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Wise Counsel Interview Transcript: An Interview with Dr. Michelle Craske on Anxiety Disorders Research and Treatment

David Van Nuys, Ph.D.

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David Van Nuys, Ph.D.: Welcome to Wise Counsel a podcast interview series sponsored by CenterSite, LLC. Covering topics on mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

[music]

David: On today's show we'll be talking about anxiety with my guest, Dr. Michelle Craske.

Dr. Craske is Professor of Psychology and Psychiatry and Behavioral Sciences and Director of the Anxiety Disorders Behaviors Research Program at the University of California, Los Angeles. She has published widely on the topics of fear and anxiety disorders, their etiology, assessment and treatment, including several textbooks, as well as clinical guides.

Her research pertains to risk factors for phobias, anxiety disorders and depression in youth and adolescence. Cognitive behavior and psychophysiological characteristics of anxiety, fear and the anxiety disorders, the translation of basic science of fear extinction to the treatment of human phobias and the development and dissemination of treatment of anxiety and related disorders.

Dr. Craske was Associate Editor for "The Journal Of Abnormal Psychology" and is now Associate Editor for "Behavior Research and Therapy" and a scientific board member for the Anxiety Disorders Association of America.

Dr. Craske received her Bachelor's and first class honors degrees from the University of Tasmania and her Master's and Doctoral degrees in clinical psychology from the University of British Columbia. She then completed her postdoctoral fellowship at Suny, Albany with Dr. David Barlow before joining the faculty of UCLA in 1990.

Now lets go to the interview.

Dr. Michelle Craske, welcome to Wise Counsel.

Michelle Craske, Ph.D.: Well thank you very much for inviting me.

David: I noticed in your bio that you did post doctoral study with Dr. David Barlow, whom I actually interviewed earlier this year. Is that how you got started researching anxiety?

Michelle: Well that was certainly a contributor, but in actuality I had started researching anxiety quite a few years before. I'm originally from Tasmania, which is a state of Australia and when I was doing my honors degree, following my bachelor's degree I did a separate honors degree, my mentor at the time gave me an article on the topic of anxiety and self-awareness and performance.

It peaked my interest and I conducted an experimental investigation into the affect of anxiety upon how well people can perform in stressful situations, and that was the beginning. Then I moved to British Columbia to conduct my Ph.D. and was very fortunate to have as my mentor, Jack Rackman.

And Jack Rackman actually is the one who I had been following for many years in terms of his research. He's really one of the leading world researchers in the phenomenology and treatment of anxiety disorders. So with him, I studied features, again, of performance anxiety and also obsessive-compulsive problems. And then I moved to New York where I worked with Dave Barlow and developed more into the field of anxiety disorders and their treatment.

David: OK, and now you've become one of those world-class researchers whom you aspired to be. Do you also have training as a therapist?

Michelle: Yes, yes, my training is in clinical psychology, and therefore as part of my training, I went through the basic methods for learning how to be a therapist, and in fact, nowadays not only do I do research with treatment studies, but I also have my own small private practice where I treat clients.

David: OK, well, what a wonderful blend. I think it's rare to find the combination of someone who's both a therapist and as committed a researcher as you have been. And I know at UCLA--I was on your website--and it looks to me like you've created or supervised a clinic there for the treatment of anxiety.

Michelle: Yes, it's called the Anxiety Disorders Behavioral Research Program. It's a clinic in which we provide treatments, mainly cognitive behavioral therapies, for people from the community who are suffering from anxiety disorders. What is somewhat unique about this clinic is that it's also a research center, so everybody who enters our clinic is automatically part of a research study where we're trying to investigate the methods and mechanisms of treatment.

David: Yeah, so it's kind of a win-win.

[Both laugh]

Michelle: Yes, yes.

David: Right. Now, before we go too much further, maybe it'd be a good idea for us to have you define anxiety, in case we have listeners who are new to the series, maybe didn't hear the interview with Dr. Barlow.

Michelle: Certainly. Yes, so anxiety is a very normal emotional state that we as a human species experience when we're faced with threat or danger. And I typically like to separate out fear from anxiety, so anxiety is that emotional state in anticipation of an upcoming threat or danger.

So the student who's worrying about an exam at the end of the week, or the mother who's worrying about her children's well-being at school. Fear is a more immediate fate of fight-flight, the need to immediately escape from or fight off danger when danger is imminent.

