Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC covering topics on 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 anxiety and its treatment with my guest, Dr. Richard G. Heimberg. Richard G. Heimberg, PhD is Professor of Psychology at Temple University. He also serves as Director of the Adult Anxiety Clinic there.
Dr. Heimberg is well known for his efforts to develop cognitive behavioral treatments for social anxiety and to examine their efficacy in comparison to or in combination with medication treatments.
More recently, he and his colleagues have initiated a program for the study and treatment of generalized anxiety disorder. His research has been supported by a number of grants from the National Institute of Mental Health.
Dr. Heimberg has published more than 275 articles and chapters on social anxiety, generalized anxiety disorder and related topics. He is co-editor or co-author of six books, including the 2006 book, "Managing Social Anxiety: A Cognitive Behavioral Therapy Approach".
Dr. Heimberg is Past President of the Association for Behavioral and Cognitive Therapies. He currently serves as editor of Behavior Therapy, the flagship journal of that association, and he is on nine additional editorial boards. Finally, Dr. Heimberg was named one of the foremost influential psychological researchers in anxiety.
Here's the interview.
Dr. David: Dr. Heimberg, welcome to Wise Counsel.
Dr. Richard G. Heimberg: Thanks for having me on.
Dr. David: The bulk of your career has been devoted to research on the treatment of anxiety. So, perhaps, the place for us to start is the definition of anxiety. What's the modern definition?
Dr. Richard: All right. It is defined many different ways by many different people.
Dr. David: Aha.
Dr. Richard: I think what we should focus on here is that it is a feeling of distress that everybody feels at some point or another in some degree or another in lots of different situations in their lives. And it is not a problem unless it is excessive, and it interferes with your ability to function or do the things that you want to do in your life.
Dr. David: Right. Sometimes, when I've been teaching I've spoken about it as that three in the morning feeling. I don't know if it's true for everybody, but sometimes when I wake up in the middle of the night around three in the morning it feels like all of my defenses are just stripped and I'm assaulted by anxiety.
Dr. Richard: In fact, I imagine there are a number of people who have a particular kind of anxiety which is worrying about whether or not you would get back to sleep and in fact, interfering with your ability to get back to sleep by having that kind of internal dialogue going on inside your head.
Dr. David: I pretty much manage to control it for myself by learning to control that dialogue and just shut it off. What do we know about the origin of anxiety?
Dr. Richard: One of the things that we might say here is that anxiety comes in a number of different stripes. They're certainly related, but they're not all the same. It's not a direct answer to your question, but anxiety is part of our normal genetic evolutionary development.
It's good for us to be afraid of things, even things that are kind of vague future possibilities because it's adaptive. It helps us survive. In modern context if we weren't anxious about doing well we wouldn't study for tests and we would fail.
If we weren't worried about making reasonable impressions on people, then we'd all be slugs and we'd make no good impression.
Of course, we can worry too much about those things and become too anxious about them. Those things can then become a problem, but they are natural parts of the way that we as human beings are constructed.
One of the things that I think is very important for everybody to understand is that anxiety is a normal part of life, and maybe a normal part of several different parts of one's life. If we didn't have some degree of it, we would actually be worse off for it.
Dr. David: Yeah. Now, it sounds like you are saying that in some way it is related to fear.
Dr. Richard: It is very much related to fear. One of the things that you can think of as a difference between the two without getting into the technical things that only scientists can love is that if you step out into traffic and you take a look to one side and you see a truck coming down on you and your heart starts to beat 250 miles an hour, that's fear.
Dr. David: Right.
Dr. Richard: There is real mortal danger there right then.
Dr. David: Right.
Dr. Richard: OK. Now, you can get almost the same kind of revved up thoughts and feelings from worrying about how you are going to do in a job interview next week.
Dr. David: Sure.
Dr. Richard: The difference is you have created in your head the scenario that may or may not ever come to exist. A lot of the circuitry is actually the same, but anxiety is basically an analogue or something similar to the fear response but about future possibilities rather than present moment threats.
