Clinical Conversation on Treating Anxiety Disorders
by Professional Development and Communications Staff
April 19, 2006 -- David H. Barlow, PhD, is the first psychologist to be featured in this new series of articles entitled “Clinical Conversations.” The conversations focus on clinical information and developments of interest to practicing psychologists. The APA members featured in the conversations offer their own professional perspective on a particular topic. The series will present topics and observations spanning various theoretical orientations.
Importantly, the conversations are intended to stimulate feedback from APA members. Please send your communication along with your name and location to practice@apa.org by Wednesday, May 3, 2006. While we are unable to respond to all feedback we receive, Dr. Barlow has kindly agreed to address selected questions and comments in a future article.
The following conversation is adapted from a transcript of a telephone interview between Dr. Barlow and Lynn F. Bufka, PhD, concerning the latest in the treatment of anxiety disorders.
Dr. Barlow is currently professor of psychology, research professor of psychiatry, and director of the Center for Anxiety and Related Disorders at Boston University. He has published over 500 articles and chapters including close to 50 books and clinical manuals, mostly in the area of emotional disorders and clinical research methodology. For more on Dr. Barlow, see http://www.bu.edu/anxiety/dhb/index.shtml.
Dr. Bufka is the director of professional development demonstration projects in the APA Practice Directorate. She has worked as a clinical psychologist specializing in the treatment of anxiety.
Dr. Bufka: Thank you for taking the time to talk with me, Dr. Barlow. It’s always a pleasure to get an update on your work and it’s exciting to have a chance to share your perspective with other APA members. What do you think are the essentials a psychologist should know about treating anxiety symptoms?
Dr. Barlow: First of all, obviously every psychologist should be able to recognize symptoms of anxiety in its various manifestations. And, principally that would be adopting the distinction that most researchers in the field have adopted these days, [the distinction] between anxiety and fear.
Dr. Bufka: Could you say more about that?
Dr. Barlow: Fear is a present-orientated emotion, typically in reaction to some sudden threat to one’s integrity. It’s best recognized by the fight-or flight response, or a strong urge to engage in the emotion-driven behavior of escape. It’s an immediate response, and it’s best characterized by the experience that “something terrible is happening to me right now, and I need to take some immediate action to get out of here.”
Anxiety, on the other hand, is focused on something that might happen in the future that one needs to be worried about. It’s a focus on a potential future threat. An individual is motivated by the emotion to get ready for the potential threat, and the typical action tendencies or emotion driven behaviors are to become more vigilant, size up the threat, and worry about the various outcomes. It’s not happening right now; it’s something that’s going to happen soon, anywhere from the next several minutes to the next several months. And the purpose of that emotion is readiness, to get people ready to deal effectively with an upcoming threat.
Dr. Bufka: And how does that apply to treatment?
Dr. Barlow: The treatments of choice for coping with and reducing anxiety symptoms are psychological treatments. That’s because the drugs used to treat anxiety are a bit more intrusive, have a number of side effects, and a number of unwanted consequences -- both the SSRIs and the benzodiazepines. If available, the best ameliorative interventions are brief psychological interventions. And that includes ascertaining the source of anxiety and some calming techniques and some reframing techniques to give people a better sense of control over their condition.
Dr. Bufka: What kinds of calming techniques?
Dr. Barlow: The general kinds of procedures would be the time-tested calming techniques such as relaxation training, meditation training and stress control procedures that would be designed to lower generalized arousal and levels of vigilance.
Dr. Bufka: What techniques to restore the sense of control?
Dr. Barlow: Psychologists typically do a little psycho-education. Since the basis of anxiety is a sense that both internal and external events are careening out of control, we’re really helping them to recognize that, as far as their internal symptoms, these bodily sensations are very natural responses of your body when stress arises. They are not harmful in and of themselves. Furthermore, the external events in one’s life that are provoking these kinds of sensations can be looked at a little bit differently, and one can begin to experience them a little bit differently -- in such a way that they won’t be so threatening. Finally, anxious and avoidant behavior that serves to perpetuate the cycle of anxiety and prevent reality testing requires therapeutic attention.
And that’s the basis of the standard psychological procedure -- psycho-education and reframing along with some collaborative behavior change. All psychotherapists do this to some extent or another, and it’s usually quite effective.
Dr. Bufka: What can psychologists do to prevent the development of anxiety disorders?
Dr. Barlow: Actually some of those procedures are very useful. If someone has disruptive things going on in one’s life, then they might come in kind of generally anxious or a bit depressed and that puts them at risk for more severe anxiety. With additional vulnerability factors, both biological and psychological, they are at more risk for developing something more severe, like major depression or severe panic disorder. So the preferred intervention is pretty much what we just talked about. It’s some calming techniques, some psycho-education, about resolving the ongoing difficulties, and preventing unnecessary avoidance. We can help people get back to seeing the glass as half full rather than half empty.
