Treating anxiety disorders: Dr. Barlow responds to psychologists’ questions

by Professional Development and Communication Staff

May 31, 2006 — Last month, the APA Practice Organization invited readers to submit questions and comments in response to a Clinical Conversation with David H. Barlow, PhD, about treating anxiety disorders. Below, Dr. Barlow answers selected readers’ questions on a range of topics related to these disorders, including treating individuals who demonstrate hypervigilance, using eye movement desensitization and reprocessing, working with shy children to prevent the development of anxiety disorders in adulthood, and the prevalence of anxiety and related disorders in stressful times.

Question for Dr. Barlow from Dr. A in Florida: “I have a patient who has developed such a severe case of PTSD and GAD that she has become delusional in her belief that there really is something bad about to happen and that she needs to be hypervigilant in order to prevent ‘it’ from hurting her and her family. Relaxation and reframing have not provided much relief. Any suggestions?”

Dr. Barlow responds: Dr. A’s case illustrates how severe some anxiety disorders can be. In fact, almost all individuals with anxiety disorders have a very strong emotional belief of impending threat, danger or catastrophe that motivates extreme vigilance and avoidance. However, in the settled calm of the therapist’s office, they can usually admit to the irrationality of these fears and anxieties even if they are unable to change their way of thinking in their day-to-day life. This “battle” between rational and irrational (emotional) defines an anxiety disorder.

In addition, there are some individuals suffering from these disorders, usually less than 10 percent, who are unable to appreciate the irrationality of these fears even when they are in a therapist’s office. These individuals will not accept reevaluation of threat as being relatively minimal, at least initially, no matter how much evidence the therapist can muster. This “over-valued ideation” is most common in obsessive-compulsive disorder and is also found in some somatoform disorders, such as body dysmorphic disorder.

In either case, a strong cognitive approach is indicated where evidence for these anxious beliefs is evaluated, first in the office and then in the real world. After reviewing collaboratively with the patient the fact that these events have not occurred in the past (they almost never have) and therefore the probability that they will occur in the future is very low, the therapist and patient may then plan some “behavioral experiments.” In these exercises they test out the patient’s hypotheses about danger by having the patient actually engage in some of these frightening behaviors—albeit low in the hierarchy of threat so that they can learn at an emotional level that their hypotheses are greatly exaggerated.

For patients with “over-valued ideation” we follow this same process, but we expect it to take longer, since the therapist must persevere.

While relaxation may serve a mental hygiene function by helping the patient become generally less tense, this procedure in and of itself is unlikely to alter these strong beliefs in the absence of cognitive therapy and exposure.

Question for Dr. Barlow from Dr. S in Arizona: “What is your assessment of eye movement desensitization and reprocessing (EMDR) in the treatment of anxiety disorders? I see EMDR as utilizing desensitization, relaxation, and hypnosis. This approach allows the patient to process images and memories of trauma while remaining relaxed, which leads to a totally different association between the stimulus (traumatic memories) and response (the relaxation response).”

Dr. Barlow responds: While there is still some controversy in the utility of EMDR, most experts in the area agree with Dr. S that EMDR is just another way of helping patients to process images and memories of trauma (in the case of PTSD), which allows the patient to create new meanings for stimuli that have become associated with the traumatic experiences. As such, it is sound psychological treatment.

Research to date, however, has not demonstrated conclusively that the eye movement component of this procedure contributes anything to the outcomes of treatment over and above the remaining procedures. This particular issue is the subject of continuing research.

Question for Dr. Barlow from Dr. C in Canada: “I wonder if you could tell us something about the importance of subclinical levels of anxiety in temperamentally shy and timid children who find it hard, for instance, to use the phone or take a message into the school office. Is there any evidence that such personality characteristics increase the probability of anxiety disorders in adulthood? If there is such evidence what would be the best way of dealing with the child’s problems?”

Dr. Barlow responds: Possessing a shy or similarly inhibited temperament in childhood is, in fact, a substantial risk factor for the later development of an anxiety disorder. While numerous temperament types and constructs have been implicated in the etiology of anxiety, the bulk of longitudinal research on this topic has focused on the link between a temperament categorization known as behavioral inhibition and later social phobia development. For instance, research by Jerome Kagan, PhD, and colleagues suggests that approximately 40% of children meeting full criteria for behavioral inhibition in infancy will go on to exhibit an anxiety disorder—typically, social phobia—in childhood or later in life.

While evidence about the treatment of children with such temperaments, but not clinical anxiety disorders, is scant, several recent efforts at school-based prevention of anxiety disorders provide information about the efficacy of intervention strategies for such children. One such study by Lowry-Webster, Barrett, and Dadds (2001) found that a universal, school-based prevention program for children “at-risk for anxiety,” in which cognitive-behavioral treatment (CBT) strategies such as psychoeducation, cognitive restructuring, and basic exposure techniques were delivered in a classroom setting, significantly reduced participants’ internalizing symptoms. Therefore, we may glean that many of the same strategies utilized in the typical CBT of children with clinical anxiety disorders may also be effective for children with subclinical symptoms.

At our Center for Anxiety and Related Disorders at Boston University, children with some notable anxiety symptoms that fail to meet criteria for a clinical anxiety disorder are typically offered an abbreviated version of CBT, lasting anywhere from three to eight sessions, to help strengthen the coping skills of these children with the hope of staving off the development of more significant anxiety disorders.

Question for Dr. Barlow from Dr. A in Massachusetts: “Given the current state of the world, with war, terrorism, economic challenges, and so on, do you foresee escalations in anxiety and related disorders in Americans? And if so, how can we as professionals best prepare?”

Dr. Barlow responds: Most of us share Dr. A’s concerns, and there is evidence of increasing rates of various psychological disorders such as depression and some anxiety disorders.

There is also professional consensus that we live in stressful times and that the levels of stress and challenges we confront have, by and large, been increasing in recent decades. We also know that life stress is a major precipitant for mental and emotional disorders in those who possess the biological and psychological vulnerabilities for these disorders.

Furthermore, factors known to be protective against excessive stress in the development of mental and emotional disorders in society have been deteriorating and disintegrating at a rapid rate. These include a strong sense of community, social networks and support, and a sense of shared values and purpose.

As mental health professionals, we can encourage lifestyles that emphasize these values and promote positive social supports, relationships, and a more measured way of life. To make a substantial impact, of course, we would need to develop a consensus among society at large on the urgent need to attend to our emotional well-being, as well as our physical health, in the public policy arena.

David H. Barlow, PhD, is professor of psychology, research professor of psychiatry, and director of the Center for Anxiety and Related Disorders at Boston University. He 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. For more on Dr. Barlow, see his Boston University faculty pageopens in new window.