Table of Contents
This page contains research and general information about Panic, Anxiety, Phobias and OCD.
A look at Behaviour Therapy
Behaviour therapy is rooted in experimental psychology and most books will tell you that behaviour therapy it based on the principles of Pavlov (of the salivating dogs) and Skinner (of the rat box). However, in my view, much current behaviour therapy is based on a practical, pragmatic approach rather than fossilised psychological therapy. The original applications of behaviour therapy can be traced to the 1950’s when Joseph Wolpe, a South African psychiatrist working in America, applied systematic desensitisation to the treatment of simple phobias. This approach was based on the idea that if you taught people to relax, this was incompatible with feeling anxious.
Wolpe called this process “Reciprocal Inhibition”, i.e. one emotion cancelling out another. As Well as using relaxation, Wolpe also taught his patients to evoke feelings of anger or sexual arousal in association with their phobic fear and these were as successful as relaxation. Wolpe’s original ideas still have some utility today. Perhaps, the next time you are anxious you should try to imagine something which makes you angry or something which…………… (write to the editor with your views on this).
During the 1960’s and 1970’s, behaviour therapy rapidly expanded and treatment became much more based in real life. For example, helping the patient to enter their phobic situations, often with the help of a therapist, or training the patient to deal with obsessional impulses by sitting out the anxiety or performing some kind of competing activity. Certainly, by the 1980’s behaviour therapy was indicated for approximately 30% of problems going to outpatient psychiatrists and these included not only obsessions, simple phobias and complex phobias such as agoraphobia and social phobia, but also sexual difficulties, social skills problems, a whole host of habits and, more recently, the application of behaviour therapy to physical illnesses such as asthma, irritable bowel syndrome and even cancer.
In recent years, behaviour therapy has grown to embrace cognitive therapy.
This involves treating thoughts in the same way as one treats behaviour, i.e. treating thoughts as recurrent and habitual patterns which are open to modification. Therefore, for example, in the cognitive therapy of depression, depressive thoughts are treated as learned bad habits and patients are trained to identify the when, where and how of these thoughts and to replace negative thoughts with more realistic or coping thoughts.
Behaviour therapy is now much more widely available although, as most of you know, some areas are better than others. Currently, behaviour therapy is offered by about 100 nurse behaviour therapists nation-wide, by some clinical psychologists and, encouragingly, by an increasing number of psychiatrists and general practitioners who have learned behavioural procedures in their training.
General practitioners now receive 3 years training before going into general practice and very often they spend some of this time with a department of psychiatry and may spend some of that attachment with a behaviour therapist. Indeed, since 1978, I have been responsible for giving dozens of psychiatrists and GPs a period of apprenticeship in behaviour therapy and I can vouch for the fact that some of these GPs spend a considerable amount of their time helping patients with behavioural procedures. In years to come there will be many more GPs and psychiatrists using this approach as, thankfully, there is now considerable evidence to show that the stranglehold of the old psychoanalytical approaches is lessening and doctors are now much more interested in acquiring skills in procedures which are known to be efficacious.
Whether you are referred to a psychologist, a nurse or doctor with a background in behaviour therapy is, in some senses immaterial. What probably counts most is having confidence in that person and if you have a good rapport with your therapist, this is probably much more important than whether they spent 7 years at medical school or completed a period of specialist training after qualifying as a nurse. The research carried out on who makes the best therapist indicates that the results of treatment are much the same for nurses, doctors and psychologists and therefore you should have no concerns provided the person has undertaken the appropriate training.
Currently, in this country there are several ways to train in behaviour therapy and although there are, of course, cutbacks in the educational provisions in the health service, training in behaviour therapy is gradually becoming more accessible to a larger number of health professionals.Overall the results of behaviour therapy with anxiety states are very good. The rule of thumb is that 70% of people who complete treatment will improve by 70% or more and this figure probably holds for obsessional rituals as well. However, treatment outcomes with obsessional thoughts are not quite as good, although behaviour therapy is still worth trying.
