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Chris Edwards is a Clinical Psychologist (B.Psych M.Psych) who specialises in Anxiety Disorders, previous Chairman of the Anxiety Disorder Foundation and has started an Anxiety Disorder Clinic. He has undertaken research into various aspects of Anxiety Disorders 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.
J. Do you think that a person with an Anxiety Disorder can recover?
C. I think that 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 and 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.
J. How long was the last follow up period, was it a year or..
C. Varying, I am giving results over a range of studies ... there is one and two year follow ups.
J. Oh right, that's really good, isn't it ..
C. 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.
J. So can you give us a simple explanation of what CBT is and how that would work for someone with Anxiety Disorder?
C. Lets 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.
J. How would you start with someone with say a Panic Disorder, when they first come to you to start working with their thinking?
C. 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.
J. So does that include graded exposure to some extent?
C. 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.
J. 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 to a situation therefore youll lose the fear. You must have strategies to work with in the situation.
C. Yes. You certainly do. I think that approach is fairly naive and doesn't work with many people.
J. And rather cruel I feel ..
C. 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 doesnt 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.
J. 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?
C. 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 your then response would be quite normal. However, once a persons 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.
J. Which ultimately is a logical conclusion.. considering what is happening ..
C. Absolutely. Its extremely logical. There are a proportion of people who have the same strong physical feelings at different times, and Im talking about an initial panic attack now, which we know that some people develop Panic Disorder and other people have panic attacks and dont go on to 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.
J. Have they looked into that, Chris? What is the difference between the two types of people?
C. 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 called 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 had 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.
J. So reaction is the whole clue to it .. how you are reacting ..
J. How successful is CBT really?
C. 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 wont come up in the future or its not to say we wont find our theories wrong in the future and that theyll be replaced by something thats 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.
CONTINUED NEXT ISSUE - VARIOUS THEORIES RE. ANXIETY DISORDERS
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J. What about medication ..... especially the benzodiazepine dependence issue?
C. In my practice I see benzodiazepine dependence as being a problem in a substantial proportion of my clients. However, it could be that I see a biased population, that is I am more likely to see people that develop troubles with medication. There are a group of panic disorder people who actually panic when they take a drug. You really need to look at a drug as a chemical and some people take tablets and don't have ill effects. Other people might take medication and that's like introducing a new chemical into the body and one of the things that people with panic disorder are scared of is sudden changes on bodily physical sensations. So for people that misinterpret the change due to the drug as meaning something bad, they are likely to panic more as a result of having taken it.
J. Everyone is so confused about the different theories about what is causing their Anxiety Disorder .. some say chemical imbalance, some Behavioral, some childhood issues. What can people do to sort through this quagmire?
C. All of those things can cause panic disorder and the literature generally supports a conclusion that panic disorder develops within the context of a multiple of causal factors including biological variables. In other words, some people might have a medical condition which can bring on their panic attacks. Another person might have an injection .. Ive heard of people having gold injections ... and injections for other things which have brought on or precipitated panic. Cannabis is another substance that can change the biological nature of the individual for a time period and bring on a panic as well.
J. Mercury teeth fillings ..?
C. Well, I havent heard of that one. There are a lot of biological causes for panic. Now the question is, is a biological cause really important? It seems like you can use cognitive therapy even when the disorder is caused by some chemical and still get a good result. Another way a person might develop the disorder is as a result of learning influences within their family or perhaps some idiosyncratic thought. Another way a person may develop panic disorder is through stress. Say for example, a person is in a bad relationship or an abusive relationship. They may develop panic disorder and it is unlikely to be resolved until they do something about that relationship. So there are a whole lot of causative factors. So it really doesnt make sense to talk about a single cause. What people need to do is to go to somebody that has some experience in assessing these causes and have a Behavioral and cognitive analysis done to determine what the cause is for them. That assessment might even require a medical assessment. We must remember, however, that many people do not need to know what caused the disorder to be successfully treated.
J. So, what about chemical imbalance ..?
C. All behaviours ranging from a brief thought through to playing tennis causes neurophysiological changes. People who are treated with CBT often show similar changes in brain chemical systems as those treated with medication. So, you can change behaviour and you can change brain chemistry.
J. So, basically whatever the initial cause was for the Panic Disorder, it is still very possible to recover, regardless of what that cause was. Is that right?
C. I think so. You know, there are allot of combinations in recovery but for most people the promise for recovery and good management of panic attacks is very very promising at this present time.
