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Anxiety Disorders Causes & Treatments

Interview w/ Chris Edwards, Clinical Pysch.

Chris Edwards is a Clinical Psychologist (B.Psych, M.Psych) who specialises in Anxiety Disorders. He's previous Chairman of the Anxiety Disorder Foundation and has started an anxiety disorder clinic. Mr. Edwards has undertaken research into various aspects of Anxiety Disorders and is currently running the GP training program.

Jasmine interviewed Chris Edwards in April,1997 and the subsequent interview was serialised in the Panic Anxiety Disorder Association Inc., newsletter.

• Part 1: Cognitive Behaviour Therapy (CBT): What is it, how does it work and how successful is it?
• Part 2: The various theories about the cause of Anxiety Disorders.
• Part 3: How to choose an appropriate therapist.
• Part 4: Keys to successful therapy.
• Part 5 What is available for people in rural areas, GP training for Anxiety Disorders & CBT.

Part 1

Jasmine: Do you think that a person with an Anxiety Disorder can recover?

Chris: The majority of people that have Anxiety Disorders, in particular Panic Disorder, I think the treatment outcome studies are showing that recovery is possible. The Cognitive Behaviour Therapy (CBT) studies using the Oxford model suggest that overall between 84-94% of people taking part in those studies are panic free at the end of treatment and they're going to generally maintain that over the follow up periods.

Jasmine: How long was the last follow up period? Was it a year or...

Chris: Varying, I am giving results over a range of studies. There are one-and-two year follow ups.

Jasmine: Oh right, that's really good, isn't it?

Chris: Thats very good. Now, of course, not everybody is going to be able to go and get a little bit of CBT and get results that quickly because as we know Panic Disorders are caused by a number of different causes and those causes will generally predict the speed with which a person recovers.

Jasmine: So can you give us a simple explanation of what CBT is and how that would work for someone with Anxiety Disorder?

Chris: Let's start off with what CBT is and I think we have to look at it historically because the cognitive principles are derived from the work of our earlier philosophers such as Socrates and Epitites. Epitites said that it is not the things of this world that hurt us, but what we think about them. So it taught us that within regard to a whole range of emotional disorders that our thoughts are very important. And that is regardless of the cause of the disorder. But once you have a disorder, your thoughts about the disorder are very important. In particular, with Panic Disorder, the thoughts are very important. I think if you a look at what a Panic Disorder is in terms of cognitive theory, a panic disorder is generally seen as misinterpretation of bodily sensations. That is a catastrophic misinterpretation of bodily sensations. Now, once a person learns to misinterpret these sensations, a pattern tends to be fairly enduring. So the cognitive theory helps a person to assess the evidence which supports, or does not support, their beliefs about what is happening to them.

Jasmine: How would you begin with someone, with say a Panic Disorder, when they first come to you to start working with their thinking?

Chris: By a very careful Cognitive Behavioral assessment of the person with the Anxiety Disorder. First of all, you want to know what their beliefs are about how they developed the Disorder. You want to know what their beliefs are about their symptoms. You want to know what kind of avoidance behaviours they might be engaging which continue to maintain the symptoms. For example, people might be avoiding watching things on TV for fear that if they see something about somebody who has something it might make them worse hearing about it. Once you think about that, you can see that there is a fair amount of room there for cognitive distortions about the meaning of getting dangerous information.

You know, people are certainly unique, and I think there are many commonalities between people with Panic Disorder, but each case is unique and you really do need to assess the individual or idiosyncratic beliefs of the individual. Now, once you have assessed them, the sorts of therapies that you generally do go over a whole range of issues. There are some cognitive strategies that you use, in addition to that there are a number of behavioral strategies.

Jasmine: So does that include graded exposure to some extent?

Chris: No. I think people are changing their beliefs about what graded exposure means. In terms of graded exposure for cognitive therapy, certainly you may use some kind of exposure, but what we do is use a number of behavioral experiments. That is, a person may go out and test a belief they have about a certain situation. Now, before the person goes out, they are certainly armed with a number of strategies that they can use to help them overcome their beliefs in that situation.

Jasmine: That is the clue. What is termed as graded exposure is not simply just forcing yourself into a situation without any strategies. You know the theory: exposure yourself to a situation, therefore you'll lose the fear. You must have strategies to work within the situation.

