Kim Mills: We’ve all had good reason to feel anxious over the past two years. But sometimes, anxiety is more than a normal response to stress. Anxiety disorders are among the most common of all mental health disorders, affecting an estimated 15% to 20% of people at some point in their life. In recent years, scientists have begun to learn more about the underlying causes of these disorders, which include generalized anxiety disorder, panic disorder, and specific phobias such as fear of needles or flying. They’ve also learned more about how to treat anxiety effectively.
So what ties different anxiety disorders together? Where do they come from? What’s the difference between feeling anxious and an anxiety disorder – how do you know if it’s time to seek help? And what effective treatments do we have for anxiety?
Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. Our guest today is Dr. Bunmi Olatunji, director of the Emotion and Anxiety Research Lab at Vanderbilt University. Dr. Olatunji studies the role of emotions, particularly disgust, in driving anxiety symptoms and disorders. He is also interested in using the knowledge gained from basic research to develop effective treatments for anxiety disorders. Dr. Olatunji also serves as director of clinical training in the clinical science program in psychological sciences at Vanderbilt, and as associate dean of academic affairs in the graduate school.
Thank you for joining us today, Dr. Olatunji.
Bunmi Olatunji, PhD: Thank you so much for having me. It's a pleasure to be here with you.
Mills: So we all experience anxiety at times, I think it's a familiar feeling to a lot of us, and many of us have been feeling more anxious than usual these past two years, almost two years now. What is the difference between everyday anxiety and a clinical anxiety disorder?
Olatunji: I think that your question raises a very important point that I hope we're able to get across from this conversation. And that is, anxiety is an adaptive, affective process. So when we think about anxiety, we think about this as being a feeling of nervousness and apprehension in response to a perceived threat. And this can take many shapes and sizes and the things that trigger anxiety vary for different people. So for example, some people's anxiety may be in response to an anticipation of a specific event. It may be in response to an intrusive thought. Or it could just be an uneasy feeling with regards to uncertainty. And those type of experiences are relatively normal.
Now, when we start to about the transition from adaptive, normal anxiety into clinical anxiety, then the question really is, to what extent do these experiences interfere with one's ability to function? So are these things getting in the way of our ability to hold a job? Are they getting in the way of our ability to be social the way that we want to? Are they interfering with our ability to function within our family systems? So really, the question of whether or not these things are clinical levels of anxiety is really predicated upon the extent to which they interfere with one's ability to live the life that they want to live.
Mills: And so, how do you know that it's time to start seeking mental health treatment?
Olatunji: Yeah, I think that that question really highlights this disconnect between the experience itself and the dysfunction that's associated with it. And I think that, for people, when they start to ask the question, “Well, when do I need help? When should I go see a therapist?” And I think that, the answer that I often times give people is, when is your quality of life impacted? When is it the case that you're not able to have a high quality of life? And when you reach that point, when your quality of life is impacted, I think that's the time that's really important to go see a professional.
Mills: Now, you are an expert in cognitive behavioral therapy. Can you tell us more about CBT in relation to anxiety? How does it work and how is it used to treat anxiety disorders?
Olatunji: Yeah, so cognitive behavioral therapy, or CBT, is really based on several core principles. And so, this particular therapy is largely based on the notion that anxiety disorders are based, at least in part, on faulty or dysfunctional ways of thinking. That anxiety disorders are based on learned patterns of maladaptive behavior. And so the notion here is that if we can change how people think or change the maladaptive behavior—in the case of anxiety more often than not it's avoidance—if we can alter those thinking patterns and behavioral patterns, then we can help treat the anxiety disorder. So that's really the underlying premise of cognitive behavior therapies, really trying to address the cognition, the thinking patterns and the behavior, the maladaptive behavior that'll maintain the anxiety disorders.
Mills: And so, when we talk about CBT and anxiety, what might that treatment look like? Particularly, say, if I have a phobia. How would you use CBT to treat that?
Olatunji: Yeah, so with specific phobias, I think the good news is that we actually have very, very efficacious, highly effective cognitive behavioral interventions for phobias. And those treatments largely emphasize the process or the intervention of exposure therapy. So in the context of treating somebody who has a phobia, the approach that I would take, within the umbrella of cognitive behavioral therapy, is implementing an exposure protocol that basically requires me to expose you to elements of the things that you are afraid of.
But we're going to do it in a very gradual sense. So we may come up with a list, a hierarchy if you will, of elements of the phobia that you're afraid of. And work our way up from the least anxiety provoking, so looking at pictures of spiders, to the most anxiety provoking, having a spider crawl on your shoulder. And work our way up that hierarchy and use exposure as a way of learning to habituate the experience of anxiety, but also as an opportunity to learn that there is no catastrophe associated with coming into contact with a thing that you're afraid of.
Mills: Now, what about medication? Are there effective medications to treat anxiety disorders? And do you use medication in concert with CBT? Do you try one first, one second, work them together? How does that go for most people?
