future directions in anxiety disorders

Journal of Anxiety Disorders, Vol. 14, No. 1, pp. 69–95, 2000Copyright 2000 Elsevier Science Ltd

Printed in the USA. All rights reserved0887-6185/00 $–see front matter

Pergamon

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THEORETICAL PERSPECTIVE

Future Directions in AnxietyDisorders: Profiles and Perspectives

of Leading Contributors

Peter J. Norton, MSc. and Gordon J. G. Asmundson, Ph.D.

Clinical Research and Development Program, Regina Health District, Regina,Saskatchewan, Canada

Brian J. Cox, Ph.D.

University of Manitoba, Winnipeg, Manitoba, Canada

G. Ron Norton, Ph.D.

University of Winnipeg, Winnipeg, Manitoba, Canada

Abstract—Eight of the most influential clinicians and researchers in the study and treat-ment of anxiety disorders were identified by polling professional members of the Anxi-ety Disorders Association of America. These eight individuals are (in alphabetical or-der): James C. Ballenger, David H. Barlow, Aaron T. Beck, David M. Clark, Edna B.Foa, Rick G. Heimberg, Donald F. Klein, and Isaac M. Marks. Each offered theirthoughts on a set of questions concerning the current and future status of the anxietydisorders field. Profiles and perspectives of these individuals are presented. 2000 Else-vier Science Ltd. All rights reserved.

It is our sincere hope that the perspectives and comments presented here will prove useful to aca-demics, clinicians, and students alike. This information provides a solid framework from which tostimulate discussion and debate, generate new approaches, and focus our efforts. The authorswould like to express their gratitude to the individuals who were profiled, for donating their timeand efforts in sharing their perspectives on the future of the anxiety disorders.

Requests for reprints should be sent to Peter J. Norton, MSc., Department of Psychology, Uni-versity of Nebraska-Lincoln, Lincoln, NE, 68588-0308, USA. E-mail: [email protected]

69

70 P. J. NORTON ET AL.

Keywords: Anxiety disorders; Future directions; Anxiety

Published research on anxiety disorders dramatically increased in volumefrom 1981 to 1990 (Norton, Cox, Asmundson, & Maser, 1995). During that de-cade, the percentage of articles referenced on the PsycLIT database that fo-cused on anxiety disorders increased from less than 0.2% in 1981 to over 2.1%in 1990, representing a 10-fold increase in magnitude. Similarly, the percent-age of anxiety disorders articles referenced on the MEDLINE medical ab-stract database rose from less than 0.1% to over 0.2%.

At the 1993 Annual Meeting of the Anxiety Disorders Association ofAmerica (ADAA), Dupont (1993) reported that anxiety disorders were themost costly of all psychological disorders. He noted that the direct and indirectcosts of all psychological disorders in the United States was $147.8 billion in1990. Of that amount, $46.6 billion or 31.5% was related to anxiety disorders.The indirect economic costs, such as lowered productivity, were especiallyhigh. Of $74.9 billion in indirect costs of mental illnesses, $35.4 billion (47.3%)was attributable to anxiety disorders.

Treatment efficacy for the anxiety disorders has shown considerable im-provement in recent years. For example, specialty clinics in Europe and NorthAmerica reported a panic-free success rate of 80%, with gains being main-tained in follow-ups of up to 2 years (Margraf, Barlow, Clark, & Telch, 1993).In addition, issues of prevention permeate discussions on the anxiety disor-ders, although little research is being conducted to identify onset factors andhow they may be controlled.

The results of the aforementioned papers provide informative retrospec-tive information, but offer little direction for future endeavors in the anxietydisorders. This is especially pertinent in the case of the anxiety disorders. Withthe dramatic increase in research also came a dramatic increase in the knowl-edge base and there are likely as many new questions and unresolved contro-versies as there are clear answers. As an illustration, the anxiety disorders sec-tion grew from 15 pages in the third edition of the Diagnostic and StatisticalManual of Mental Disorders (DSM-III; American Psychiatric Association,1980) to 52 pages in the fourth edition of the DSM (DSM-IV; American Psy-chiatric Association, 1994). Because of this tremendous increase in the knowl-edge base, we felt it was time to “take stock” of where we are and where thefield is heading.

This article, following a similar format to that used in an examination of fu-ture directions in sport psychology (Straub & Hinman, 1992), extends beyondthe retrospective investigation by Norton et al. (1995) by (a) identifying andprofiling leading anxiety disorders professionals, and (b) exploring their opin-ions regarding the future of anxiety disorders research, treatment, and educa-tion. As Straub and Hinman (1992) suggest, identifying leading scholars in an

71PROFILES AND PERSPECTIVES

area and obtaining their opinions about current and future issues, is “one ofthe most interesting and productive ways” (p. 298) to study a discipline.

METHODS

To identify the current leading contributors in anxiety disorders researchand treatment development, we conducted a poll of 196 ADAA professionalmembers. One hundred and eighty of the participants were randomly selectedfrom the ADAA Professional Membership list. The remaining 16 participantswere international members of the ADAA, and were selected to attaingreater international diversity. Reflecting the interdisciplinary nature of anxi-ety disorders research and treatment, 59 of the 196 members polled wereM.D.’s, 4 held an Ed.D. degree, and 128 held either a Ph.D. or a Psy.D. degree.A further 5 participants held both M.D. and Ph.D. degrees.

Participants were contacted by mail and asked to nominate up to 10 indi-viduals whom they considered to be the current leading contributors in theanxiety disorders. Participants were asked to consider contributors whosework covers any of the anxiety disorders, as classified in DSM-IV. For reasonsof objectivity, self-nomination was discouraged, as was nomination of thisstudy’s authors. Nominations were returned via return mail, facsimile, andelectronic mail. Completed nomination forms were received from 68 ADAAprofessional members, a response rate of roughly 35%. Overall, 140 separateindividuals received at least one nomination as a leading contributor in anxi-ety disorders research and treatment development.

A frequency distribution of the number of nominations received by each ofthe nominees was charted in a fashion similar to a Scree plot. Visual inspectionof this Scree-type plot revealed a distinct break in the votes. In terms of thenumber of nominations received, eight individuals were clearly separatedfrom the others by a margin of several nominations. Only one nomination sep-arated the subsequent ordinal ranks. For this reason, a decision was made torestrict the focus of this article to these leading eight individuals. The meannumber of votes received by these contributors was 26.5 (6 15.1), rangingfrom 17 to 55 votes.

The eight leading contributors (in alphabetical order) are James C. Bal-lenger, M.D.; David H. Barlow, Ph.D.; Aaron T. Beck, M.D.; David M. Clark,D.Phil.; Edna B. Foa, Ph.D.; Rick G. Heimberg, Ph.D.; Donald F. Klein,M.D.; and Isaac M. Marks, M.D. Although not by design, psychiatrists andpsychologists were equally represented among the eight leading contributors.

The second phase of the study involved briefly profiling the leading eightcontributors identified in phase one, and questioning them regarding theirviews on the current state of the anxiety disorders field and important futureareas of research and clinical intervention, treatment development, and pre-vention. All contributors to the article were provided with a presubmission


copy of the manuscript for their reactions. Final modifications to the manu-script were then completed.

BRIEF PROFILES OF LEADING CONTRIBUTORS

James C. Ballenger, M.D.

Dr. Ballenger was born in North Carolina in 1944. He received his B.A. inPsychology from the University of North Carolina at Chapel Hill in 1966, andhis M.D. in 1970 from Duke University School of Medicine. He followed thisby an internship in Internal Medicine at Duke University Medical Center, anda residency in psychiatry at the Department of Psychiatry, Harvard MedicalSchool. Dr. Ballenger currently holds the position of Professor and Chair ofthe Department of Psychiatry and Behavioral Sciences at the Medical Univer-sity of South Carolina (MUSC). He is also the Executive Director of the Cen-ter for Drug and Alcohol Problems at MUSC, and Director of the MUSCAnxiety Disorders Program.

Dr. Ballenger has published or edited five books in the areas of anxiety dis-orders and mood disorders. Additionally, he is an author on almost 300 chap-ters and journal articles. Dr. Ballenger is an accomplished and respectedspeaker, as demonstrated by his 604 presentations. Furthermore, he currentlysits on four editorial boards and is a reviewer for 19 journals.

