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An Interview with Michelle Craske, Ph.D. on Anxiety Disorders Research and Treatment

David Van Nuys, Ph.D.

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Michelle Craske, Ph.D.

In this episode of the Wise Counsel Podcast, Dr. Van Nuys interviews Michelle Craske, Ph.D., a clinical psychologist and anxiety disorders researcher. Originally from Tasmania (i.e., Australia), Dr. Craske has traveled the world in the course of her studies. She originally became interested in anxiety studies as an undergraduate in Australia, and followed up on this interest during graduate and postdoctoral research work with Dr. Jack Rachman in British Columbia (Canada) and Dr. David Barlow in Albany, NY. She is currently a professor at UCLA where she directs an anxiety disorders research clinic and has a small private practice treating anxiety disorders in addition to her research and teaching responsibilities.

Dr. Van Nuys leads off the interview by asking Dr. Craske to confirm her newfound understanding that anxiety and fear are now regarded as separate entities. Dr. Craske confirms this impression, suggesting that anxiety and fear are related but distinct emotions. Fear has to do with the fight or flight response that occurs in the presence of danger, while anxiety has to do with the anticipation of possible danger. Brain activation in fear takes place at the evolutionarily older mid-brain level (in the amygdala, amongst other places), while during anxiety, brain activation of the cortex (that part of the brain associated with human-style thought, judgment, language, etc.) occurs. Both fear and anxiety are normal emotions, but some people develop anxiety disorders when they experience these emotions in exaggerated ways (for instance, when there is no objective danger).

Over the years, Dr. Craske has investigated several different aspects of the anxiety disorders, one of which is nocturnal panic. Most people are familiar with panic attacks that occur during the daytime when they are awake. However, a minority of panickers (some 15 to 20%) report nocturnal panic attacks that rouse them from a sleep state, generally about one and a half hours after going to sleep. Nocturnal panic is a distinct phenomena from night terrors which more frequently occur for children during stage 4 (REM) sleep, producing amnesia for the event upon wakening. In contrast, nocturnal panic is more common in adults, and tends to occur during the transition between stage 2 and stage 3 sleep states, with no associated amnesia. As is the case with daytime panic, nocturnal panickers awaken feeling like they've just had a heart attack, or maybe are going insane. The relationship between night terrors and panic (nocturnal or otherwise) isn't clear just now. It may be that children who experience night terrors are more likely to go on to have panic attacks later in life.

Together with Dr. David Barlow, Dr. Craske is co-author of the Mastery of Your Anxiety and Panic workbook series, which describes an empirically validated (e.g., scientifically "proven" to work) form of cognitive behavioral therapy designed to address panic attacks and agorophobia, normally taking place over the course of 12 to 16 sessions. In essence, this therapy teaches participants to not be afraid of the various aspects of panic attacks that they enter the treatment fearing. Exposure therapy techniques are utilized to help people recreate panic symptoms (or symptoms similar to panic feelings) and then habituate to them (e.g., get used to them; learn that while they may be uncomfortable, they aren't dangerous). Cognitive Restructuring techniques are used to help people identify thoughts they have that fuel the flames of panic, such as the idea that many panickers have that they must be dying or having a heart attack. Advanced participants are also encouraged to expose themselves to situations that they have come to avoid so as to habituate to these stressors and no longer fear them.

MAP based treatment for panic disorders is quite successful, with up to 80% of participants reporting that they are no longer experiencing panic attacks at the conclusion of therapy. Up to 60% of participants report they are not only no longer experiencing attacks, but are also no longer afraid of future attacks occurring. Almost everyone who completes the program improves somewhat, although some 10-15% of participants drop out of therapy.

Dr. Van Nuys asks about the phenomena of relaxation-induced panic, which he related to based on his recent interviews with therapeutic proponents of mindfulness meditation. According to Dr. Craske, the likelihood is that some people are unfamiliar with how being relaxed feels and may panic in response to newfound feelings such as the sense of heaviness or the sensation of floating that often accompanies deep relaxation. In her eyes, the thing to do, should you find yourself having such a reaction, would be to remain in the state, treating it as an opportunity to do exposure therapy until you habituate to the feeling of relaxation.