So that would be the emotional state that's experienced when, for example, if we're driving on the freeway, we suddenly feel as if we're about to get into an accident or somebody is directly confronting us or attacking us.

Now, so these states of anxiety and fear are part of normal human emotional experience, but for certain individuals they become more frequent, or they start to occur at times that are out of proportion with the actual danger inherent in the situation.

And therefore, the anxiety is a problem and it starts to interfere with the individual's daily life functioning, and that's what we mean by an anxiety disorder, where the states of anxiety and fear are occurring too often and are impairing functioning.

David: Yeah.

Michelle: Then of course, there are different types of anxiety disorders, but they share that common element.

David: Well, I think that our understanding of these things has become more differentiated, even since I was in graduate school. Where I seem to recall having learned that anxiety was defined as a kind of fear where you didn't know what you were afraid of.

But I understand that more recently, brain scans indicate that actually different areas of the brain light up in relation to fear versus anxiety. Is that right?

Michelle: Yes. It's not my main area of research [inaudible], certainly not the expert on the neurobiology, but there are believed to be different areas associated with those states. So for example, in fear, you see more of the amygdala, that part of the emotional center of the brain lighting up.

Whereas in anxiety, you'll see more of the cortical areas, which is the thinking, the verbal processing connected areas, lighting up as well as parts of the hippocampus. So, yes, there has been some differentiation of both the neurobiological level, as well as at a behavioral or expressive level.

David VaDavid, Ph.D.: OK. I notice you have done considerable research on nocturnal panic attacks. What are nocturnal panic attacks? Are they what we properly refer to as night terrors?

Michelle: Right. There are actually distinct from night terrors in certain ways. Yes. So, nocturnal panic is waking up, usually about an hour and a half after falling asleep. So, waking up in a state of panic and panic meaning that state of fear that I described before. The fight/flight system is activated and the symptoms that are experienced are things like a racing heart, shortness of breath, sweating, dizzy, light headed and so forth.

David: What do people think when they have this experience? What do they think has happened to them?

Michelle: Well, oftentimes they think that something is terribly wrong physically. So that they might think they are having a heart attack or that they are dying.

Sometimes they think that something is wrong mentally. In other words, I'm going insane. I'm losing my mind or just the sense of being out of control. And that's parallel between panic attacks that happen during the daytime, as well as panic attacks that happen at nighttime.

Now, the difference between nocturnal panics and night terrors, is that night terrors typically occur out of very deep sleep, so stage four sleep and usually there's amnesia for the event. So the individual doesn't remember what happened.

It's often in children. So it's the parents who observe and remember what happened, not the child. Whereas, nocturnal panics tends to occur from the transition from stage two to stage three sleep, so in lighter sleep. And the individual is usually fully aware of what's going on.

So, they may be connected at a very basic level, in terms of arousal mechanisms, but at the manifestation they are slightly different phenomenology, phenomena. And I think of nocturnal panic attacks as being similar to the panic attacks that occur during the day in individuals who suffer from panic disorder.

And so, we developed a treatment for nocturnal panic attacks that resembles the treatment we use for daytime panic attacks.

David: Well, I'm surprised that I was so unaware of this nocturnal panic attack. Do you have any statistics on their frequency?

Michelle: There are some small-scale, prevalent studies. These are not huge epidemiological studies, but within samples of patients who suffer from panic disorder, about 15 to 20% report having had nocturnal panic attacks with some regularity. Now some regularity might mean once a month or once a week.

About 60% will say that they have had it at least one time. So that's within the group of individuals who already have panic disorder. Then in the general population, as far as we can tell, approximately 5% of the population, if you survey, will say that over the last 12 months, they've had at least one episode of waking up with an abrupt sense of fear and experiencing those symptoms that I described before and not really knowing why.

Now there are studies that are clearly limited. They are not huge epidemiological studies, but nonetheless it's fairly consistent with other surveys. When you ask people how many have experienced a panic attack during the daytime for no apparent reason and then about eight to 10% will say, yes, in the last 12 months, I don't know why but I just suddenly got afraid.

And of course most people are able to just dismiss it and it sort of passes and doesn't mean anything. Whereas, for those who go on to develop panic disorder, it becomes a source of great anxiety and worry.

David: Now we associate night terrors with children. Are these nocturnal panic attacks, do they happen with children as well, or is this an adult phenomenon?

