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Wise Counsel Interview Transcript: An Interview with David Barlow, Ph.D. on the Nature and Treatment of Anxiety and Panic Disorders

David Van Nuys, Ph.D.

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Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I am a clinical psychologist and your host. On today's show we will be talking about emotional disorders, particularly anxiety and panic reactions with Dr. David Barlow.

David H. Barlow received his PhD 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 at the Medical Center at Brown University, and he founded the Clinical Psychology Internships in both settings. He was also Distinguished Professor in the Department of Psychology at the University of Albany State University of New York.

Dr. Barlow is the recipient of several awards which include the 2006 Distinguished Service Award in the Profession of Psychology from the American Board of Professional Psychology, the 2000 American Psychological Association 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 appointment as Honorary Visiting Professor of Clinical Psychology.

He is currently a Diplomate in Clinical Psychology of the American Board of Professional Psychology and maintains a private practice.

Here's the interview.

Dr. David Van Nuys: Dr. David Barlow, welcome to Wise Counsel.

Dr. David Barlow: Well, thank you very much, David.

Dr. David Van Nuys: It's great to have you here. Now, in addition to being a Professor of Psychology and Psychiatry at Boston University, I see that you're a Founder and Director Emeritus of the Center for Anxiety and Related Disorders at Boston University. And, I also see that a big part of your career has been devoted to research of the treatment of anxiety.

Perhaps, a place for us to start is, maybe, with the definition of anxiety, and then also what drew you into this particular area.

Dr. David Barlow: Sure. Well, by now given my advanced age and the fact that I am emeritus from directing my center although not retired yet from teaching, it's a long story so I'll...

Dr. David Van Nuys: We've got lots of time.

Dr. David Barlow: So, what brought me into it? I'll give you the short version.

Dr. David Van Nuys: OK.

Dr. David Barlow: But, when I was getting... we'll talk about definitions of anxiety... But, when I was in graduate school in the 1960s, at the time this was at the University of Vermont there was a new development begun by a South African psychiatrist named Joseph Wolpe that had to do with the possibility of treating phobias in a different way. And, of course, we all know now that was through a technique called systematic desensitization where basically he had his patients imagine confronting the feared object or situation in a very gradual way that he could individualize to each patient while they were in a very relaxed state.

He had reported really just in a series of cases in the late '50s some success with this. So, it had begun to attract some attention. I had the good fortune in 1966 of actually down at the time he was at Temple University in Philadelphia, and I had the good fortune to go down and spend three months working with him one summer while I was still in graduate school.

In those years the kind of research in psychotherapy was still in its infancy, any psychotherapy, and it was thought to be very difficult to work with real patients. Many of us in graduate school at the time worked with analogues of fears and phobias. The most popular analogue in those days was fear of snakes among college sophomores, particularly college sophomore women.

There was just a large number of dissertations in the '60s, people like Jerry Davidson and myself, where we did our dissertations on college sophomore women who were afraid of snakes. We looked at things like the effectiveness of systematic desensitization and various components of it, what made it effective, do you really need to relax, what happens if you are actually in a room with a snake, you know, versus just imagining it - a variety of parameters like that.

So, it was sort of a convenient way to actually get into research, and it had the added benefit by 1970 that there probably wasn't a college sophomore afraid of snakes in the whole country. We all got through, but it did peak my interest in the possibility of actually coming up with new and better treatments. The ironic thing is that we learned in the next decade that systematic desensitization really was not a very effective technique when you started working with real patients.

Dr. David Van Nuys: Oh good. I'm going to want to hear something about that. I know it's been remarked elsewhere a lot of psychology is mostly the psychology of the college sophomore. [laughter]

Dr. David Barlow: That was certainly true back in the '60s and '70s.

Dr. David Van Nuys: Yeah. Yeah. I know back when I was in school the definition of anxiety in a sort of colloquial way had something to do with the fear, but you didn't quite know what you were afraid of. Has that definition changed since then?