Olatunji: Yeah, that's an excellent question. The medication question obviously is one that comes up quite a bit. And so, it's a complicated question, so the answer is going to be equally as complicated, I'm afraid. So the short answer is that, well, yes. So there are evidence-based pharmacological interventions for anxiety and related disorders. And in most cases, some of those pharmacological agents tend to be SSRI's. Now, the question then becomes, well, how do we choose? How do we decide which one do we try? Which one do we go with first? And I think that part of that answer comes with, well, what is the comparative efficacy? So if I take my medication and I compare it to, let's say CBT, what does the data say about outcome? And all things being equal, it tends to be the case for anxiety disorders, that medication and cognitive behavior therapy tend to be about comparable in their efficacy.
But of course, the question with the medication is, well, how does the side effects factor in to your decision making about whether or not to use medication versus CBT? There's also the issue of the long-term benefits. Because with medication, more often than not, that's something that you're going to have to stay with for the long term. Whereas with CBT, you do anywhere from 12 to 20 sessions, you have the tools and the skills, and then you're on your way. So although there tends to be relatively equivalent efficacy, I think there's a different picture when we start to ask the questions about long-term effectiveness. Because often times, when you take the medication away, what happens is that you have a lot of relapse. Whereas with CBT, you don't see that as much because now the people have the skills to deal with the anxiety related symptoms.
Mills: So, many people, when they think about the emotions that are associated with anxiety, they think about fear. And I know you mentioned that earlier. But your research focuses a lot on a different emotion, disgust. Let's talk about that. What's the connection between disgust and anxiety?
Olatunji: Yeah, so our interest in the emotion of disgust is largely a result of listening to our patients. And when you think about a disorder like obsessive compulsive disorder, for example, or even spider phobia or individuals who may be phobic of blood, needles, injections, and things of that sort. It became clear to us that there's a large majority of those patients, and OCD, I think, is a good example, especially with patients who have contamination concerns, that a lot of those patients describe the distress associated with their symptoms as one of disgust and not fear.
So the language that they oftentimes use is really this notion of, “I'm not really afraid of it, but it certainly grosses me out and I just cannot handle that.” So in the language, they're really describing a different affective process that they're experiencing. And so, we've been really interested in really trying to figure out, well, is this distinction that they're making, is it a meaningful one? And does that really tell us anything different about the prognosis of their illness?
Mills: Let's talk for a minute about needle phobia, which is something that's been very much in the news of late because everybody is, or at least we hope everybody is, getting vaccines. How do you use CBT to treat needle phobia? I mean, are you giving people bogus injections? I mean, an injection is an injection. So how do you desensitize people to that?
Olatunji: So the question of, how do we use CBT to treat blood, injection, injury phobia? The good news is that the data that we have on the exposure-based approaches to treating that particular phobia is really quite impressive. So much so that there are, in fact, treatment protocols that, within three to five hours of treating somebody, can actually get pretty good effects. So this can be something that, if a person was committed to, they can overcome in a day of intensive therapy. So to your question about what exactly does the therapy actually look like from an exposure standpoint, well, again, so we very well may start from looking at pictures of injections and then working our way up. Looking at videos, maybe taking a trip over to the Red Cross and observing, and maybe putting a needle right up to the arm.
So there are things that we can do in a very hierarchical way to, A) facilitate this notion of habituation. To get the person to habituate to their anxiety. But also to use those exposure items as a way of engaging in some corrective learning. So nothing catastrophic is going to happen. Now, of course, we do have the issue of fainting. That's a very common thing that happens with people who are phobic of needles. So the vasovagal syncope response is a very common thing. And what's really interesting is that, there've been some modifications to the exposure protocols, they can also effectively treat individuals who have this fainting response. And that is often referred to as the Applied Tension Technique. So within the context of doing the exposure work, if you're having patients who have fainting symptoms also engage in some applied muscle tension, that actually helps to suppress the fainting response. So they can fully benefit from the exposure work. So there's actually very good evidence-based work out there for individuals who may have that fear, who want to get vaccinated, they can actually be effectively treated fairly quickly so they can do that.
Mills: For many people, the COVID-19 pandemic has been a major cause of anxiety over the last almost two years and you've been doing some research on anxiety during the pandemic. Can you talk about that? What is it that you're seeing and is there indeed a measurable increase?
Olatunji: Yeah, I think that there is a measurable increase in anxiety symptoms over the time course of the pandemic. And of course, part of the challenge for us as clinical scientists is really trying to conceptualize, well, how much of that is normative? Is adaptive? Because the truth is, we are in this context of uncertainty. We're in this context of uncontrollability. We're in this context of unpredictability. So the new variants are coming out at rates that we can't often predict. And the uncertainty, the uncontrollability, and the unpredictability is a context in which anxiety tends to manifest. So those are the building blocks, if you will, for people to experience anxiety.
