Treating panic and social anxiety disorders
Our treatments for anxiety disorder have had a significant impact on healthcare guidelines and policy
Clinical Anxiety Disorders
Professor David Clark and colleagues from the Departments of Experimental Psychology and Psychiatry have made a significant breakthrough for people suffering from two common and disabling anxiety disorders.
Everyone experiences feelings of anxiety at certain times, particularly when in a dangerous, uncertain or stressful situation. However, people with clinical anxiety disorders persistently feel anxious in situations that are not objectively dangerous. In panic disorder, people experience, and fear, sudden attacks of anxiety, many of which seem to come 'out of the blue'. Social anxiety disorder is far more than being a little shy. People with the condition experience intense fear over routine social interactions, such as speaking up at work, meeting strangers, going to parties, talking on the phone or eating while being observed. Often the fear is driven by worries about doing something embarrassing or humiliating, and of people seeing your anxiety. 'It’s a fear of other people seeing your fear', says Professor Clark.
Developing new treatments
In the past, there were few effective treatments for these two anxiety disorders. Treatment with antidepressants had limited success and many patients relapsed after they stopped taking the drugs. Early behavioural therapies focused on repeated exposure to the stressful stimulus. However, less than half of patients benefitted from this treatment.
David Clark’s team adopted a unique strategy to understand these conditions and to develop treatments for them. First, they developed a psychological model of each disorder that particularly focused on the psychological processes that maintain it and prevent recovery. They then tested their models in experimental studies. Finally, they devised novel forms of cognitive therapy that specifically target the processes identified in the models:
- In panic disorder the team found that a fundamental component of the condition is a tendency to misinterpret harmless body sensations (e.g. racing heart, intrusive thoughts) as a sign of an imminent physical or mental disaster (e.g. heart attack or go mad). People often adopt safety behaviours (such as sitting down to rest or trying to push intrusive thoughts out of their minds) that prevent them from learning that the sensations are not dangerous. They also become hyper-attentive to their bodies and are able to detect sensations that many others are not aware of. David Clark’s team developed a cognitive therapy to specifically target the misinterpretations, safety behaviours and hyper-attention. In clinical trials the new therapy was found to be highly effective and superior to both drugs and behaviour therapy. These findings were soon confirmed in independent trials in the Netherlands and Sweden.
- In social anxiety disorder, the team identified negative self-imagery, focusing too much attention on oneself during social interactions, and the use of safety behaviours as key maintenance processes. In treatment, video feedback is used to help people gain an accurate impression of how they appear. People are also taught how let go of their safety behaviours and to 'get out of their heads and into the social interaction'. The new treatment has now been evaluated in seven randomised controlled trials in the UK, Germany and Sweden. The trials show that the treatment is highly effective and superior to other psychological therapies (exposure therapy, interpersonal psychotherapy, psychodynamic psychotherapy) and to medication (anti-depressants).
As a result of the new therapies, recovery from these two debilitating disorders can be as high as 70-80%. The National Institute for Health Care and Excellence (NICE) has recognised the importance of these findings. The 2011 NICE guidelines for treatment of panic disorder and the 2013 NICE guidelines for the treatment of social anxiety disorder both recommend the cognitive therapies developed by the Oxford group as first choice treatments.
Recently, the government has launched an initiative to Improve Access to Psychological Therapies (IAPT) within the NHS. The Oxford group’s therapies have been included in the national IAPT training curriculum and to date around 2,200 new therapists have learned the treatments and are delivering them in over 130 local services. A further 900 therapists will be trained over the next two years, further increasing access to the treatments.
In recent years Professor Clark and Lord Layard (a distinguished economist) have worked together to outline the economic and health case for increasing access to evidence-based psychological therapies within the National Health Service. Clark and Layard's recent book, Thrive: The power of evidence-based psychological therapies summarizes the arguments, which have had a marked influence on public policy. A podcast of David Clark & Richard Layard discussing the issues with Andrew Marr is available.