Dr. David: OK. You mentioned circuitry. We know so much more now about the brain and the various neurological systems in the brain.
Dr. Richard: Yes.
Dr. David: Has brain imaging research shed any new knowledge on anxiety?
Dr. Richard: It has, but I am going to claim minimal expertise there. I can give you a minimally expert answer if you like, but I want people listening to this to understand that this is not my area of expertise.
There is a primary area within the brain called the amygdule, and it seems to be among all of the millions of different brain areas that are made up of billions of cells. It's the part of the brain that seems to be most related to most of your anxiety response.
Several other areas are involved, but I want to make one thing really clear, and that is, because there is neuro-circuitry responding doesn't mean that anxiety is a purely biological non-psychological phenomenon.
What you think affects what's in your brain; what's in your brain affects what you think. They are inextricably related to each other.
Dr. David: Yes. Two sides of the same coin.
Dr. Richard: Or different levels of analysis, if you will.
Dr. David: A lot of your work has focused on generalized anxiety disorder or GAD. What is that? Tell us about that.
Dr. Richard: It is worrying about future possibilities, as we were talking a little while ago, but basically doing that about some large number of areas in your life - whatever large is differs from person to person - worrying about something that you may or may not be able to do anything about, worrying about things that are future possibilities but that may never come to be about, worrying in a way that it is very distracting from the rest of your experience.
But having a sense that the worry is excessive to the circumstances and uncontrollable in the sense that once it gets started it's going to take you on its own merry ride and you don't have a choice.
Dr. David: I noticed one of your recent papers talks about an emotional disregulation model of general anxiety. Now, I'm not familiar with what that is. It almost seems to be saying as simple as -- people who suffer from anxiety have a problem regulating their emotions.
Dr. Richard: Well, it does say that. Depending on how you state that it can sound a little bit circular, but there's really a great deal more to it although I will say it is a model and a theory we're investigating. And it's by no means widely accepted specifically for generalized anxiety disorder.
But, it is a very common thing for, you know, for people who work with mental and emotional disorders to believe that this regulated emotion plays a role in the overall picture of, you know, what it is that the person experiences.
What I thought about generalized anxiety disorder is, is that the person who experiences anxiety all the time, to some extent does so because they experienced that anxiety in, as a result of having other experiences that might cause them to experience different emotions.
But they lack the skills, experience, or propensity to be able to regulate those emotions in, in any of a number of different ways. In order to have a successful emotional experience, something happens to you.
It raises an emotional reaction. Not necessarily anxiety. It can be anything. Something can make you angry. But in order for you to react reasonably you have to understand that you're aroused, understand that you're having an emotion.
You have to have some language for being able to describe to yourself what it is that's happening to you. You need to interact with that emotion in some way, OK? I'm angry. What am I angry at? I'm angry at my wife because she did A, B, or C.
What do I need to do about that? Well, first I need to go in the other room and cool off for a little bit, then I need to have a discussion with her because this is something that really bothers me. Of course there could be a lot of different answers to that.
But, and then, you know, that includes in our way of thinking about it four different pieces. One is... see if I can remember them right. One is identification and description of one's own emotion. Another one is a problem.
Another one is that people with generalized anxiety disorders seem to be frightened of emotional experiences. And that's true whether it's anger, depression, or even positive emotions.
They don't like variation from a kind of a flat baseline in terms of their emotional experience. They don't manage their emotions well in some of the ways that I was talking about, and they don't seem to either possess the skills or execute them to help themselves moderate a difficult emotion or bad mood.
So when they're depressed, for instance, it goes on for longer and longer then it would for somebody who had better emotional regulation skills.
Dr. David: So, you're talking about emotional regulation skills. What have we learned about how to effectively treat anxiety?
Dr. Richard: There are, and here's again a place where we have several different kinds of anxiety, and there are different ways of approaching different ones. Generalized anxiety disorder is treated in, I don't know that there is a one single way of going about it.
There are medication treatments. I'm not an M.D. I'm not going to talk about that in particular. There is a generic school of therapy called cognitive behavioral therapy, which is what I practice. And it's often practiced for generalized anxiety disorder.