J. The big question everyone wants to know is how long does it take to recover? I know it is individual but what is your general opinion on this big question?
C. Some of the Cognitive Therapy sessions are down to around 3 and 4 sessions. However, in my own experience I've found between 6 and 13 sessions. Of course, not everybody can be guaranteed that kind of a result. It depends on a persons individual situation. Say for example, a person who has been traumatised may have more than an Anxiety Disorder. The therapist may need to treat issues related to the trauma in order to successfully treat the panic.
CONTINUED NEXT ISSUE : KEYS TO SUCCESSFUL THERAPY
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J. So if anyone has Post Traumatic Stress Disorder, they definitely have to go and see a therapist .. it's not really possible for them to sort through that by themselves...
C. I dont know, we only see the people that don't. And you know, it was once said that people couldn't overcome Obsessive Compulsive Disorder (OCD) without the help of a therapist. But certainly, when I have been lecturing different groups of people, I've heard of relatives of people who have OCD say that they had it and they got rid of it without seeing anybody. Now I'm sure that the same is true of some of the other Anxiety Disorders. A good example of this is Goethe. Do you know Goethe?
J. No ..
C. Goethe was a law student and is a world famous poet. When he was 20 years old in the 1700s at Salsburg University he was the first person to cure himself using exposure. Goethe said something like 'I ventured quite alone up into the cathedral spire and sat there for a period before venturing out and looking over the edge.' He said 'it was as if one was suspended by a balloon with nothing before ones eyes and nothing below. I repeated this so often until the perception became quite different to me.' He then said 'Ive derived benefits from these practices when going on geological surveys, when running across freeling beams on buildings, when pushing ones way to the front of a crowd for a better view of an important work of art in Rome.' What Goethe was talking about was exposure therapy but the difference between Goethe and many other people is that Goethe initiated it himself. He was aware that if he did expose himself that he could get better. Now the other thing about Goethe is that he had a sense of courage. In other words, he had changed his thoughts which allowed him to do it. So he did his own cognitive therapy first. Its a really nice example. It is really important because you can have a person who is very courageous in a whole lot of areas of their life and develop panic disorder and that's the only spot where they don't have courage. One of the main goals in therapy is to assist people to develop a sense of courage to work on their panic attacks.
J. What should a client with an Anxiety Disorder look for in a psychiatrist or psychologist or therapist? How do they know they are going to get someone who is going to help them?
C. Three things are important here - rapport, experience and qualifications. As a client you must feel comfortable with the therapist and be willing to work in a collaborative way to achieve a good result. So if you are not comfortable or disagree with the approach being taken you need to find a new therapist. People should ask the therapist about their qualifications. Psychiatrists training is fairly uniform so the question of qualifications is not so important. On the other hand, psychologists have varying levels of qualification. People with Anxiety Disorders most often require assistance from a Clinical Psychologist who will have a Masters degree in Psychology and will most likely be a member of the APS College of Clinical Psychologists.
J. Are all Psychologists at this level trained in Cognitive Behaviour Therapy?
C. Yes, these Clinical Psychologists will have a good knowledge of cognitive/Behavioral therapies and the therapies that flow from them. The third and perhaps most important criteria is the therapists experience. It is quite appropriate for people to ask their therapist how much experience they have had in treating Anxiety Disorders and how progress is measured.
J. Also another problem .. many clients feel they don't have the right to direct their own therapy.
C. Thats right. Essentially, the first criteria of good therapy is that the person feels comfortable with the therapist. For some reason, because individuals are all different and it might not be the fault of either, a person just might not feel comfortable. So under those circumstances they are better to find someone who they do feel comfortable with. At the end of the assessment period a person needs to make sure a that a clear model of how the treatment is supposed to work is described to them. Sometimes even given to them in diagrammatic or written form, so that they see what the therapist is trying to achieve. The next step is that clear goals have to be set. Take for example the goal 'I want to be relaxed'. Thats not actually a goal. A more appropriate goal might be that 'I want to learn to challenge my thoughts when I experience certain physical sensations.' You the know the consequences of the goal might be that the person does relax but its not always the case. One of the big errors in thinking that people make is that they arent well unless they are relaxed all of the time. The next thing that you have to watch is that some things happen in therapy, but the most important things happen between therapy. So theres generally some kind of homework assignment that is set up between therapeutic sessions. There also needs to be a way of actually monitoring changes so that you know things are working .. that you review your progress with your therapist every 2 or 3 weeks. In other words, you problem solve at regular intervals. A good therapist will make sure this happens.