Dr. David Barlow: Yes. You're quite right. Back when you and I were in school, anxiety was really sort of unfocused fear or pervasive fear. That was kind of the colloquial definition. It has changed quite a bit now. We now know, for example, that fear and anxiety actually seem to be different emotions.

Dr. David Van Nuys: Interesting.

Dr. David Barlow: They are different emotions. They actually feel different. They activate different brain circuits, somewhat different brain circuits, different neurotransmitter systems to some extent and they had different action tendencies or behavioral action sense associated with them. So, they are somewhat different emotions although they are closely related.

For example, fear is most closely associated with the well-known flight or fight reaction. That's the action tendency.

Dr. David Van Nuys: Right.

Dr. David Barlow: And fear has to do with eminent danger, something very dangerous happening to you right at that moment. You know, you cross the street and you don't see a car coming quickly at you from the other side and suddenly you see it.

Dr. David Van Nuys: OK.

Dr. David Barlow: A neuroscientist named Joe LeDoux, established a decade ago that there are direct connections from the retina to the emotional brain, the limbic system. Specifically, to the amygdala. When that car comes, you don't have to think about it. You don't have to go through an elaborate thought process here. Just says, oh, here comes a car. Gee if it keeps on going on its course it's going to hit me. I'd better move. Obviously your reaction is instantaneous. The fight/flight reaction energizes the body to react with some kinds of superhuman efforts and...

Dr. David Van Nuys: Would you say anxiety follows a different kind of pathway?

Dr. David Barlow: Anxiety involves a different kind of path. Anxiety is a future emotion. It is not about what is happening right now. It's about what may be about to happen that could be threatening or dangerous in the minute, the next hour, the next day, etc.

And the action tendency is a readiness, a vigilance. The notion is something threatening, bad, dangerous may be about to happen and I'd better be ready to deal with it. It's not happening right now, but I'd better be ready to deal with it and there's a... Jennifer Gray used to call it in animals a "stop, look and listen response." And that is basically, you stop, you identify the source or the threat. This is, of course, in animals. You kind of evaluate it, your attention narrows onto it. And you are ready to engage in some behavior, but you are not running away or fleeing. So, it's a future orientated emotion.

You know, there's a lot of cognitive correlates to anxiety, which have to do with obviously focusing on the threat maybe being hyper vigilant for the threat, and processing the kinds of ways that you might cope with the threat. And that process is called worry.

Dr. David Van Nuys: Yes, right. Something known to us all.

Dr. David Barlow: Yep, very much so.

Dr. David Van Nuys: Now, you've been studying anxiety and then involved in research and treatment for 20 or more years. I wonder if there have been any surprises for you along the way.

Dr. David Barlow: Oh, very much. Gee, when I started back in the mid-'60s, we didn't know that fear and anxiety were different emotions. We also didn't know about the phenomenon of panic attacks, even though Freud had written about, and other clinicians had written about anxiety attacks and in their writings you could see it was something seemingly qualitatively different.

Nevertheless, the establishment, you know, it wasn't really recognized as an important phenomenon. Then in the '70s and early '80s, we discovered panic and there was a lot of theorizing about, well what is panic? What are panic attacks?

Dr. David Van Nuys: Are they seen in fact on a continuum of the anxiety disorder continuum or are they considered to be qualitatively different?

Dr. David Barlow: They are considered to be qualitatively different than anxiety although obviously in nature, these are closely related responses. So if you are anxious if you are ready for an imminent danger or threat, or attack, as our ancestors were than that panic attack more quickly. In other words it lowers the threshold for that fight or flight response to fire. They are very closely related.

But what we discovered is there are some people who have this enormous sympathetic surge that goes all through their brain and their body that we call the flight/fight response for no good reason, that is there is nothing to be afraid of. At least objectively. Nothing to be afraid of, and the anxiety turns inward to the panic attack itself.

Dr. David Van Nuys: Do we think that is some kind of an inborn vulnerability. Where is that surge coming from?

Dr. David Barlow Well, it does turn out that there is a partial disposition to experience panic attacks. That is what we called unqueued or fear under stress. It does just seem to be another one of several bodily stress responses that runs in families. In other words inheritable. For example, if you tend to react to stress with tension headaches chances are so did your parents and so will your children. If it is Irritable Bowel Syndrome, same thing highly familiar. Panic attacks seems to be in that same class of responses.