And what we do in my clinic, which is the Adult Anxiety Clinic of Temple University, is that we're working to develop a cognitive behavioral therapy, which I'll explain in a minute that also focuses on teaching some of the kind of skills for regulating emotions that would follow from what we were just talking about.
In cognitive behavioral therapy, also known as CBT, for generalized anxiety disorder, one of the things that is necessary to do is figure out what it is that the person's worrying about, and trying to understand what the functional purpose of that worry is.
A funny stripe on this, it relates to what we were talking about with emotion regulation before, is that even though worrying, which is the main symptom of generalized anxiety disorder, is not pleasant. It seems to often happen as a way to avoid, not necessarily purposely, but more out of habit, more intense and difficult emotional experiences, you know.
So, and the person with generalized anxiety, the college student with generalized anxiety disorder may find out that they're worrying a lot about tests, and in fact that may...what would be...I'm not sure that's a great example.
What often happens with people with generalized anxiety disorder is that the worry that what they have isn't really about what's called minor matters. Am I going to be on time for this? Am I going to be able to do this?
Do I have enough food around to make dinner? Am I going to get my bills paid on time? You know, not that those are trivial things, but they are things that most people manage just fine, and therefore things that don't require our attention during much in worrying.
But in fact, people can worry about them a lot. That occupies your brain space if you will, in a way that keeps you from thinking about other things that may be going on in your life, such as your being angry at your wife, or that you have some choice to make about careers, or there's some health issue that you have, or something that you really need to be thinking about. But...
Dr. David: That's interesting because it almost, it almost sounds a teeny bit Freudian in the sense of a symptom that's masking a deeper concern.
Dr. Richard: A major difference is that Freud would tell you that whatever's being masked is so deep that the person, himself or herself is not able to get access to it, because it's part of unconscious experience. I'm not saying any such thing.
Dr. David: OK.
Dr. Richard: I'm, I'm saying the person paid their attention to the worry rather than pay their attention to things that are possibly more valid, ongoing life concerns. And even if they're worrying about things that are incredibly valid life concerns, it doesn't lead them to do anything but worry.
Dr. David: Yeah. I, you started to talk about an example about students, and it put me in touch with, way back when I was a student, and I used to be terribly anxious about, about school and tests and so on.
Dr. Richard: Hmm.
Dr. David: ...Until I realized that the best way that I could deal with that anxiety, I was so anxious that I wouldn't study. And I finally realized that the best thing I could do is to just put in the time studying and do the best I could, and let the chips fall where they may.
Dr. Richard: It's, you know, as simple and straightforward as that sounds, it's not that easy a realization to come to. And, you know, if I could package a way to get that realization into the heads of students worldwide, we probably would have been better off.
Dr. David: Well it took me two or three years to come to it.
Dr. Richard: Yeah. But just in the same way as students may avoid studying by cleaning their apartment.
Dr. David: Yeah, yeah.
Dr. Richard: And that an otherwise pigsty of an apartment may be absolutely clean around test time. A person can worry about things that are either fictional futures, things that they're worrying about that they don't know whether have any chance of coming to be or not, or they're things that they can do nothing about, and just need to accept and move forward.
And, it gets them stuck in a cycle of worrying rather than problem solving or moving on.
Dr. David: Yes, that's such an important distinction, isn't it? The difference between an endless worry cycle and problem solving, which, which does imply moving on as you say.
Dr. Richard: Right. Yes, problem solving involves coming up with a potential solution to a problem, implementing it. It may or may not work. Evaluating whether it works. If it doesn't try something else, so on, until you get whatever resolution you're going to get to whatever the problem is.
Whereas worrying basically is a less controlled kind of a thought process where the person just basically is restating the problem to themselves over and over again without getting to the, OK, what should we do about it phase.
Dr. David: Right. Now, even though you're not an M.D., I believe your research has focused on comparing drug treatment to cognitive behavior therapy for the treatment.
