What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (11 page)

I urge you to weigh your everyday anxiety. If it is not intense, or if it is moderate and not irrational or paralyzing, live with it. Listen to its dictates and change your outer life, rather than your emotional life. If it is intense, or if it is moderate but irrational or paralyzing, act now to reduce it. In spite of its deep evolutionary roots, intense everyday anxiety is often changeable. Meditation and progressive relaxation practiced regularly can change it permanently.

But anxiety, when intense and unremitting, can be a sign of a
disorder
that requires exorcising rather than just acknowledgment. The next three chapters are about the three anxiety disorders we know the most about—panic, phobia, and obsession—and what is changeable and not changeable about them.

*
Throughout this book, I will give my overall evaluation of both psychotherapy and drugs for each problem in
The Right Treatment
summary tables. I will use an upward and downward pointer system, where
means the best and
means the worst.

5

Catastrophic Thinking:
Panic

S. J. R
ACHMAN
, one of the world’s leading clinical researchers and one of the founders of behavior therapy, was on the phone. He was proposing that I be the “discussant” at a conference about panic disorder sponsored by the National Institute of Mental Health (NIMH). This meeting would pit the established biological psychiatrists against the Young Turk cognitive therapists.

“Why even bother, Jack?” I responded. “Everyone knows that panic is a biological illness and that the only thing that works is drugs.”

“Don’t refuse so quickly, Marty. There is a breakthrough you haven’t yet heard about.”

Breakthrough
was a word I had never heard Jack use before. Very British, he had recently immigrated to Canada from England, where he had run Europe’s premier anxiety clinic at the University of London’s Maudsley Hospital. Understatement and modesty are Jack’s strong suits.

“What’s the breakthrough?” I asked.

“If you come, you can find out.”

So I went.

I
HAD KNOWN
about and seen panic patients for many years, and had read the literature with mounting excitement during the 1980s. I knew that panic disorder is a frightening condition that consists of recurrent attacks, each much worse than anything experienced before. Without prior warning, you feel as if you are going to die. Here is a typical case history:

The first time Celia had a panic attack, she
¹
was working at McDonald’s. It was two days before her twentieth birthday. As she was handing a customer a Big Mac, she had the worst experience of her life. The earth seemed to open up beneath her. Her heart began to pound, she felt she was smothering, she broke into a flop sweat, and she was sure she was going to have a heart attack and die. After about twenty minutes of terror, the panic subsided. Trembling, she got in her car, raced home, and barely left the house for the next three months
.

Since that time, Celia has had about three attacks a month. She does not know when they are coming. During an attack she feels dread, searing chest pain, smothering and choking, dizziness, and shakiness. She sometimes thinks this is all not real and she is going crazy. She always thinks she is going to die
.

Panic attacks are not subtle, and you need no quiz to find out if you or someone you love has them. As many as 5 percent of American adults probably do. The defining feature of the disorder is simple: recurrent, awful attacks of panic that come out of the blue, last for a few minutes, and then subside. The attacks consist of chest pains, sweating, nausea, dizziness, choking, smothering, or trembling. They are accompanied by feelings of overwhelming dread and thoughts that you are going to die, that you are having a heart attack, that you are losing control, or that you are going crazy.

The Biology of Panic

There are four questions that bear on whether a mental problem is primarily “biological” as opposed to “psychological”:
²

• Can it be induced biologically?
  

• Is it genetically heritable?
  

• Are specific brain functions involved?
  

• Does a drug relieve it?
  

Inducing panic
. Panic attacks can be created by a biological agent. For example, patients who have a history of panic attacks are hooked up to an intravenous line. Sodium lactate, a chemical that normally produces rapid, shallow breathing and heart palpitations, is slowly infused into their bloodstream. Within a few minutes, about 60 to 90 percent of these patients have a panic attack. Normal controls, subjects with no history of panic, rarely have attacks when infused with lactate.
³

Genetics of panic
. There may be some heritability of panic. If one of two identical twins has panic attacks, 31 percent of the co-twins also have them. But if one of two fraternal twins has panic attacks, none of the co-twins are so afflicted. More than half of panic-disorder patients, moreover, have close relatives who have some anxiety disorder or alcoholism.
⁴

Panic and the brain
. The brains of people with panic disorders look somewhat unusual upon close scrutiny. Their neurochemistry shows abnormalities in the system that turns on and then dampens fear. In addition, PET scan (positron-emission tomography), a technique that looks at how much blood and oxygen different parts of the brain use, shows that patients who panic from the infusion of lactate have higher blood flow and oxygen use in relevant parts of their brain than patients who don’t panic.
⁵

Drugs
. There are two kinds of drugs that relieve panic: tricyclic antidepressant drugs and the anti-anxiety drug Xanax, and both work better than placebos. Panic attacks are dampened, and sometimes even eliminated. General anxiety and depression also decrease.
⁶

Since these four questions had already been answered “yes,” when Jack Rachman called, I thought the issue had already been settled. Panic disorder was simply a biological illness, a disease of the body that could be relieved only by drugs.