Dr. Ballenger’s experience in the anxiety disorders field began in 1971when he designed and ran the first comparison of imipramine to phenelzine ina controlled trial. At a later date, he and David Sheehan demonstrated for thefirst time that the monoamine oxidase (MAO) inhibitor was actually better thanthe “gold standard” of pharmacological treatment at the time (imipramine).When Dr. Ballenger presented the results of that study for the first time, the dis-cussant was Donald Klein, who stated in his discussion that it was “nice to seeanother American psychiatrist interested in panic disorder.” Dr. Ballenger con-siders this to be perhaps his principal contribution (i.e., bringing the study of theanxiety disorders into greater prominence in academic psychiatry).

David H. Barlow, Ph.D.

Dr. Barlow was born in Needham, Massachusetts in 1942. He completedundergraduate training at the University of Notre Dame, and then attendedthe University of Vermont, where he received his Ph.D. in 1969. Dr. Barlowhas published over 300 articles and chapters, and over 20 books, mostly in theareas of anxiety disorders, sexual problems, and clinical research method-ology.

Dr. Barlow currently is Professor of Psychology, Director of Clinical Train-ing Programs, and Director of the Center for Anxiety and Related Disorders


at Boston University. Past positions include Professor of Psychiatry at theUniversity of Mississippi Medical Center, Professor of Psychiatry and Psy-chology at Brown University, Distinguished Professor in the Department ofPsychology at the University at Albany, SUNY and Director of the Phobiaand Anxiety Disorders Clinic at the University at Albany, SUNY.

Dr. Barlow was the recipient of the First Graduate Alumni Scholar Awardfrom the Graduate College, University of Vermont; the Distinguished Scien-tist Award from Section III of the Division of Clinical Psychology of theAmerican Psychological Association; the Excellence in Research award fromthe State University of New York at Albany; and a MERIT award from theNational Institute of Mental Health for long-term contributions to the clinicalresearch effort. He is Past-President of the Association for the Advancementof Behavior Therapy, and the Division of Clinical Psychology of the AmericanPsychological Association. In addition, he was Chair of the American Psycho-logical Association Task Force of Psychological Intervention Guidelines, wasa member of the DSM-IV Task Force of the American Psychiatric Associa-tion, and was Co-Chair of the Work Groups for revising the anxiety disordercategories. He is also a Diplomate in Clinical Psychology of the AmericanBoard of Professional Psychology, and maintains a private practice. Dr. Bar-low’s personal interests include golf, skiing, and walking beaches around theworld.

Aaron T. Beck, M.D.

Dr. Beck was born in Providence, Rhode Island in 1921. He received abachelor’s degree from Brown University in 1942 and, subsequently, an M.D.from the Yale School of Medicine in 1946. Although initially interested in psy-chiatry, he found the then-dominant role of Kraeplinian approaches to be ni-hilistic and unrewarding. Dr. Beck then attended the Philadelphia Psychoana-lytic Institute, graduating in 1956. Findings from his experimental work ondreams and other ideational data, combined with his clinical observations, ledDr. Beck to discard psychoanalytic theory and to formulate his cognitive the-ory and therapy of depression and other psychiatric disorders.

Dr. Beck is currently the Director of the Center for Cognitive Therapy,serves as Emeritus Professor of Psychiatry at the University of Pennsylvania,and is the President of the Beck Institute for Cognitive Therapy. He has pub-lished 375 articles and book chapters, as well as 12 books. Dr. Beck has beenthe recipient of numerous awards, including the 1989 American PsychologicalAssociation Distinguished Scientific Award for the Applications of Psychol-ogy, and the 1997 Annual Cummings PSYCHE Award.

Dr. Beck is considered by many to be a founding father of cognitive ther-apy, and has been described as “the grandfatherly white-haired gentlemanwith the red bow tie.” He personally feels that his greatest accomplishment/


contribution has been in refining the conceptualizations and the cognitive be-havioral interventions.

David M. Clark, D.Phil.

Dr. Clark was born in 1954 in Darlington, England. He studied Experimen-tal Psychology at Oxford University where he received his B.A. and D.Phil.He completed his clinical training at the Institute of Psychiatry (London Uni-versity) where he received an M.Phil. in Clinical Psychology. His first appoint-ment was as Lecturer in Clinical Psychology at Oxford, where he is currentlyProfessor of Psychiatry and a Wellcome Trust Principal Research Fellow.Other posts have included Chairperson of the British Association of Behav-ioural and Cognitive Therapies (1992), President of the International Associa-tion of Cognitive Psychotherapy (1992–1995), and Visiting Professor of Psy-chology at University of Pennsylvania (1991) and at City University, London(1992–1995). Awards have included the May Davidson Award for Early Ca-reer Achievement (British Psychological Society), and the Behaviour Re-search and Therapy award for the most outstanding article published in thatjournal between 1965 and 1990.

Dr. Clark’s research has focused on the effects of mood on informationprocessing and on the role of cognitive factors in the development, mainte-nance and treatment of anxiety disorders. In the anxiety disorders, his strategyhas been to use patient interviews, and experimental and correlational studiesto identify the core cognitive abnormality in a disorder and the factors thatnormally prevent cognitive change. A specialized form of cognitive therapythat focuses on the core abnormality and its maintaining factors is then devel-oped and evaluated in controlled trials. In collaboration with other research-ers, this strategy has helped produce new, effective cognitive-behavioral treat-ment (CBT) for panic disorder (PD) and hypochondriasis, and is currentlybeing applied to two other anxiety disorders—social phobia (SP) and post-traumatic stress disorder (PTSD). Among Dr. Clark’s personal interests arewalking, movies, art exhibitions, English country houses, wine, and learningabout life from his 5-year-old son.

Edna B. Foa, Ph.D.

Dr. Foa, born in 1937, completed a B.A. in Psychology and Literature atBar Ilan University, a M.A. from University of Illinois, and graduated fromthe University of Missouri in 1970 with a Ph.D. in Clinical Psychology and Per-sonality. She currently holds the titles of Professor of Psychiatry, and Directorof the Center for the Treatment and Study of Anxiety at the Medical Collegeof Pennsylvania and Hahnemann University.


Dr. Foa has published several books and over 200 articles and book chap-ters, has lectured extensively around the world, and was the co-chair of thePTSD work group and the chair of the Obsessive-Compulsive Disorder(OCD) work group of the DSM-IV. She is on the editorial board of 11 jour-nals, and an editorial consultant for 13 others. Dr. Foa has been recently hon-ored with the 1995 Association for Advancement of Behavior Therapy’s Out-standing Research Contribution Award, the 1996 American PsychologicalAssociation Distinguished Contributions to Clinical Psychology Award, andthe International Society for Traumatic Stress Studies’ 1997 LifetimeAchievement Award.

Dr. Foa’s research aims at delineating etiological frameworks and targetedtreatments. This research has primarily been in the areas of PTSD and OCD.The program that Dr. Foa and colleagues have developed for rape victims isconsidered to be the most effective therapy for posttrauma sequela in womenassault victims.

Richard G. Heimberg, Ph.D.

Dr. Heimberg was born in North Carolina in 1950. He received his bache-lor’s degree, Magna Cum Laude, in 1972 from the University of Tennessee fol-lowing a brief period at Vanderbilt University. He then attended Florida StateUniversity where he received a master’s degree in 1974 and a Ph.D. in 1977.Dr. Heimberg currently holds the position of Professor of Psychology at Tem-ple University, and he also serves as the Director of the Social Phobia Pro-gram at Temple University. In addition, Dr. Heimberg is on the Board of Di-rectors for the Association for Advancement of Behavior Therapy as arepresentative-at-large. In his free time, Dr. Heimberg is an avid skier andself-styled “computer nerd.”

Dr. Heimberg has published or edited five books, and is an author on 138chapters and articles. He has delivered 159 papers and presentations and 13workshops and institutes to professional associations. Additionally, Dr.Heimberg is the Associate Editor of Cognitive Therapy and Research, sits onthe editorial board of 9 journals, and is an ad hoc reviewer for 12 others.

