Research / InfoLast Modified 2009-10-05 10:24:33
This page contains research and general information about Panic, Anxiety, Phobias and OCD. The articles on this page are: Current Research In The PsychologicalCause And Treatment Of Anxiety Disorders. (will open in a new window as this article is quitelarge)
This article covers the following
- A look at Behaviour Therapy
- Neurosis or Psychosis
- What is Cognitive Therapy
- Anxiety - The Common Complaint
- Tackling Work-Related Stress (will open in a new window)
A look at Behaviour Therapy
Behaviour therapy is rooted in experimental psychology and most books will tell you thatbehaviour therapy it based on the principles of Pavlov (of the salivating dogs) and Skinner (of therat box). However, in my view, much current behaviour therapy is based on a practical, pragmaticapproach rather than fossilised psychological therapy. The original applications of behaviourtherapy can be traced to the 1950's when Joseph Wolpe, a South African psychiatrist working inAmerica, applied systematic desensitisation to the treatment of simple phobias. This approach wasbased on the idea that if you taught people to relax, this was incompatible with feelinganxious.
Wolpe called this process "Reciprocal Inhibition", i.e. one emotion cancelling out another. Aswell as using relaxation, Wolpe also taught his patients to evoke feelings of anger or sexualarousal in association with their phobic fear and these were as successful as relaxation. Wolpe'soriginal ideas still have some utility today. Perhaps, the next time you are anxious you should tryto imagine something which makes you angry or something which............... (write to the editorwith your views on this).
During the 1960's and 1970's, behaviour therapy rapidly expanded and treatment became much morebased in real life. For example, helping the patient to enter their phobic situations, often withthe help of a therapist, or training the patient to deal with obsessional impulses by sitting outthe anxiety or performing some kind of competing activity. Certainly, by the 1980's behaviourtherapy was indicated for approximately 30% of problems going to outpatient psychiatrists and theseincluded not only obsessions, simple phobias and complex phobias such as agoraphobia and socialphobia, but also sexual difficulties, social skills problems, a whole host of habits and, morerecently, the application of behaviour therapy to physical illnesses such as asthma, irritablebowel 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 thoughtsas recurrent and habitual patterns which are open to modification. Therefore, for example, in thecognitive therapy of depression, depressive thoughts are treated as learned bad habits and patientsare trained to identify the when, where and how of these thoughts and to replace negative thoughtswith more realistic or coping thoughts.
Behaviour therapy is now much more widely available although, as most of you know, some areasare better than others. Currently, behaviour therapy is offered by about 100 nurse behaviourtherapists nation-wide, by some clinical psychologists and, encouragingly, by an increasing numberof psychiatrists and general practitioners who have learned behavioural procedures in theirtraining.
General practitioners now receive 3 years training before going into general practice and veryoften they spend some of this time with a department of psychiatry and may spend some of thatattachment with a behaviour therapist. Indeed, since 1978, I have been responsible for givingdozens of psychiatrists and GPs a period of apprenticeship in behaviour therapy and I can vouch forthe fact that some of these GPs spend a considerable amount of their time helping patients withbehavioural procedures. In years to come there will be many more GPs and psychiatrists using thisapproach as, thankfully, there is now considerable evidence to show that the stranglehold of theold psychoanalytical approaches is lessening and doctors are now much more interested in acquiringskills in procedures which are known to be efficacious.
