An Interview with David H. Barlow Ph.D. on the Nature and Treatment of Anxiety and Panic Disorders
Dr. Van Nuys interviews David Barlow, Ph.D. a highly influential clinical psychologist and psychotherapy researcher well known for his seminal work on anxiety and panic disorders. In this interview, Dr. Barlow talks about some of the knowledge that research over the last several decades has taught us about the nature of the anxiety disorders.
One of the big lessons is that anxiety and fear are distinct emotions. Anxiety used to be thought of as a variety of "unfocused" fear, but it turns out that this is wrong. Fear is the immediate emotionally charged "fight or flight" reaction that people experience when they are facing immediate danger or threat. Anxiety, in contrast, is an emotion that has to do with the future anticipation of threat. Anxiety produces a "stop, look and listen" response which orients and readies the person to take action to respond to threat in a different manner than fighting or fleeing. The state of anticipation produces worry, which contrasts to fear which produces terror. These are not superficial differences but rather reflect different underlying neural brain circuits.
Another big lesson is that anxiety and panic are distinct processes. It used to be thought that panic disorder was just a variety of extreme anxiety. However, during the 1970s and 80s research showed that there are real differences between these states. Some people are more vulnerable to having panic attacks than others, and in many cases they are born that way. Research suggests that being susceptible to panic attacks is an inherited disposition not unlike the disposition to have tension headaches or irritable bowel syndrome. A panic attack is basically a fear or terror episode that gets triggered in the absence of real threat. Dr. Barlow describes them as "an enormous sympathetic surge", of emotion that overwhelms the person experiencing it. In this context, the term sympathetic refers to the sympathetic nervous system which is responsible for creating arousal.
There are people out there who have panic attacks on a regular basis but do not think of them as panic attacks. Instead, these "non-clinical panickers" (up to 10% of the population!) attribute their emotional surge as due to factors they might have controlled and don't get worked up about them. A minority of people (1-3% of the population) experiencing panic attacks as devastating and disabling and do what they can to avoid ever having to experience them. These are the people who are susceptible to developing a panic disorder or other form of anxiety disorder.
According to the "Triple Vulnerability Theory" three separate kinds of vulnerabilities are usually in place before an anxiety disorder will occur. First, a generalized biological vulnerability must be present, perhaps in the form of a genetically inherited tendency to respond anxiously. Second, a generalized psychological vulnerability should be present, usually in the form of some early learning that taught the person that they did not have good control over their lives. Children can learn to feel they have no control when parents are either neglectful or overly restrictive; when needs are not met at all, and when children are not allowed to make mistakes and build competencies due to overprotection. Finally, a specific psychological vulnerability may be present either in the form of a traumatic event or in the form of learning from an anxious model (such as a parent who modeled anxious behaviors, providing a model of what to be anxious about and how.
Treatment of anxiety and panic has changed a lot since Dr. Barlow was a student. It has been known for a long time that the key to treating anxiety is to help patients overcome avoidance of what they fear. At the start of Barlow's career, systematic desensitization was a cutting edge technique. Subsequent research revealed that it wasn't much use except for treatment of very specific kinds of fears (such as fears of spiders or snakes). Researchers next moved on to other forms of direct exposure therapy and found that they worked better but not that much better. Again, the more complex the anxiety or fear was, the more resistant it was to traditional exposure based therapies. The most recent research suggests that for therapy for a complex anxiety disorder to be effective, what patients have to be exposed to is not the external things they fear in the environment, but their tendency to avoid their own emotional experience. Thus, the more effective modern treatments for anxiety disorders help patients to better understand, experience and process their emotions. Cognitive and behavioral techniques are useful for this work, but also so are techniques that have traditionally been labeled as being psychodynamic or humanistic. These older "school-based" models for doing psychotherapy are breaking down now as a more unified picture emerges regarding what works for treating emotional problems.
