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View Full Version : Live chat with Paul Salkovskis - Paul's replies



nomorepanic
02-02-07, 14:12
All

Here are the questions that were asked last night in the Live chat and Paul's replies. I am sorry that we ran out of time to get them all asked but Paul has replied to all those that I sent him in time.

I hope you all enjoyed it. Sorry if it was a bit manic at times but hard to get eveything done in an hour!

Thanks again Paul for taking time out to do this.

1) After a recent post on the forum suggesting that forums such as this could be detrimental to people's recovery, what is his view as a therapist? Does he feel that using sites such as this will help or hinder the therapy he uses?

I’m generally completely in favour of this and other forums as a real help and support. I understand that sometimes there can be destructive interchanges, but then that also happens in coffee shops, and there are not so many nice people to try to sort it out (especially ones who know about anxiety etc)

I also confess to benefiting; for many years I have “lurked” on bulletin boards like nomorepanic and OCDUK forums, and it had given me lots of insight into things which people sometimes find it hard to say to people like me. My old favourite (long gone now) was an ocd board called Fairlite.

Probably worth making a point that I think that the greatest benefits come from mutual support; sessions like this (with a professional) have a different function. For that reason, I don’t post on general forums with the recent exception of nomorepanic on the house of agoraphobics, and that was because there was so much potential for misunderstanding that could easily be dealt with.

I will not, as a rule, show my face on other forums, because what you guys say to each other is more important than what I might say, and I can say what I need to say in other ways. Hope that makes sense.


2) Maybe not very important but I would like to know how effective Paul thinks CBT is.

In all anxiety disorders CBT is the most effective first line treatment. However, some are not helped, some are partially helped. In addition, some are completely helped. Thus, for panic disorder (without agoraphobia) 70% of sufferers are likely to be symptom free at the end of well conducted treatment.

For OCD the figure is more like 40%, for specific phobias (spiders etc) 90%. Most of the others benefit somewhat. Other factors affect outcome, eg. Severe depression, substance misuse, background stress (e.g. relationship problems and so on). “Comorbidity” (having more than one problem) can make treatment less effective, but not always.

Other problems vary, but quite simply CBT is the most effective of the psychological treatments that we have.


3) Firstly, I know he focuses on CBT but what does he think about medication? I'm on Lexapro for panic disorder, health anxiety and depersonalisation. I hate the idea of being on medication but I was desperate so I gave it a shot. I was wondering if he would ever recommend medication or if he only believes in therapy?

I “believe” in medication as an appropriate choice in treatment for anxiety problems. The research shows that it is typically a second line/augmentation strategy (not the first thing you would go for) purely on effectiveness grounds.

However, it is fine if people want to take it as their preferred therapy; I have been for some years advocating “evidence based patient choice” meaning that the professionals (and organisations such as nice) make the evidence (including the pros and cons) for each treatment available to those who wish to be involved in the choice of treatment. It’s not up to me to choose for someone.

However, I won’t of course support a treatment I regard as harmful if there is an alternative. I do sometimes recommend medication (through an appropriate professional, e.g. GP, psychiatrist). There are issues about combination of therapy and medication which I will return to later.

4) Depersonalisation terrifies me because I wonder if it's a symptom of another more serious mental illness. Is that possible? How do I know that I'm not schizophrenic? Or might I have a brain tumour or something? I'm too scared to google it because I think that my symptoms are going to point to something really serious and I couldn't deal with that.

Actually, for many people exactly that terror is the key. Anxiety is typically about misinterpreting a symptom (e.g. depersonalisation) as more dangerous than it really is (e.g. as a sign of schizophrenia or a brain tumour). That misinterpretation makes the person anxious (which can increase depersonalisation) and makes them pay attention to how depersonalisation is affecting them (looking for trouble…..and if you look for trouble, guess what you are most likely to find????). And round it goes. Anxiety, as all here know, is very serious.


5) Can panic lead to serious health problems such as heart attack, high blood pressure, stroke etc?

Very very unlikely. A panic attack makes your heart beat faster and puts you BP up. But only about the same amount as climbing up six or seven stairs. What this means is that if you have really serious physical pathology (e.g. previous heart attacks) panic has the same chance of harming you as very mild exercise, but we also know that properly prescribed exercise reduces risk. So the answer is no.