Whether you are referred to a psychologist, a nurse or doctor with a background in behaviourtherapy is, in some senses immaterial. What probably counts most is having confidence in thatperson and if you have a good rapport with your therapist, this is probably much more importantthan whether they spent 7 years at medical school or completed a period of specialist trainingafter qualifying as a nurse. The research carried out on who makes the best therapist indicatesthat the results of treatment are much the same for nurses, doctors and psychologists and thereforeyou 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 althoughthere are, of course, cutbacks in the educational provisions in the health service, training inbehaviour 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 isthat 70% of people who complete treatment will improve by 70% or more and this figure probablyholds for obsessional rituals as well. However, treatment outcomes with obsessional thoughts arenot 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 thosereferred to me are taking some sort of medication. Overall, the evidence is that most medicationsprescribed for phobic states are not very helpful. Certainly tranquillisers produce verysignificant problems in the medium and long term and I have no need to describe the horrendousaddiction 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 noreal evidence of their efficacy. In my text book on agoraphobia we reviewed the evidence regardingbeta-blockers and could find no long term evidence that they were in any way successful. The onegroup 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 theproblem or in some specific cases of obsessive/compulsive disorder. In my view there is very littlereason why antidepressants should be prescribed in phobic disorders as any benefit for phobics as agroup is probably outweighed by the longer term difficulties associated with antidepressants, whichcan include a very significant weight gain.
Although there is some encouraging evidence that people respond to antidepressants, one mustbear in mind that many of these studies are only of a few months duration and that there is verylittle evidence that in the long term, people who take antidepressants do any better that peoplewho don't. Overall, therefore, the message is that antidepressant drugs can be helpful in certaincases 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 medicationis being offered, for how long it is being prescribed, what evidence there is that it is useful inthat particular kind of condition and, last but by no means least, ask for a full account of sideeffects.
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 littledoubt that many patients can have their symptoms markedly alleviated by behaviour therapy, thereis, in my view, no real cure for any of the phobic and obsessional problems which come fortreatment; rather people may at best aim to become 98% better. There are, of course, some rareexceptions to this and in my career I can certainly remember more than a handful of patients whohave 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
The first thing that many patients ask when they present withserious anxiety problems is "Am 1 going mad?" Very often, people with anxiety states feel that theyare 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 theirfamily, friends or strangers and behave in a bizarre, inappropriate or even violent or a dangerousway. These feelings of loss of control are triggered by high levels of arousal and consequentmuscle tension. Thus, if one feels "keyed up" for no apparent reason, the brain is alert to thepossibility of action. In turn there is a misinterpretation on the part of the sufferer, thatsomething 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 aninstitution. Indeed, some mental health professionals perpetrate the idea that serious mentalillness, 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 healthproblems, ranging from anxiety and simple phobias to severe and long-standing obsessive/compulsivedisorder. In between the term captures mild and moderate levels of depression, stress reactions ofone sort or another and an array of conditions which are probably best seen as exaggerated forms ofnormal thinking, behaviour and feeling. Indeed, who amongst us has not had some sort of neuroticreaction, whether it be an anxiety attack, an obsessive thought, or a reaction to stressful lifeevents? On the other hand, psychosis refers to very specific conditions and these are largelycovered by two umbrella categories, i.e. schizophrenia and manic depressive disorder. Schizophreniais probably best seen as an umbrella term to cover a variety of different conditions, but these areessentially characterized by a condition wherein the personality fragments and the sufferer ishandicapped 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, oftenleading to a very impoverished life. Sufferers often have hallucinations and delusions, i.e. theyhear voices and suffer false beliefs, which are impervious to any logical reasoning, in additiontheir thoughts show considerable disorder.
Sometimes there is a lack of coherent speech and generallymotivation 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 numberof different biological factors. Increasingly, it is being seen as a neurological illness ratherthan a mental health problem caused by stresses and strains. Although, some people withschizophrenia suffer anxiety, it is impossible for people with anxiety disorders to developschizophrenia as a result of anxiety disorder. Anxiety sufferers should be reassured that theycannot develop schizophrenia as part of anxiety state, no matter how bad anxiety becomes.
The symptoms of schizophrenia and thedeteriorating course can be linked to changes in brain structure and functioning, which areentirely different to those associated with anxiety.