A current project of Dr. Barlow is the development of a unified treatment model which is an attempt to distill the main principles that are common to all treatments of emotional disorders into a simplified "trans-diagnostic" treatment approach which would be useful for helping most anyone using proven empirically validated (scientifically studied and shown to work) techniques. A preliminary version of this model addressing the anxiety disorders has been published in a few places (see Dr. Barlow's website for recent journal article and book chapter links), but he hopes to extend the model to apply more widely to other emotional disorders.
The last section of the interview has to do with Dr. Barlow's' bullish take on the state of the profession of clinical psychology. He notes that despite the challenging funding environment due to managed care, that the quality of clinical applicants has remained very high, and that increasingly, health policy is being influenced by all the work that has been done on empirically validated psychotherapy such that psychologists are in demand as providers of these treatments. He is particularly impressed by the energy and drive of Chinese psychologists who are in the process of rebuilding their field which was decimated during the "great leap forward".
Dr. Van Nuys closes the interview by asking Dr. Barlow what advice he has for people suffering from anxiety. The advice is simple. Really effective treatment is available either from the medical profession (in the form of medications) or from the psychological profession (in the form of empirically validated psychotherapy). If your choice is to go the psychotherapy route, it is best to work with an experienced therapist who is familiar with the latest research on relevant empirically validated treatments as this scenario offers the best chances for good results to occur.
Links Relevant To This Podcast:
- Dr. Barlow's website offers a wealth of information. Sections describe scientifically proven (empirically validated) treatment manuals he and his colleagues have written, his recent publications and book chapters, and a brief biography. Many of the treatment manuals can be purchased online through vendors like Amazon.com. These books come in pairs. There is a therapist manual and a client workbook. If you are using this in a self-help modality, think about getting the workbook.
- Dr. Barlow's book Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic is required reading for all mental health professionals who work with the anxiety disorders. It is very worthwhile reading for lay people dealing with anxiety disorders too, but weighing in at over 700 pages, it is not primarily aimed at a consumer audience.
- His edited work Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual (4th Edition), is similarly required reading for psychotherapists. This book reviews the empirically validated treatment protocols currently available and provdies information on how to apply them.
About David Barlow, Ph.D.
David H. Barlow received his Ph.D. from the University of Vermont in 1969 and 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.
Dr. Barlow is currently a professor of psychology and psychiatry at Boston University, where he is Founder, and Director Emeritus, of Boston University's Center for Anxiety and Related Disorders.
He was formerly Professor of Psychiatry at the University of Mississippi and Professor of Psychiatry and Psychology Medical Center at Brown University and founded clinical psychology internships in both settings. He was also Distinguished Professor in the Department of Psychology at the University at Albany, State University of New York.
Dr. Barlow is the recipient of several awards which include, the 2006 Distinguished Service Award to the Profession of Psychology from the American Board of Professional Psychology, the 2000 American Psychological Association (APA) Distinguished Scientific Award for the Applications of Psychology, the 2000 Distinguished Scientific Contribution Award from the Society of Clinical Psychology of the APA, Career Contribution Awards from the California, Connecticut and Massachusetts Psychological Associations, a certificate of appreciation for contributions to women in psychology, and an award in appreciation of outstanding achievements from the General Hospital of the Chinese People's Liberation Army, with an appointment as Honorary Visiting Professor of Clinical Psychology.
He is currently a Diplomat in Clinical Psychology of the American Board of Professional Psychology and maintains a private practice.
Skillful ways - Derrick Pohl - Jan 25th 2008
I was particularly fascinated with the idea of various schools of psychological therapy and treatments tailored to specific conditions all converging on a unified set of principles, as discussed toward the end of the interview. It reminds me strongly of Buddhism, at least as presented and practiced in the West over the past few decades, which is not exactly a religion nor a philosophy but more a body of guiding principles for dealing with life, nature, consciousness, and reality itself, usually described as "skillful" ways of being and acting. I find the precepts of this kind of Buddhism are also on a course of convergence with the psychotherapeutic coalescence, and may form an important part of the cognitive-behavioural evolution of the human species necessary for our well-being and even survival over the next century, and the planet's.