Dr. Richard: It has, but, it has, but not generalized anxiety disorder. It's for a closely related type of anxiety called social anxiety disorder.
Dr. David: Great. Well, I want to...
Dr. Richard: If you want to talk about that we can certainly talk about that as well.
Dr. David: Yes, I would like to. So first of all, tell us what your research has found in terms of comparing drug treatment to cognitive, to CBT for social anxiety.
Dr. Richard: Can we take a step back and let me say a word or two about what social anxiety disorder is? Because it's fairly different from what generalized anxiety disorder looks like, although there are some common ground.
Dr. David: Yeah, that sounds like an excellent idea.
Dr. Richard: OK, good. Thank you. The person who would receive a diagnosis of social anxiety disorder is somebody who is very, very concerned to the point that it causes really serious distress or impairment in function. They are very concerned with what other people think of him or her.
Again, like I said, anxiety is on a continuum and the things that we're concerned about are things that may not be a problem if we think about them in moderate ways. We're all concerned about what other people think of us.
But if we are so concerned about being negatively evaluated by other people that we pull out of interaction with other people, we avoid social interactions, we don't go to college because we're afraid of evaluation, we don't take the job where we have work with other people because they're other people and they may think bad things about us.
If we want to raise a family but we've never had a date, then that level of concern about what other people think about us is obviously getting in the way in a way that can be tragic in the amount of impairment that it costs.
Those are the people that we see in our clinic. At the severe end is the person that will only go grocery shopping at three in the morning because they can then go all the way through doing their grocery shopping and checkout at the automated teller and not talk to anybody.
At the list on the other end is your college student who is extremely afraid of public speaking and might choose to drop out of college rather than taking a speech course.
Dr. David: Oh, yeah. Yeah.
Dr. Richard: Obviously, that's not as impaired as the first person but that's not a small consequence. So that's kind of a nutshell description of social anxiety disorder. It is, by the way, the most common mental disorder in the United States, other than depression and alcohol.
Dr. David: Is it related to phobias, for example, agrophobia?
Dr. Richard: In fact, it used to be called and is still is called in a lot of places by the name, "social phobia". In the sense of fear of a particular situation or object, that is what a phobia is. It kind of fits that label.
But many others have the idea that a phobia is a very specific fear that is not that impairing and people can avoid it in a way that it doesn't really mess up their lives too badly, which is a mistaken notion for the most part, but it doesn't really describe what happens when most people with social anxiety whose fears may be that specific, like they only fear public speaking.
But it can be that they fear almost any interaction with any other human being and, of course, since human beings are like all over the place, it's hard to be in a position where you're not in the middle of what it is that you fear.
And so the name "social anxiety disorder" has tended to come more to the forefront just as a way of suggesting that this is a serious mental disorder. It is the especially the second most frequent disorder because there's some new data out behind depression.
But it also increases the risk of depression very much, it also increases the risk for alcohol and substance abuse very much, and those things make logical sense.
If you are so anxious in your social and personal world, you run the risk of missing out on life in very dramatic ways. Many of the rewarding, satisfying things that happen in life are interpersonal or require you to interact with people in order to get to them.
Losing out on those things can lead somebody to be depressed. Also, if you feel pain, if you feel anxiety, it is not unusual in an extreme degree, it is not unusual to try and do something to help yourself, even if it's not in your best interest.
One of those things that many people do is use alcohol or drugs as a self-medication device.
Dr. Richard: There are lots of people who drink at parties, not because they want to get drunk but because they feel more comfortable around people that way. If that gets to be extreme, then you've got a problem. You've got two problems instead of one.
Dr. David: Yes. Now, getting back to the research that you've done on self-medication, you've compared drug treatment to CBT for the treatment of social anxiety.
Dr. Richard: I have, yes.
Dr. David: What did you find out?
Dr. Richard: We've done a couple of different studies over time. I've been working with a colleague who is a medical doctor, Michael Liebowitz, who until recently was the head of the Anxiety Disorders Clinic at the New York State Psychiatric Institute, recently retired.