Manic depression is also a severecondition, often running a life long course where there are violent swings of mood. We all, ofcourse, have "ups and downs" in the way we feel, but manic depressive swing from a very extremeformulation and over activity to the depths of depressive despair, with the condition becoming sobad 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 withspells 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. Thedepression experienced by sufferers of manic depression is of a much greater depth than thatexperienced by sufferers anxiety and cannot be explained by external circumstances. People withanxiety states can feel profoundly depressed, but usually this depression is a direct result offeeling chronically anxious. Again it is impossible for anxiety depression to become manicdepression.
On a more optimistic front, newtreatments, mostly medication, are being involved for both schizophrenia and manic depressiveillness although; it must be noted that cognitive behaviour therapy techniques are being developedfor both conditions. New techniques in examining the brain with magnetic resonance imaging andother forms of scanning are helping neuroscientists to understand the pathology of theseconditions.
At the Institute of psychiatry where Iwork, 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 moreone sees of these conditions, the more one realises that they are very different from anxietydisorders.
What is Cognitive Therapy
Cognitive therapy was first described by Aaron T. Beck in thelate 1960s. At this time, the primary treatment for psychological problems was psychoanalytictherapy and behaviour therapy was in its infancy.
In 1976 Beck wrote his now classic book "Cognitive Therapy and the Emotional Disorders". It wasadvertised as 'a major exploration of an influential new approach to the understanding andtreatment of mental illness' and 20 years later it has been described as "the single most importantand 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 ofexperiences gives rise to emotional disturbance (Beck, 1995). The idea is that it is themeaning of the event to the individual that needs to emotions, rather than the eventsthemselves (Salkovskis, 1996). For example, if hear a loud bang in the middle of the night andthink 'that must be a burglar', you will undoubtedly feel anxious. If, on the other hand, you heara loud bang and think "my clumsy husband has knocked over the vase in the hall; the mess will bethere for me to clear up in the morning', you are likely to feel angry. If you think, 'My husbandhas 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 vasein 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 thoughtscan 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.
Cognitive therapy is designed to modify the individual's dysfunctional thinking with the view thatthis will improve mood, behaviour, physical reactions and so on. Beck first described the basiccognitive techniques as consisting of identifying the person's specific dysfunctional thoughts andbeliefs, 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 itthere, I can't do anything right, I'm so stupid,' the cognitive therapist could help the persontest the thought that 'I can't do anything right.' This may involve going through some exampleswhen 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 anythinking 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 andtreatments use principles from behaviour therapy to help challenge and change beliefs. The idea isthat the person can use some behavioural 'experiments' to test their beliefs in a 'scientific' wayand 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 tobecome 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 thendiscuss 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 upontouching something dirty without washing.
If not, then this disconfirms the person's views that illness is very likely to result fromtouching something dirty without washing. In this way, the dysfunctional beliefs that aremaintaining the person's problem can be challenged and changed, leading to an improvement insymptoms.
Some cognitive therapists consider thatdifferent types of thoughts may play different roles in the maintenance of emotional distress andmay require different techniques.
Thoughts have been classified into 'negative automatic thoughts" which are the ones that firstgo 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 everythingright 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.' Theselong-standing beliefs can be difficult to change and so treatment for psychological problems inwhich these types of beliefs are particularly problematic can sometimes take a long time.
Cognitive theory and therapy has developed at a rapid pacesince 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 andscientifically proven to be efficacious in the treatment of a range of conditions including panicdisorder, social phobia, post-traumatic stress disorder, health anxiety, obsessive-compulsivedisorder and bulimia nervosa (see Nathan and Gorman, 1997). The specific models vary but they havein common the cognitive principle that it is the interpretation of the event (rather than the eventitself) that maintains the psychological problem. For example, the cognitive model of panicdisorder proposes that the interpretation of a normal body sensation (such as a rapid heartbeat) asindicating 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 bodysensation. In the example above, the rapid heartbeat may be caused by the person climbing thestairs and the cognitive therapist helps the person to realise this. As a result, anxiety and panicattacks are likely to be significantly improved.
Cognitive theory and therapy was developed by Beck in the late 1960s.