J. So you keep a diary ...
C. It may be a diary. It might be a workbook which people fill in specific exercises or it might be a rating of the persons subjective level of anxiety week by week. There is a whole range of different ways in which the therapist comes to an agreement with a client in how they are going to measure change in therapy.
NEXT MONTH: CONTINUATION OF GUIDES TO THERAPY AND DISCUSSION OF PSYCHOLOGIST TREATMENTS - SHOULD IT BE PAID IN PART BY MEDICARE?
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J. As far as the client is concerned, after say 4 or 5 sessions and they feel they are not getting anywhere ....
C. I think at the minimum they should talk to their therapists and try to establish why this is the case. It could well be that there is very good reason for it. What I haven't covered is that sometimes people feel that they need not only be comfortable with the therapist but they also feel that they need to be comfortable with the therapy. They should take comfort in an understanding of the therapy but quite often good CBT is pretty boring therapy. And it is often not all that pleasant. In some recent research, people described CBT as "bitter medicine ......" and I think that is a very apt description of it. Most people at the other end of therapy describe it as "bitter but useful". Other people take to it with relative comfort. If you are a person with very high anxiety sensitivity then you are going to be very suspicious of anything which causes any change or any increase in your level of physiological arousal. Even working on your problem at a thinking level can cause some distress. So it is sometimes unpleasant but if you understand it, it is usually tolerable.
J. What about the clients that are trying to "please" the therapist .. the story about the guy that kept going back to the therapist saying "I'm getting better, I'm getting better" but he was actually getting worse and he didn't want to let the therapist down ..
C. This happens all too frequently. I think the important thing is for clients to work collaboratively with their therapist. If they are saying they are getting better when they are not, there is only going to be one loser .. and that is the client because it means they are not going to get their needs met. Of course the therapist might feel bad as a result of not been able to help their client, but that's our problem. It's a worse thing for the therapist, if the client keeps it a secret, the therapist will never understand why they are not helping the client. Therefore the therapist fails to learn from this kind of therapeutic experience.
J. Some people feel guilty if they make the therapist feel bad .. it's a whole cycle .. being a nice person ..
C. It's an interesting dilemma. Trying to not make the therapist feel bad .. if it's a good therapist who cares about their work , they will be more interested in the client who shares their problems.
J. Many people complain that all the good therapists are psychologists but they can't afford to see them. Where do you stand on the issue of Psychologist treatment being paid in part by Medicare?
C. I think it is an excellent idea. I don't think there are any moves afoot for that to occur but it would certainly help. Psychologists are fairly expensive. However, if the psychologist has the skills they need it may not be expensive in the long run. If a person goes and sees a person who isn't helpful then they will find themselves paying for bad therapy for a long period of time. The individual needs to consider both the economic and social cost of delaying their treatment. A Senate Committee report released last year recognised that Psychologists were being under utilised in the care of patient's emotional disorders.In reference to Anxiety Disorders, much of the evidence came from psychiatrists, support groups, psychologists and who worked in those areas. The federal government did recognise that this was a problem but handed responsibility back to the States by suggesting that they should work out ways in which they could employ more Psychologists. This looked like an attempt to avoid the issue of losing control of costs by extending Medicare to another group of people. In some ways their concerns are justified in that psychologists have such a broad range of differing qualifications .. it would be quite hard for them to work out who they should pay and who they shouldn't. It is a difficult issue and I don't think we are any closer to resolving it at this present time. It's something that I would like to see resolved.
NEXT MONTH: SUPPORT FOR PEOPLE WHO EXPERIENCE AN ANXIETY DISORDER AND LIVE IN THE RURAL AREAS OF AUSTRALIA. WHAT IS BEING DONE?
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J. Many people live in rural areas of Australia where the support for Anxiety Disorders is at best minimal. What suggestions do you have for them as far as getting help?