He feels that his most important professional agenda beyond research andclinical practice is mentoring and nurturing his students. In terms of significantcontributions, Dr. Heimberg notes three that he feels “matter.” First, he feelsthat by studying SP from the early days, he has had a significant role in raisingawareness about SP in the professional community. Second, he feels he hashad a significant role in the development of CBT strategies for SP. Third, Dr.Heimberg has played an important role in multidisciplinary collaborationwithin the anxiety disorders. His hope here is that medical professionals willbecome more aware and accepting of CBT options for SP and other anxiety


disorders, and that psychologists will become more aware of and accepting ofmedical treatment options.

Donald F. Klein, M.D.

Dr. Klein was born in 1928 in New York City. He attended Colby Collegein Maine, where he received his B.A. in 1947. He subsequently earned hisM.D. from State University of New York, College of Medicine, in 1952. Dr.Klein then completed an internship at U.S. Public Health Service Hospital inStaten Island, New York, and a residency in psychiatry at Creedmoor StateHospital. Dr. Klein is a professor of psychiatry at Columbia University, andsits as the Director of Psychiatric Research for the New York State PsychiatricInstitute.

Dr. Klein has published 537 articles and chapters, and is an author or editorof 19 books. He has recently been awarded with the Society of Biological Psy-chiatry’s Lifetime Achievement Award (1996), Exemplary Psychiatrist Awardfrom the National Alliance for the Mentally Ill (1997), and the Castilla delPino Prize for Achievement in Psychiatry (1997). Dr. Klein played a majorrole in the classification of anxiety disorders in DSM-III and its successors.

A prevailing theme in Dr. Klein’s research over the years has been to con-ceptualize and understand the phenomenology of spontaneous panic attacks,in an effort to identify the most efficacious treatments. Regarding his ap-proach to research, Dr. Klein considers himself to be a nosological splitter us-ing pharmacological and, more recently, physiological dissection. Outside ofhis academic and clinical interests, Dr. Klein is an amateur cellist and a Parisenthusiast.

Isaac M. Marks, M.D.

Dr. Marks was born in Cape Town, South Africa in 1935, and qualified inmedicine there in 1956. He trained as a psychiatrist at the University of Lon-don at the Bethlem-Maudsley Hospital from 1960 to 1963, obtaining the Aca-demic D.P.M. and the M.D. in 1973. He was a founding Member of the RoyalCollege of Psychiatrists in 1971, and became a Fellow in 1976. He has doneclinical research at the Institute of Psychiatry and the Bethlem-Maudsley Hos-pital since 1964, becoming a senior lecturer and Honorary Consultant Psychia-trist there in 1968, Reader in 1974, and Professor of Experimental Psychopa-thology in 1978.

He has been a Fellow at the Center for Advanced Study in the BehavioralSciences in Stanford, Salmon lecturer and medallist at the New York Acad-emy of Sciences, consultant to the World Health Organization and the Na-tional Institute of Mental Health. Dr. Marks has been a visiting professor to


universities in six continents, Chairman of the British Association for Behav-ioural Psychotherapy, President of the European Association of BehaviourTherapy, and sits on the editorial boards of numerous professional journals.Furthermore, he has won the Starkey Medal and Prize of the Royal Society ofHealth, and a Health Care 1998 Information Technology Clinical Effective-ness Award for the BT STEPS system of self-care of OCD. To date, Dr. Markshas published 12 books, and over 380 professional papers.

Dr. Marks’ research has included the origins, features and treatment ofanxiety, phobic, obsessive-compulsive, and sexual disorders. He has examinedinteractions between drugs and behavioral psychotherapy, development of anational nurse therapist training program, community care of serious mentalillness, and health care and cost effectiveness evaluation. Recently he has de-veloped computer aids for the evaluation and delivery of psychiatric treat-ment.

PERSPECTIVES OF LEADING CONTRIBUTORS

Four specific questions were presented to each of the eight leading contrib-utors. The questions queried their opinions about: (1) the future of anxietydisorders research, (2) the future of anxiety disorders intervention, treatmentdevelopment, and prevention, (3) education and clinical training related to theanxiety disorders, and (4) the greatest accomplishments and biggest disap-pointments in the anxiety disorders during the past 10 years. Furthermore,each contributor was provided with an opportunity to discuss other relevantissues at their discretion. Every effort was made to preserve the exact re-sponses of the eight leading contributors, although some minor modificationswere made. We have arranged and presented the responses in an order thatwe felt provided the best flow. Responses to each question are providedbelow.

What Do You Feel Are the Key Future Areas for Research Within the Fieldof Anxiety Disorders?

Heimberg: This is a broad question and deserves a broad answer. Basically,we need to refine our knowledge in almost all areas of study within the fieldof anxiety disorders. We have made tremendous strides in the last decade toincrease our understanding of the various anxiety disorders and how to treatthem, but knowledge in this area is cumulative and we still have some dis-tance to go. The battle is not over until we are able to prevent the occurrenceof most anxiety disorders and effectively treat virtually all others. The mostimportant areas for research will be those that will increase our basic under-standing of the various anxiety disorders, that is, studies that will elucidatethe mechanisms by which affected persons develop anxiety responses and


anxiety disorders and the protective factors which permit other persons toundergo the same experiences or be exposed to the same environmentswithout developing these difficulties. Studies in this vein will call upon pro-fessionals from many disciplines and areas of expertise, including genetics,familial environment, information-processing, and social behavioral pro-cesses. The future will call upon us to adopt a multidisciplinary perspectiveon the anxiety disorders, integrating these and other areas of inquiry into acomprehensive view of what the anxiety disorders are all about. The biggestchallenge may be allowing ourselves to rise above our own personal andprofessional points of view in an attempt to accomplish this goal.

Ballenger: You would probably not be surprised that I think the key issue forthe near future will be the further elucidation of brain structures and circuitsunderlying anxiety in general, as well as specific types of anxiety and disor-ders. I am personally impressed with the emerging confluence of basic ani-mal studies and human functional neuroimaging studies implicating theamygdala, and believe this is central to general anxiety, and perhaps relateddisorders such as PTSD, generalized anxiety disorder (GAD), and phobiasincluding PD. A similar statement can be made for different circuits (basalganglia and frontal lobe) in OCD. As we use functional MRI and positronemission tomography to follow out these leads, it is my expectation that wewill make significant advances. This could speed up the process of devel-oping both new medications and new psychological treatments as we betterunderstand the pathophysiology of these disorders.

This reflects the general trend of increasing use of rapidly evolving tech-nologies (e.g., functional neural imaging, molecular biology, etc.) to studythe anxiety disorders. Only a few years ago these technologies were muchless developed and very little of the most modern neuroscience was directedtowards understanding the anxiety disorders. Investigators are increasinglyturning to working on these disorders, and I think that is a significant andimportant trend. A related trend is the coming together of different types ofscientists to forge a greater synthesis. At the 1998 ADAA meeting, SteveHyman and I pulled together groups of scientists whose work is significantlyconverging. This included molecular neuroscientists, neurophysiologists,psychologists, and functional neuroimaging workers, all to focus on the con-vergence of their findings and the stimulation that might provide the nextphase of research. In many ways, this is more possible with the anxiety disor-ders than with any of the other psychiatric disorders.

I think another important area of evolving and future research will be inPTSD. I think it is important that the epidemiology is finally being deline-ated and appreciated, instead of being denied. The level of difficulty peoplewith PTSD have, and even the nature of the symptomatology, is an impor-tant area of research. There is important work on brain structures, for exam-ple, decreased hippocampal volume. Again, attention is beginning to swingaround to developing better psychological treatments, and medication treat-ments, of this very prevalent and severe problem. We need significant prog-ress in this area, and I think we will see more of it in the relatively nearfuture.


To return to a research perspective, one important area is to understandthe neurobiological (and psychological) differences in children before theydevelop an anxiety disorder. Are there biological differences from the sameanxiety disorder in adults? There is early evidence that this is, in fact, thecase. If so, prevention efforts could be better focused based on these data.For instance, could we treat the changes observed in children to preventthem from evolving into disorders in adults (e.g., we could prevent the childwith separation anxiety from later developing panic attacks and then PDand/or agoraphobia).