Chris: Yes. You certainly do. I think that approach is fairly naive and doesn't work with many people.

Jasmine: And rather cruel, I feel.

Chris: A definition of the cognitive theory of panic--people who experience recurrent panic attacks--they are said to do so because of a relatively enduring tendency to interpret body sensations as catastrophic. OK, so the sensations interpreted are normally those associated with ordinary anxiety responses such as being breathless, having palpitations, feeling dizzy, experiencing numbing of the extremities. So these are all ordinary sensations.

Now what seems to happen is that when a person develops Panic Disorder there is generally an increased sensitivity to all bodily sensations so the person begins to interpret what are still normal body sensations as meaning that something quite bad could occur. The difficulty with Panic Disorder is generally they fear that something is about to occur right then and there. For example, a person might have Panic Disorder for many years and fear having a heart attack. But all of the evidence is that they haven't had one over all of the years that they have feared it, is insufficient evidence to contradict the belief that they might have a heart attack in the next minute, next hour, or the next day. So consequently, Cognitive therapy helps the person address those issues.

I dont think it is a matter of simply telling the person their thoughts are incorrect, or that they have nothing to worry about because family members have been doing that all along and it doesn't seem to help. It is a matter of helping to guide the person to discovering their own evidence which either supports, or doesn't support, their beliefs about their symptoms.

Jasmine: Then cognitive therapy also approaches the way that thinking can keep on triggering the fight-and-flight response, so that fear continually keeps the symptoms going and therefore justifying their own belief system on that?

Chris: Oh, yes! You really have to look at where the thoughts are. Sometimes a persons fear is triggered by a physical sensation. Another time it might be triggered by a thought about the possibility of having physical sensations and on other occasions it is triggered by images. So, I guess one of the difficulties is that if you are being chased by a sabor-tooth tiger then your response would be quite normal. However, once a person's anxiety response has been triggered by any of those three means, the person really needs to interpret how is it that they are having these extra physical sensations or is it any sabor-tooth tiger. So in order to try and explain it to themselves, they come up with 'this must mean that I am about to have a heart attack, go crazy ..' or something like that.

Jasmine: Which ultimately is a logical conclusion, considering what is happening.

Chris: Absolutely. Its extremely logical. There are a proportion of people who have the same strong physical feelings at different times, and I'm talking about an initial panic attack now, which we know that some people develop Panic Disorder and other people have panic attacks and don't go onto develop Panic Disorder. Now some people can even have those very strong, scary sensations and five minutes later not be terribly scared about them at all.

Jasmine: Have they looked into that, Chris? What is the difference between the two types of people?

Chris: I think this is where personality comes into it. Not only personality, but life circumstances. A person who might have had very adverse early life circumstances and has a general feeling of insecurity, they're more likely to worry about very strong physical sensations because it is just one more thing in their life that is going wrong. However, there is a psychologist in the USA named George Clum. George was writing a book on Panic Disorder and he was burning the midnight oil so he had been under stress for a number of months writing this book and all of a sudden he had a panic attack himself.

Fortunately, for George, he understood what was going on, so the anxiety dissipated fairly quickly. But it prompted him to go around and talk to his colleagues on a university campus about how many of them had experienced these attacks and how many of them went on to develop Panic Disorder. He was surprised to find that many people had experienced the attacks and some of them almost without fear. In other words, they reported that rush of physical sensations but didn't become fearful of them. That is really telling us something else about the importance of thinking and cognitive therapy as well because really if people can have the same physical sensations and not develop the Disorder, then a person is really saying that it is what they think about the sensations, rather than the sensations themselves, which cause the Disorder.

Jasmine: So reaction is the whole clue to it, how you are reacting.

Chris: Yes.

Jasmine: How successful is CBT really?

Chris: Well, I think, as of this present time, CBT is very successful compared to most other treatments. Now, it is not to say that new treatments won't come up in the future; or, its not to say we won't find our theories wrong in the future and that they'll be replaced by something that's even a better treatment. But right now, most people would agree that Cognitive Behaviour Therapy is the most effective treatment for Panic Disorder and for that matter, all Anxiety Disorders.

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