CHRIS AIKEN: I'm going to speak with Steve Hayes about how a panic attack inspired him to develop Acceptance and Commitment Therapy, one of the most widely used therapies in practice today. Welcome to The Carlat Psychiatry Podcast. I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report, and our co-host, Kellie Newsome, is out today. In 1999, Guilford Press releasedAcceptance and Commitment Therapy: An Experiential Approach to Behavior Change.The 300-page book by Steve Hayes, Kirk Strosahl, and Kelly Wilson presents an approach to psychotherapy that was 20 years in the making, carefully constructed from lab-tested ideas. Ideas like psychiatric disorders are not driven by negative thoughts, but by our relationship to those thoughts, whether we accept or avoid them, and how closely we identify with them. Are we tied down by the excruciating logic of our minds? Or can we step back and watch our thoughts flow by like boats on a river, sometimes entertaining, sometimes alarming, but rarely carrying the truth? Acceptance and Commitment Therapy, or ACT, spread quickly after the book's release. Around a million therapists have trained in ACT, and the books have sold over 13 million copies, translated into 28 languages, and supported by about a thousand trials. ACT has a wide reach, and its origins are broad as well. Although it challenged some of the ideas of cognitive behavior therapy, ACT also built upon CBT. ACT has roots in a theory of language that Steve Hayes developed in the 1980s, a theory that proposes that children learn words through associations, and from those associations, they build abstract systems that allow us to solve problems, make plans and rules, and navigate our way through the world. The problem is we also have a stubborn tendency to cling to these abstract rules even when they fail us, and that is what Steve Hayes found himself doing in the early 1980s as a young psychologist trained in classical cognitive therapy and behaviorism, until he realized that the rules he was clinging to were making his panic disorder worse. We are going to throw in some research updates on panic disorder as we interview Dr. Hayes. And here's one from our CME quiz. You can earn CME through the link in the show notes.

1. Which medication performed worse than benzodiazepines in early trials of panic disorder, but recently augmented an SSRI in a placebo-controlled trial of panic disorder? 

A. Pindolol 

B. Propranolol 

C. Inositol 

D. Buspirone

Tell me the story about how you went from having panic attacks to discovering the theories of ACT.

STEVE HAYES: You know, the panic attack it was a three-year-long struggle. It started in a horrific department meeting. I was watching full professors fight in a way that only wild animals, the full professors, are capable of. I didn't understand at the time why it was hitting me so hard. I eventually learned that as I walked through it. You know, when you have your first panic attack, the logical thing to do is to figure out how to not have it again. Especially since mine was in a public setting where people who could promote me or fire me were in the room, et cetera, it was horrific and embarrassing. And so I started making sure that it wouldn't happen again, doing all the things that make it worse, because you now are turning anxiety into something to be anxious about, so you get a self-amplifying loop. And it eventually spun me down to the point where I couldn't easily give a talk to an undergraduate class of five people. It didn't matter the audience size. In fact, a big audience was easier than a small one, because to get anxious in front of a small one is insane. So my mind was telling me, meaning there's something really, really, really, really wrong with feeling anxious, which means anxiety is something to be anxious about. You know, eventually I had a hit-bottom moment. It so changed everything that I spent the rest of my life trying to figure out what was that, what were the processes, and how can I put them into the heads, and hearts, and hands of people around the world.

CHRIS AIKEN: What type of treatments did you try before you hit that moment?

STEVE HAYES: Of course, I was trained in CBT and BT, and so I tried exposure, which turned into white-knuckle exposure. In the animal models, if you directly expose an animal to something that's been conditioned to be afraid of, it's just a linear reduction. But not in human beings, it can make you worse to white-knuckle exposure, because you come out thinking and saying things like, "Oh, I almost lost it completely. Oh, if I did it again, it'll...” you know, language has that funny transformational effect. And so I was in traditional therapy with a really good clinical social worker, who had a great reputation. I recently tried to find her, I think she's probably deceased, but she did a good job in helping me kind of put it in a larger context, but it didn't change the struggle. And so then, in just exposure, self-done, because I'd had so much training. David Barlow was my mentor, you know, the father of modern exposure therapy, practically, or one of them, maybe Edna Foa would be a mother, but David would be up there. And I did what I knew from cognitive therapy, trying to talk myself out of it, catching the irrational cognitions. I had about as much effect as standing in front of an 80-mile-an-hour wind and spitting.

CHRIS AIKEN: And did you try medications?

STEVE HAYES: Well, of course I did. I had benzos and the beta blockers, and when I walked out of it, I eventually, you know, I was still on those side of ACT, using beta blockers less and less and less and less’ and finally, after about three or four or five years, I gave a talk after licking the pill, and I said, "Come on, this is ridiculous, Steve." But I was okay with that, because you got to start where you are, and as long as you know that these compromises are compromises and on the list of what you will address, I don't think they're that toxic.