So it seems like we have this disposition to experience panic attacks which is under stressful conditions which is partly inheritable. But there are many people who experience these attacks without significant concern or anxiety about them. They just attribute it to something they ate, or working to hard, or had a disagreement or argument with a family member. In other words they attribute it to an occasion an external occasion that theoretically they could control so they said, "well I won't eat so much of that Chinese food, " or "I need to take it easy at work. I am getting too uptight."

Dr. David Van Nuys: That sounds almost kind of paradoxical. A panic attack without the panic.

Dr. David Barlow: Right. It's what we call non-clinical panic. Non-clinical panic. There were a number of people who had those Epitologist pinpointed that approximately 10% of the population.

Dr. David Van Nuys: Interesting.

Dr. David Barlow: Will have these non-clinical panics, but people get on with their lives. But for a minority 1-3% of the population one of those panic attacks can be devastating and it results in severe anxiety about having another attack and a variety of anxiety and pathological emotional reactions to it. These are the people who develop panic disorder or social anxiety disorder or any one of the disorders.

What is at the heart of the difference of these people who react badly and the people with the non-clinical panic attacks is that the people who react badly are also susceptible to developing severe anxiety. Pathological anxiety that gets focused on possibly having another panic attack.

Dr. David Van Nuys: OK, now on your website I noticed that you gave a talk that sounds like it could be related to where you are going now. It was called The Psychopathology Of Fear Anxiety And Panic Triple Vulnerability Theory And The Origins of Anxiety Disorders.

Dr. David Barlow: Right.

Dr. David Van Nuys: I wonder if you could kind of give us a sense of what is meant by "Triple Vulnerability Theory" and how that plays into the origins of anxiety disorders.

Dr. David Barlow: Sure, and again, a lot of this has built up from basic research and clinical research over the last several decades. But the short version is that again there seem to be these two related emotions, fear and anxiety. And when it comes -- and that the real culprit in developing anxiety disorders is caused by the anxiety, it's not necessarily the fear. And the anxiety seems to have three sort of different origins. That's where the triple vulnerabilities come from.

Dr. David Van Nuys: OK.

Dr. David Barlow: And these origins each creates its own kind of diathesis or vulnerability. So one of them is genetic, so many of us are born with an anxious temperament. And we know we can breed an anxious temperament in animals, and dogs, and chimps and the like.

Dr. David Van Nuys: Yes.

Dr. David Barlow: So that has a strong heritable component on the order of 50 percent.

Dr. David Van Nuys: Yeah, I think I'll raise my hand to that one actually.

Dr. David Barlow: [laughs] Many of us do. But that alone is not sufficient to lead someone to a disorder.

Dr. David Van Nuys: OK.

Dr. David Barlow: So there need to be some other things that line up. And we call that a generalized biological vulnerability.

The second of the three vulnerabilities we call a generalized psychological vulnerability. And this is the long tradition of psychological research going back decades that specifies early learning experiences. And the attachment theorists have done important work in this area; the early animal learning people, the developmental psychologists.

And what they have basically found out that is one of the important things we learn at a very early age is a sense of control over the world in which we live. If we are able to develop a sense that well, the world presents some challenges, but we have the resources and the coping power to deal with it. Then that's a very, very healthy development. This sense of control or self-efficacy as Bender calls it.

The attachment theorists have noted for example, that this develops in families where there is a strong attachment, but never the less the child is left to leave the safe place, venture out on his own, maybe fall down, pick himself up, but can always come back to the safe place.

What we find in our anxious families, families that have anxious children, is that you often get well meaning but very smothering kinds of parents who are protective to the point that they don't let their children venture out, experience the world, learn they can master situations because their parents are always mastering it for them.

