What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (12 page)

Next, Clark and his colleagues asked if activating this habit with words would induce panic. All the subjects read a series of word pairs aloud. When panic patients got to “breathlessness-suffocation” and “palpitations-dying,” 75 percent suffered a full-blown panic attack—right there in the laboratory. No normal people had panic attacks, no recovered panic patients (I’ll tell you more in a moment about how they got better) had attacks, and only 17 percent of other anxious patients had attacks.

The final thing Clark told us was the “breakthrough” that Rachman had promised.

“We have developed and tested a rather novel therapy for panic,” Clark continued in his understated, disarming way. He explained that if catastrophic misinterpretations of bodily sensation are the cause of a panic attack, then changing the tendency to misinterpret should cure the disorder. His new therapy, as he described it, was straightforward and brief:

Patients are told that panic results when they mistake normal symptoms of mounting anxiety for symptoms of heart attack, going crazy, or dying. Anxiety itself, they are informed, produces shortness of breath, chest pain, and sweating. Once they misinterpret these normal bodily sensations as an imminent heart attack, their symptoms become even more pronounced because the misinterpretation changes their anxiety into terror. A vicious circle culminates in a full-blown panic attack.

Patients are taught to reinterpret the symptoms realistically, as mere anxiety symptoms. Then they are given practice right in the office, breathing rapidly into a paper bag. This causes a buildup of carbon dioxide and shortness of breath, mimicking the sensations that provoke a panic attack. The therapist points out that the symptoms the patient is experiencing—shortness of breath and heart racing—are harmless, simply the result of overbreathing, not a sign of a heart attack. The patient learns to interpret the symptoms correctly.

One patient, when he felt somewhat faint, would have a panic attack. He became afraid that he would actually faint and collapse, and interpreted his anxiety as a further symptom of imminent fainting. This escalated to panic in a few seconds.

“Why,” Clark asked him, “have you never actually fainted?”

“I always managed to avoid collapsing just in time by holding on to something,” replied the patient.

“That’s one possibility. An alternative explanation is that the feeling of faintness you get in a panic attack will never lead you to collapse, even if you don’t control it. In order to decide which possibility is correct, we need to know what has to happen to your body for you actually to faint. Do you know?”

“No.”

“Your blood pressure needs to drop,” said Clark. “Do you know what happens to your blood pressure during a panic attack?”

“Well, my pulse is racing. I guess my blood pressure must be up,” the patient responded.

“That’s right. In anxiety, heart rate and blood pressure tend to go together. So you are actually less likely to faint when you are anxious than when you are not,” said Clark.

“But why do I feel so faint?”

“Your feeling of faintness is a sign that your body is reacting in a normal way to the perception of danger. When you perceive danger, more blood is sent to your muscles and less to your brain. This means there is a small drop in oxygen to the brain. That is why you feel faint. However, this feeling is misleading because you will not actually faint since your blood pressure is up, not down.”

The patient concluded, “That’s very clear. So next time I feel faint, I can check out whether I am going to faint by taking my pulse. If it’s normal or quicker than normal, I know I won’t faint.”
⁹

“This simple therapy appears to be a cure,” Clark told us. “Ninety to one hundred percent of the patients are panic free at the end of therapy. One year later, only one person had had another panic attack.”

At this point in the meeting, Aaron Beck, the father of cognitive therapy, spoke up. “Clark’s results are not a fluke. We have run the same study with the same therapy in Philadelphia. We also find complete remission with almost no recurrence of panic attacks one year later.”

This, indeed, was a breakthrough: a simple, brief psychotherapy with no side effects showing a 90-percent cure rate of a disorder that a decade ago was thought to be incurable. In a controlled study of sixty-four patients, comparing cognitive therapy to drugs to relaxation to no treatment, Clark and his colleagues found that cognitive therapy is markedly better than drugs or relaxation, both of which are better than nothing. Such a high cure rate is unprecedented. I could not recall a single instance in the annals of psychotherapy or drug therapy where a treatment produced almost complete cure with almost no recurrence. Lithium for manic-depression, at 80 percent effectiveness (with dangerous side effects), was the closest I could remember.

How does cognitive therapy for panic compare with drugs? It is more effective and less dangerous. Both the antidepressants and Xanax produce marked reduction in panic in most patients, but drugs must be taken forever; once the drug is stopped, panic rebounds to where it was before therapy for perhaps half the patients.
¹⁰
The drugs also sometimes have severe side effects, including drowsiness, lethargy, pregnancy complications, and addictions.

After this bombshell, my “discussion” was an anticlimax. I did make one point that Clark took to heart. “Creating a cognitive therapy that works, even one that works as well as this apparently does, is not enough to show that the
cause
of panic is cognitive.” I was niggling. “The biological theory doesn’t deny that some other therapy might work well on panic. It merely claims that panic is caused at bottom by some biochemical problem. Is there any differential prediction that the catastrophic-misinterpretation theory makes that the biological theory must deny?”

The Right Treatment

PANIC SUMMARY TABLE
¹¹

Two years later, I had my answer. Clark carried out a crucial experiment that tested the biological theory against the cognitive theory. The main pillar of the biochemical theory is panic attacks produced with infusions of lactate. Carbon dioxide, yohimbine (a drug that stimulates the brain’s fear system), and overbreathing all induce panic as well. There is no known neurochemical pathway that all these have in common. The cognitive theory, on the other hand, claims that the common element is their production of bodily sensations that get misinterpreted as catastrophe.