We've been working together for the last 20 years, comparing and contrasting medication treatments for social anxiety and cognitive behavioral therapy for social anxiety disorders that I've been working on developing for most of that time. The studies have changed some over time because the therapies have evolved and the drugs have evolved.
One of the earliest studies that we did compared a group version of cognitive behavior therapy to a drug called Phenelzine, which is an anti-depressant of a class called Monoamine oxidase inhibitors that is not used so much anymore because of the side effects.
It's very good drug and roughly as effective as the drugs that are more common in today's market. It was a very interesting study. Basically, what we found was that each of the treatments by themselves - and this study had no treatment that put the two of them together, we did that in another study - the two treatments were both much better than our control conditions.
There were scientific parts of studies that you need like placebo pills and things like that. In the short run, they were roughly equal. The drug actually had a little bit faster onset of action, which really makes sense if you think about it because cognitive behavior therapy involves learning new ways to be in social situations and it takes some time to spend in social situations before you learn the new ways to be.
Dr. David: Right.
Dr. Richard: So sometimes it takes a little bit longer than some drugs to have its effect. But after the time in which the medication was administered and the therapy was being given, we included a period of time where the treatment schedule was thinned out and ultimately stopped. Then we followed our participants for a while to see what happened to them.
Of the people who were on the drug during the study period, about half of them relapsed. The relapse rate amongst the persons who had received the CBT was very low. I think the percentage was one person out of six. I don't remember exactly. The number's off the top of my head but that was pretty close.
Dr. David: That's great. It kind of makes sense, doesn't it, that in the one case, the drug was almost sort of like a crutch, whereas in the other, you're learning a skill that stays with you like teaching a man to fish.
Dr. Richard: That's the idea. I wouldn't want to say drugs are just a crutch. Not that that's necessarily the tone that you put on in what you just said.
Dr. David: OK.
Dr. Richard: But drugs are a legitimate treatment option and they work and they help a lot of people. They are faster acting. Sometimes, you get better short-term effects, but the person is more vulnerable to relapse if they stop.
And there are times when somebody will not want to take drugs. There will be side effects and those would bother some people and not others.
There will be complications that different drugs may cause, such as long-term weight gain. They may not be OK for women when they're expecting a child. There may be times when somebody needs to stop.
In some ways, CBT may be a preferred alternative, depending on the person's choices or preferences, and also depending on what's available in your neighborhood. CBT is a sophisticated therapy.
It's not something that everybody knows how to do that has a Ph.D. or M.D. or practices psychiatry. But most medical doctors have some degree of acquaintance with the administration of anti-depressant meds.
Dr. David: Right.
Dr. Richard: So they may be more available. You have to think about those things. It's also true that if you live in a very rural area, you are more likely to find someone who can administer medication than somebody who can provide CBT just because of numbers.
Dr. David: Sure. Now, this interview is going to be posted on the Internet. So I was intrigued to see that you recently co-authored a paper about social anxiety on the Internet, titled, "The Internet: Home to a Severe Population of Individuals with Social Anxiety Disorder?"
Dr. Richard: Yes, I did.
Dr. David: Tell us a little bit about that.
Dr. Richard: OK. I'd be happy to. That study was done with the help of a very important organization called the Anxiety Disorders Association of America, which is a group of professionals and people who suffer from anxiety disorders that advocate for better treatments, research, and taking care of people with anxiety.
So the Anxiety Disorders Association of America, ADAA, website, which is www.adaa.org, gets about a million hits a month. It's a great resource for people with anxiety. And they have information about a lot of different anxiety disorders, and you can find a therapist through some of their resources and so on.
So we put up a survey that was linked to their website, when we were doing this study - it's not there now - that asked people who believed that they had social anxiety, or who were shopping for information about social anxiety, to fill out a series of questionnaires online that involved how they use the Internet, and also what kind of symptoms they might have related to social anxiety.
And many of them spent a lot of time online. Many of them used chat rooms, and so on and so forth. And many of them used those Internet resources, which can be very positive in some circumstances, as substitutes for direct, face-to-face contact, because they were really, very, very interpersonally anxious.