Barlow: Over the next several years it is very likely that our basic concep-tions of the nature of anxiety and related emotional states will change sub-stantially with implications for the nature and classification of anxiety andrelated disorders. Specifically, new conceptual models of anxiety, depres-sion, and related states are emerging using sophisticated modeling tech-niques that go well beyond current conceptions of anxiety and depression.Ignoring current categorical systems of nosology, key to the development ofanxiety, depression, and related emotional disorders will be the more pre-cise identification and increased understanding of basic psychosocial traitsthat constitute a vulnerability for these disorders.

Beck: I think that there is a considerable future area for exploration of thebasic psychopathology of the anxiety disorders. There has been consider-able progress even in the last couple of years dealing with different aspectsof information processing, the patients’ attitudes towards their symptoms(e.g., obsessions), and various personality factors that affect both the mani-festation of these symptoms and the appropriate interventions.

Clark: My view is inevitably personal and colored by my own recent re-search experience. Others will no doubt have different priorities. I wouldparticularly like to see more research in which the paradigms and conceptsthat are prominent in cognitive psychology are applied more closely to thespecific threat stimuli and activating conditions that characterize differentanxiety disorders. In this way, it will hopefully be possible to more preciselydelineate the subtle processing biases that maintain suffers’ fears. To date,we have seen a considerable amount of work looking at selective attentionand memory for emotionally valenced verbal material. It has often been as-sumed that this material serves as a reasonable proxy for the real-life threatcues involved in anxiety disorders, but recent research suggests that this maynot be correct. For example, in a series of studies we have found that al-though socially anxious subjects show an attentional bias towards socialthreat words, they can show an avoidance of processing threatening faces,but only when they consider themselves to be under social evaluation. Bi-ased recall of negative information in anxiety disorders may be similarly spe-cific to activating circumstance and type of information. For example, it


would make little sense for social phobics to have numerous intrusive recol-lections about past social interactions while they were engaged in a conver-sation. However, it seems reasonable that they might engage in a selectivememory search when they are anticipating a difficult social interaction andare trying to work whether to go ahead with it or to avoid. A recent experi-ment by Warren Mansell has provided some support for this notion byshowing that high socially anxious subjects have enhanced explicit memoryfor negative information, but only when they are anticipating a social inter-action and when the information concerns the way they think about howthey are viewed by other people, rather than the way they privately thinkabout themselves. Anke Ehlers has observed a comparable type of specific-ity in her studies of interoceptive awareness in hypochondriasis. Patientswhose preoccupations focused on cardiac disease, but not patients whosepreoccupations focused on cancer, had better than normal ability to per-ceive their heart beats and changes in airway resistance. I would hope thatfurther research along these lines will provide further clinically useful infor-mation about the specific cognitive abnormalities that maintain particularanxiety disorders.

Another area in which further research is likely to be fruitful is the rela-tive efficacy of CBT and medication alone or in combination. David Barlow,Jonathen Davidson, Edna Foa, Jack Gorman, Michael Liebowitz, RichardHeimberg, Katherine Shear, and others have recently reported pioneering,multisite studies in this area. These studies have helped establish cross-disci-pline acceptance of the utility of both CBT and medication. In addition, theyhave produced some intriguing findings. Perhaps the most intriguing is Bar-low and colleagues data in PD. In the short-term, combined CBT and medi-cation was more effective than active medication alone, but it did not matterwhether the pill combined with CBT was active medication or a placebo.However, when the pill was withdrawn, relapse was greater if it had been anactive medication. This study raises intriguing questions about the psycho-logical processes involved in combined treatment and is practically very im-portant as many patients who receive psychological treatment are alreadytaking medication.

A currently underresearched area is the process of change in CBT anddiscrepancies between therapist and patient perceptions of the value of cer-tain procedures. I gather some of Dietmar Schulte’s recent data suggeststhat deviations from treatment protocol to collect extra background infor-mation may lead to increased hope of a good outcome in therapists but in-creased pessimism in patients. If confirmed, this type of research may helpus improve the consistency with which therapists deliver effective proce-dures.

Foa: One key area for research is the etiology of the different anxiety disor-ders and the distinction between etiological factors and maintenance factors.One nagging issue is as follows: Given the familial vulnerability to anxiety


and mood disorders, why do some patients become social phobics and oth-ers develop PD? It seems that we do have some handle on some factors thatare implicated in anxiety disorders, for example, cognitive distortions, cogni-tive biases, habituation. Are those etiological factors, maintenance factors,or both? Here, the study of children of adult probands and the parents ofchildren probands would be very important. Also, genetic studies that aremaking progress in other disorders should be focusing also on the anxietydisorders.

Another potentially fruitful area of research is the interface between thebrain neurostructures of anxiety or fear and the anxiety disorders. Somework has already began in this respect. For example, Lang and his col-leagues are working on the startle response as measuring aversive system,the work of Le Deux has inspired many researchers of anxiety disorders,particularly in the area of PTSD. Another interesting pursuit is to bring to-gether research on nonpatient anxious populations and research on patientpopulations. Do patients simply occupy the extreme range of the same fac-tors that operate in nonpatient anxious individuals, or do the two popula-tions differ qualitatively from one another?

Klein: There are several major findings in the anxiety disorders that set thefield for research. Many of the anxiety disorders have some peculiar rela-tionship with depression, or at least with some depressive syndromes. Thiscannot be ignored. Studies on GAD show that the longer the period of theGAD, the more likely the patient is to be depressed. Studies on SP show themore likely the patient is to be depressed, the more likely it is that they areto have an atypical depression. Studies in PD indicate a very high comorbid-ity with both atypical and non-atypical depression. Studies in OCD indicatethat depressive episodes strongly exacerbate obsessive-compulsive symp-tomatology, etc. Therefore, a major field of investigation is in the relation-ships between the various anxiety and depressive disorders. Further, manyanxiety and depressive disorders are developmental disorders. Breslau,Schultz, and Peterson (1995) have shown that the excess amount of de-pressive disorders in females is an exact epiphenomenon of the precedingfact of an excess of anxiety disorders in females. Many of the psychologicalattempts to understand depression have ignored this.

Further, important issues are that there is excellent evidence of quite spe-cific genetic loadings for some anxiety and depressive disorders. The idea ofa generalized neurotic disorder should no longer be credible, but the area ofGAD requires refinement. The confusing secondary effects of demoraliza-tion and anticipatory anxiety blurring the difference between anxiety disor-ders and depressive disorders makes detailed longitudinal studies necessary.

The notion that the panic attack is a misplaced fear is contradicted bylack of a hypothalamic pituitary adrenal (HPA) exacerbation during boththe clinical panic attack and the lactate and carbon dioxide-induced panic.The fact that normal fear is not associated with dyspnea, whereas the clinicalphenomenon is, indicates once again that they are different phenomena.The bland assumption that the misrelease of fear is an adequate explanationfor the anxiety disorders is obstructing progress.


The notion of anxiety sensitivity requires further evidence that its devel-opment is not due to a prior pathological anxiety state, or if it does occur,that the subsequent panic-like phenomena actually resemble PD. A key is-sue is understanding why the spontaneous panic attack is short-lived andself-terminating, since this is inexplicable on psychological grounds, al-though understandable on the basis of hyperventilation being not a panico-gen, but a panic terminator, as predicted by the suffocation false alarm the-ory. That SP responds to the MAO inhibitors but not to the tricyclics, andthat when social phobics become depressed, it is predominantly atypical de-pression, indicates another important area.

Since there has been extensive evidence that many of the various condi-tions breed true, but there has been little progress in molecular genetics, theissue of phenotypes and false positives looms large. In particular, the utilityof age of onset as a discriminating variable for all illnesses bears emphasis.Recent studies have shown that the age of onset in atypical depressionallows for a specific imipramine response, as well as evidence of right hemi-sphere deficit in comparison to early onset atypical depression.