Michelle: As far as we can tell, it's an adult phenomenon. That may be because there hasn't been enough research in children, but in the research that I've done, it's always adults. And it may be that night terrors in children are a predictor of the later development of nocturnal panic attacks in adults. We're not exactly clear.

David: Well, that's an interesting idea. In fact, do children get daytime panic attacks? At what age does this begin to set in?

Michelle: Right. Yeah. There are some people who have been investigating the issue and it appears that post-puberty panic attacks start to appear. They become a little bit more prevalent in adolescents, you know, between 15 and 16, 17 years of age. And then the medium age of onset for panic disorder is in the early 20s.

Children under the age of 12 or 13 seem to occasionally seem to have symptoms of arousal. They might feel that their heart rate increase or they might feel afraid, but it doesn't seem to fit the characteristic of a full-on panic attack. Perhaps because children are not cognitively mature enough to think that this kind of emotional state is scary or dangerous or that it represents some threat to them.

So you rarely see children saying, I'm afraid I'm going to die or I'm afraid I'm going losing my mind, in response to these kinds of physical sensations. They may have the physical sensations.

David: OK. You alluded to treatment. How does one treat these panic attacks, both the nocturnal and the daytime?

Michelle: In the daytime... Yes, this is the work that I developed under the guidance of David Barlow when I was working with him back in New York. And basically, the treatment is helping individuals to learn not to be afraid of two types of stimuli. The first are the physical sensations themselves that characterize panic attacks.

So, for example, let's say that a person has a panic attack and what they remember from that panic was the pounding heart. And so, subsequent to the panic, any kind of change in heart rate becomes a little scary to them, because it signals a possibility of another panic attack.

Well, unfortunately, being afraid of that heart rate is actually only going to increase the strength of the speed of the heart rate, because by being afraid heart rate tends to increase, right? And so it becomes a bit of a vicious cycle, where the fear of the physical sensation, such as heart rate, actually intensifies the very thing that the person is afraid of.

David: Yes.

Michelle: And that's, hence, the panic attack itself. So the treatment helps individuals learn not to be afraid of those sensations. So that they don't escalate into a spiral. And we do that through what's called cognitive restructuring, where we help the individual to recognize that they may be misinterpreting those physical sensations of being harmful, when in fact they are not harmful.

And we try to help individuals develop more realistic ways of thinking, more evidence based ways of things about the sensations. Then secondly, we help people to do exercises to directly and repeatedly confront those sensations and learn through experience that they are not harmful and therefore they don't need to be afraid of the sensations.

So we might do things such as having a person spin around in order to produce a feeling of dizziness. And do that enough times that they learn, hey, it's uncomfortable, but it's not dangerous.

And then, aerobic exercise would be another example or drinking coffee would be another example or hyperventilating would be another example. And this is called exposure to inter-receptive cues or cues internal. That is one sort of focus.

And then the second focus of treatment is helping people to repeatedly face the situations in which they are afraid of having a panic attack. So that might be driving in a car, or being at home alone or being in a meeting or shopping mall. And again, during repeated exposure to those situations to learn that they can handle whatever feelings that come up in those situations.

David: I know that you have researched this so what are the success rates of this form...

Michelle: Actually, yes, the success rates for this particular treatment are quite good. If you look at just the statistics of how many people report that they are no longer panicking at the end of a treatment. And the treatment is usually about 12 to 16 visits. It is somewhere between 60-70 to 80% who say no longer having panic attacks.

And then if you look at the proportion of people who not only are not having panic attack, but they also not worried about having panic attacks. Nor they are avoiding any situations for fear of having panic attacks, then it is about 60%. So that is fairly good in terms of psychological treatments.

Almost everybody improves. About 10 to 15% do not complete the treatment. And we are currently researching ways of trying to reduce that so people get the full benefit by staying in the treatment.

David: Yes, this is maybe a little bit of a sideline here but I was browsing through your long list, your very long list of publications and I saw an early one that you collaborated on, relating to relaxation-induced panic.

And I am interesting in that because I recently interviewed others using mindfullness meditation to deal with the variety of psychological conditions. And I am wondering if for some people, meditation might induce panic. Tell us about relaxation-induced panic.

Michelle: Yes it is an interesting thing phenomenon. It was actually first written by Tom Bolkevink and then we observed some of the same kind of phenomena in our studies with panic disorder. And what it is essentially is as the person is going into a state of deep relaxation; something about that state evokes anxiety.