CHRIS AIKEN: Beta blockers like propranolol have a mixed reputation in anxiety. It's often said that their widespread use for anxiety is not supported by any evidence, but that is starting to change. In the 1980s, propranolol equaled imipramine, a popular tricyclic for anxiety in panic disorder, but it fell short of benzodiazepines in trials of panic disorder. After that, propranolol disappeared from research, unstudied, but still widely used for physical symptoms of anxiety. And last year, propranolol successfully augmented the SSRI sertraline in a small placebo-controlled trial of panic disorder. The dose in that trial was very low, just 20 milligrams a day. Compared to older studies in panic, where the daily dose of propranolol ranged from 80 to 320 milligrams, averaging 180 milligrams. And if you use propranolol in anxiety, here's a tip that I learned from Conrad Swartz: use the long-acting formulation. The LA, the LA gives steady levels for around 12 hours, while the instant release goes up and down every three to six hours. Conrad shared that he's seen withdrawal anxiety with the instant release of propranolol. But does propranolol work if you just lick the pill like Steve did? No, that kind of magical thinking is a classic symptom of panic disorder. It's a safety behavior, a type of avoidance, and when you see it, it ought to move panic disorder up the rungs of your differential. Here are some examples. The patient has to map out the location of every emergency room on the highway before they take a road trip. They carry a rescue medication at all times. They always have to have a plastic bottle, hoping a sip of water will prevent somatic symptoms that might explode into a panic. They listen to music on headphones to stay grounded and ward off the derealization that comes with panic. They never travel alone or only travel to familiar places. They know where all the exits are before taking a seat and sit as close to the door as they can. They clutch good-luck charms or have to hold on to a shopping cart, a railing, or a friend while walking, or they need to have a distraction at hand at all times, like a magazine or, more often today, a cell phone. Woody Allen famously had to read the newspaper to control his anxiety when he was in an elevator. William Shawn, editor of The New Yorker and father of actor Wallace Shawn, kept a defibrillator in his office to ward off anxiety. The goal in therapy for panic disorder is to give up these superstitions, as Steve did with that last lick of propranolol.

STEVE HAYES: If you think you can get away with negotiating with anxiety, just try it, dude, and send me a letter about how that works; because your mind knows what you're doing, if you say, "Oh, as long as it doesn't get to a number 10," you know, a one-to-10 scale, "I can handle eight, but I can't handle 10," yeah, well, then it gets to eight, and your mind says “it's about to go to nine. It's going to go to nine. After that is turned”, you know, so—

CHRIS AIKEN: All this rational if-then wasn't working.

STEVE HAYES: Well, not for me, and, you know, if I look at the data on that, that's out there, it's not that reappraisal and so forth isn't unhelpful, having a lot of different thoughts, but it's not the technique, challenge, dispute, and change. It's not out with a bad thought, in with a good. That was thought to be how it worked in the early days, but if you actually do careful longitudinal mediational analysis, the geeky term for it, in traditional CBT and CT, that's not how it works. It was really good to go through a process where I had a punch in the nose, because there's something very invalidating to be part of an evidence-based therapy thing where the things you're telling people to do don't work with you. That's a horror.

CHRIS AIKEN: So you were practicing cognitive therapy, and it wasn't working on yourself. Can you describe the moment when you hit bottom and when you had that new realization?

STEVE HAYES: Well, yeah, it was at 2:30 in the morning, sitting on a shag carpet in a girlfriend's house, for some reason, she wasn't there. I've never figured that. I woke up in the middle of the night thinking I was having a heart attack, and I had every possible symptom that you could name, which, of course, you can produce. It's not that hard if, well, maybe that would be a little hard, but if you wanted to get nauseous right now, I could just give you about four or five sentences, and you'd feel nauseous. It's not very hard to get your mind to have that kind of impact on your body. And then somewhere in there, as I'm really, you know, my mind's just telling me to call the ambulance, I got to go to the emergency room, I'm about to die. But somehow or another, my hand won't grasp the phone. It was the weirdest thing. It was almost like dissociative, my hand— I don't know if I fully told that story, but my hand went out and came back, went out and came back, went out and came back. Must have done that six times. It's like, I'm not going to make this call, but I really want to make this call, and somehow my hand knew what my head didn't, which was, "This was not a heart attack. Dude, this is a panic attack."

CHRIS AIKEN: At this point, you're a young man. You know you have panic disorder, but you're still thinking this could be a heart attack.

STEVE HAYES: Yeah, because my dad died of a heart attack. We had a lot of heart disease in the family. He had an early heart attack, and his father died at a pretty young age of a heart attack. Got up to get some toast and thunk, he was on the floor dead, which turns out to be a big part of my family story. And the backstory, I think, of why I had lots of epigenetic pushes, so did my brother and sister. I'm the last one standing, but they struggle with that panic and anxiety and things of that kind, too. So though I was young, it did seem plausible, given that I had young heart attacks in males in my family history.