The development of carbon dioxide sensitivity as a model of PD, in com-bination with the early recognition of separation anxiety as an antecedent ofPD and perhaps other disturbances, argue looking for a common physiocen-tric abnormality, which may be a periodic endorphin deficiency, as has alsobeen suggested for premenstrual syndrome. Since lactate is a highly specificpanicogen for PD (except for premenstrual syndrome) the development of amodel for producing clinically similar panic attacks in normals as a modelfor psychopathology becomes extraordinarily important. Since naloxone de-creases endorphins, thus, in principle, increasing both carbon dioxide sensi-tivity and separation anxiety, it may make normals vulnerable to lactate in-fusions. Our recent pilot studies have shown this may be the case. We nowneed to show that this perhaps artifactual finding can be blocked by treat-ment with the standard antipanic agents. This can lead to a fruitful criticalmodel of PD allowing the test of pharmacological intervention.

For each of the anxiety disorders, studies must be made that would linkthem to understandable ethological difficulties. SP seems related to perfor-mance anxiety, deference to authority, and fear of humiliation. PD seemsheterogeneous, consisting of attacks analogous to ordinary fear and thoseanalogous to sudden suffocation alarms. Agoraphobia indicates the abilityof such alarms to incite severe anticipatory anxiety, the possible restimula-tion of the alarm, and possible chronicity produced by sensitization.

OCD remains a probably heterogeneous mystery. Recent studies on basilganglia autoimmune phenomena suggest that many obsessive-compulsivephenomena consist of derangements in hard-wired action programs. How-ever, the pervasive doubt in OCD may indicate a derangement in a match/mismatch mechanism that allows one to say that current data has satisfied areasonable inference. Many such match/mismatch devices may be tied toparticular biological needs, such as cleanliness. In particular, the over-wash-ing compulsive is plagued by the persistent doubt that he is not cleanenough. That this is associated with a grooming monitor is possible.


PTSD remains a confused area. People who are prone to trauma seemdifferent from those that are not prone to trauma, in terms of being morethan usually impulsive and short-sighted. We need to partial out the propen-sities of this group for such problems as alcoholism and drug abuse from ac-tual effects of the trauma. Other predispositions consist of a propensity foranxiety in the family. Insufficient attention has been paid to defining PTSDin terms of spontaneous panic, flashback and the implication of flashback,sleep disturbance, and the propensity to dissociate. The report of lowchronic cortisol in PTSD, as well as the lack of HPA activation in the sponta-neous panic, indicates the possible involvement of HPA inhibitory pro-cesses, and the utility of metapyrone studies.

Marks: A key area for research will be the elucidation of the effective andredundant ingredients of treatment. Existing paradigms do not clearly ex-plain why exposure therapy (E) alone and cognitive restructuring (CR)alone are each similarly therapeutic for PTSD, OCD, panic/agoraphobia,and probably nightmares. In the randomized controlled trials for PTSD,even in the CR-alone group, cognitive changes appeared after, not before orsimultaneously with, improvement in symptoms and work/social adjust-ment. CR was thus unlikely to have worked by straight CR. And as no CRinstructions were given to the E group, we cannot argue that E worked byCR. We can think of several mechanisms of anxiety reduction, by habitua-tion and/or by stepping back and getting perspective on a problem andlearning to deal with it bit by bit (problem-solving)—but how do we testwhether this view is right or wrong?

We can also learn from results of randomized controlled trials for depres-sion. Interpersonal therapy (which is a kind of problem-solving), problem-solving, CR including behavioral activation, and behavioral activation with-out CR are all significantly therapeutic. And why does meditation and alsoreligious behavior/belief have such wide appeal? What do those achieve,and how do they fit into our framework? Neither relaxation alone nor pillplacebo are especially and lastingly therapeutic. Are there several roads totherapeutic Rome/Nirvana from different directions, or do they overlap andconverge at some point? We need to separate those methods that enhancemotivation to do effective maneuvers from the effective maneuvers them-selves.

Understanding the above could increase our therapeutic potency, helpmore sufferers, and help us devise better preventive strategies. The latterneed long-term studies with children over several years. We have known atleast since 1971 that irrelevant exposure can be as therapeutic as relevant ex-posure. How do we distinguish between toughening-up stress-immunizingprocedures on the one hand and sensitizing ones on the other? We can getsome ideas from the animal literature.


What Do You Feel Are the Key Future Areas for Clinical Intervention,Treatment Development, and Prevention Within the Field ofAnxiety Disorders?

Ballenger: I see a promising and important area evolving between the anxi-ety disorders and certain somatic/medical processes and problems. Thiswould include, but not be restricted to, the interface between anxiety and ir-ritable bowel syndrome and also with cardiovascular illness. The epidemiol-ogy is evolving and the basic science is beginning to be explored. Again, liai-sons between anxiety researchers and basic brain and medical researchersare evolving for the first time, to carry out work in these very importantareas.

I would make specific mention of the high quality research studies thatare evolving studying and comparing the benefits of medication and psycho-logical treatments used alone and in combination in areas such as PD, SP,and OCD. Multicenter, well-controlled trials are evolving and the quantita-tive and qualitative differences between the single and combined treatmentsare important and should form the basis for more scientifically validatedtreatments. I am more pessimistic about treatment advances in the area ofOCD, because it appears we have reached a plateau phase of our therapeu-tic work. I do see potential progress in that animal models seem to be on thehorizon. Elucidation of a good animal model would be an extremely impor-tant step.

I also personally think it is very important that the real impact clinicallyof the anxiety disorders will not be appreciated until we appreciate and dealwith their presentation in nonmental health settings. It is still true that theaverage anxious patient is not seen in mental health settings and is usuallymisdiagnosed and mistreated. With most of the world either utilizing ormoving towards a primary care model of treatment, recognition and treat-ment of anxiety disorders in those settings needs to be a high research prior-ity, as does treatment in those settings.

I have obviously been commenting on the intervention, treatment, andprevention issues above but would make a few additional comments. Thebiggest area if you think broadly about these issues is that these disordersare not recognized in most settings, or in most people. There needs to be amajor expansion in our efforts with the public and with the nonmentalhealth professionals to more appropriately recognize and treat these condi-tions. A greatly underemphasized area in my opinion is the prevention area,even with the leads we currently have. We now have leads that can identifyvery high-risk populations for early intervention, but we rarely act on this.These populations include the children of parents with anxiety disorders,children with an anxious temperament with behavioral inhibition as de-scribed by Jerome Kagan, or the victims of trauma. We know there are veryhigh rates of anxiety disorders in these populations and others, but our sys-tem is not set up to prevent the future evolution of these disorders.


Foa: The enterprise of behavior therapy began with enormous optimismabout the potential efficacy of its treatment techniques. The success of be-havior therapy was especially noted with the anxiety disorders. As the fielddeveloped, behavior therapists began to recognize that the efficacy of be-havior therapy is limited and that even when behavioral procedures werefaithfully followed, many patients did not improve or relapse. For example,with OCD, exposure and response prevention helps about 75% of thosewho complete treatment, but 25% either do not benefit, or relapse, andmany refuse this treatment because of the very obsessional fear that it is de-signed to reduce.

Recognition of the limitations of behavior therapy led many experts toemphasize cognitive mediation of behavior and emotion as the target oftreatment and various treatment programs have emerged from the cognitiveapproach (e.g., anxiety management training, cognitive therapy). Cognitive-oriented therapies have been applied to various anxiety disorders. The liter-ature yields the general impression that cognitive techniques are effective,but have not dramatically improved upon outcomes achieved with treat-ments derived from exposure.

Contemporary attempts to advance treatment efficacy involve a theoreti-cal integration of various therapies or components thereof, in order to outdothe efficacy of the individual components. Such attempts have yielded mixedresults. For example, both exposure and stress inoculation training were par-tially helpful with chronic PTSD, but their combination did not yield a supe-rior outcome.

How can we improve over present efficacy? One important factor is theincreasing gap between research in experimental psychology, psychopathol-ogy, and treatment research. The history of developing behavioral therapieswas highly connected with experimental psychology (i.e., systematic desen-sitization and flooding for phobias, exposure and response prevention forOCD). In the last two decades, experimental psychology has been heavilyinfluenced by information processing concepts and, in turn, research on psy-chopathology of anxiety disorders has been greatly informed by develop-ments in cognitive experimental psychology (e.g., cognitive biases in anxiousindividuals). I suggest that the slowing advance of therapy is the result of itsalienation from psychopathology and experimental psychology and that ad-vances in treatment effectiveness would emerge from cross fertilizationamong these disciplines.

