What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (45 page)

5
. For a meta-analysis (composite analysis of many studies), see K. Eppley, A. Abrams, and J. Shear, “Differential Effects of Relaxation Techniques on Trait Anxiety: A Meta-analysis,”
Journal of Clinical Psychology
45 (1989): 957–74. In their review of seventy studies, TM does best, exceeding progressive relaxation and other relaxation and meditation techniques, which all reduce trait anxiety as well. Recent evidence also suggests benefits of meditation for even the severely anxious patient: See J. Kabat-Zinn, A. Massion, J. Kristeller, et al., “Effectiveness of Meditation-Based Stress Reduction Program in the Treatment of Anxiety Disorders,”
American Journal of Psychiatry
149 (1992): 937–43. See also G. Butler, M. Fennell, P. Robson, and M. Gelder, “Comparison of Behavior Therapy and Cognitive Behavior Therapy in the Treatment of Generalized Anxiety Disorder,”
Journal of Consulting and Clinical Psychology
59 (1991): 167–75.

6
. My one warning about meditation and relaxation concerns depression. I do not recommend either of these techniques if you are highly depressed (see
chapter 8
). Both relaxation and meditation work by lowering autonomic nervous system arousal. Highly depressed people (who are not agitated) need autonomic rewing-up, and not dampening, since lowering arousal further can feed into their depression. Adverse effects of TM are not unknown, but the majority of practitioners report no adverse effects at all. See L. Otis, “Adverse Effects of Transcendental Meditation,” in D. Shapiro and R. Walsh, eds.,
Meditation: Classic and Contemporary Perspectives
(New York: Aldine, 1984), 201–8.

CHAPTER
5
Catastrophic Thinking

1.
You might wonder about my choice of sex for case histories. When there is a clear prevalence for females, as there is for panic (two to one, women versus men), I choose
she
. If there is a clear prevalence for males, I use
he
. If there is no difference, I will use
he
and note the prevalence.

2
It has become fashionable to claim that the distinction between the biological and the psychological is not meaningful. It is all a pseudoquestion of historic interest only, some writers tell us. Or we’re told that there is no deep distinction between mind and body. “Reductionists” tell us that all psychological events are ultimately biological, but that we just don’t know the biology of them yet. “Interactionists” tell us that all psychological events are just the interaction of environmental events and biology.

I plead agnosticism.

Both reductionism and interactionism are philosophical positions, unproven matters of faith. One or the other might turn out to be correct—in a thousand years. It may ultimately turn out, for example, that cognitive therapy works because it changes the trait of pessimism that is located in a presently unknown chemical pathway in the hippocampus. Such a possibility, however, is completely unhelpful to the consumer trying to decide if cognitive therapy or imipramine is the best thing for her depression
now
. Such a possibility is completely irrelevant to the scientist trying to find out
now
if pessimism is a risk factor for depression.

Right now, 1994, there are clear and useful distinctions between the biological and the psychological. Psychological events are measured at the molar level, the level of the whole intact person: Feelings, thoughts, traits, and behaviors are examples. Biological events don’t require a whole person for measurement; they are specified molecularly: Neural firings, endorphin changes, and dexamethasone suppression are examples. When something is primarily psychological, this means that it can be treated by interventions involving the whole person—cognitive therapy, psychoanalysis, hypnosis, behavior therapy, meditation, or day care, for example. When something is primarily biological, this means that intervention can successfully occur at the molecular level: drugs, surgery, or electroconvulsive shock, for example.

When someone tells you that there is no biological/psychological distinction, that the nature/nurture dispute is settled or passe, or that there is no mind/body distinction, keep a close eye on your wallet. That someone is stating an article of faith, one that is unhelpful to any actual scientist or consumer of therapy and, worse, that is intellectually anesthetic.

3
. This is a highly reliable finding, shown in dozens of studies. See, for example, M. Liebowitz, J. Gorman, A. Fryer, et al., “Lactate Provocation of Panic Attacks,”
Archives of General Psychiatry
41 (1984): 764–70; and J. Gorman, M. Liebowitz, A. Fryer, et al., “Lactate Infusions in Obsessive-Compulsive Disorder,”
American Journal of Psychiatry
142 (1985): 864–66.