CHRIS AIKEN: Patients with panic disorder may imagine that they are having a heart attack, but there is also a real risk that they will. If you have panic disorder, you are about 1.5 times more likely to have a heart attack in the future, even after excluding comorbid depression, which we know raises the risk of heart attacks. The cause of this association, however, is not clear. Heart disease and panic disorder share biological mechanisms like autonomic dysfunction and enhanced carbon dioxide sensitivity, as well as lifestyle risks like smoking and physical inactivity.

STEVE HAYES: Then I realize in the middle of it, no, this is, as I said on the TEDx talk, another level down of hell. And that hit bottom for me. I mean, I sat there a long time. There was a crazy, crazy scream at the bottom of it, which was a scream of desperation. "This is the end, you know. I'm going to lose my job. I'm not going to be able to—" the whole thing. A lot of things are on the line if I can't even sleep at night, you know, without having a panic attack from a dead sleep.

CHRIS AIKEN: What clicked in you that wasn't the usual exposure or challenging or rational process?

STEVE HAYES: Somehow or another, I had an instinct to run towards the anxiety and basically say, "Kill me if you're going to." The metaphor I used is one that happened to me as a child, which was that I would have dreams of a Tyrannosaurus Rex being outside my window with gigantic eyes, and I'd try to hide in a room, and then I would lock the room, and then eventually I'd leave the house. And somewhere in there, I had a lucid dream, and I realized, you know, every single time the dinosaur catches me, I wake up. So I turned around and headed right at the dinosaur, and jumped in its mouth, and woke up. I think that was somehow in my head. I turned towards the dinosaur. I ran towards it, jumped in its mouth, and I woke up. There's no other easy way to explain it, kind of a spiritual experience, an out-of-body experience. Part of it was realizing that the voice that was telling me that I had to run and fight and hide was not me, but a voice in my head, which we all have. As I say, even four-year-olds understand goofy with horns on one shoulder and goofy with a halo on the other shoulder, which means you're really young when you understand you have an argument inside your head going on once language gets at a certain level. I made a choice to stop running away, instead running towards. When I got up off the floor, I knew my life was different. I could just feel that that was radically, radically different, and I've spent the rest of my life trying to understand it and come up with the theory and the data and so forth and put it into the lives of others. And that's why in ACT, the first word is acceptance. It's not tolerance or resignation. It's receiving a gift that's offered. And the gift of emotion is a tremendous gift. It's the source of our wisdom. If you didn't know how to feel about your past history, how would you know how to let it navigate your future history? You need that navigation, which means you need to be open, which means you need to notice it, and then all that rolls out. And how to do that with a critical, judgmental, problem-solving mind that's telling you, "No, happy, happy, joy, joy” is what you should be seeking, if you're feeling anxious, something's wrong with you. No, you're just human, and you feel anxious when something is important, and there might be negative consequences. That's a wonderful feeling in terms of utility. It's not a wonderful feeling to feel, necessarily.

CHRIS AIKEN: It sounds kind of poetic or maybe jarring to hear a therapist speak of how wonderful it is to feel anxiety instead of seeking ‘happy, happy, joy, joy’, but Steve tested these ideas over 20 years of research before he released them through ACT. So, let's take a peek at one of those studies. This one is about depression, not panic, and it delivers a cautionary note about the dangers of being too happy. In 2002, John Teasdale and colleagues looked at which cognitive changes helped people stay out of depression. After they went through a course of CBT therapy, people who came out of CBT with a lot of negative thoughts went right back into depression. No surprise there. But also, people who came out with a fixed positive outlook, those stubborn, happy thoughts, went back into depression just as fast. The patients who stayed out of depression the longest were those who developed metacognitive awareness. Understanding metacognitive awareness brings us closer to ACT. It's the ability to experience your thoughts as mental events instead of identifying with them and believing in them. When you're not tied to your thoughts and emotions, you are better able to experience their full range and let them guide you through life as Steve suggested. Sometimes life calls for rose-colored glasses, other times for self-criticism and doubt. People with metacognitive awareness can move more easily between those outlooks, allowing them to respond to the world around them, solve problems, manage stress, and adapt flexibly to life's ‘slings and arrows’. Teasdale's finding is held up over time, recently confirmed in a meta-analysis of 27 trials. And it has changed how we practice CBT, bringing in more mindfulness and acceptance techniques and bringing it closer to the Acceptance and Commitment Therapy approach that Steve glimpsed in that panic-stricken moment. We'll have more with Steve Hayes in our interview next week. Avoidance is also a driving force in depression, and my new book, Difficult to Treat Depression, has brief psychotherapy tips to help patients break out of experiential avoidance and other vicious cycles that perpetuate depression, like hopelessness, passivity, shame, ambivalence, transference reactions, and disability benefits.