6) One thing that used to prolong the anxiety for me was the thought that you are doing yourself damage all the time and so you end up in a vicious circle of worrying that the worry is doing you harm!! I know he did some research into mortality rates of panic and anxiety sufferers against the standard population and found no difference if you remove suicide from the equation.
Has he done more research on this area?
Are the previous findings still valid?

Findings still valid.
People often think that stress is cumulative; however, ask yourself; how do we train soldiers to deal with stress…..by resting a lot? Stress does not take you to breaking point.


7) What the best treatment is for health anxiety? And also - What the best treatment is for severe attachment disorders? Thanks.

Health anxiety: cognitive behavioural treatment. Attachment disorders; not clear, but if you are talking about things like “borderline personality disorders” then Schema focussed CBT


8) I have been taking Magnolia & Rhodiola Complex which has Relora, Rhodiola Rosae and L-Theanine for about the last 6 months and my PANIC ATTACKS are now 95% gone. I have found these more effective than the CBT I was having. I know the tablets are effective because when I stopped taking them I relapsed in to an anxious state. Does Paul have any views on these or any other tablets and is it something which he would/does endorse?

Glad to hear it. Anything which helps YOU is good. The nice guidelines group examined alternative remedies and did not find evidence for them, but clearly they work sometimes for some people, so if not harmful go for it.


9) I guess I would like to know his position on medication as an *adjunct* to CBT. I don't think medication alone is effective, but I also don't believe that CBT is 100% effective without medication, and that some people need to be on meds for a while before they can begin the intense CBT that was depicted on the programme.

Correct. Problem is, however, that there is some good evidence that CBT helps medication, but not the other way round, and worst of all in panic at least medication undermines the long term effectiveness of CBT. This is not true in depression and we don’t know about the other problems because the research is not there.

10) What could be a first sensible step for an agoraphobic to take to try to recover?

It does, of course, depend on the individual and their specific problems, situation etc. Asking for help (from a trusted person) is always a good start. This should be someone able to support you in your efforts to try to change things. Secondly, find out as much as possible about your problem, including from here etc, Look at what is known, for example, about panic; this boils down to the idea, reasonably well established, that people suffer panic attacks because they tend to misinterpret bodily sensations (especially those caused by anxiety) as a sign of catastrophe.

For example, the person whose heart races believes this is a sign of an imminent heart attack; the person who feels unreal interprets this as a sign that they are going insane; the person who feels dizzy misinterprets this as a sign that they are about to faint. Anyway, these misinterpretations understandably increase anxiety, which can then increase the sensations, and so on round in a vicious circle.

Note that all this takes place quick as a flash, in the same way as you would react quickly (and with anxiety) if you saw, from the corner of your eye, someone rushing towards you waving a big stick.

Once started, the panic rapidly escalates, and can trigger safety seeking behaviours (e.g. leaving the situation, holding onto someone to stop yourself from falling, things like that) which can have the effect of preventing you discovering that the things you (understandably) fear don’t happen EVEN IF YOU DO NOTHING AT ALL.

One of the big safety seeking things is avoidance, and there has to be confronted. Sometimes we compare anxiety to a bully. What do you do if a bully says “stay in your house or I’ll beat you up?”. If you do as you are told, what happens next? If you defy it, what happens then?

The second way of dealing with it takes the kind of courage that needs really good support.

Many people can’t manage this for a range of very good reasons, and that’s where a good cognitive behavioural therapist can help. CBT is about supporting people’s own efforts to change, not least by helping them to understand how the problem works.

The therapist typically acts as “coach”, helping the person to analyse what is happening at the moment, then working collaboratively with them to find better ways of dealing with things, helping them make sense of what they have found out etc.

Phew, that’s a big set of first steps. Hope there is something of use in that ramble.

11) If I approach my doctor what sort of support could I expect him to give me or indeed should I be asking for?

A very tough one. As ever it depends on all kinds of things. Hopefully, the doctor should be able to help you identify the nature of your problem (or, if they are unable to do this, refer you to someone who can).

Assuming that they are able to “diagnose” your problem, then they should be able to offer you information about the range of treatment options; first in terms of the pros and cons of the treatments, and secondly in terms of availability to you. Some doctors may wish to offer more help, others may wish to pass this role on to someone else, such as a practice counsellor or mental health professional.