And what you might see clinically is a person sitting up very intensely and feeling panicky. Tom [inaudible] had proposed that it was something about letting go. That the concept is letting go, becoming vulnerable, letting down the guard was anxiety-producing to certain individuals.

And we had also hypothesized that sometimes the state of deep relaxation induces physical sensations that are unfamiliar, like a heaviness or floatiness. And for persons with panic disorder at least those sensations might again become scary because they somehow signal the possibility of having another panic attack.

And so yes, it may be that certain individuals will find the process of meditating and relaxation to be somewhat anxiety provoking. But in our minds that would mean, oh, OK so we need to help this person learn how to relax, how to meditate and not becoming anxious.

So we would keep going with the treatment using that as a type of exposure exercise. So they are being exposed to relaxation. Just like we have somebody else be exposed to going out into the shopping mall and walking around. That becomes a tool.

David: Somebody who is more psychodynamically disposed might think that it would not be so much sensations arising they are unfamiliar is perhaps unwanted, unexpected thoughts. The material arising from the unconscious, if you will.

Michelle: Yes, I think certainly, persons with particularly generalized anxiety that tendency to worry excessively about a number of areas in one's life. I had observed clinically that as they relax sometimes they will comment on being flooded with worries with intrusive images and thoughts about being things that could go wrong, so some similarity with the more psychodynamic perspective.

David: OK. I noticed you have done research on avoidance and panic and to say a little bit about relationship there.

Michelle: OK, when we think of anxiety disorders, we typically think of three response systems. So there is a physiological response system, there is the cognitive/verbal response system, and then there is the behavioral response system.

So for example, if somebody has a phobia of animals, the physiological response system would be that "fight or flight" activation or the fear response. The cognitive/verbal might be statements such as, "I think I am going to be attacked by the animal." And the behavioral would be an urge to want to escape from or avoid future encounters with those animals.

So that is common across all different types of anxiety disorders. I was particularly interested a few years ago in what is called "agoraphobia" the tendency to avoid situations in which panic attacks are expected to occur.

And the interesting issue is that the level of agoraphobia or how much avoidance there is does not seem to be directly related to how severe the panic attacks are or how frequently they occur. So, in other words some people may panic frequently and be very worried about panic attacks, but yet still go out and do everything that they need to do in their daily life.

Whereas for others, a panic attack might result in them becoming housebound and not wanting to leave the house. And so we have tried to evaluate what predicts the level of agoraphobia, why do some people become more agoraphobic than others.

And as far as we can tell there are two main predictors right now. One is gender. So females are more prone to become more agoraphobic than males. And interestingly, occupational status, so somebody is already working or has a job they are less likely to become agoraphobic than those who are not employed,

This has led us to conclude that the degree of avoidance is largely guided by the social culture circumstances that would permit or allow avoidance compared to other circumstances that do not permit or do not allow avoidance.

David: As interesting, I noticed a lot of your research is focused on agoraphobia and so it looks like there this really close relationship between that and panic attack. And it made me wonder, well, maybe agoraphobia's has it been misclassified. Is it maybe separate from other phobias?

Michelle: Well, that is really an interesting question, we sort of conceptualized agoraphobia as definitely part of the panic spectrum. So it is a tendency to avoid situations for fear of having panic attacks or for fear of having symptoms that are similar to panic attacks.

For example, we do a lot of work with individuals who have irritable bowel syndrome, that is a lot of discomfort in the digestive system. And oftentimes, those individuals become agoraphobic, because they are afraid of being out in the public eye, so to speak, and away from access to a bathroom.

David: Sure.

Michelle: So its functions very similarly to the person who is afraid of having a panic attack when they are out in public.

And to that degree, agoraphobia may be different from the other phobias. But this is an empirical question that is actually being addressed right now in the DSM-V discussions that are going on.

David: Interesting. And I notice that you make a distinction between predicted versus unpredicted panic attacks. What's that about?

Michelle: Yes. In the individuals who experience panic disorder, a very frequent and in fact a diagnostic criterion is for some of the attacks to be experienced out of the blue. So the person might say, I don't know where it came from; I just suddenly was afflicted with this panic attack.

For other people, it becomes very predicted. In other words, they can say I know when I'm going to have a panic attack. It's in certain situations. So it's fairly reliable. So we were interested in the affect of unpredicted versus predicted panic attacks. Generally speaking, when the panic attack is unpredicted it tends to illicit more anxiety than the predicted panic attack.