4
. See S. Torgersen, “Genetic Factors in Anxiety Disorders,”
Archives of General Psychiatry
40 (1983): 1085–89; and R. Crowe, “Panic Disorder: Genetic Considerations,”
Journal of Psychiatric Research
24 (1990): 129–34.

5
. See D. Charney and G. Heninger, “Abnormal Regulation of Noradrenergic Function in Panic Disorders,”
Archives of General Psychiatry
43 (1986): 1042–54; and E. Reiman, M. Raichle, E. Robins, et al., “The Application of Positron Emission Tomography to the Study of Panic Disorder,”
American Journal of Psychiatry
143 (1986): 469–77.

6
. See, for example, S. Svebak, A. Cameron, S. Levander, “Clonazepam and Imipramine in the Treatment of Panic Attacks,”
Journal of Clinical Psychiatry
51 (1990): 14–17; and G. Tesar, “High-Potency Benzodiazepines for Short-term Management of Panic Disorder: The U.S. Experience,”
Journal of Clinical Psychiatry
51 (1990): 4–10.

7
. The proceedings of this conference are published in S. J. Rachman and J. Maser, eds.,
Panic-Psychological Perspectives
(Hillsdale, N.J.: Erlbaum, 1988).

8
. Parallel examples can be generated for fear of going crazy and fear of losing control, two other common contents of a panic attack. In each case, the first bodily sensations are misinterpreted as a sign of insanity or of losing control. The vicious cycle of misinterpreting mounting anxiety symptoms as further evidence of imminent cataclysm then starts.

9
. This dialogue is adapted from D. Clark, “Anxiety States: Panic and Generalized Anxiety,” in K. Hawton, P. Salkovskis, J. Kirk, and D. Clark, eds.,
Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide
(Oxford: Oxford University Press, 1989), 76–77.

10
. For relapse with Xanax (alprazolam), see, for example, J. Pecknold, R. Swinson, K. Kuch, C. Lewis, “Alprazolam in Panic Disorder and Agoraphobia: Results from a Multicenter Trial: III. Discontinuation Effects,”
Archives of General Psychiatry
45 (1988): 429–36. A very informative lay article about Xanax, “High Anxiety,” appeared in
Consumer Reports
January 1993, 19–24.

11
. On 25–27 September 1991, NIMH brought the leading figures in panic together again for a “consensus” meeting, a trial by jury of the panic therapies. Their conclusion was equivocal and disappointing. The numbers presented agree very closely with my summary table. In spite of this, the jury did not explicitly compare the cognitive therapies to the drug therapies, and therefore no mention was made of the superiority of the cognitive treatment to drugs. I can only speculate as to what interests were served by this, but I think their conclusions were pusillanimous and a disservice to the general public. See “National Institutes of Health Consensus Development Statement. Treatment of Panic Disorder. September 25–27, 1991.” See especially J. Margraf, D. Barlow, D. Clark, and M. Telch, “Psychological Treatment of Panic: Work in Progress on Outcome, Active Ingredients, and Follow-up,”
Behaviour Research and Therapy
31 (1993): 1–8.

Since my conclusions are not as yet universally accepted, I want to list the main outcome studies that document the unusually powerful effects of the cognitive treatment:

D. Clark, M. Gelder, P. Salkovskis, A. Hackman, H. Middleton, and P. Anastasiades, “Cognitive Therapy for Panic: Comparative Efficacy.” Paper presented at the annual meeting of the American Psychiatric Association, New York City, May 1990.

A. Beck, L. Sokol, D. Clark, B. Berchick, and F. Wright, “Focussed Cognitive Therapy of Panic Disorder: A Crossover Design and One Year Follow-up” (manuscript, 1991).