Patients very often ask me about the drugs they have been prescribed and probably 50% of those referred to me are taking some sort of medication. Overall, the evidence is that most medications prescribed for phobic states are not very helpful. Certainly tranquillisers produce very significant problems in the medium and long term and I have no need to describe the horrendous addiction problems which have occurred with hundreds of thousands of people.
Like tranquillisers, beta-blockers often work in the short term but in the long term there is no real evidence of their efficacy. In my text book on agoraphobia we reviewed the evidence regarding beta-blockers and could find no long term evidence that they were in any way successful. The one group of drugs which may be successfully combined with behaviour therapy is the antidepressants,although it is likely that they are only helpful where major depressive illness accompanies the problem or in some specific cases of obsessive/compulsive disorder. In my view there is very little reason why antidepressants should be prescribed in phobic disorders as any benefit for phobics as a group is probably outweighed by the longer term difficulties associated with antidepressants, which can include a very significant weight gain.
Although there is some encouraging evidence that people respond to antidepressants, one must bear in mind that many of these studies are only of a few months duration and that there is very little evidence that in the long term, people who take antidepressants do any better that people who don’t. Overall, therefore, the message is that antidepressant drugs can be helpful in certain cases of phobic anxiety and obsessive/compulsive disorder but this represents a small minority.
Anyone being offered medication for their condition should seek to find out why the medication is being offered, for how long it is being prescribed, what evidence there is that it is useful in that particular kind of condition and, last but by no means least, ask for a full account of side effects.
Overall, therefore,behaviour therapy is a useful treatment for many phobics.
It can certainly transform people’s lives but it is by no means a panacea. While there is little doubt that many patients can have their symptoms markedly alleviated by behaviour therapy, there is, in my view, no real cure for any of the phobic and obsessional problems which come for treatment; rather people may at best aim to become 98% better. There are, of course, some rare exceptions to this and in my career I can certainly remember more than a handful of patients who have described themselves as cured.
Overall, though, my feeling is very much that phobic disorders are underpinned by a genetic cause as well as the causes which are rooted in learning and, although my treatment approach is very much a psychological one I still believe that we should place considerable research effort into looking for genetic and biochemical aspects of phobic and obsessional disorders.
Neurosis or Psychosis
By Professor Kevin Gournay (MPhil, PhD, CPsychol, AFBPsS)
The first thing that many patients ask when they present with serious anxiety problems is “Am 1 going mad?” Very often, people with anxiety states feel that they are teetering on the edge and that loss of control is imminent.
Indeed, many people become obsessed with the idea that they will lose control in front of their family, friends or strangers and behave in a bizarre, inappropriate or even violent or a dangerous way. These feelings of loss of control are triggered by high levels of arousal and consequent muscle tension. Thus, if one feels “keyed up” for no apparent reason, the brain is alert to the possibility of action. In turn there is a misinterpretation on the part of the sufferer, that something dreadful is about to happen. Other sufferers of anxiety (in all its shapes and forms) fear that their anxiety may progress to madness and they may end up being locked away in an institution. Indeed, some mental health professionals perpetrate the idea that serious mental illness, such as schizophrenia or manic depression can develop from an anxiety state.
This article is designed to set the matter straight
Neurosis is a term which covers a whole array of mental health problems, ranging from anxiety and simple phobias to severe and long-standing obsessive/compulsive disorder. In between the term captures mild and moderate levels of depression, stress reactions of one sort or another and an array of conditions which are probably best seen as exaggerated forms of normal thinking, behaviour and feeling. Indeed, who amongst us has not had some sort of neurotic reaction, whether it be an anxiety attack, an obsessive thought, or a reaction to stressful life events? On the other hand, psychosis refers to very specific conditions and these are largely covered by two umbrella categories, i.e. schizophrenia and manic depressive disorder. Schizophrenia is probably best seen as an umbrella term to cover a variety of different conditions, but these are essentially characterized by a condition wherein the personality fragments and the sufferer is handicapped in a wide range of areas. Schizophrenia sometimes comes on acutely and then disappears.However, in the majority of cases it is a condition which has a waxing and waning course, often leading to a very impoverished life. Sufferers often have hallucinations and delusions, i.e. they hear voices and suffer false beliefs, which are impervious to any logical reasoning, in addition their thoughts show considerable disorder.