Marks: Self-help methods have been repeatedly effective in randomizedcontrolled trials, even with treatment by mail and by computer. These needfurther development. Computer-instructed treatments are wonderful re-search tools. They aid dismantling exercises and speed data collection andanalysis (see Marks et al.’s forthcoming review on computer aids to mentalhealth problems, in Clinical Psychology; Research and Practice, Summer1998). They can do for some aspects of psychotherapy what the microscopedid for biology and the telescope for astronomy. They can also help mass


dissemination of effective treatments, in that respect doing what Henry Forddid for transportation (let’s hope there will be fewer equivalents of roaddeaths!)

Clark: Barlow and Lehman’s (1996) recent review of psychosocial treat-ments for anxiety disorders makes it clear that we now have specific and ef-fective CBT’s for all of the disorders. However, if one computes what onemight call the “bottom line” (proportion of patients who accept the treat-ment X proportion who recover to normal level of functioning X proportionwho stay well for at least 1 to 2 years) it is clear that there is considerable be-tween disorder variability in the effectiveness of our interventions. PD andspecific phobias give figures around 0.6–0.7, but for most other anxiety disor-ders the figure seems to be more in the ballpark of 0.3–0.4. A major chal-lenge is therefore to enhance the “bottom line” for these disorders. In thecase of PD, we took the approach that the best way of developing a highlyeffective treatment was to develop a disorder specific model of the processesinvolved in preventing cognitive change in everyday life and then devising atreatment that specifically targeted those maintaining factors, or at leastthose that were supported by empirical work. Many other groups also adoptthis general strategy and it is to be hoped that future application of it toother disorders will enhance overall effectiveness. GAD will be perhaps themost exciting area to watch in terms of success or failure. At the moment,David Barlow, Tom Borkovec, Robert Ladoceur, Mark Freeston, StanleyRachman, and Adrian Wells, all have different theories of the maintenanceof the disorder and it is unclear which will lead to the greatest improvementsin treatment.

Beck: Among the key areas for clinical intervention and treatment develop-ment are the shortening of the therapy time when an appropriate conceptu-alization or formulation of the anxiety disorder has been developed; for ex-ample, the Oxford group has now been able to reduce the length of time forinterventions for PD down to five sessions. Similarly, the knowledge of psy-chopathology has been a guide to more effective and shorter treatment ofagoraphobia (again, the Oxford group). The findings by various groups thatcognitive restructuring is an important component of PTSD, OCD, panic,and GAD have been an important step forward. The more recent formula-tion of OCD that concentrates on the patient’s sense of responsibility is animportant step that leads to a relevant intervention. Similarly, the focus onneutralizing cognitions in obsessions has provided the framework for a moreeffective approach to this disorder.

Klein: The most important area in the field of anxiety disorders with regardto intervention is developing close collaborations between the psychologi-cally minded and the pharmacologically and biologically minded. The psy-chological framework for many anxiety disorders can be persuasive. Fur-ther, those psychotherapies focused upon the reduction of anticipatoryanxiety and avoidance through exposure often prove successful. This raises


the question of functional autonomy. It is certainly possible that the dis-traught patient develops a variety of apprehensions that lead them to avoid-ances because of fear of the recurrence of the distraught state. Simply dem-onstrating to them by exposure that this does not occur can be fruitful.However, treatment failures and relapses offer the opportunity to focus oncurrent pathogenic processes via longitudinal follow-up and challenge pro-grams.

Joint comparative studies of pharmacotherapies, psychotherapies, andtheir combination, appropriately controlled with pill and, as indicated, psy-chological placebo therapies, allows for public health relevant as well as heu-ristic decisions as to the important components of care. Such studies couldalso lead to advances in our understanding of causation, or at least physio-pathology. Acute, continuation, and maintenance studies are all needed. Itis clear that short-term medication trials often are insufficient for long-termgains, but there is little data on the potential of extended treatment periods.

Barlow: Research in the near future will also target both biological and psy-chosocial factors that are associated with the development of these basicpersonality traits as well as factors that influence the differentiation of keybehaviors and cognitions that currently make up the defining features ofDSM-IV anxiety disorders. This basic psychopathological research, in turn,will lead to a new generation of interventions targeted, perhaps, more di-rectly at underlying vulnerabilities with a particular emphasis on preventionof emotional disorders. Much of the initial activity will most likely occur inthe context of identifying children at risk for developing anxiety disordersand (a) developing a better understanding of the psychosocial factor thatlead to the development of specific disorders, (b) evaluating the variety ofpreventive interventions for these children at risk, (c) following these sub-jects longitudinally based on new but robust findings on the chronicity onanxiety disorders.

Heimberg: It is my own view that advances in treatment will be most rapidlymade by putting much of our energy into furthering our understanding ofthe basic processes underlying the anxiety disorders. Nevertheless, it willalso be important to keep the positive momentum we have generated in thelast decade in the direct study of treatment interventions. Major advanceshave been made in the treatment of anxiety disorders with cognitive-behav-ioral and pharmacological approaches, but here again there is much roomfor additional growth. Cognitive-behavioral approaches have demonstratedsubstantial efficacy for several of the anxiety disorders (notably PD, SP,OCD, and specific phobia). Similar statements can be made about pharma-cological approaches. However, there are at least five areas that call for ourattention: (1) the other anxiety disorders (e.g., GAD, PTSD) need our in-creased efforts in treatment development; (2) even for the disorders forwhich demonstrably effective treatments are available, there are too manypersons who do not respond or who do not respond completely enough toavailable treatments; (3) we have done little to examine the potential utility


of combined or multidisciplinary treatments; (4) we know little about the ef-ficacy of treatments for persons with anxiety disorders who also experienceany of a number of comorbid conditions; and (5) we have developed too lit-tle knowledge about the predictors of treatment outcome.

One of the great developments over the past few years in cognitive-behavioral intervention has been the increasing reliance on manualizedtreatments. While not everyone is enamored with treatment manuals, theyhave immensely facilitated the development of CBT for anxiety. An impor-tant agenda for the future has to do with the further study of manualization,when it is good and when it is restrictive, and how such intervention materi-als may best be disseminated and shared with the clinical community.

In the area of prevention, there are any number of things that we need todo, prevention of anxiety disorders being a field in its infancy. Probably, themost important aspect of this is public education about the nature of anxietyand anxiety disorders. We have made great strides in terms of the public’sawareness of anxiety disorders such as PD and agoraphobia. However,other disorders like SP, are much less familiar to the person on the street. Asa result, many persons who might receive treatment do not and those whodo so receive treatment only after a long interval has passed. Increasing thepercentage of people who are aware of all of the anxiety disorders and thatthere is help available for them will increase the numbers of persons who re-ceive treatment and do so more quickly. While this may not actually preventthe occurrence of anxiety disorders, it may prevent an anxiety experiencefrom becoming a disorder, keep an acute problem from becoming a chronicone, or reduce the amount of impairment experienced as the result of disor-der. In addition, it is also possible that anxiety disorders may be risk factorsfor other disorders, which may develop later in life as a consequence of un-fulfilled goals and dreams (depression) or attempts to control the pain (alco-hol and substance abuse). Certainly, effective treatment of anxiety disorderscan reduce the devastation associated with these disorders.

Are There Any Areas or Issues With Regard to the Anxiety Disorders ThatYou Feel Should Be Introduced, Emphasized, or Changed inEducation and Clinical Training?

Klein: Current education and training is grossly deficient because the bestinterdisciplinary collaboration occurs within one brain. Training Ph.D.s inthe importance of Pavlovian, Freudian, and Skinnerian theory with a lack ofconcern for biological and pathological predispositions (although Skinner,Pavlov, and Freud recognized these variables as important) allows trivialpursuit. The biological studies have regularly focused upon the importanceof fear as central, thus implicitly assuming that ordinary fear or anticipatoryanxiety, as can be produced in the Geller-Seifter model, are really relevantto pathological affective states. This is an assumption rather than a demon-stration.