And so all of this, that's just a smattering of research from a number of different areas. All of which comes together to say that if one does not develop this sense of mastery and control of one's environment, then that creates a psychological vulnerability to develop fairly severe anxiety growing up. That's one explanation, for example, some people have cited as to why severe anxiety is more prevalent in women than men. Because even with the changing times, women, perhaps, aren't allowed the opportunity to go out and establish their own identity and their resilience and their strengths, to the extent that young boys are.

Dr. David Van Nuys: OK. Well, if I'm tracking you correctly, I think we have two of the three legs here.

Dr. David Barlow: Yeah.

Dr. David Van Nuys: We have genetic vulnerability and a failure to achieve a sense of mastery vulnerability.

Dr. David Barlow: Which is the psychological vulnerability. The third one is a specific psychological vulnerability; and that simply says that in some disorders, we're actually taught what to be afraid of. So, for example, many people with specific phobias--let's say a specific phobia of dogs. They may never have had a bad experience with a dog, but their parents had modeled fear about dogs.

Many people with severe social anxiety, we know, from some research, come from families where the atmosphere was, "Whatever you do, don't embarrass yourself or your family in front of others." My grandmother, growing up, used to say, "The last thing we want you to do, Dave, is go out of the house with dirty underwear..."

Dr. David Van Nuys: [laughs] Right.

Dr. David Barlow: "Because if you're hit by a car and taken to the hospital, and they discover your dirty underwear, " the implication was the family would be embarrassed. So there's that kind of specific learning, which sometimes directs people in terms of where to focus their anxiety.

So, if all of this lines up--so, if you have the genetics (that's the biological vulnerability), you have the generalized psychological vulnerability based on early learning that the world's a dangerous and threatening place and you don't think you're going to be able to cope with it, and you also have some specific models of what it is to be afraid of--then you can develop some certain anxiety disorders.

Dr. David Van Nuys: OK. Well, let's talk about treatment some, then.

Dr. David Barlow: OK.

Dr. David Van Nuys: I know you said that, initially, you started it off with a systematic desensitization based on Wolpe's work. But things have moved along since then.

Dr. David Barlow: Yeah, very much so. Part of the consequence of beginning to do research on psychotherapeutic procedures is that, perhaps, the most important development of this research process is that we learn that some things don't work and that we have to go in another direction.

Dr. David Van Nuys: Yeah, that's important to know.

Dr. David Barlow: Yeah. And early on, we learned that systematic desensitization really didn't work, when we got into the clinical arena.

Dr. David Van Nuys: I don't even know if that word's gotten fully out yet. [laughs]

Dr. David Barlow: It may not have. You still hear of some people thinking that it's a viable treatment. But when you get beyond the college sophomores, or get beyond the just very, very circumscribed phobias to the more complex social anxiety and agoraphobia and things like that, then you just don't see systematic desensitization really having any effect.

So, when we learned that, the years were going by, and then we discovered, well, there's this phenomenon of panic. And we also discovered that exposure techniques could be effective with the more severe phobias, but even the exposure techniques were not all that effective. A lot of people were left with a lot of residual anxiety and fear. Again to make a long story short we learned that rather than focus on the external kinds of events that they are frightened of, the crowded location, the shopping mall, in the case of agoraphobia etc. we should began to look back at what they are experiencing emotionally.

We discovered really mostly in the last decade that one of the major difficulties with people with all emotional disorders is that they become very avoidant of their own emotional life. And that panic attacks can be very frightening experiences. That any intense emotion can sometimes evoke that out of control type feeling. Which is at the heart of anxiety.

So, now we are at the point where we have almost come full circle, we still use our exposure techniques, but the actual context of the exposure is often dealing with individual internal emotional life. Teaching them how to better process and experience their own emotions.

Dr. David Van Nuys: And cognitive life as well? The thoughts that they think and the things they tell themselves?

Dr. David Barlow: That's right, and the way they are praising their own emotions in context, you know, these emotions arise, and how better to regulate them. As you can see the therapy has really come to a point where you can see hints of the old humanistic techniques. Some of the old Psychodian techniques.

