enlargement downward and their fluctuating character will
usually provide features by which they may be accurately
recognized.
Treatment.—The treatment of intermittent hydronephrosis in its
earlier stage may be accomplished by some measure
less radical than nephrectomy or nephrotomy, particularly when due
simply to abnormal movability or to pressure of some extrinsic
growth. Hydronephrosis due to obstruction by renal calculus may be
relieved by removal of the obstructing stone, but a hydronephritic
cyst, which has attained large size, in which practically all semblance
to secreting kidney structure has disappeared, should be extirpated,
unless this should entail too formidable an operation, in which case it
should be freely opened and drained until such time as it has
contracted to a size justifying enucleation (Fig. 642).

THE URETERS.
There are a few morbid surgical conditions of the ureters, so
distinct from those of the bladder below or the kidneys above as to
require separate consideration here. They are frequently involved in
the pyogenic and tuberculous infections, which spread along them in
either direction, but the chief surgical diseases deserving mention
here are stricture and calculus.

STRICTURE OF THE URETER.

Stricture of the ureter may result from intrinsic or extrinsic lesions.
Thus it has been injured in operations upon the pelvic viscera, as in
parturition, and it is not infrequently pressed upon by neoplasms; but
the majority of its contractions are cicatricial, and are consequences
of ulceration or injuries done by calculi. Stricture of the ureter is to be
recognized rather by its consequences—i. e., hydronephrosis—than
by more direct symptoms. Its accurate location is now possible by
the use of the cystoscope and the ureteral bougie or catheter. When
by the cystoscope no urine is seen escaping from the ureter one
naturally infers its complete obstruction—in fact, the degree of the
latter is fairly estimable with this instrument. However, with the
passage of a bougie the trouble may be found. This is particularly of
value when the lesion is an impacted calculus, for it indicates to the
surgeon the level at which he should direct his operative relief, a
matter which may also be decided by a skiagram.
While in the hands of experts dilatation of the ureters may be
accomplished from below, it is usually beyond the ability of the
average surgeon. He has to decide, then, as to whether the ureter
should be exposed along its course, from the loin, extraperitoneally
along the groin, or by abdominal section. A ureter hopelessly
entangled in a mass of cancer may be turned into the other ureter or
into the bowel. A ureter fixed in a narrow, cicatricial band may be
divided and its upper end turned into the tube below the stricture by
a process of transplantation or anastomosis, which is one of the
feats of modern surgery; but a ureter hopelessly involved for a
considerable portion, or hopelessly diseased, will require
nephrectomy, as the kidney above it may be compromised and can
probably be well spared.
Calculi impacted in the ureter are most commonly arrested at
those points where its caliber is normally smallest, just below its
origin, at the pelvic brim, and just above its orifice. The symptoms of
impaction are those of renal colic, already considered. It should be
sufficient that extreme pain and the escape of pus and blood in the
urine, accompanied by more or less distention of the kidney above,
are noted. If there be a history of previous attacks of this kind, with
the passage of small calculi, the diagnosis may be regarded as
positive. This may or may not be confirmed by the x-rays, or by the
catheterization of the ureter from below.
Gibbon has suggested intra-abdominal exploration and palpation
of the ureter for the discovery and location of impacted calculi, and
recommends that when discovered they may be removed by
extraperitoneal incision, which may be lumbar, iliac, inguinal, vaginal,
or even sacral or rectal; while with the advantage of combined
manipulation, the operator having one hand in the abdominal cavity,
the actual work is more rapid and certain.
This procedure is not to be advised in every case by any means,
but may prove of advantage in doubtful cases, and especially in
those where, when the abdomen has been already opened, a stone
is accidentally found in the ureter, since when the latter is opened
extraperitoneally it is rarely necessary to suture it.
The non-operative treatment of ureteral calculi has been
considered when speaking of renal calculi. The operative treatment,
inversion of the patient having failed, may consist of exposure of the
upper two inches of the tube, by an incision parallel to the twelfth rib,
and carried well forward and downward toward the middle of
Poupart’s ligament. Through such an incision the whole length of the
ureter may be reached. The opening is made down to the
peritoneum, which is then pushed toward the median line. On its
posterior surface, adherent to it, will be found the ureter. At the point
where the stone is impacted the ureter is to be divided and the stone
removed. In theory sutures should be inserted; in practice, they are
rarely needed, as these incisions usually heal kindly without them.
A stone impacted at the vesical orifice of the ureter may, in the
female, be removed after such dilatation of the urethra as shall
permit access, or it may be removed through the vault of the vagina.
In the male only the most expert manipulators within the bladder will
attempt its removal in this way without at least a perineal section.

OPERATIONS UPON THE KIDNEYS AND URETERS.