So some of the increase that we're seeing during the pandemic really should be expected and is what would be predicted. Some of that is adaptive. But within that, we are seeing a certain percentage of individuals who were already at risk to begin with, so they had various risk factors, and this is just the stressor that makes those risk factors manifest. So we are seeing an uptick, if you will, in not only adaptive anxiety but also clinical levels of anxiety. But again, some of that is to be expected, given the context that we're in.
Mills: When you say adaptive anxiety, what exactly do you mean by that?
Olatunji: Well, I think we would agree that anxiety can also motivate problem solving. And so, for a lot of people, the anxiety motivates them to socially distance. It motivates them to make sure that they have their mask handy. And so, some of that anxiety that we're feeling, that we're seeing, is adaptive in the sense that it's motivating us to do the things that we need to do to keep us safe.
Mills: So it's not always a bad thing, sometimes.
Olatunji: No, it's not always a bad thing. I would be more concerned about the absence of some anxiety.
Mills: So what got you interested in studying anxiety in specific? Are you an anxious guy?
Olatunji: I don't think so. Not terribly so. Well, my graduate school advisor, Dr. Jeffrey Lohr, who unfortunately passed away this year, this was his bread and butter. So this was something that he was very interested in and studied quite extensively. And he was really the one that opened my eyes to this question of disgust and anxiety and how do we fit this emotion into the clinical picture? And when I first started really working in this area, back in 2000, there really wasn't any research on disgust within the context of anxiety pathology.
So it was really working in his lab and trying to figure out this new piece of the anxiety puzzle, this question of disgust, then that then motivated me to start thinking about other things. Just in terms of, what are the evidence-based therapies for anxiety disorders? How do we implement those? What are some questions with regards to dissemination of these therapies? So it was really that basic work in graduate school that really motivated me to start asking some of these other questions about anxiety related psychopathology.
Mills: So what are the next big questions for you? What are you working on? Where do you hope to go with this?
Olatunji: For myself and as a field, there's several areas where I think that we still need to do much better work. So cognitive behavioral therapy is a highly efficacious treatment. And I think that most people would agree that it's the best psychological treatment that we have. But that being said, not everybody benefits from this therapy and for those that do benefit, we oftentimes see a relapse or a return of symptoms. So our therapy is good, but it's clearly not great. And so, I think that's one of the areas where we really need to figure out, what are the factors, even before somebody starts therapy, that can tell us who's really going to benefit? And for those who we know beforehand, they're not going to fully benefit, well, what do we do with those individuals? How do we help those individuals? So this question of prognostic indicators, I think, is a really important question moving forward. Similarly, I think the question of, going back to your question about medication, I do think that medication can be a good therapy for some people. But not for everyone.
And I think the question is, what are the prescriptive indicators? That is, what are the things that I can have in my hands before a person starts therapy, that will tell me, oh, you know what? Given these factors, that person should get cognitive behavioral therapy. Or, given these factors, that person really should get medication. So having these prognostic and prescriptive indicators, and then trying to figure out how do we implement them and trying to figure out who's going to benefit, even before they start, I think is a really important future direction. The other area is just one of dissemination. I mean, we have this good therapy but not everyone has access to it. Not everyone can afford it. And I think there's issues of—That question is a larger question just in terms of our healthcare system. But really giving people access to this therapy, I think, is—really the next frontier is really, how do we get this out there to the masses so people can access it?
Mills: Well, Dr. Olatunji, this has been really interesting. I hope our listeners have found some of this helpful. I appreciate you joining us today, thank you.
Olatunji: Well, thank you for your time. Really enjoyed it.
Mills: You can find previous episodes of Speaking of Psychology on our website at www.speakingofpsychology.org or on Apple, Stitcher, Spotify, or wherever you get your podcast. And, where it's possible, please leave us a review. If you have comments or ideas for future podcasts, you can email us at speakingofpsychology@apa.org. That's “speakingofpsychology,” all one word, at A-P-A dot org. Speaking of Psychology is produced by Lea Winerman. Our sound editor is Chris Condayan.
Thank you for listening. For the American Psychological Association, I'm Kim Mills.
Bunmi O. Olatunji, PhD, is a professor in the department of psychology and psychiatry at Vanderbilt University, where he also serves as the director of clinical training. He is associate editor of the Journal of Consulting and Clinical Psychology and currently serves on the editorial boards of Behavior Therapy, International Journal of Cognitive Therapy, Journal of Obsessive-Compulsive and Related Disorders, Psychological Bulletin, Psychological Assessment, and Psychotherapy. He has published more than 160 journal articles and book chapters, and has participated in more than 100 conference presentations. As director of the Emotion and Anxiety Research Laboratory at Vanderbilt University, his primary research interest involves multilevel examination of cognitive behavioral theory, assessment and therapy for anxiety disorders. He is currently adopting an experimental psychopathology framework to examine the role of basic emotions, especially disgust, as they relate to the assessment, etiology and maintenance of anxiety-related disorders. His research has been funded by the National Institute of Health and the Anxiety Disorders Association of America.