Sometimes there is a lack of coherent speech and generally motivation to lead a normal life is impaired and personality, behaviour and drive deteriorate overtime. Schizophrenia is present in perhaps 1 % of the population and is probably caused by a number of different biological factors. Increasingly, it is being seen as a neurological illness rather than a mental health problem caused by stresses and strains. Although, some people with schizophrenia suffer anxiety, it is impossible for people with anxiety disorders to develop schizophrenia as a result of anxiety disorder. Anxiety sufferers should be reassured that they cannot develop schizophrenia as part of anxiety state, no matter how bad anxiety becomes.
The symptoms of schizophrenia and the deteriorating course can be linked to changes in brain structure and functioning, which are entirely different to those associated with anxiety.
Manic depression is also a severe condition, often running a life long course where there are violent swings of mood. We all, of course, have “ups and downs” in the way we feel, but manic depressive swing from a very extreme formulation and over activity to the depths of depressive despair, with the condition becoming so bad that people are sometimes in a stupor, being unable to feed themselves or even get out of bed.The person may swing from one state to the other but, commonly, they may be deeply depressed with spells of normality in between, with only rare periods off elation.
These periods of elation and over-activity are called “hypomania”.
During this phase, the person often loses contact with reality and may hear voices. The depression experienced by sufferers of manic depression is of a much greater depth than that experienced by sufferers anxiety and cannot be explained by external circumstances. People with anxiety states can feel profoundly depressed, but usually this depression is a direct result of feeling chronically anxious. Again it is impossible for anxiety depression to become manic depression.
On a more optimistic front, new treatments, mostly medication, are being involved for both schizophrenia and manic depressive illness although; it must be noted that cognitive behaviour therapy techniques are being developed for both conditions. New techniques in examining the brain with magnetic resonance imaging and other forms of scanning are helping neuroscientists to understand the pathology of these conditions.
At the Institute of psychiatry where I work, a great deal of research is being carried out in both schizophrenia and manic depression and,indeed, some of my work is now directed towards helping the sufferers of schizophrenia. The more one sees of these conditions, the more one realises that they are very different from anxiety disorders.
What is Cognitive Therapy
Cognitive therapy was first described by Aaron T. Beck in the late 1960s. At this time, the primary treatment for psychological problems was psychoanalytic therapy and behaviour therapy was in its infancy.
In 1976 Beck wrote his now classic book “Cognitive Therapy and the Emotional Disorders”. It was advertised as ‘a major exploration of an influential new approach to the understanding and treatment of mental illness’ and 20 years later it has been described as “the single most important and best validated psychotherapeutic approach” (Salkovskis, 1996; p.xiii).
Cognitive therapy is a common-sense approach but goes beyond ‘common sense’. It is based on the cognitive theory that the distorted interpretation of experiences gives rise to emotional disturbance (Beck, 1995). The idea is that it is the meaning of the event to the individual that needs to emotions, rather than the events themselves (Salkovskis, 1996). For example, if hear a loud bang in the middle of the night and think ‘that must be a burglar’, you will undoubtedly feel anxious. If, on the other hand, you hear a loud bang and think “my clumsy husband has knocked over the vase in the hall; the mess will be there for me to clear up in the morning’, you are likely to feel angry. If you think, ‘My husband has knocked over the vase in the hall, I shouldn’t have left it there, I can’t do anything right,I’m so stupid,’ then you may feel depressed. You may think, ‘My husband has knocked over the vase in the hall that my in-laws gave us. I never liked it. Great, I can now get a much nicer one!’,then the emotion experienced will be different.