In addition to the operative procedures already described the
principal operation upon the kidney is nephrectomy. While this may
be partial, under rare circumstances, the procedure is so essentially
similar to the complete operation that it is only necessary to say that
if a portion of the kidney be removed, bleeding from spurting vessels
should be arrested by ligature, while the oozing, at first pronounced,
will soon subside under the application of hot water, after which
absorbable sutures may be used in sufficient number to approximate
the parts.
 Fig. 643

Position of patient and various lines of incision for nephrectomy and other
operations upon the kidneys. A, the favorite method of approach for most
purposes. (Hartmann.)

Total nephrectomy is usually done by the lumbar route, the kidney

being exposed by an oblique incision extending obliquely downward
from near the spine, parallel to the lower rib, between it and the crest
of the pelvis, and as far forward as may be required for the purpose.
For removal of a large solid tumor a large opening should be made,
and the above incision may be extended in any required direction, or
an additional cut may be made wherever required. In fact, in
attacking some of the very largest growths it becomes necessary to
apparently almost bisect the patient in order to furnish sufficient
space. As the mass to be attacked lies behind the peritoneum it is
rarely necessary to open the peritoneal cavity. This is usually done
only by inadvertence or because of density of adhesions, and the
effort should then be made to at once close it temporarily or
permanently. Especially should every attempt be made to prevent
contamination when dealing with tuberculous or suppurative renal
disease. Ordinarily the abdominal opening does not extend nearer to
the spine than the border of the spinal muscles. These may,
however, be divided if necessary. So also may the deep fascia be
divided in any direction, and, in fact, the last rib may be removed in
toto if required. The kidney or the tumor, having now been reached,
should be isolated. If the condition be cancerous as much of the
surrounding tissue should be removed as the case will permit; if
otherwise, an enucleation of the kidney from its more or less
infiltrated bed will be sufficient. It is usually removed with its capsule,
but sometimes the latter is so adherent that it is easier to enucleate
the kidney itself from within it. Adventitious vessels may enter the
kidney, more especially from below. The surgeon must be prepared,
then, at any time to clamp and secure them if found. Sometimes
enucleation of the kidney is exceedingly easy; at other times old
adhesions or surrounding infiltration make it a matter of great
mechanical difficulty. The intent is to not only isolate it, but to make
such exposure of its pedicle that one may be securely protected
against hemorrhage. Incidentally the ureter should be examined from
above, by passage of a probe, or by injecting a colored solution, in
order to know later if it passes freely into the bladder. It is the
accurate securement of the renal vessels which is perhaps the most
necessary feature of the operation and upon which most depends.
When this is made impossible by extraordinary circumstances
expedients must be adopted, as, for instance, the use of an elastic
ligature—i. e., a piece of small rubber tubing, drawn tightly around
the base of the mass and secured by clamp, ligature, or suture, the
intent being to leave it for at least two or three days until it shall have
accomplished its work, and then either to remove it or to allow it to
loosen itself in time and come away.
 Fig. 644

Nephrectomy. Complete delivery of kidney and ligation of its vessels and ureter.
(Hartmann.)

Under some circumstances the surgeon may so complete the

nephrectomy that the external wound may be closed without
drainage; but when there has been contamination, as by escape of
contents, either purulent or urinary, or when a considerable mass of
tissue has to be left enclosed within an elastic ligature surrounding
the stump, then an opening should be left in order that slough may
easily escape and ample drainage be afforded. A reliable ligation of
the renal vessels should be made, which is best done with at least
two ligatures, taking the pedicle in parts, or else carefully isolating
the vessels when sufficiently exposed, and tying each one of them
separately, after which the whole group may also be enclosed in a
single ligature. A few operators have reported such accidents as
tearing the renal vein from the vena cava, and such a wound has
been successfully sutured, the patient recovering; this requires,
however, both coolness and resourcefulness in the presence of
serious difficulty and danger. Certain dense tumors can be removed
by process of morcellation, i. e., removal of a portion at a time, the
separate pieces being cut away with scissors or knife, as may be the
more convenient, and hemorrhage being controlled by clamps.
The anterior or Trendelenburg route is rarely selected for
nephrectomy, but may be adopted when this procedure is made a
part of other abdominal work, or may be necessitated by the
presence of a large tumor in a small abdomen, as, for instance, in
children. The abdomen will be opened as for any abdominal tumor,
either in the middle or to one side, as may seem best. The tumor
itself will so far displace the viscera as to perhaps present at once
beneath the knife. It may be necessary to go through the peritoneum
twice. After being thus exposed, and the abdominal cavity protected,
the balance of the operation is again a process of enucleation, with
securing access to the pedicle of the tumor, where its vessels and
the ureters may be found. These again are ligated and the mass
removed as though it were from the peritoneal cavity. Posterior
drainage may be added, although rarely necessary.
Other operations have been suggested to meet the needs of
individual cases. Thus pyelectomy, or removal of a portion of the
dilated pelvis of the kidney, has been performed by Murphy and
others, the process being essentially an excision of a portion of the
sac wall and its retrenchment by sutures. Plastic attachment of the
dilated upper end of a ureter to the floor of the renal pelvis has also
been effected in much the same way, as in a case reported by
Murphy, where, after opening the sac of the pelvis, the ureter was slit
for a considerable distance, while at the lower angle a V-shaped
piece of the sac was fastened into the ureteral opening, thus making
a funnel-like communication.
Again, as illustrative of some of the radical suggestions of recent
years, Watson has proposed that in instances of hopeless bladder
conditions, where the patient is made miserable, there should be a
turning out of both ureters on the loin, and the formation of two
ureteral fistulas, after which the patient may wear a drainage
receptacle, and in this way enjoy a comfort otherwise unattainable.
He has reported the case of such a patient, who has thus passed all
the urine for four years, and urine from one side for eleven years,
who was otherwise in comfortable health.
 Fig. 645 Fig. 646 Fig. 647