The cognitive theory predicts that you should be able to block lactate-induced panic attacks merely by countering the misinterpretation. The biological theory, in contrast, predicts that lactate is sufficient to produce panic attacks. Clark gave the usual lactate infusion to ten panic patients, and nine of them panicked. He did the same thing with another ten patients, but added special instructions to allay the misinterpretation of the sensations. He simply told them: “Lactate is a natural bodily substance that produces sensations similar to exercise or alcohol. It is normal to experience intense sensations during infusion, but these do not indicate an adverse reaction.” Only three out of the ten panicked. This confirmed the theory crucially.

The therapy works very well, as it did for Celia:

Celia’s story has a happy ending. She first tried Xanax, which reduced the intensity and the frequency of her panic attacks. But she was too drowsy to work, and she was still having about one attack every six weeks. She was then referred to Audrey, a cognitive therapist who explained that Celia was misinterpreting her heart racing and shortness of breath as symptoms of a heart attack, that they were actually just symptoms of mounting anxiety, nothing more harmful. Audrey taught Celia progressive relaxation, and then she demonstrated the harmlessness of Celia’s symptoms by having her breathe rapidly into a paper bag. Audrey pointed out that Celia’s heart was racing and that she felt she was suffocating, normal symptoms of overbreathing. Celia then relaxed in the presence of the symptoms and found that they gradually subsided. After several more practice sessions, therapy terminated. Celia has gone two years without another panic attack
.

6

Phobias

B
EFORE
I
DISCUSS PHOBIAS
, I must lay the groundwork for the role of evolution in what we can change about ourselves. Some of what resists change does so because it was an adaptive trait for our ancestors and is the product of natural selection. Phobias, and much else in our emotional lives, are like this.

The
sauce béarnaise
phenomenon
.
Sauce béarnaise
used to be my favorite sauce until one evening in 1966, when I had a delicious meal of filet mignon with
sauce béarnaise
. About midnight I became violently ill, retching until there was nothing left to throw up. After that,
sauce béarnaise
tasted awful to me; just thinking about it set my teeth on edge.

At the time, I was a fledgling learning theorist. I was familiar with Pavlovian conditioning, and this seemed like an instance. Pavlovian conditioning is, of course, the science of how we learn what signals what. A child hears a dog growl, but she is undisturbed. Then the dog bites her. After that, she is afraid whenever she sees a dog. She has learned, by Pavlovian conditioning, that growling signals hurt, and she is now afraid of dogs. How can this be explained?

Pavlov’s dogs, you will remember, first had the conditional
¹
stimulus (CS) of the sight of Pavlov paired with their unconditional response (UR) of salivating for the unconditional stimulus (US) of food. After half a dozen such pairings, they began to salivate just on seeing Pavlov. Salivating to Pavlov was the conditional response (CR). Pavlovian conditioning worked because the dogs associated the sight of Pavlov with the response of salivating to food.

Some events turn us off or turn us on the very first time we encounter them: Thunder is frightening the first time it happens; stroking of the genitals is exciting the first time
it
happens. Other events have to acquire their emotional significance. The emotional significance of the face of our mother or of the words “Your money or your life” must be learned. All of our emotional life that is not inborn might be Pavlovian conditioning. This idea had placed Pavlovian conditioning among the most exciting fields in all of psychology by the mid-1960s.

My
sauce béarnaise
aversion seemed to fit. The taste was the CS, and sickness was the UR. This pairing rendered future encounters with
sauce béarnaise
nauseating. At any rate, this was what I mused about over the next month.

What focused my musings was a remarkable paper published a month after this incident. John Garcia, a young radiation researcher, published an experiment with findings so anomalous that—once accepted—they revolutionized learning theory. So hard to swallow were these findings for learning theorists that the leading textbook writer in that field said at the time that they were no more likely to be true than that “you would find bird shit in a cuckoo clock”!
²

Garcia was an obscure investigator studying radiation sickness in a government laboratory. He noticed that when his rats got sick, they went off their food. After they recovered, they still wouldn’t eat their old chow. Otherwise, though, they looked completely unperturbed. This was bewildering, but it also looked like Pavlovian conditioning, with the taste of the chow the CS, sickness the UR, and coming to hate their chow the CR. But if the rats were conditioned by being sick, why only a taste aversion? Why not a more widespread aversion—to their handlers, to lights going off, to doors opening, to everything else that occurred with their illness? Garcia was bewildered—for the same reason I was bewildered about
sauce béarnaise
.

Garcia then carried out a classic experiment, my candidate for the most significant experiment conducted during my lifetime in the psychology of learning:

Every time his rats licked at their drinking spouts, they tasted saccharin, and a burst of light and noise came on. This is called a
compound CS
—bright, noisy saccharin water. Then a burst of X rays occurred. Within a few hours the rats were sick to their stomachs. When the rats recovered, Garcia tested the elements of the compound CS separately to see what the rats had learned to fear. They now hated saccharin, but they were completely unperturbed by the bright noise. When they got sick, they blamed it on the taste and ignored everything else.

Maybe they had just failed to notice the bright noise during conditioning? So Garcia counterbalanced the experiment. Other rats were given the same bright, noisy saccharin paired now with foot shock instead of stomach illness. What did they learn? They now cringed in fear of bright noise, but they still loved saccharin. When they suffered pain, they blamed it on the bright noise and ignored the taste.