L. Michelson and K. Marchione, “Cognitive, Behavioral, and Physiologically-based Treatments of Agoraphobia: A Comparative Outcome Study.” Paper presented at the annual meeting of the American Association for the Advancement of Behavior Therapy, Washington, D.C., November 1989.

L. Ost, “Cognitive Therapy Versus Applied Relaxation in the Treatment of Panic Disorder.” Paper presented at the annual meeting of the European Association of Behavior Therapy, Oslo, September 1991.

J. Margraf and S. Schneider, “Outcome and Active Ingredients of Cognitive-Behavioural Treatments for Panic Disorder.” Paper presented at the annual meeting of the American Association for the Advancement of Behavior Therapy, New York City, November 1991.

CHAPTER
6
Phobias

1
. Through mistranslation, the CS and CR have become known as the “conditioned” stimulus and response. Conditions/ (that is, the conditional stimulus only acquires its properties conditionally, upon pairing with the US and the UR) is the actual meaning of the adjective, however.

2
. J. Garcia and R. Koelling, “Relation of Cue to Consequence in Avoidance Learning,”
Psychonomic Science
4 (1966): 123–24.

3
. For the detailed discussion and debate about these five problems, start with M. Seligman and J. Hager, eds.,
The Biological Boundaries of Learning
(New York: Appleton-Century-Crofts, 1972).

4
. The anesthesia experiment can be found in D. Roll and J. Smith, “Conditioned Taste Aversion in Anesthetized Rats,” in Seligman and Hager,
The Biological Boundaries of Learning
, 98–102.

Garcia tried his experiment with coyotes who made a habit of killing sheep. He laced ground lamb with nonlethal doses of poison. When the coyotes recovered, not only did they hate the taste of lamb, but they ran away from sheep! Lambs would actually chase them around the barnyard. When around lamb meat, the coyotes urinated on it and buried it. They didn’t treat lamb meat as a mere signal that sickness was on its way; rather, they came to hate and fear sheep in themselves. See C. Gustavson, J. Garcia, W. Hankins, and K. Rusiniak, “Coyote Predation Control by Aversive Conditioning,”
Science
184 (1974): 581–83.

Pavlovian conditioning is defined operationally: pairing of CS and US that results in a CR. This operational definition masks a basic distinction between two different processes that can be engaged.

The first is bloodless and intellectual: A CS is treated as a mere signal for the US. Dogs salivated to the sight of Pavlov because they expected to be fed. Pavlov himself had not become like food.

The second is deeper: The CS actually takes on the properties of the US, and becomes aversive in and of itself. Coyotes urinating on lamb meat, trying to bury it, and treating lambs as if they were dominant coyotes all indicate that the lamb has taken on aversive properties in itself. Unlike ordinary Pavlovian conditioning, whatever occurs during taste aversion does not occur at a rational level. Prepared CS-UR relationships, in my view, create conditioning at this deeper level.

5
. L. Robins, J. Helzer, M. Weissman, et al., “Lifetime Prevalence of Specific Psychiatric Disorders at Three Sites,”
Archives of General Psychiatry
41 (1984): 949–58; I. Marks, “Epidemiology of Anxiety,”
Social Psychiatry
21 (1986): 167–71.

6
. Until the early 1960s, psychoanalysis was the therapy used by default. The discovery of systematic desensitization and of flooding ended this. It is worth reading Freud’s famous “Little Hans” case, which originated the Oedipal theory of phobias. See S. Freud, “Analysis of a Phobia in a Five-Year-Old Boy,” in
The Complete Works of Sigmund Freud
, vol. 10, trans. J. Strachey (London: Hogarth Press, 1974), 5–100; and, for a demolition of Freud’s argument, J. Wolpe and S. J. Rachman, “Psychoanalytic ‘Evidence’: A Critique Based on Freud’s Case of Little Hans,”
Journal of Nervous and Mental Disease
131 (1960): 135–47. See also H. Laughlin,
The Neuroses
(Washington, D.C.: Butterworth, 1967), 545–606, on phobias, for the analytic view at this time. The “never easy” comes from Laughlin. This view of phobias is—at last and deservedly—a dead horse.