Dr. Bufka: Do you see this as something that all psychologists do to some extent already?
Dr. Barlow: Yes, I think that all psychologists, of all theoretical persuasions, do this to some extent. This is an immediate “first aid” intervention. When someone comes in who’s anxious, they’re mystified by what’s going on in their life, it feels like life is going out of control. They’re having these physical symptoms. Typically it’s implemented in a session or two as the psychologist is assessing more fully the nature of the problems and where to go with them.
Dr. Bufka: Is there anything you’d suggest to help them fine-tune that “first aid” approach or make it a little more focused?
Dr. Barlow: Well, I think there are a nice variety of sources available for clinicians these days that integrate these kinds of very quick and immediate interventions. Many of them are published by APA Books and some are available online.
Dr. Bufka: What would you recommend for the role of relaxation strategies in the treatment of anxiety?
Dr. Barlow: First of all, relaxation never hurts. The only way psychologists or mental health professionals can go wrong with relaxation is if they apply it inappropriately at the wrong time. If they simply use it as kind of a palliative -- something that they might have the individual do perhaps at night before he or she goes to bed, and not as a way to directly cope with severe anxiety, it can be very helpful. Listening to music for half an hour in a semi-dark room, any of the calming, meditative, relaxing procedures, even exercise can be very relaxing. Exercise is another intervention with proven stress reduction capabilities. You can’t go wrong with prescribing that in a general kind of way. However, if the individual rises well above the threshold for certain specific anxiety disorders, such as PD, OCD, then there are different psychological approaches that are much more effective and you wouldn’t necessarily want to use relaxation to help patients specifically cope with panic attacks or severe obtrusive thoughts. But generally at night if they’re just doing it to calm themselves a little bit, that’s fine.
Dr. Bufka: What about people who have experienced trauma? Do you think relaxation is useful for them, or would there be times where they might need to be cautious about using relaxation?
Dr. Barlow: For people experiencing severe trauma, we now have very good treatments that provide an immediate attempt to address the experience of trauma, to both treat the acute reactions to trauma and to prevent the later development of PTSD. Certainly experienced psychologists working in this area know that simply attempting to relax the person might let his or her defenses down to the extent that they may re-experience trauma in an unhealthy way. So, when you get above the threshold for severe emotional disorders you have to reconsider the use of relaxation or calming techniques as a direct treatment for the symptoms.
Dr. Bufka: What might a psychologist want to consider if he or she is dealing with someone who is sub-threshold with anxiety but is also saying, “Look, I really want to deal with these life issues.” How should somebody go about choosing what strategies to employ and in what fashion?
Dr. Barlow: I think psychologists really have the best clinical wisdom and judgment for dealing with these issues. For someone who is anxious over a variety of specific problems occurring in one’s life, it’s really the problems that need attention and resolution. If the anxiety and depression arose in the context of the life events, and the individual was reasonably ok before that, then we’d obviously want to deal with the functional relationship as we call it. And they probably wouldn’t attend directly to the anxiety/depression, except in the kind of brief intervention that we talked about earlier, briefly reframing and some calming techniques. So clearly they’d want to do that analysis regarding the cause of the anxiety, and or depression.
But if, on the other hand, the anxiety (and/or depression) has really been there a while, and it waxes and wanes and it seems to have a life of its own or it might be exacerbated by certain life events but it never goes away, then the clinician may want to focus more directly on the emotional reaction itself. So, the all-important analysis focuses on what is causing the anxiety.
Dr. Bufka: What about when somebody is clearly comorbid with two or more diagnoses or has an anxiety disorder and co-occurring substance use disorder?
Dr. Barlow: Taking the latter first, the common wisdom has been you can’t treat severe anxiety or depression if the person is abusing substances. So the clinical wisdom is that you need to deal with the substance abuse first. However, we’re beginning to question that. We know, for example, as many as 20-50% of people presenting with substance abuse (which is principally a male disorder) began down that slippery slope to abusing substances by attempting to self-medicate their own anxiety or panic. This is particularly true for males for whom it’s less culturally acceptable to talk about being fearful or anxious. But then the solution turns out to be worse than the original condition.
So now we’re experimenting in one project at our Center with treating the anxiety directly while at the same time attempting to manage the substance abuse, to see if we get better results. We detox the individual abusing alcohol, but then go right into anxiety treatment. We provide standard, good clinical care for detox without a more prolonged focus on the addictions, but then focus the treatment on the associated anxiety. These are individuals who obviously present with a comorbid anxiety disorder, and we want to know if this approach greatly increases the time to relapse back to drinking or maybe even eliminates the alcohol abuse. But we don’t have the results of that yet -- it’s a new direction. For the time being, certainly attending to both problems is the best clinical wisdom.
Dr. Bufka: In the current study, are the people who are getting detoxed and presenting with anxiety disorders more likely to present with a particular disorder?