My experience is that most GPs want to provide more support, but have problems with the time available to them, which is often only a few minutes. It is reasonable to indicate that support is needed, and be as clear as possible about what type and how much, with a view to discussing how your needs can be met.

12) Given that we are advised to get out there and give it a go, do you thinking flooding is a good thing or a bad thing cos my experience with this tends to put me backwards not forwards?

Flooding is not a recommended treatment. However, it is easy to get confused about what is and is not flooding. CBT involves a simple sequence which can, if not viewed in the whole, look like flooding. The sequence is this

Therapist and patient meet for an assessment

Assessment can lead to a “shared understanding”; boils down to “So lets see if this is how your panic attacks might work”.

Assuming a shared understanding, this leads to the question “if that’s true, how can we test it out?”. For example, the person with chest pain thinks that this means they are having a heart attack, and therefore understandably panics.

Maybe instead chest pain is from tightening of muscles between the ribs. We check this out by expanding our chests as far as possible when we breathe, and find very similar sensations to those in panic.

What next? Well, there is some chest pain there now, so lets go for a brisk walk. Surprisingly, the chest pain gets worse when we stop walking, and better when we start jogging. There are probably several other behavioural experiments to be done next, considering the same issues.

Finally, we “go for broke” by trying to “bring on a heart attack”; we run as fast as possible up and down stairs. Conclusion; its not a heart attack, it’s a panic attack, otherwise I would have died. Total time: probably six hours from start to finish. There are several “leaps of faith” involved, but the therapist seeks to make them all manageable, and provides a supportive and uncritical setting to explore “how things work”.

The therapist should be aware of, and help with, the tendency to be self critical. If the person tries something and its doesn’t work, then lots of things can be learned, and that is discussed. Its not a cause for criticism (“so that was too difficult; lets find out why, and that info will help with the next thing we try”).

Hey, isn’t that last bit flooding? No!!

However, if we had started with the running up and down stairs bit that would have been flooding. It would also have, in all probability, made things worse. However, typically “being thrown in at the deep end” is resisted by most sensible folks. Doesn’t mean you don’t eventually have to take the plunge, but having a good idea of how to swim first is essential.

13) What tips can you give if we have a panic attack while alone on an outing - as it's so hard to hold onto reality when in the grips of panic and all it's accompanying symptoms?

See previous answer regarding panic attacks and how they work. Ideally, it’s a matter of getting to grips with the panic ahead of going out, then having someone support you while you try to apply this if it happens. During therapy we welcome panic attacks as a way of learning how to deal with……..panic attacks!

14) Can general anxiety on a more daily basis also be improved by dealing with the panic attacks or are different methods needed for each.

Depends on the pattern for each individual. If the general anxiety is worry/anticipation about panic, then dealing with the panic attacks is likely to help the general anxiety. Indeed that is one of the first things we demonstrated in our research in panic (back in 1986….the good old days…er….).

However, if panic has started against a background of generalised anxiety, probably requires separate treatment. For this (and other problems) it reminds me of the story of the man who discusses the operation on his hand with his surgeon.

Patient: “Doctor, will I be able to play the piano after the operation?”
Doctor: “Of course”
Patient: “That’s really wonderful”
Doctor “Why?”
Patient “Because I can’t play it now”

Dealing with panic will not necessarily stop other problems (or make your rich, improve your golf) unless it is stopping you managing those things now.

15) How do we best deal with feeling physically and emotionally overwrought while trying to recover?

Do more, especially things you enjoy! “Reach for the sky”

Anxiety does not remove physical energy, but does sap motivation and pleasure. So having fun is good.

Sleep is also good, and worry tends to affect that. There are some very usefully CBT strategies for sleep management, sometimes worth considering.
That all being said, bear in mind that feeling physically and emotionally overwrought is also a normal reaction to all kinds of things.
Actually, come to think of it………. ;-)

16) How to deal with setbacks cos if I have a panic it puts me off trying again as I think all the wrong things and I know the right way to go is to go right back and do it again but its hard. When panicking is it best to distract or try to ride with it. ie when trying to overcome a fear is it better to take small baby steps towards achieving that goal or it is better to just face it full on (flooding).

First part of this; sounds like you need some more help with managing panic related beliefs… see above.