C. There are some really interesting things beginning to happen in that many of these people in the future will be able to receive some assistance through the Telemedicine program which is being run by the State Mental Health service. There are some really interesting developments there. In particular, one of the psychiatrists that works in that program is Fiona Hawker .. she is a very experienced therapist with people who have Anxiety Disorders. Secondly, another very experienced psychologist in the area of Anxiety Disorders, Andrew Livingstone, has taken up a position with that service. So the rural and remote services are likely to be very well served with people experienced in Anxiety Disorders. That, of course, doesn't solve the whole problem. Now, another large chunk of the problem is currently being taken care of by the Panic Anxiety Disorder Association ... who visits the country quite regularly and perhaps are providing the biggest service to people with Anxiety Disorders in the country at present. Even with those things working in the favour of country people, the there is still the tyranny of distance .. where people may be housebound, they may not even be having contact with people who recognise and understand that they have disorders. For those people, I think organisations like PADA and the Anxiety Disorder Foundation need to be taking a health promotion view of things, where they can continue to increase community awareness about the incidence and possibility that help is available. Another thing which might help people in the future ... manualised treatment programs. That is, workbook type programs which are specifically designed for people with Anxiety Disorders. However, having said this, my own experience has been that these only work well when they are combined with the assistance of a therapist.
J. Even so, this is better than nothing ...
C. It is better than nothing. And if the motivation is there and it is a good workbook which they understand then they can go a long way. The important thing when using a workbook is to complete all suggested exercises rather than just reading the book.
J. What about a National Telephone Support Line for people in the rural areas ...?
C. In order for support to be useful it has to have some very specific objectives. Now if support means that a person is supported by the "Now, now you will be alright .." type support. That wouldn't be useful at all. Because just listening to a person's problem is all that is going to occur it may in fact be detrimental. There was once a psychologist that said that a person knows what they think when they hear themselves say it. So they not only need to be able to share their problems but they need to be able to have a method of constructively looking at the issues involved in the problem. They need to be able to have some understanding of how the problem operates. Now that could be disseminated through written information. For example, Bronwyn's book is one way that people have gained very good understanding about the nature of their problems and more importantly some solutions. Consequently a good telephone support service will usually make use of other resources like books, allow people to share problems and prompt them to find solutions.
J. Another issue for clients of Anxiety Disorders is the lack of training/ understanding of Anxiety Disorders by General Practitioner's. Can you tell us about the General Practitioner training you are currently supervising?
C. Let me start off with a more positive note. There is a growing awareness amongst General Practitioners of Anxiety Disorders .. and I am aware of 3 or 4 projects which have been set up at present to actually assist General Practitioners to
In respect to our program, it was intended to teach general practitioners about cognitive behavioral strategies that they might use to assist their clients to manage their Anxiety Disorders in a better way. One thing that consumers have complained about is a lack of diagnoses . So the first thing that general practitioners were taught in my project was how to diagnose Anxiety Disorders. General Practitioners overall treat a large number of medical conditions. So it is perhaps unfair to expect that every General Practitioner to be able to diagnose and treat Anxiety Disorders. So there will be some General Practitioners who develop a very clear focus and wish to treat the person's Anxiety Disorder wholly. General Practitioners are usually the first person to see people who develop Anxiety Disorders. By teaching them not only to diagnose but to provide an immediate cognitive behavioral approach they will have an important role in preventing more serious Anxiety Disorders from developing. I think their most powerful role is in the prevention of more serious Anxiety Disorders. If a project achieves nothing else but to be able to help General Practitioners communicate and prevent the deterioration of Anxiety states then I think it will have been very successful.
J. I agree .. many clients say "If only I had been told earlier .." Even the span of a couple of months makes all the difference.
C. Oh yes. It makes a huge difference. Some people almost seem chronic in a week. One of the things the General Practitioners have told me is that they want to be able to offer an immediate intervention for their clients. Almost without exception, General Practitioners have said by learning Cognitive Behavioral skills it has given them a another way of communicating with their patients.
J. CBT revisited ...
C. Let's just say a few more things ... let me give you a summary. Cognitive therapy packages use a fairly wide range of cognitive and Behavioral procedures to help their clients change. The first set of treatment strategies help their client to change misinterpretations of bodily sensations. The second lot of Cognitive treatment strategies are aimed at modifying processes that tend to maintain the misinterpretations. Now, a third sort of cognitive intervention is a review of a recent attack .. we are not so much interested in the history but in actually reviewing a person's understanding of an attack. Helping a person to look for explanations which might be involved in the misinterpretation and then helping them to consider a number of alternative explanations. Additionally, techniques are also used to help people to consider explanations for images. These were previously considered not to be all that important but now we know that many of our people have very vivid images and if we only treat the sensations and not the images then they are likely to remain symptomatic. A Behavioral strategy might be to induce a fear sensation and that's called an introceptive technique. You might have a person focus their attention on their heart rate and see if they can discover the reasons why their heart rate might increase as they focus their attention on it. So that is a summary of Cognitive Behaviour Therapy.
J. Thankyou very much Chris for your time.
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