So, if you could imagine for example, if you are about to be shocked, electrically shocked, making that as the parallel to being hit by a panic attack, if you know exactly when the shock was going to happen, that somehow releases some of the anxiety in comparison to sitting there waiting for when it is going to happen.

So that was the research that we were looking at. It's very much tied to basic science of learning and the role of unpredictability in generating distress.

David: Sure and I imagine that that's one place where avoidance would come in. That if a person can predict that a certain situation is going to lead to panic, then avoidance is going to kick in there, right?

Michelle: That's right. That's would be adaptive, wouldn't it?

David: Yes. Now I gather that there's some relationship between depression and anxiety, is that right?

Michelle: Yes. There's clearly a high rate of pro-morbidity between the two. What I mean by that is: individuals who have anxiety disorders are at increased risk for also having depression and vice versa, in comparison to the rest of the population.

We've been very interested in that relationship and currently have a longitudinal study going on where we are following adolescents from the age of 16 through the age of 24. Doing repeated assessments every six months for these kids.We're trying to establish what are the predictors of anxiety and depression and, in particular, what predicts both of those problems and what predicts each one, uniquely.

In other words, we're thinking that there are certain factors that are non-specific and increase the risk for both anxiety and depression. On top of that there may be other factors that are unique to the prediction of anxiety, versus the prediction of depression.

So the common factor that we are looking at is the personality trait called neuroticism. This trait is representative of the tendency to experience negative emotions, in general. And it's a fairly heritable trait. That kind of trait, having that tendency to become angry or sad or feel down or feel ashamed or be afraid, that is a predictor of both anxiety and depression.

Then on top of that, we're looking to see whether there is specific tendencies, which lead more in the anxiety direction, such as certain types of life events that happen to an individual that may lead one more in the pathway of becoming anxious, versus more in the pathway of becoming depressed. So it's a fairly complex set of questions.

The other comment I'll make about that is that most often anxiety precedes depression. So, if you look at samples of children through adolescence, the anxiety tends to emerge in childhood through early adolescence, where depression tends to emerge towards later adolescence. Not always, but typically that's the pattern.

And so, in many cases, we think of depression as being a secondary result of anxiety. Although at the same time, influenced by the same non-specific vulnerabilities in the person.

David: Well that's fascinating news to me. I hadn't heard that. That's very interesting. I know that there's... and I know that brain imaging and so on is not your specialty, but it seems to me that I've sat in on some workshops where they talk about these conditions that if they go on for some time, it affects the brain and kind of sets it up for other kinds of problems.

I'm imagining a picture here of being in a long term state of anxiety, somehow setting the brain up then to enter into maybe a more habitual kind of pattern that would begin to look like depression.

Michelle: Yes. Yes. We have some people in our department at UCLA who study that at a very basic level. I'm not sophisticated enough to explain their research, but they are certainly looking at it from that angle.

David: Well, I probably wouldn't be sophisticated enough to understand it if you could explain it to me. [laughter]

Michelle: That is an interesting area.

David: yeah. And I notice that you have been doing some research on computer-assisted treatment of anxiety.

Michelle: Yes. Yes. So, in the United States we have a very interesting situation and that is: well, first of all, anxiety disorders are very common. So if you evaluate prevalence for the entire population, it looks like about 30% of the population will have experienced at least one anxiety disorder by the time of being 75 years old. So, one in three.

The second fact is that there are some treatments that have been established as being empirically supported for anxiety disorders, cognitive behavioral therapy is one of those treatments. Psychotropic medications are another treatment.

The third fact is that are only about 11% of mental health providers who are trained in the delivery, at least in the delivery of the psycho-social treatment that has empirical support, that being cognitive behavioral therapy. So there's a huge gap between the need and the actual ability to deliver these treatments by trained professionals.

And so, we have been doing work for the last seven or eight years trying to enhance the implementation of cognitive behavioral therapy, as well as medications in real world settings. In particular we have targeting primary care. And that's because a lot of patients with anxiety disorders first go to their primary care doctor, but they don't get effective treatment. They just tend to go around and around in the system, without being treated appropriately.

And so, given this dilemma of the gap between the need and the delivery, what I designed is a computer assisted CBT which is really to help a novice or un-trained clinician to be able to provide CBT to the client. So, we're assuming that the clinician is not going to have a lot of background training, but they can use this computerized program to help guide them in how to deliver CBT to the client.

