What You Can Change _. And What You Can't - Martin E. Seligman [34]
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 TABLE11
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