The Past and Future of Anxiety: An Interview With Dr. Barlow

Source: wokandapix/pixabay and Arash Emamzadeh

I recently sat down to speak with Dr. David H. Barlow about anxiety disorders and their treatments, the DSM classification...and the latest changes to his triple vulnerability model.^1-5

Barlow’s model, which explains the origins of anxiety disorders, contains three components: a generalized biological vulnerability (having an anxious temperament or low threshold for the fight-or-flight response), a generalized psychological vulnerability (an unpredictable and uncontrollable early life environment), and a specific psychological vulnerability (in some disorders, anxiety becomes associated with a specific stimuli; in social anxiety disorder, for instance, anxiety is focused on social evaluation).

But recently, there has been a shift of focus in his model, from anxiety to neuroticism. But why? I needed to find out. Oh, and I also had to ask Dr. Barlow about a quote of his, one of my favorites: “May you continue to retain your illusion of control.”

The author of more than 75 books and 600 articles or chapters, Dr. Barlow, PhD, ABPP, is Professor of Psychology and Psychiatry Emeritus at Boston University. He is also Founder and Director Emeritus at The Center for Anxiety and Related Disorders at Boston University, and Past-President of the Division of Clinical Psychology of the American Psychological Association:

Emamzadeh: Dr. Barlow, I am very grateful for you having kindly granted me this interview. While I was working on another article (on fear of snakes), I actually came across a paper of yours, published in the late 1960s. It seems you have been researching emotional disorders for five decades! How has our understanding of emotional disorders, anxiety disorders in particular, changed since the ‘60s?

Barlow: Our understanding of the nature of anxiety has changed enormously. To take just one example, we did not recognize panic attacks that occur ubiquitously across all anxiety disorders as a distinct phenomenon. And, since 1980, we have had a disorder called “panic disorder."

Emamzadeh: Fear has survival value, at least in the right amount. Would you say the same about anxiety? In other words, would there be any drawbacks to a magical pill that could completely eliminate anxiety?

Barlow: In a book published several decades ago I noted (on page 12) “without anxiety, little would be accomplished. The performance of athletes, entertainers, executives, artisans, and students would suffer; creativity would diminish; crops might not be planted. And we would all achieve that idyllic state long sought after in our fast-paced society of whiling away our lives under a shade tree. This would be as deadly for the species as nuclear war.”⁶

Emamzadeh: Your triple vulnerabilities theory of anxiety disorders traces the origin of anxiety disorders to early in life, to factors that as adults we cannot change. But as parents, how much control do we have over raising a non-anxious child? Can you elaborate a little on parenting styles?

Barlow: Attachment theory informs us that parents can contribute to reducing anxiety and increasing resilience and coping in their children by avoiding overprotection and encouraging children to venture out and fend for themselves even if they fail from time to time, knowing that they can return to the family for support. In this way they learn to cope with stress and failure reducing anxiety upon subsequent encounters with stressful situations.

Emamzadeh: In your recent paper,⁷ you appear to advance a novel and complex view of neuroticism, suggesting that even though neuroticism is a personality trait, it may be modifiable in early life. Could you define neuroticism and then elaborate on your view?

Barlow: Neuroticism is typically defined as the tendency to experience frequent and intense negative emotions in response to various sources of stress along with a general sense of inadequacy and perceptions of lack of control over intense negative emotions and stressful events.⁷

When I originated triple vulnerability theory I was referring to the origins of trait anxiety. But we came to realize that trait anxiety is actually a temperament better described by the broader term “neuroticism” and that triple vulnerability theory accounts for the origins of neuroticism in our view.⁸ In subsequent papers we describe evidence that neuroticism may be more malleable than previously assumed in both children and adults.⁹

Source: Dr. David H. Barlow

Emamzadeh: Some trauma victims claim that though they were never truly in control before, they had at least the illusion of it—an illusion shattered perhaps beyond repair subsequent to the trauma. In dedicating your 2002 book Anxiety and Its disorders to Deneige and Jeremy, you write, “May you continue to retain your illusion of control.”² How do we retain this illusion in a world that regularly undermines it?

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Barlow: That dedication to my children was widely noted and reflects that most of us, fortunately, possess an illusion of control over events in our life that, on more rational analysis, are largely random and uncontrollable.

To take one example, very few if any of the 30,000 to 35,000 people killed a year in car accidents in the United States alone assumed prior to their trip that they would die that day. Almost all assumed that they could deal successfully any danger that arose. But this illusion of control is very protective. We will recover from illness and injuries more quickly, be released from hospital sooner after surgery, and generally perform better and live longer harboring the illusion that we can cope successfully with life’s vicissitudes.

Emamzadeh: Dr. Barlow, you have been part of the distinguished task force that oversaw the development of DSM-III¹⁰ and DSM-IV.¹¹ Has the time come to classify disorders based on their causes, instead of symptoms? Also, you have recently suggested a change towards a—still symptom-based but—dimensional as opposed to categorical classification of emotional disorders.¹² Could you briefly explain your proposal, especially as it would apply to anxiety disorders?

Barlow: Everybody, including the framers of DSM categories, recognizes that dimensional descriptions of psychopathology, assuming some continuity with normality, would provide a scientifically more satisfactory strategy for classification.

The problem was, until recently, experts could not agree on which dimensions would be relevant. Nevertheless, this system could more accurately describe psychopathology in individuals and avoid problems with comorbidity and deciding on psychopathology that does not fit neatly into existing categories. Beyond that, classification based on causality is the ultimate goal but we are just not there yet.

Emamzadeh: Would you say that particular DSM-5 anxiety disorders cause more dysfunction, or are more difficult to treat? If all anxiety disorders have a similar origin, why are there differences?

Barlow: I think the larger concern is the severity of the disorder rather than the type of disorder. Some individual cases of specific phobia or panic disorder I have seen have been far more disabling than many presentations of obsessive-compulsive disorder for example. But the most complex and serious presentations are characterized by extensive comorbidity.

Emamzadeh: From trying psychodynamic therapy to any of the several waves of cognitive behavioral therapy,¹³ not to mention medications, many people with anxiety have found relief from their symptoms. But not everyone. As a Diplomate in Clinical Psychology of the American Board of Professional Psychology, and a master clinician, what do you consider the best current therapies (including complementary ones such as exercise or yoga) for anxiety disorders?

Barlow: Well, that is an interesting question asked by many people and of great interest to consumers. In this regard, my answer may be disappointing in that I think that most therapies contain useful strategies, some of which may be more effective for some individuals than others. This is one reason we have tried to distill the most active ingredients from many different approaches based on the best evidence we have into a unified transdiagnostic protocol that is applicable in theory (and with increasing evidence) to all individuals suffering from emotional disorders.^14,15

Emamzadeh: Thank you again for this interview. My last question concerns the future of psychotherapy for emotional disorders. Where are we headed?

Barlow: I think we are on the threshold of enormous advances, I mentioned emerging transdiagnostic approaches above. In view of the number of people suffering from emotional disorders, including anxiety and depressive disorders, we have to find a way to be more efficient and effective in our delivery of these treatments, and I think we are now seeing exciting advances in strategies for dissemination and implementation, particularly in the area of telehealth.