Dr. David Van Nuys: Yes, it does seem like there has been a coming together in recent years of; you know, psychology, psychotherapy use to be very divided by schools of thoughts and approaches and it seems like there has been a kind of confluence is what I am sensing as a result of all of the interviews that I have been doing.

Dr. David Barlow: Yeah, I think that is definitely the case. I think we are seeing the last messages of the old schools of psychotherapy kind of approach that you and I grew up with. Where we learn the Chinese menu of psychotherapy, "Well there's a psycho interlude with this." "Well there is a humanistic view." "Well there is a biological view and there is a behavioral view." You had to sort of learn each one separately. If you want to do any integration on your own well you free to do it, but that's not how you were taught for the most part.

Now I think those days have past. We are coming to the point where we have learned so much about the psycho-theology that we treat and we have learned so much about the kinds of ways in which our treatments work, that we find that all of the old schools had some wisdom to offer. But, now the emphasis is really on demonstrating more imperically what is it about all of our techniques that seem to be effective. How can we best combine it so the patient benefits maximum.

Dr. David Van Nuys: In fact I see that you gave a presentation on "a unified protocol for emotional disorders."

Dr. David Barlow: Yeah, that is our latest effort.

Dr. David Van Nuys: [laughter] So, what is this "unified protocol?" I mean that sounds very ambitious.

Dr. David Barlow: Yeah, it's the way we are putting a lot of our efforts at this point in time. Basically is what we recognized several years ago was that, as I was alluding to earlier, that there are common processes across all of the anxiety and indeed, across all of the emotional disorders. There are common processes of emotional regulation and disregulation, common behavioral processes of avoidance, common cognitive processes, distorted cognitive processes and that maybe rather than coming up with all these different approaches that are tailored to individual disorders, maybe we could distill the main principles that are common to all treatments of these disorders and come up with a more simplified, more direct, transdiagnostic treatment.

Dr. David Van Nuys: Is that paper published anywhere? I would love to see what you came up with as the elements of this unified protocol.

Dr. David Barlow: Yes, we published some preliminary versions. The grant from NIMH we currently have is really to further develop and define the protocol. We are pretty much just finishing that up now but we published our thinking on this in a couple of places. Again, it's certainly on my website.

Dr. David Van Nuys: OK.

Dr. David Barlow: You can take a choice of several articles or chapters that all have similar title, Unified Approach to Emotional Disorders. What we are trying to do actually is to push it beyond anxiety mood disorders to the entire overall neurotic spectrum of disorders. So I think we are more ambitious. We are not there yet.

Interviewer: You have a very rich website because you have done so much work and published so much and I will be putting a link to your website in my show notes and I will announce the URL after our interview here.

Dr. David Barlow: Well, thank you.

Dr. David Van Nuys: Another thing that I found on your website was a presentation that you gave to the American Psychological Association which was titled, "Clinical Psychology in Ascendancy" and since I am also a clinical psychologist, I found myself curious about in what way we are ascending.

Dr. David Barlow: Right. [laughter] I was trying to be provocative there, get some people to come to the talk. Yeah that was last year to the American Board of Professional Psychology meeting at APA. They were kind enough to give me an award. So that was my brief address. And basically in this time when my major point there was that in this time, when there is a lot of pessimism about our field and declining rates of reimbursement, the unfairness and destructiveness of managed care and those sorts of things.

Dr. David Van Nuys: Yes.

Dr. David Barlow: that there was also a lot to be optimistic about in the future.

Dr. David Van Nuys: Oh goody. [laughter] Let's hear what.

Dr. David Barlow: And so again, the just of it was, three or four points. One of them is we are still attracting the best and the brightest. Here at Boston University, this year, for example, we are at 650 applications for our 10-12 slots and we get absolutely I think the brightest people in the world applying.

Dr. David Van Nuys: This is for your doctoral program that you are talking about.

Dr. David Barlow: Doctoral program in clinical psychology. We are getting superb people. I am also on the board of trustees on our neighboring Massachusetts school in professional psychology where we get 300 applications. I think all the schools are still attracting very bright people. One of the other issues is, there's a much greater emphasis I see beginning to emerge, not just the light at the end of the tunnel. There is actual evidence happening now where there is a greater emphasis on quality, on competence, and quality.