The main principle behindcognitive theory and therapy is that the distorted interpretation of experiences gives rise toemotional disturbance.
A variety of methods areused to challenge and change a person's distorted interpretation of their experiences, includingbehavioural 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 beefficacious in the treatment of a range of conditions.
Beck AT (1976). Cognitive therapy and the emotionaldisorders. 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. BehaviourResearch 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 totreatments 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 pracis of an article that Charlie (a message forum member) read in the September issue of NewScientist. She thought it was very interesting, and might be useful to some of you others outthere. 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 mostcommon mental health problem. One in four people will suffer from an anxiety related disorder atsome point in their lives.
There is no discrimination between class, race, intelligence and wealth.
Anxiety disorders cover Panic Disorder, Obsessive Compulsive Disorder, Phobias and PostTraumatic 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, andthat 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 sufferedor will suffer the same problems as you. (Ok all you statisticians out there - I know it doesn'twork 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 tosuffering. 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 goodresponse. It helps us run away from danger, and keeps us alive. The problem occurs when response tofear 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 youto respond inappropriately to your own triggers and developing fear of everyday things - usingpublic transport, answering the telephone, driving.
The only thing that makes all anxiety sufferers different is that with each person the triggerswill vary.
The response will be shared - all though not all symptoms will be felt by all sufferers eachtime - 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 "spacedout", 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 handin it will be painful!
Scientists have discovered that the brain stores memories of fear in a different way to ordinarymemory. In people who suffer anxiety, these fear memories override the ordinary memories, and aremuch stronger.
The fear memories are stored in your brain as an "emotional memory", as opposed to rationalmemory. Unfortunately, emotional memory is pretty much permanent, whilst rational memory can bereadily manipulated.
Many sufferers of anxiety disorder appear to have a more dominant emotional memory to rationalmemory.
WHY IT HAPPENS
LeDoux, a neurologist, discovered that a specific area of the brain, the amygdala, isresponsible for learned fear.
When you are faced with your trigger the amygdala reacts immediately and the learned fear isstrengthened. Rational memory is stored differently, and is a more slow response, through thecortex and into the hippocampus.
LeDoux then tracked the brain as individual triggers were released. A signal travels through thebrain 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, whichcontrols involuntary fear.
The body then prepares for flight (panics) before the high road has had time to process theinformation rationally.
You see a spider. The message travels through to the brain. The low road receives message SPIDERand tells the brainstem. The brainstem tells you to panic. You scream for yourpartner/husband/brave friend.
Five minutes later the high road gets its act together and says, why did I do that? It's aspider. I'm one hundred times bigger than it. It's more scared of me than I am of it. Why have Ijust 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 sufferfrom anxiety phobia have an over sensitive response to fear. There are severaltheories as to what may make us more sensitive
In an non anxiety sufferer the amygdala seems to do a good job, filtering out inappropriatefears, 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 muchinformation is getting through, causing a state of "hypervigilance"
The amygdala is balanced by GABA (an inhibitory neuro transmitter). The inhibitors allow theamygdala 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 wasfound to have receptors on the interneurons found in the lateral nucleus of mouse amygdala.
These interneurons 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 GABAsystem.
Shumyatsky believes that a deficiency of this peptide or its receptor may enhance fearmemory.
Another strongly held belief is that in anxiety sufferers the controls for fear memories havemalfunctioned.
Although fear memories are difficult to modify, they can eventually be altered with carefulexposure. Think of Pavlovs dogs - bells = food, and they could associated feed time with bellsringing.
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 inlevels 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 haveshown in mice that this gene, which controls the neurons which produce serotonin, is related toanxiety. Mice without this gene were significantly more anxious, and they therefore believe thatthis gene helps control serotonin through life.
Some people respond well to drug therapy. Benzodiazepines help the anxiety, but do not help much with any accompanyingdepression. Drugs which raise the serotonin levels however can be used to treat both anxiety anddepression.
The down side of drugs is that they can suppress the problem, which will still need to betackled 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.