But most of the people who answered the survey were not accessing treatment of any kind. And it's kind of like they were window shopping but never buying, in terms of coming by looking for treatment resources but not really doing anything with it.
So they filled out these questionnaires that I was talking about, which are basically diagnostic questionnaires, or ways of putting a metric on how severe your social anxiety is. And we compared their scores to both the published norms and to the average scores of clients who come into our clinic to get treatment, which is a fairly severe group.
And that last comparison was really, really interesting, in that the people who filled out the Internet survey scored much more severe than the people who were coming into the clinic for treatment.
So, there is a group out there, and I hope it's a group that will be listening to this webcast, that is not accessing treatment, when in fact treatment exists. And in fact we know some of the reasons why that happens.
And one of the reasons is that the person feels very ashamed about talking about what it is that they're afraid of, and that they are afraid that they're going to be negatively evaluated by the person who is doing their initial interview.
Dr. David: Sure.
Dr. Richard: It makes great logical sense that that would happen with somebody who has social anxiety. But if it keeps them from getting in the door when we can help them, it's really quite a shame.
Dr. David: Well, I can see the Internet as possibly being both part of the problem and part of the solution.
Dr. Richard: Mm-hmm.
Dr. David: It can be a way of hiding out from contact with other people. But also, I think, for some people, it's a way, maybe, of baby steps, of a kind of involvement with other people that's not so threatening.
Dr. Richard: And if that's the way it's used, then more power to them, because that's a very adaptive thing.
Dr. David: Yeah. I actually heard from a listener recently an intriguing story, where she was actually learning social skills by using "The Sims" Internet game. It's a computer game.
Dr. Richard: [laughs] OK.
Dr. David: Yeah. She wrote me with some enthusiasm, saying, "You know what? I'm learning that the things that I do with these simulated people in Sims leads to certain effects. And so I'm using these in my real life and I'm discovering how to make friends."
Dr. Richard: You know what's really interesting about that? It sounds like it was really helpful to this person, so I'm certainly not going to say anything the least bit negative about it.
But it does make me wonder about something that we know about people with social anxiety and that is that they are typically a great deal more socially skilled than they give themselves credit for.
Dr. David: Interesting.
Dr. Richard: Everybody can always have better social skills, and I would certainly include myself in that group, but the truth is that in order to be socially skilled enough to be acceptable to other people, you don't have to be a movie star. A lot of us can get along really OK with kind of adequate skills.
Dr. David: That's a great place for us to wind down. Do you have any advice if any more of our listeners feel that they need to see a professional about their anxiety, any resources you'd recommend?
Dr. Richard: I do, and most of them are accessible on the web. That dovetails with the discussion that we were just having.
One of them is the Anxiety Disorders Association of America. Its web address is adaa.org.
Another is the Association for Behavioral and Cognitive Therapies. It is a group of scientists and practitioners of cognitive behavioral therapy. Its website abct.org also has a Find a Therapist kind of thing.
Another is called the Academy of Cognitive Therapy and it also has a website which is, I think, is academyofct.org.
All of these sites have information about different disorders. The most anxiety-specific information is at adaa.org, but all of them have Find a Therapist tools that are geographically workable so you can find people in your area.
I'll also put in a plug for the website of my clinic which is in Philadelphia if anyone wants to come for treatment directly. It's www.temple.edu/phobia and there are a number of links and information about social anxiety in general and anxiety disorders.
Dr. David: Excellent. That's a really rich resource list. Dr. Richard Heimberg, thanks so much for being my guest today on Wise Counsel.
Dr. Richard: It's a pleasure. Thanks for having me.
Dr. David: I hope you found this interview with Dr. Richard Heimberg both informative and thought provoking. As he pointed out, we all suffer from a certain amount of anxiety from time to time and it's probably adaptive in some situations.
However, if you or someone you know experiences excessive anxiety, you may well want to follow up with the resources mentioned here by Dr. Heimberg, especially the www.adaa.org site he mentioned.
You've 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.