Our current schools for clinical training are divorced on straight guildgrounds. That is unfortunate because it promotes guild allegiances and sim-plistic notions about what is important. I think a major defect is that psychol-ogists know little about the complexity of organic functioning. Therefore, amere taste of medical training is unlikely to remedy this. At the very least,prolonged exposure to medical problems and care is necessary. The contrarypoint is often made that physicians are blind to psychological issues such asthose that deal with learning, development, conditioning, etc. Perhaps so,but I think as a matter of hard fact that this material is a lot easier to learnthan the differential diagnosis of temporal lobe epilepsy. I see no conceptualproblem of building into the postgraduate psychiatric education an appro-priate understanding of current neuropsychology, as well as relevant learn-ing and developmental theory. There may be turf problems.

This enormously complexifies Ph.D. training, makes current Psy.D. train-ing almost irrelevant, and moderately complexifies M.D. training. However,all schools of training should understand that if they are producing prac-titioners that the level of therapeutic intervention and understanding largelystops at graduation and that the ability to critically evaluate new advances isskimpy at best. How to deal with this is not clear because the economic in-centives are not there in our current structure and Continuing Medical Edu-cation is problematic. One wishes to develop a core of people really inter-ested in the determinants of pathology and therapeutic correction, who arenot primarily rewarded by the acclaim and income of reputed therapeuticexpertise. That would require a very advanced reconstruction of presenttraining, as well as scientific and therapeutic practice. Periodic work sam-pling in specialized facilities is probably a minimum for evaluating realexpertise.

Beck: The curricula of clinical training programs should introduce recent ad-vents in the treatment of anxiety disorders; for instance, the more effectiveand shorter therapies for PD and agoraphobia developed by the Oxfordgroup. In addition, practitioners-in-training should develop a working knowl-edge of the new conceptualizations in treatment approaches for several anx-iety disorders, such as neutralizing cognitions in obsessions for OCD.

Barlow: As with other disorders, radical new training procedures in our pro-fessional programs in the near future will emphasize competence with thevariety of empirically supported psychological and drug treatments that arecurrently available for specific anxiety disorders. Currently, it seems that dif-ferentiated training based on a competency model will occur in four differ-ent tracks. The first track will involve competent diagnosis and assessmentof anxiety and related disorders to preestablished levels of reliability. Thesecond track will involve developing competence in treating the closely re-lated DSM-IV disorders of PD, phobias, and GAD. The third track will con-centrate on the technically more difficult interventions for OCD and itsclose relatives (e.g., body dysmorphic disorder, trichotillomania, etc.). Thefourth track will involve developing competencies in treating the family of


trauma-related disorders beginning with PTSD but extending on to some ofthe dissociative disorders and, perhaps, personality disorders. Licensing re-quirements in the future will most likely tap into competencies to assess andtreat rather than baseline of general knowledge.

Heimberg: I strongly believe that exposure to the anxiety disorders shouldbe an integral part of the training of every mental health professional. Sinceanxiety disorders are so prevalent, there is virtual certainty that prac-titioners will be asked to treat persons with anxiety disorders. In the contextof my own profession, clinical psychology, I believe several things are neces-sary: (a) exposure to the different disorders and clinical information aboutthem, (b) understanding about how anxiety disorders relate to and interactwith other disorders, (c) knowledge of basic theories from psychology andmedicine, (d) familiarity with medications that their clients may use and howthese medications may influence both the presentation of symptoms and thecourse of CBT, (e) comfort in dealing with medical professionals in a collab-orative manner, and (f) exposure to the empirically supported approaches tothe psychological treatment of the anxiety disorders in the classroom and inthe consulting room.

Marks: Self-help materials can serve to instruct students. Training studentsin the appropriate use of such materials, as well as their shortcomings, willaid immensely in the dissemination of effective treatments to a broad rangeof patients with anxiety and depressive disorders. This is especially impor-tant for people who may face geographical or financial barriers to treatment.

Ballenger: In the area of “clinical education and training,” at the very least,we need to utilize what we already know. At this point, we know very wellthat CBT is effective in many anxiety syndromes and yet formal training inthese areas is not widely available, especially to psychiatrists. The samecould be said with different emphasis about exposure therapy. A parallelproblem exists with training of nonphysicians in the use of medications totreat the anxiety disorders. Appreciation of the value and limitations ofmedication treatment of anxiety disorders should be much more broadlyavailable to nonphysicians. In a similar vein, it is my opinion that clinicaltraining programs should rigorously teach the empirically derived diagnosticschemes and treatment protocols.

Clark: One of the main problems in anxiety disorders is that although wehave effective CBTs, very few patients receive them. To help overcome thisproblem we need to pay more attention to: (a) focusing clinical training onempirically validated packages for specific disorders, (b) making these inter-ventions briefer and easier to deliver, (c) understanding therapists’ reasonsfor deviating from empirically validated interventions, and (d) persuadinghealth-care providers of the interventions’ economic utility, particularly byproviding data on long-term comparative effectiveness as this is the mostlikely area for cost differences between CBT and medication.


What, in Your Opinion, Are the Greatest Accomplishments and BiggestDisappointments in the Field of Anxiety Disorders Research and/orTreatment in the Past 10 Years?

Barlow: The greatest accomplishments in our field in the last decade havebeen the development of truly effective and empirically supported cognitivebehavioral interventions for anxiety disorders. These developments have“driven the field” in that any psychosocial and drug treatment developed inthe future will use the results gathered thus far as a benchmark of efficacy.Since empirically supported cognitive behavioral procedures are findingtheir way into clinical practice guidelines, these procedures will quickly as-sume more central importance until other, more efficient and effective pro-cedures are developed to replace them.

At the same time clinical trials have demonstrated that few, if any, of ourprocedures are truly curative and that anxiety and related disorders withvery few exceptions are chronic and characterized by periods of waxing ex-acerbation and remissions. While our treatments are clearly capable of im-proving one’s functioning over the long-term, the improvement is not nearlywhat it should be and patients with these disorders, for the most part, arestill subject to various stress related exacerbations. Discovering that ourtreatments are not as effective as we once thought they were sets the stagefor a new generation of research on long-term strategies in the treatment ofanxiety disorders.

Marks: Disappointments include the failure of sufficient dissemination of ef-fective treatment methods, and continuation of many practitioners’ use ofdemonstrably ineffective and/or inefficient methods. Related to this, thefailure of health-care systems to encourage and reward practitioners to usesimple but valid outcome measures as part of their daily routine therapy isdiscouraging, but this problem might be on the point of changing. Also,there has been insufficient focus on teasing out effective therapeutic mecha-nisms and discarding redundant aspects of treatment.

Klein: One clear accomplishment is the finding that short-term treatment ofsimple phobia can be accomplished by exposure; but it is disappointing thatthere is a lack of systematic longitudinal follow-up indicating that this per-sists. There have been claims of persistent improvement during follow-up,but they have been data poor. A second accomplishment is the discoverythat within OCD response prevention is a useful therapeutic tool for about50%. The proportion of OCD that can be actually benefited by this proce-dure is not plain, nor is the long-term follow-up. The discovery that groupCBT can be valuable for SP is a major advance. Here too, the question oflong-term effect is not clear. The attempts to deal with PD and mild agora-phobia by panic control methods and exposure to exteroceptive/interocep-tive anxiogenic cues seem helpful, although the mechanism of action re-mains quite obscure, as does its applicability to the more severely


agoraphobic. Demonstration of long-term benefit is still required given thewaxing and waning characteristic of this illness.

Many important psychopharmacological contributions have been madeto the field of anxiety disorders, in particular, benzodiazepines for anticipa-tory anxiety, and the high-potency benzodiazepines for panic attacks andSP. The use of seratonin active antidepressants for panic attacks and OCD,the MAO inhibitors for SP and PD, and the distinction between the efficacyof low-dose tricyclics compared to the relative lack of utility of MAO inhibi-tors for GAD, deserve mention. The confused state of PTSD is evidenced bythe fact that civilian PTSD differs sharply from veteran PTSD, with some ev-idence of selective serotonin reuptake inhibitors’ efficacy in civilian PTSD.

Beck: I believe that the greatest accomplishments have been in the area ofdefining the psychopathology and the appropriate psychological interven-tions for the anxiety disorders. The utilization of pharmacotherapy has beena disappointment insofar as the patients often show a rebound effect if thedrugs are terminated too early and, in any event, are likely to relapse afterdiscontinuation of the treatment.