In essence, cognitive theory suggests that dysfunctional thoughts can lead to emotional disturbance. The emotional disturbance can be manifest in terms of mood,physical sensations or behaviour, and all are suggested to be inter-linked (Greenberger &Padesky, 1995) as shown below.
The influence of a person’s environment is not forgotten in the cognitive model.
ENVIRONMENT
Cognitive therapy is designed to modify the individual’s dysfunctional thinking with the view that this will improve mood, behaviour, physical reactions and so on. Beck first described the basic cognitive techniques as consisting of identifying the person’s specific dysfunctional thoughts and beliefs, and then helping the person test their validity and reasonableness.
Taking the example ‘My husband has knocked over the vase in the hall, I shouldn’t have left it there, I can’t do anything right, I’m so stupid,’ the cognitive therapist could help the person test the thought that ‘I can’t do anything right.’ This may involve going through some examples when the patient has done things right, or helping the person accept that he/she does not make anymore mistakes than anyone else. The cognitive therapist is likely to help the person identify any thinking errors that may be going on. In this example, the person is ‘overgeneralising’ i.e.drawing a global negative conclusion on the basis of a single incident.
Many of the cognitive theories and treatments use principles from behaviour therapy to help challenge and change beliefs. The idea is that the person can use some behavioural ‘experiments’ to test their beliefs in a ‘scientific’ way and to contribute to the evidence that is being gathered to evaluate their beliefs.
For example, in obsessive-compulsive disorder, a person may think that he/she is likely to become ill if he/she touches something dirty without washing his/her hands. To test this belief,the person may be asked to touch something “dirty’, refrain from washing his/her hands and then discuss the implications of this experiment. Did the person become ill?
If so, then this would support the person’s beliefs that he/she is likely to become ill upon touching something dirty without washing.
If not, then this dis-confirms the person’s views that illness is very likely to result from touching something dirty without washing. In this way, the dysfunctional beliefs that are maintaining the person’s problem can be challenged and changed, leading to an improvement in symptoms.
Some cognitive therapists consider that different types of thoughts may play different roles in the maintenance of emotional distress and may require different techniques.
Thoughts have been classified into ‘negative automatic thoughts” which are the ones that first go through your mind when faced with a specific event.
For example, “My husband has knocked over the vase in the hall. I shouldn’t have left it there,I can’t do anything right, I’m so stupid”.
A second category of thoughts is ‘dysfunctional assumptions” which usually take the form of’ if…. then statements.’ In the above example, the person may think ‘if I don’t do everything right at all times, it means I am stupid’.
A third category of thoughts is termed “core beliefs” or sometimes ‘schema’.
These types of thoughts are held constantly across situations e.g., ‘I am stupid.’ These long-standing beliefs can be difficult to change and so treatment for psychological problems in which these types of beliefs are particularly problematic can sometimes take a long time.
Cognitive theory and therapy has developed at a rapid pace since Beck first described cognitive theory and therapy for depression. As many of you will know,specific cognitive (or cognitive-behavioural) models and treatments have been developed and scientifically proven to be efficacious in the treatment of a range of conditions including panic disorder, social phobia, post-traumatic stress disorder, health anxiety, obsessive-compulsive disorder and bulimia nervosa (see Nathan and Gorman, 1997). The specific models vary but they have in common the cognitive principle that it is the interpretation of the event (rather than the event itself) that maintains the psychological problem. For example, the cognitive model of panic disorder proposes that the interpretation of a normal body sensation (such as a rapid heartbeat) as indicating imminent catastrophe (such as a heart-attack) gives rise to an episode of panic (Clark,1986).