Dr. Van Nuys asks about agoraphobia and its relationship to panic. Agoraphobia generally occurs when people become so fearful of panicking that they refuse to leave "safe" spaces such as their home. Dr. Craske points out that most any event that people fear and are embarrassed about contemplating can result in agorophobia if it is extreme enough. The example she offers is Irritable Bowel Syndrome, which causes some people to avoid places where they cannot control access to a toilet. What is interesting to Dr. Craske is that there is no direct relationship between the amount of restriction or home-boundedness experienced by agoraphobics and the actual severity of their panic attacks. She studied this relationship and found that two things predict severe agorophobia: 1) being female, 2) not being employed outside the home. Her conclusion is that the severity of agoraphobic restriction is related to the opportunities people have for it to happen without causing social upsets to others. People who are working outside the home have great incentive to keep working outside the home and this need to continue working seems to act to protect them from becoming house-bound. People who don't have to work or who aren't working don't have this protective restraint and are more likely to become house-bound.

The influence of expecting vs. not expecting panic attacks to occur and how this factor influences the severity if attacks is also discussed. Generally, if you don't expect a panic attack to occur, the symptoms of that unpredicted panic attack will tend to be more severe. It seems that being able to predict when you are likely to have a panic attack takes some of the wind out of the panic "sails" so that the resulting event is less intense when it does occur. Exactly why this should be or how it works is not known at present.

Dr. Craske discusses the relationship between anxiety and depression, stating that there is a high rate of co-morbidity (meaning, if you develop one, you are very likely to develop the other one too). Interestingly, anxiety problems usually precede depression problems when you look at how these problems unfold across time. It may be that something about experiencing protracted anxiety creates a vulnerability to experiencing later depression. Studies of the relationship between anxiety and depression have shown that there are both non-specific and specific factors that play into the development of these two problems. The personality trait known as Neuroticism, or Emotional Stability functions as a non-specific vulnerability factor. If you are neurotic by temperament (and this is highly likely to be a genetically inherited thing) you are more likely to have problems with both anxiety and depression than your non-neurotic peers. Other sort of vulnerabilities such as particular kinds of life events and abuse, may be more specific vulnerability factors unique to anxiety or depression.

The interview wraps up with a discussion of Dr. Craske's development of a computer-assisted therapy program for treating anxiety disorders. Basically, she has developed a computer program that assists therapists who are not already experts in using MAP or CBT therapies to treat anxiety disorders (and that is some 89% of therapists out there (!) according to Dr. Craske). Therapists and therapy patients use the program collaboratively. The program prompts therapists to perform particular interventions at certain times, and prompts the patient to record relevant data as he or she progresses through therapy. She is presently testing the program and preliminary feedback from therapists is that the system is useful for keeping them on track. Various versions of the program have been developed specific to panic and PTSD, among other anxiety subtypes.

Dr. Craske encourages people suffering with anxiety problems to seek out effective treatment, either in the cognitive behavioral (MAP) format she has helped author, or via medication prescriptions from a psychiatrist. Both approaches are known to be effective. She suggests that some benefit can be had from reading self-help books and suggests her own MAP books as examples. It is particularly important that children who experience anxiety disorders receive prompt treatment, as emerging research suggests that prolonged anxiety may create vulnerabilities to further problems such as depression in later life.

Links Relevant To This Podcast:

About Michelle Craske, Ph.D.

Michelle Craske, Ph.D.Dr. Craske, Ph.D. is Professor of Psychology and of Psychiatry and Biobehavioral Sciences, and Director of the Anxiety Disorders Behavioral Research Program, University of California, Los Angeles. She has published widely on the topics of fear and anxiety disorders, their etiology, assessment and treatment, including several text books as well as clinical guides. Her research pertains to risk factors for phobias, anxiety disorders and depression in youths and adolescents; cognitive, behavioral and psychophysiological characteristics of anxiety, fear and the anxiety disorders; the translation of basic science of fear extinction to the treatment of human phobias; and the development and dissemination of treatments for anxiety and related disorders. Dr. Craske was Associate Editor for the Journal of Abnormal Psychology, and is now Associate Editor for Behaviour Research and Therapy, and a Scientific Board Member for the Anxiety Disorders Association of America.

Dr. Craske received her bachelor's and 1st class honours degrees from the University of Tasmania, and her master's and doctoral degrees in clinical psychology from the University of British Columbia. She then completed her postdoctoral fellowship at SUNY, Albany, with Dr. David Barlow, before joining the faculty of UCLA in 1990.