When panicking, best to ride with it. You don’t want to come out of a panic thinking “thanks goodness I distracted myself; if I hadn’t, I would have (died, fainted, passed out, had a heart attack, gone mad, been sick, weed myself etc).

When you are actively confronting panic, you want to see WHAT REALLY HAPPENS. I remember someone I worked with a couple of years ago said to me

“I stayed in the queue at the bank even thought I was panicking and thought that I would pass out. Then, suddenly……..


NOTHING HAPPENED!!


Except that my anxiety went away.

The things we do when feeling anxious can make things worse even thought they seem to be making things better. The solution becomes the problem.

Piglet
02-02-07, 15:03
I have just printed this all off so I can re-read when having a wobble.

Many many thanks to Paul for taking the time to do it and also to Nic for organsising it!! :D:D:D

Piglet xx

"Supposing a tree fell down, Pooh, when we were underneath it?" said Piglet.
"Supposing it didn't," said Pooh after careful thought.

Quirky
02-02-07, 15:17
Thanks Nic and thanks Paul.

I wasn't able to be there last night so it's great to be able to read through this here.

Thanks again,

Lisa

tommythomson
02-02-07, 17:44
Thanks Nic, this will be really handy to have. Thanks for organising this it was very helpful. I had a good day today and was quite positive because of some of the answers given.

Pass on my thanks to Paul as well.

Cheers again

T :D:D:D:D

Trev
02-02-07, 18:30
Many thanks Nic and Paul for taking the time for all this.
Cheers,
Trev

domino
02-02-07, 18:47
Interresting read, thank,s nic&paul for time and advice.

mingsy
02-02-07, 19:43
Thanks Nic what would we do without you, a big thanks to Paul to for a very big insight into anxiety.

JANE

bobsy
03-02-07, 00:26
Just wanted to say a BIG THANK YOU to both nicola and paul for last nights discussion.

Cheers

bobsy x

normalwisdom
03-02-07, 00:58
A big thanks to Nic and Paul for this it helps to know someone is on our side:D.(whatever that is!)

Steph

manmoor
03-02-07, 12:03
Thanks Nic and Paul. xxx

"When There Was Only One It Was Then That I Carried You."

heths
03-02-07, 15:13
Thank you Nic and Paul,

I wasn't there for the chat last night, thank you for putting it here, I'm going to print it off and read it.



Heather x

nomorepanic
04-02-07, 12:30
Glad you all found it of some help.

Maybe we could get Paul back again one day.

Nicola

People will forget what you said
People will forget what you did
But people will never forget how you made them feel

bernadette
04-02-07, 19:24
EXCELLENT READING CANT WAIT FOR HIM TO COME BACK ON I MISSED IT THANKS BERNADETTE XXX

wobily_lin
07-02-07, 05:00
Thanks Nic for posting this thread as I wasn't there..ty..and ty Paul for you're time..sorry i missed it.

Take care,
Lin xxx
"Fear is dat lil darkroom, wer negatives r developed", so positive thoughts okies!!!!!

Melxxx
22-02-07, 15:08
Hi Nic,

Have you got all Pauls answers sorry to be a pain some of the thread seems to missing or is it just me.

Thank you

Mel xx

nomorepanic
22-02-07, 15:38
Oops - looks like we lost of that in the move to this new forum.

Thanks for letting me know - will get Alex on to it later. If not then I have a copy in a Word document so can repost.

Cheers

Melxxx
22-02-07, 15:44
Oops - looks like we lost of that in the move to this new forum.

Thanks for letting me know - will get Alex on to it later. If not then I have a copy in a Word document so can repost.

Cheers

Thank you so much Nic,

Thought it was me. Love the new forum.

Mel xx

nomorepanic
25-02-07, 21:22
Mel

I have re-posted it as it was quicker than Alex trying to recover it.

Hope it helps.

Melxxx
01-03-07, 16:34
Thank you Nic,

I really do appreciate you posting this back up. I have printed it off now so when I have wobble I can read it.

PanchoGoz
02-08-12, 19:04
This is good stuff, wish Paul was on the forum!

nomorepanic
02-08-12, 19:46
He is a member Pancho lol. Wow this was 5 years ago now

Serenitie
02-08-12, 20:13
Thank you. This is helpful x