So for example, many state departments of mental health, having noted that many of our psychological procedures have empirical support that they are proven effective, and that they're at least as effective if not more effective than drugs in many cases, are now pouring money into efforts to recruit more psychologists and train the ones that currently are in the systems to provide these services. I think there's a greater demand coming along for competent psychologists. These are mostly doctoral level psychologists that they are looking for.

The "A" system for example, has started an initiative where they're pouring hundreds of millions of dollars into recruiting psychologists and training existing psychologists with certain well developed competencies.

The whole National Health Service in the United Kingdom has just announced an effort funded by the government over there to the tune of over a billion dollars based on the current exchange rate. 600 million dollars in the first three years alone to recruit thousands of additional psychologists with competence in treating people with depression and anxiety.

The notion being that too many people are getting drugs that are only partially effective. Not enough are getting psychological treatments. And you know, increasing competence in neuropsychology, other areas of our field, I think is beginning to really have a telling effect. And I think this is a very positive harbinger of things to come.

Dr. David Van Nuys: OK. Now, I note that you mention the UK. I've noticed that you've had some involvement with China, that you've been going over there. I think you've received some recognition.

What's going on in China in relation to mental health? I mean a lot of what we hear about China sounds so repressive, and all. So what's your take on the mental health situation there?

Dr. David Barlow: Well, China's just a fascinating laboratory now for the development of psychology. Since of course with the Great Leap Forward psychology was basically wiped out until the late 80s and 90s when things began to change. So we've had close working relationships with our Chinese colleagues.

We have two visitors here this year from Beijing. And I'll be going back there and visiting myself once again, next October -- or this coming October. And there's a great deal of energy there. Very exciting energy to try to make up for lost ground in the 60s and 70s and to try to bring their field back to the point where they can begin to provide some rudimentary behavioral health services. That's true for psychiatry too.

So there's a great hunger to learn as much as they can there. They're just voraciously translating all of our books and taking every opportunity to develop some of the competencies we've been talking about. And the government is supporting them, interestingly.

Dr. David Van Nuys: Oh, that's great.

Dr. David Barlow: Study abroad, and to bring experts into China. So next October there's an International Psychotherapy Conference in Beijing that has been in the works for two years, and that's going to be a very, very exciting conference. So there's a lot of very, very interesting things happening there.

Dr. David Van Nuys: Boy, it does sound that way. Well, as we begin to wind things down here, I wonder if you have any advice to listeners who might be suffering from anxiety and/or if there's a book that you would recommend for the general public.

Dr. David Barlow: Well, certainly the advice I would have is that while anxiety can be devastating and is very widespread in its extremes that there are good treatments now. There are good drug treatments; actually, for those who would prefer that option. There are good psychological treatments, and in skilled hands sometimes these treatments can be combined although sometimes they do more harm than good by combining them. It does take a skilled practitioner.

We have a series called Treatments That Work that is published by Oxford University Press, and there is a link on my website. Many of the books that can be used in a self-help kind of format can be found on that website. What we've learned though is that for people who, let's say, suffer from more severe forms of anxiety, depression or other emotional disorders that these programs are most effective when administered under the guidance of a mental health professional.

Dr. David Van Nuys: Certainly. Well, Dr. David Barlow, thanks so much for being my guest today on Wise Counsel.

Dr. David Barlow: My pleasure, David.

[music]

Dr. David Van Nuys: I hope you found this interview with Dr. David Barlow as stimulating as I did. I can't tell you how honored I feel to have had the privilege of interviewing a psychologist of his stature.

I recommend that you visit his website and experience for yourself the staggering list of publications, awards and honors. You'll find it's an invaluable gateway to additional information on the origin and treatment of emotional disorders.

You will also find links to Dr. Barlow's important contributions to the growing movement toward evidence-based treatment, and you'll find that website at www.bu.edu/anxiety/dhb/, and that's dhb as in David H. Barlow.

You have been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. David Van Nuys and you've been listening to Wise Counsel.