A few months later, I was in Bethesda, Maryland,
⁷
listening once again to the same four lines of biological evidence. An inconspicuous figure in a brown suit sat hunched over the table. At the first break, Jack introduced me to him—David Clark, a young psychologist from Oxford. A few moments later, Clark began his address.

“Consider, if you will, an alternative theory, a cognitive theory.” He reminded us that almost all panickers believe that they are going to die during an attack. Most commonly, they believe that they are having a heart attack. Perhaps, Clark suggested, this is more than just a symptom. Perhaps it is the root cause. Panic may simply be the
catastrophic misinterpretation of bodily sensations
.

For example, when you panic, your heart starts to race. You notice this, and you see it as a possible heart attack. This makes you very anxious, which means your heart pounds more. You now notice that your heart is really pounding. You are now sure it’s a heart attack. This terrifies you, and you break into a sweat, feel nauseated, short of breath—all symptoms of terror, but for you, they’re confirmation of a heart attack. A full-blown panic attack is under way, and at the root of it is your misinterpretation of the symptoms of anxiety as symptoms of impending death.
⁸

This psychological theory handles the biological findings well.

• Sodium lactate induces panic because it makes your heart race. It creates the initial bodily sensations that you then misinterpret as catastrophe.
  

• Panic is partially heritable because having a particularly noticeable bodily sensation, such as heart palpitations, is heritable, not because panic itself is directly heritable.
  

• Brain areas that prevent the dampening of anxiety are active because this activity is a mere symptom of panic.
  

• Drugs relieve panic because they quiet the bodily sensations that get interpreted as a heart attack.
  

I was listening closely now as Clark argued that an obvious sign of a disorder, easily dismissed as a mere symptom, is in fact the disorder itself. This kind of argument had been made only twice before in history, and both times the argument had revolutionized psychiatry.

In the early 1950s, Joseph Wolpe, a young South African psychiatrist, astounded the therapeutic world, and infuriated his colleagues, by finding a simple cure for phobias. Established thinking held that phobia—an irrational and intense fear of certain objects, for instance, cats—was just a surface manifestation of a deeper, underlying disorder. The psychoanalysts said a phobia was the buried fear that your father would castrate you in retaliation for lusting after your mother. The biological psychiatrists, on the other hand, claimed that it was some as-yet-undiscovered brain-chemistry problem. What both groups had in common was the belief that some deeper disorder lay underneath the symptoms. Treating only the patient’s fear of cats would do no more good than it would to put rouge over measles.

Wolpe, however, claimed that the irrational fear isn’t just a symptom; it is the whole phobia. If the fear could be removed (and it could be), this would extinguish the phobia. The phobia would not, as the psychoanalytic and biomedical theorists claimed, return in some displaced form. Wolpe and his followers routinely cured phobias in a month or two, and the fears did not reappear in any form. For his impertinence—for implying that there was nothing deep about this psychiatric disorder—Wolpe was ostracized.

The other precedent for David Clark’s assertion involved the founding of cognitive therapy. In 1967, Aaron Beck, a University of Pennsylvania psychiatrist, wrote his first book about depression. Depressives, he noted, think awful things about themselves and about their future. Beck speculated that maybe that is all there is to depression. Maybe what looks like a symptom of depression—gloomy thinking—is the cause. Depression, he argued, is neither bad brain chemistry nor anger turned inward (Freud’s claim) but a disorder of conscious thought. Lightening the gloom of conscious thought should cure depression. This simple theory remade the field of depression and founded a new, effective form of therapy.

David Clark, unassuming of demeanor and only thirty-two years old, was now making the same bold argument for panic. My head was spinning. If he was right, this was a historic occasion. All Clark had done so far, however, was to show that the four lines of evidence for a biological view of panic could be fit equally well with a misinterpretation view. But Clark soon told us about a series of experiments he and his colleague Paul Salkovskis had done at Oxford.

First, they compared panic patients with patients who had other anxiety disorders and with normals. All the subjects read the following sentences aloud, but the last word was presented blurred. For example:

When the sentences were about bodily sensations, the panic patients, but no one else, saw the catastrophic endings fastest. This showed that panic patients possess the habit of thinking Clark had postulated.