Annals of Clinical Psychiatry, Vol. 12, No. 2, 2000

Book Reviews

Anxiety Disorders. Psychological Approaches toTheory and Treatment. By Michelle G. Craske.Westview Press, 1999; 425 pp. (hardbound).

This textbook teaches the reader the historicaldevelopment of the non-medical, psychological, cog-nitive-behavioral therapy (CBT) theory of the causeand the treatment of anxiety disorders.

The first six chapters of the textbook explain thegeneral theory of this psychology as conceived bythe author. Chapter 1 Worry, Anxiety, and Fear andImminence of Threat defines the titled terms.

Chapter 2 Features of Anxiety Disorders doesnot discuss particularly the features of anxiety, butmiscellaneous topics, e.g., ‘‘cultural differences,’’‘‘anxiety in the elderly,’’ and ‘‘fear and anxiety inchildren.’’

Chapter 3 Etiology of Anxiety Disorders startswith fundamental theories and leads to a brief expla-nation of the cognitivists-behavioralists’ model ofcausation of anxiety disorders.

Chapter 4 Methods and Mechanisms of Empiri-cally Supported Treatments teaches how three meth-ods of treatments work: cognitive, behavioral, andpharmacologic. Less than one page is devoted topharmacologic. Clinical psychiatrists familiar withthe fact that placebo response in OCD is indeed rarewill become suspicious of the author’s work at thispoint with the statements giving emphasis to the pla-cebo psychological effects of medicine: ‘‘. . . the ef-ficacy of placebo medications for 20 to 70% of individ-uals with anxiety disorders.’’

Chapter 5 Return of Fear delves into the interest-ing area of relapse. I was disappointed to see littleabout the observation of the latent reappearance ofdeconditioned phobias in dogs even years later whenthe dogs were stressed.

Chapter 6 Integrated Treatments for Anxiety Dis-orders discuss the merits of combining medicationtreatment and cognitive-behavior treatment. Clinicalpsychiatrists may find this chapter to be controversialand thought provoking. The author states that ‘‘. . .medications generally have no effect or only slightlyenhance behavioral treatment efficacy in the shortterm but may be detrimental to behavioral treatments

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in the long term.’’ Some softening in the anti-medica-tion viewpoint is voiced in the area of treatment com-pliance and drop-out rates with CBT alone. There isdiscussion of the order of treatments of medicationand CBT being important.

In these first six chapters, the author reachesinto a wealth of psychology references to footnotethe running commentary on the historical evolutionof CBT psychological theory. Clinical psychiatristswho are not well versed with psychology history willfind the first six chapters of the book devoted tothis topic tedious to read. These chapters are notparticularly instructive to the rare clinical psychiatristwho wishes to learn about the historical developmentof CBT. If you’re not a psychologist, you probablywon’t fully understand the explanations as these sixchapters seem to be written for an audience alreadyknowledgeable about CBT theory and models. Anexcellent bibliography is made available for thosewho may need appropriate references in this area.

Finally, halfway through the book, the authorfinishes with the theoretical discussions. The rest ofthe text book is devoted to the task of addressingthe topic of treatment of each of the anxiety disor-ders. Each subsequent chapter furnishes the author’s‘‘conceptualization’’ of the disorder and the author’srecommended treatment. One of the peculiar aspectsof the textbook is that it spends the majority of eachof these chapters ‘‘conceptualizing’’ the anxiety dis-order. This indulgence appears to limit the spacedevoted to teaching the reader how one actuallytreats the disorder with CBT. The author, for exam-ple, spends only from a single paragraph in the caseof generalized anxiety disorder to six pages in thecases of panic disorder to teach the reader how todo CBT. Typically, only about four pages in eachchapter are devoted to the details of instructing thereader on how to carry out CBT in each anxietydisorder. In chapter 7 (Panic Disorder) the author‘‘conceptualizes’’ panic disorder as a psychologicalproblem, not a medical disorder. Many clinical psy-chiatrists well acquainted with this area of scientificevidence staunchly maintain that panic disorder is abiological disorder (1). Our medical field’s leadingexperts in anxiety David Sheehan and Donald Klein

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have established this with the support of convincingevidence (1,2). The author defended the viewpointof psychological etiology with numerous items of evi-dence. The author’s conclusions based on this evi-dence I think may appear flawed to most clinicalpsychiatrists familiar with this area. For example, theauthor concludes that panic disorder patients haveno abnormal sensitivity to CO2. Research has foundelevations of CO2 in typical agoraphobic environ-ments to be 200 to 300% as high as outdoor fresh air,suggesting strongly a hypersensitivity to CO2 (3).