Longitudinal suture Implantation or invagination of Longitudinal incision and

of ureter. ureter with fixation and then transverse suture of ureter for
(Hartmann.) with circular sutures. stricture, similar to the
(Hartmann.) pyloroplastic method of
dealing with pyloric stenosis.
(Hartmann.)

Operations upon the Ureters.—The surgery of the ureters is also

quite modern, and has been
worked out in the experimental laboratory. That ureteral tissue will
heal has been proved by Murphy, who has remarked that “The
peritoneum is the only tissue that unites as kindly as does the
ureter.” After accidental injuries during other operations the ureter
may be sutured almost as though nothing had happened. These
sutures should be made with fine round needles, and be placed
closely together. They should be made of fine silk or thread.
Not only end-to-end union but lateral anastomosis and even more
ingenious methods of transplantation and implantation are now in
vogue. Figs. 645, 646 and 647 illustrate some work in this direction,
and show what may be done by work quite similar to that done upon
the small intestines or the bloodvessels. More complete instances of
transplantation have been effected in connection with exstrophy and
carcinoma of the bladder, where, for instance, the ureters
individually, or the base of the bladder containing the ureteral orifice,
have been dissected out and implanted in the colon or the rectum.[67]
[67] In one case I carried out the following procedure, necessitated by
cancer involving the urethra, the base of the bladder, the rectum, and the
whole floor of the pelvis, in a female patient, the disease having attained a
degree making urination or even catheterization impossible. I opened the
abdomen, dissected out the right ureter from the bladder, implanted it into
the appendix, and then dissecting the left ureter in the same way implanted
it in the right, the intent being to direct the whole urinary stream into the
colon and thus spare the bladder. The operation was not finally successful. I
afterward found that this method had been tried experimentally by
Jacobson, of Toledo, but without success.
 C H A P T E R LV.
THE BLADDER AND PROSTATE.
Methods of recognition of surgical diseases of the bladder have
been vastly improved, as well as complicated, within the past few
years. The bladder has now been made accessible not alone to
touch, as through the rectum or vagina, or by incisions above or
below the pubis, but to sight, through the use of the cystoscope. It is
furthermore possible to detect foreign bodies within it by the Röntgen
rays. Palpation is chiefly of value in thin persons, or when the
bladder is greatly distended; still, infiltration of the base of the
bladder can be detected through the vagina or through the rectum,
as can also certain foreign bodies. Much of value is learned by both
chemical and microscopic examination of the urine. This may be
passed by the patient or withdrawn by the catheter. It has already
been indicated how much of value can be learned by separating the
urine drawn from each kidney. The difficulties of this procedure are
greater in the male than in the female, owing to the complications in
the requisite manipulation of the instruments. Nevertheless there is
no accurate method of such estimation save by ureteral
catheterization. The method of Harris, by the use of the so-called
segregator, is of occasional assistance, but is never accurate nor
always satisfactory. If the catheter alone be used it should be of
metal, if it be desired to have it serve the purpose of a probe, as in
the search for a foreign body (calculus and the like) or as a means of
estimating the size and shape of the bladder. For the latter purpose
an ordinary sound will serve as well, preferably one with a short
beak, ordinarily known as a stone searcher. In cases of prostatic
enlargement it is of great advantage to estimate the amount of
residuary urine after the patient has apparently emptied his bladder.
This may be withdrawn by a sterile catheter under aseptic
precautions. The use of the catheter is also necessary for lavage of
the bladder, a measure of great value in many cases.