Cognitive therapy for panic disorder aims to change the dysfunctional interpretation of the body sensation. In the example above, the rapid heartbeat may be caused by the person climbing the stairs and the cognitive therapist helps the person to realise this. As a result, anxiety and panic attacks are likely to be significantly improved.
To summarise:
Cognitive theory and therapy was developed by Beck in the late 1960s.
The main principle behind cognitive theory and therapy is that the distorted interpretation of experiences gives rise too emotional disturbance.
A variety of methods are used to challenge and change a person’s distorted interpretation of their experiences, including behavioural experiments.
Thoughts have been classified into negative automatic thoughts, dysfunctional assumptions and core beliefs.
Specific cognitive-behavioural models and treatments have been developed and scientifically proven to be efficacious in the treatment of a range of conditions.
References:
Beck AT (1976). Cognitive therapy and the emotional disorders. International Universities Press, New York.
Beck JS (1995). Cognitive therapy: basics and beyond.Guilford Press.New York.
Clark DM (1986) A cognitive approach to panic. Behaviour Research and Therapy. 24 (4), 461-470.
Greenberger, D. & Padesky, C. (1995). Mind overMood: A cognitive therapy treatment manual for clients.
Guilford. New York.
Nathan, P.E. & Gorman, J.M. (1998) (Eds.) A guide to treatments that work. New York NY, USA. Oxford University Press.
Salkovskis, P.M. (1996) Frontiers of cognitive therapy-state of the art and beyond. Guilford Press. New York.
“ANXIETY – THE COMMON COMPLAINT”
This is a precise of an article that Charlie (a message forum member) read in the September issue of New Scientist. She thought it was very interesting, and might be useful to some of you others out there. It is by no means a definitive guide to how, why or to treatments, but she thought it went along way to explaining what processes can make us prone to anxiety disorders.
My thanks to Charlie for writing this for the site.
Surveys ranging over many continents and countries have found that anxiety disorder is THE most common mental health problem. One in four people will suffer from an anxiety related disorder at some point in their lives.
There is no discrimination between class, race, intelligence and wealth.
Anxiety disorders cover Panic Disorder, Obsessive Compulsive Disorder, Phobias and Post Traumatic Stress Disorder.
Many people come to this site believing they are not normal,
convinced that they are mad, and that nobody else could possibly understand how they feel, and that there is no cure.
Hopefully, by spending a little time on this site, you will realise that this is not the case -imagine you are at a wedding with another 119 people.
Scientists have proved that THIRTY people in the room will actually be suffering/have suffered or will suffer the same problems as you. (Ok all you statisticians out there – I know it doesn’t work exactly like that, but it illustrates a point).
It’s only during very recent times that scientists have begun to research anxiety disorders,doctors have started recognising and treating these issues, and people have finally admitted to suffering. Gone are the days where you were told to “pull yourself together”.
HOW IT ALL STARTS
We all know about fear. It is a response of every animal and human alive, and it’s a good response. It helps us run away from danger, and keeps us alive. The problem occurs when response to fear gets “out of control” and fear is felt when it’s not required.
This creates an “irrational” fear, which in turn develops into an anxiety disorder. It leads you to respond inappropriately to your own triggers and developing fear of everyday things – using public transport, answering the telephone, driving.
The only thing that makes all anxiety sufferers different is that with each person the triggers will vary.
The response will be shared – all though not all symptoms will be felt by all sufferers each time – fear, tingling skin, raised heart rate, irregular breathing patterns, sweaty palms, nausea,need to open the bowels, lump in the throat, twitching, blurred vision, feeling of being “spaced out”, the list is endless, but most of us have experienced all the symptoms at some point.
We all need to learn fear. That’s how we get to know that a fire is hot, and putting your hand in it will be painful!
Scientists have discovered that the brain stores memories of fear in a different way to ordinary memory. In people who suffer anxiety, these fear memories override the ordinary memories, and are much stronger.
The fear memories are stored in your brain as an “emotional memory”, as opposed to rational memory. Unfortunately, emotional memory is pretty much permanent, whilst rational memory can be readily manipulated.