Dr. Barlow: Panic disorders, social anxiety disorder, generalized anxiety disorder: that threesome. The social anxiety is typically very high in the males, who then have to take a couple of drinks to function.
Dr. Bufka: And for comorbid mental health problems?
Dr. Barlow: Well, for comorbid mental health problems, often these things are related. For instance, if people present with comorbid depression and panic disorder, or they have panic disorder but also severe social anxiety, these things are related; the treatments are very similar. And, generally, we find that if you focus on one, the other comorbid presentation will improve considerably.
We think it’s because we’re basically dealing with the same fundamental principles in the treatment of each of them. We’re currently working on identifying and articulating these principles into what we call “a unified treatment.” These principles are basically applicable to all of the anxiety and depressive disorders -- principles that are psychological and might facilitate interventions whether the individual has comorbidity or not.
So, for example, in most psychological treatments you want to help the individual to process the emotion (such as anxiety) in a healthy way as opposed to avoiding and attempting to suppress the emotion. These are principles that are found both in psychodynamic and CBT approaches so we’re attempting to articulate that more clearly. We attempt to reduce any suppression of the emotional experience. We also do re-framing, which is a cognitive therapy term and strategy but it’s really a part of any good psychotherapy in many senses. Therapy helps them come to a slightly different way to experience the anxiety itself, and the somatic symptoms, as well as the life circumstances causing it. And we help them to really change the way they’re reacting to the emotion—what we call the “emotion driven behaviors;” we find that’s a very powerful way to change emotional responses. Some of these principles go back to the humanistic techniques, say Victor Frankl, with his paradoxical intention.
Dr. Bufka: When might a psychologist want to utilize a specific treatment protocol for anxiety as the basis for treatment, and when might a psychologist want to adapt or incorporate elements of an anxiety protocol into the ongoing treatment?
Dr. Barlow: First of all, you always want to integrate these treatments into a more general therapeutic approach -- there’s a misconception that somehow you pluck these new psychological treatments out of the context of relating to the patient and just apply them. You can’t do that. But, the distinction is, if you have a patient who is really presenting with a severe anxiety or depressive disorder, particularly when they’re not responding very well to medications, then you may want to use one of the new psychological treatments designed specifically for emotional disorders as your principal intervention as you attend very sensitively to other aspects of the patient’s functioning. Those would be specifically treatments for depression, panic disorder, obsessive-compulsive disorder.
Dr. Bufka: What would you say is cutting-edge in anxiety treatment these days?
Dr. Barlow: I would think that the cutting-edge is first of all distilling the variety of effective approaches into a more unified approach; we’re working on that.
Secondly, the cutting-edge is attempting to administer these approaches in a more intensive way, so that the patient is able to recover more quickly. We’re experimenting with many disorders, like social anxiety disorder and severe agoraphobia, and providing these focused psychological treatments in one week, as opposed to over several weeks of hourly therapy. Intensive treatment requires three to four hours a day on the part of the clinician, so it’s an unorthodox application. But, when it works, the patients are very, very gratified -- as they’ve been suffering for years. It’s particularly valuable for the teenagers, because it’s so hard for them to come once a week for treatment, they’re busy, they need rides, and so on. So, we have a new grant that’s exploring that application.
Finally, a lot of psychologists are exploring the applicability or the adaptation of the new psychological approaches to primary care settings. Here they seem to be proving very valuable. Some new studies show that if you go into primary care settings -- very directly into the primary care settings, and administer some of these brief treatments, you get a better response initially. Furthermore, as the months go by, the patients tend to retain that response to a substantially greater degree than people who don’t get the psychological intervention. So, really, we’re looking to adapt these approaches to primary care settings -- it’s a real growth area for psychologists.
Dr. Bufka: Thanks for the interview and all the resources. I really appreciate your time and willingness to speak.
References
Barlow, D.H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: The Guilford Press.
Barlow, D.H., & Craske, M.G. (2000). Mastery of your anxiety and panic: Client workbook for anxiety and panic (3rd ed.). New York: Oxford University Press.
Barlow, D.H., Allen, L.B., & Choate, M.L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205-230.
Craske, M.G., & Barlow, D.H., Meadows, E.A. (2000). Mastery of your anxiety and panic: Therapist guide for anxiety, panic, and agoraphobia (3rd ed.). New York: Oxford University Press.
Craske, M.G., Barlow, D.H., & O'Leary, T. (in press). Mastery of your anxiety and worry. New York: Oxford University press.
Litz, B.T. (2002). Early intervention for trauma: Current status and future directions. Clinical Psychology: Science & Practice, 9(2), 112-134.
Roy-Byrne, P.P., Craske, M.G., Stein, M.B., Sullivan, G., Bystritsky, A., Katon, W., et al. (2005). A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. Archives of General Psychiatry, 62(3), 290-298. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
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