The author’s ideas do, however, accurately re-flect the author’s discipline’s view on the matter. Psy-chologists and social workers seem to be unwillingto accept the overwhelming evidence of a biologicalabnormality at the core of panic disorder (3). Noteven the recent discovery of the gene flawed in panicdisorder by Dr. Jacques Bradwejn and his colleaguesat the Royal Ottawa Hospital (4) is apt to swaythese beliefs.

CBT discussions in the other anxiety disorderschapters seem to be traditional, expected and help-fully educational. However, I would not recommendthe book to the average clinical psychiatrist whoseeks instruction in CBT skills for anxiety disorders.

REFERENCES

1. Sheehan, DV: The Anxiety Disease. Bantam, 1986.2. Klein D: Testing the Suffocation False Alarm Theory of Panic

Disorder. Anxiety 1994; 1:1.3. Cox SM, Lawrence J, Sheehan DV: Single Ion Gas

Chromatographic/Mass Spectroscopic Quantitative Analysisof CO2 in Agoraphobic Environments. Anxiety 1994/1995;1:275.

4. Kennedy JL, Bradwejn J, Koszycki D, King N, Crowe W,Vincent J, Fourie O: Investigation of cholecystokinin systemgenes in panic disorder. J Mol Psychiatry 1999; 4:284–285.

Stephen Cox, M.D.National Anxiety Foundation andDepartment of PsychiatryUniversity of Kentucky College of Medicine

Essentials of Clinical Psychiatry. Based on TheAmerican Psychiatric Press Textbook of Psychi-atry, third edition. Edited by Robert E. Halesand Stuart C. Yudofsky. American PsychiatricPress Inc., Washington DC, 1999, 1070 pp.,$60.00.

Study Guide to Essentials of Clinical Psychiatry. ByDonald M. Hilty, Robert E. Hales, Stuart C.

Yudofsky. Washington DC, American PsychiatricPress Inc., 1999, 164 pp., $30.00.

For a change, let’s begin with the bottom line:I liked Essentials. I found it useful in several proj-ects I’m working on. For example, it operationallydefines the dexamethasone suppression test (re-member that?) more clearly than does a competi-tor. Essentials is competently written, well laid out,and covers a breadth of knowledge important tomedical students, non-physicians mental healthprofessionals, and even educated lay people. Inshort, I recommend it to all who prefer their mentalhealth information in a Reader’s Digest condensedform rather than in the full-blown, EncyclopediaBritannica version. It is $135 cheaper than and, ata relatively svelte 4 pounds, about twice as portableas its 8� pound ancestor.

That said, I intend the following as construc-tive criticism aimed at improving still further thenext addition. (Full disclosure: I am co-author ofa chapter in a competing, two-volume textbook).

Essentials was created by asking the authors ofjust half the chapters in the 8-pound progenitor toselect the 50% of their text they considered‘‘. . . more important for senior medical studentsand psychiatry residents.’’ Thus omitted are, amongothers, full treatments of behavior therapy, cogni-tive therapy, hypnosis, group therapy, and maritaland family therapy; genetics and epidemiology; vio-lence, geriatric psychiatry, and law in psychiatry. A22-page discussion of suicide in the original text hasbeen abandoned for the 4 or 5 paragraphs scatteredthroughout the remainder of the text. My own pref-erence would have been for a re-casting of portionsof the book to interleave some of this material, atask not easily accomplished through the retentionof individual chapter authorship.

Rather than completely rewriting their mate-rial, most authors have (reasonably) chosen toshorten their contributions by eliminating para-graphs and sentences. What remains is essentiallyunchanged from the larger volume; omitted aresome references, history of psychiatry, tables thatmay be insufficiently helpful, speculative material,some drawings, much color, and, from the index, thenames of individual drugs. I was relieved to notethat, with minor exceptions, the details of drug de-scriptions in the psychopharmacology section havebeen carried through to the smaller volume unal-tered. However, the selection of some material forretention appears idiosyncratic. For example, thecriteria for the Michigan Alcohol Screening Test