Many sufferers of anxiety disorder appear to have a more dominant emotional memory to rational memory.
WHY IT HAPPENS
LeDoux, a neurologist, discovered that a specific area of the brain, the amygdala, is responsible for learned fear.
When you are faced with your trigger the amygdala reacts immediately and the learned fear is strengthened. Rational memory is stored differently, and is a more slow response, through the cortex and into the hippocampus.
LeDoux then tracked the brain as individual triggers were released. A signal travels through the brain until it reaches the “high” and “low” roads.
The high road takes information, processes it, then passes it through to the amygdala.
The low road fast tracks information directly to the amygdala.
This information is basic, and travels much quicker.
As soon as information is received in the amygdala it is passed straight to the brainstem, which controls involuntary fear.
The body then prepares for flight (panics) before the high road has had time to process the information rationally.
Imagine …
You see a spider. The message travels through to the brain. The low road receives message SPIDER and tells the brainstem. The brainstem tells you to panic. You scream for your partner/husband/brave friend.
Five minutes later the high road gets its act together and says, why did I do that? It’s a spider. I’m one hundred times bigger than it. It’s more scared of me than I am of it. Why have I Just made a fool of myself like that?!?
WHAT MAKES US SPECIAL
Scientists are still working on this, but it has generally been agreed that people who suffer from anxiety phobia have an over sensitive response to fear. There are several theories as to what may make us more sensitive
Faulty Amygdala
In an non anxiety sufferer the amygdala seems to do a good job, filtering out inappropriate fears, and processing “good fear” ie. Lion = Run.
Some scientists are researching to see if anxiety sufferers have a faulty or damaged amygdala.They are working on the theory that the filter isn’t doing it’s job properly, and too much information is getting through, causing a state of “hypervigilance”
The amygdala is balanced by GABA (an inhibitory neurotransmitter). The inhibitors allow the amygdala filters to work properly.
Another scientist found a link to faulty genes.
A gene was found in the amygdala which encoded a molecule (gastrin-releasing peptide). This was found to have receptors on the inter neurons found in the lateral nucleus of mouse amygdala.
These inter neurons produce GABA, increasing the inhibitory effect.
Mice bred without the receptor were found to learn fear quicker, and to be more frightened.Scientists are now trying to discover if this is the case with humans, although interestingly,Valilum (benzodiazepine family) act on the GABA system.
Shumyatsky believes that a deficiency of this peptide or its receptor may enhance fear memory.
Faulty Mechanisms
Another strongly held belief is that in anxiety sufferers the controls for fear memories have malfunctioned.
Although fear memories are difficult to modify, they can eventually be altered with careful exposure. Think of Pavlovs dogs – bells = food, and they could associated feed time with bells ringing.
SEROTONIN
Another major cause of anxiety is believed to be an imbalance of serotonin. Serotonin is a neurotransmitter which controls mood regulation. Some anxiety disorders are accompanied by reduction in levels of serotonin. Prozac and other SSRIs are prescribed to keep the levels high.
A University in Cleveland, Ohio have started researching the Pet-1 gene in humans. They have shown in mice that this gene, which controls the neurons which produce serotonin, is related to anxiety. Mice without this gene were significantly more anxious, and they therefore believe that this gene helps control serotonin through life.
TREATMENT
Drugs
Some people respond well to drug therapy. Benzodiazepines help the anxiety, but do not help much with any accompanying depression. Drugs which raise the serotonin levels however can be used to treat both anxiety and depression.
The down side of drugs is that they can suppress the problem, which will still need to be tackled later, can cause side effects, and may become addictive.
Cognitive Behavioural Therapy
A recent study has proved CBT to be the most successful form of treatment, for the majority of people. It has long term benefits over drugs, and is more effective than counselling.
Work Related Stress
Tackling Work-Related Stress (will open in a new window)