The way it's set up is that the client and the clinician sit together and they both go through the computerized program. The program gives prompts to the clinician to do 'x, y or z' at this point in time. The program also includes video vignettes demonstrating different therapeutic techniques. It's interactive, so that the patient enters data on an ongoing basis.

And so far, we've been testing this out now in sample of over 300 cases.We've found that the clinicians, again untrained, really enjoy this program. It helps them to stay on focus. It helps them to deliver this treatment in a way that's acceptable to the clients, and does not depend on the clinician having gone through extensive training. So, that's our attempt to try to implement these treatments in a broader way.

David: Well, that's fascinating. I might have to check back in with you a few years down the line to see just how that's turned out.

Michelle: Yes, it is interesting. In fact, I'll just mention as an aside, stemming out of that work one of my colleagues, Ray Frose, was just awarded a grant from NASA to provide a computerized treatment program to help stress management in space flights.

David: Interesting.

Michelle: Yes, so we'll see how that one goes too.

David: Yeah, that's fascinating. Now of course, when you say that it makes me think about post-traumatic stress syndrome, and I'm wondering if that approach would have any applicability there.

Michelle: Well, our computerized program has been developed for various anxiety disorders, including post-traumatic stress disorder. Now, post-traumatic stress disorder can be quite difficult to treat, but nonetheless, we have been using this program in helping who have been traumatized to repeatedly face the memory of the trauma and the situational reminders of the trauma, and to become more comfortable and less afraid of those memories and reminders.

It seems to be, at least, accepted. We'll have to assess in the long-term whether it's really effective or not, but that's what we have been trying to do.

David: Have you had a chance to try working with veterans of the Iraq War yet?

Michelle: You know, I have not. I've been requested to consult with some of the therapists in various VA settings. But no, I have not done that work myself. I imagine there are various people around the country who specialize in that area, such as Terrence Keane over in Boston.

I imagine there are some nuances to that kind of PTSD that would be different from the kind of PTSD that I'm used to working with, which could be somebody who was in a car accident, or traumatized emotionally or sexually as a child - each carries with it it's own characteristics.

David: Well, as we begin to wrap up here, what would be your advice to any listeners who might be suffering from an anxiety disorder themselves, or who have family members who suffer from one?

Michelle: Well, I think a first step is to get information. And fortunately, there are various resources, such as the Anxiety Disorders Association of America and the Association for Behavioral and Cognitive Therapy. They provide information about the nature of anxiety disorders, and also provide treatment referral.

The second thing I would recommend is that there is some evidence that self-help works to a certain degree. There are some self-help books available from various sources, including works that I've done with Dave Barlow, along with other people around the country. So, if one is sufficiently self-motivated going to a self-help book that has as it's focus a cognitive behavioral treatment approach, since that's the one that's been empirically-supported, they may derive some benefit from doing that.

And then, the third thing would be, if desired, to find a therapist who has a lot of experience with treating anxiety problems, and can provide structure and training in how to develop more adaptive cognitive and behavioral skills.

The other thing that I would really emphasize is that if children are experiencing anxiety problems, we said before, they may not necessarily experience panic attacks, but certainly children can experience anxiety disorders, such as generalized anxiety, or social anxiety.

The treatments work especially well in children. And so, I would urge parents to seek treatment if their child is suffering or impaired by the anxiety because there's a very good chance of success. And, if you can intervene early on and prevent the development or the chronicity of anxiety over the long-term, I think that would be very desirable.

David: Well, great. We can finish up on that optimistic note. Dr. Michelle Craske, thanks so much for being my guest today on Wise Counsel.

Michelle: You're very welcome. Thank you.

[music]

David: I hope you enjoyed this interview with Dr. Michelle Craske. Hopefully, you learned some new things, as I did. As you heard, the whole topic of nocturnal panic was new to me.

If you or someone you know suffers from anxiety, you might be interested in the 2006 book, "Mastery of Your Anxiety and Panic: Workbook (Treatments that Work)". This is by David H. Barlow and Michelle G. Craske.

If you're a therapist and you'd like more information, I would recommend their "Mastery of Your Anxiety and Panic: Therapist Guide" by Michelle G. Craske and David H. Barlow. Both of these can be found at Amazon.com, among other places.

You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.