Heimberg: I actually think that the same “event” qualifies for both the great-est accomplishment and the biggest disappointment. In the realm of psy-chosocial treatments, the development of empirically supported, mostly cog-nitive-behavioral, treatments for the anxiety disorders and an increasedemphasis on the need to develop treatments that really produce change maybe the greatest accomplishment. The fact that there are so many personswho as yet do not respond to these and other treatments for the anxiety dis-orders and that so few people who suffer from anxiety disorders get anytreatment at all is the biggest disappointment.

Ballenger: In terms of the greatest accomplishments/disappointments, Iwould certainly place our greater diagnostic accuracy as one of our greaterachievements. I think it has brought attention to the anxiety disorders in avery useful way and pointed to different treatments for various types of anx-iety. Obviously, the development of specific psychological treatments forspecific disorders has been both conceptually and practically very important.It is also a considerable achievement that we now have medications that arevery effective for certain syndromes, and that we know relatively well thelimitations of medication treatment for various of these disorders. It hasbeen a very important advance in the field that we have finally developedsome methodologically rigorous data of psychological and pharmacologicaltreatments from centers specializing in the other (e.g., multicenter studiesemploying both types of treatments in centers which have a primary orienta-tion in one or the other area). This has led to a marked increase in the credi-bility and quality of the findings of these studies, as well as to better treat-ments and better availability of various treatments. However, there stillneeds to be considerable progress in this area (i.e., getting full psychological


and pharmacological treatments available in most settings). One of thelargest disappointments has been the resistance to the evolution of this typeof study and this type of practice. It continues to be a disappointment thatthere has not been greater cooperative work between these “types” of re-searchers and clinicians. In my opinion, it remains one of our biggest hurdlesin the field.

Certainly one of the biggest disappointments remains the relatively lowinterest of researchers, neuroscientists, and government-funding agencies inthe anxiety disorders. This is changing, but, for instance, the funding for re-search in the anxiety disorders lags far behind other areas of comparable im-portance. Another area of disappointment that is beginning to change is theincreased emphasis on the anxiety issues in children. This area has beengreatly understudied and certainly any preventative aspects have beenequally understudied.

Clark: It is difficult to say what have been the greatest accomplishments assmall progress with a very intractable problem may be a greater achieve-ment than substantial progress with a relatively simple problem. In terms ofoverall improvements in effectiveness, the success of several panic-specificCBT interventions is worth mentioning. The evolving new CBTs for PTSDpioneered by Edna Foa, Tom Keane, Barbara Rothbaum, Patricia Resnick,and colleagues must also be considered a major achievement as this is a dis-order for which we did not previously have established interventions. Thesame could be said for hypochondriasis, where until recently no treatmentshad been shown to be effective, but Paul Salkovskis and colleagues nowhave two quite distinct, empirically validated interventions. The small num-ber of patients who receive CBT, and the fact that insights from cognitivepsychology research have not yet markedly improved the effectiveness ofCBT, would rate among the greatest disappointments.

Are There Any Other Issues or Comments Related to the Current State orFuture of Anxiety Disorders Research and/or Treatment Upon WhichYou Would Like to Comment?

Heimberg: An important agenda for all of us involved with the anxiety disor-ders will be to keep them in the public eye, to maintain or increase fundingfor treatment research and research into the basic processes involved in anx-iety disorders, and to continually increase public awareness of anxiety andits associated difficulties.

Klein: Other comments are the need to face squarely the guild divisions thathave obscured the scientific issues. Put simply, psychologists, despite theircurrent efforts, cannot prescribe medication, and therefore tend to deni-grate irrationally, and counter-productively, the real utility of medication inthis area. This has not stopped them from attempting to prescribe.


Much therapeutic research focuses narrowly on symptomatic response.For medication this is largely because that is what the pharmaceutical indus-try focuses on and supports, since that is what gets you through the Food andDrug Administration. Further, multi-aspect treatment measurement in clin-ical trials has not been a high priority for the National Institute of MentalHealth or academia. It is expensive. Course; psychopathological develop-ment; social, psychological, and economic impairments; as well as end statefunctioning, relapse, and long-term benefit have received far too little atten-tion from all concerned.

The clear relationship of childhood to adult disorders has also receivedinsufficient attention, probably because of the pharmaceutical houses’ con-cerns for long-term liability in the development of child pharmacology.Also, there is premature closure on the part of much psychological thinkingthat anything the child manifests as pathology is an epiphenomenon of pa-rental mismanagement, bad love, trauma, or environmental deprivation.Therefore, care is focused on these external issues rather than the child. Therelative lack of study of genetic and high-risk contributions is apparent.

Another major problem is the lack of sophisticated, combined psycho-logical and medical treatment services that can develop rational algorithmsfor treatment and then focus on the nonresponders. It is the nonrespondersthat should generate the research questions.

AUTHORS’ CONCLUDING REMARKS

While the responses reported above detail a diverse range of opinions re-garding the future of research and treatment within the area of anxiety disor-ders, several commonalties are apparent. Most notably, all of the leading con-tributors are encouraging a multidisciplinary approach to the study andtreatment of the anxiety disorders. Seclusion within one’s discipline or ap-proach provides only a limited view. Scientists and practitioners in the area ofanxiety disorders should encourage increased collaboration between disci-plines, including pharmacology, psychology, psychiatry, neurophysiology, andthe like. This approach may need to be introduced during training to over-come disciplinary seclusion and effect greater cooperation.

A second common theme was the continued exploration, whether cogni-tive or neurobiological, of the underlying processes involved in the anxietydisorders. For example, research into information processing and cognitiveprocesses has led to an improved conceptual understanding of the anxiety dis-orders and, in turn, advances or refinements in treatment for these disorders.Further investigations of basic processes from the information-processing per-spective, as well as through neural imaging and genetic techniques, appears tobe a fruitful avenue for future research.

Identification of risk factors, and prevention/early intervention studies holdconsiderable importance in the elimination, or at least reduction, of anxiety


disorders. However, prevention remains an area in its infancy. Longitudinalstudies exploring the commencement of anxiety disorders will provide datathat can be applied toward the prevention and treatment of anxiety disorders.To this end, the issue of further exploration of anxiety and its disorders in chil-dren was common among the perspectives of the leading contributors.

Further examination into the efficacy of our treatments was an importantissue raised. Dismantling currently accepted therapies and identifying the “ac-tive ingredients” allows for the continued improvement of the efficacy and de-livery of these therapies. As noted earlier, improved and greatly shortenedtreatments for PD and agoraphobia have been developed. Refinement ofthese and similar progresses in other areas is emerging.

Additionally, the availability of valid treatments was a concern raised. CBTand pharmacotherapy have repeatedly demonstrated effectiveness, yet a largepercent of the population with anxiety disorders do not receive these treat-ments. A concerted effort must be made to disseminate these treatment proto-cols to practitioners, and further develop tools for increasing accessibility totreatment.

It must be noted that the identification of the eight leading contributors wasbased solely on the opinions of those ADAA professional members who re-sponded to the initial survey. While efforts were made to increase interna-tional representation in the sample of ADAA members who received the sur-vey, the sample was indeed largely American.

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Breslau, N., Schultz, L., & Peterson, E. (1995). Sex differences in depression: A role for pre-existinganxiety. Psychiatry Research, 58, 1–12.

Dupont, R. L. (1993). Town hall. Panel presentation at the Annual Meeting of the Anxiety Disor-ders Association of America, Charleston, SC.

Margraf, J., Barlow, D. H., Clark, D. M., & Telch, M. J. (1993). Psychological treatment of panic:Work in progress on outcome, active ingredients, and follow-up. Behaviour Research and Ther-apy, 31, 1–8.

Norton, G. R., Cox, B. J., Asmundson, G. J. G., & Maser, J. D. (1995). The growth of research onanxiety disorders during the 1980s. Journal of Anxiety Disorders, 9, 73–85.

Straub, W. F., & Hinman, D. A. (1992). Profiles and professional perspectives of 10 leading sportpsychologists. The Sport Psychologist, 6, 297–312.

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