An Interview with Post-Doctoral Fellow Kristy Cuthbert
Kristy Cuthbert, Ph.D. is an Administrative and Clinical Fellow at the Center for Anxiety and Related Disorders in Boston. She specializes in CBT and DBT for anxiety and related disorders, such as phobias.
Tori Steffen: Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Tori Steffen, research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.
I'd like to welcome with us today post-doctoral fellow Kristy Cuthbert. Dr. Cuthbert is an Administrative and Clinical Fellow at the Center for Anxiety and Related Disorders in Boston. Dr. Cuthbert specializes in CBT and DBT for anxiety and related disorders. She's also worked with individuals with post-traumatic stress disorder and borderline personality disorder. Her research focuses on alternative spectrum models of psychopathology and on treatment implementation in clinical settings. She has specialized training in working with veterans and has focused much of her clinical work on women's mental health and providing access to care for low-income populations. So before we get started today, Dr. Cuthbert, could you let us know a little bit more about yourself and what made you interested in studying, treating panic disorder and agoraphobia?
Kristy Cuthbert: Sure. So thanks for the introduction. So I think my interest came about simply because I did my graduate training at Boston University, that's the home of the Center for Anxiety and Related Disorders. And they offer cognitive behavioral therapies for anxiety and related disorders of a fairly wide range as well as mood disorders. However, I found it to be both challenging and rewarding to work with individuals who have diagnoses of panic disorder and, or a agoraphobia. Because entering into that first exposure I think, and I can talk more about what that is and what that entails in a moment, but entering into that first exposure, I think people have a lot of fear. And then once they face that fear, it just kind of unlocks this ability to do more and more. And it's really great to see people succeed and to feel empowered at the end of the process.
Tori Steffen: Yeah. And that must be really fulfilling work to do, to be able to help people and see the success rate.
Kristy Cuthbert: Yeah.
Tori Steffen: That's awesome. Well, getting down to the basics around our topic, can you explain for the audience what panic disorder and or agoraphobia are and how common they tend to be?
Kristy Cuthbert: Sure. So I think this can be kind of complicated if you're not super familiar with all of this terminology, because there are panic attacks and then there's panic disorder and then there's a agoraphobia. And so the answer can be complicated. I'll say that panic disorder is specifically related to two or more panic attacks that meet a certain set of symptoms that we ask people about and that these attacks occur out of the blue. And that's a critical distinction. So some people will report having a panic attack in the middle of the night, and it just feels really surprising and sudden.
And then for agoraphobia, people taking this a step further feel fearful about going out in public because of those panic symptoms or fear that those panic symptoms will come up. Or this can also be related to other fears about embarrassing symptoms like having an upset stomach or having to urgently go to the restroom or having trouble escaping for whatever reason from very busy and crowded places. So in addition to the two disorders, panic disorder and agoraphobia, you can also have panic attacks, which can be related to any number of other anxiety disorders. So if you have a specific phobia and you're afraid of bees, you can have a panic attack if you see a bee. And so that would be specified as a part of the phobia. The key there being, that panic attack is triggered by the bee. Whereas in panic disorder, those attacks come on very suddenly and are not related to, "Oh, well I saw a bee." Right?
Tori Steffen: Okay. That makes great sense. Thanks for making that distinction for us.
Kristy Cuthbert: Yeah. And in terms of how common they tend to be, I'll say that the 12 month prevalence rate in the DSM-5-TR for that is 2 to 3%. And for agoraphobia, it's 1 to 1.7% as the 12 month prevalence. So panic disorder is not entirely uncommon, neither is agoraphobia. So it's not uncommon to see those. And that doesn't even include panic attacks, the ones that can occur with other anxiety disorders.
Tori Steffen: Right. Have you seen any, or in the literature, are there any known causes for agoraphobia or panic disorder?
Kristy Cuthbert: So I think in terms of causes, this can be wide-ranging. For both disorders, they tend to co-occur at very high rates. So one theory is, so for example, to think about panic disorder, panic disorder and agoraphobia can be preceded by anxiety disorders. So perhaps you start with social anxiety. And when you have social anxiety, you might have a panic attack or panic symptoms. And then you start to really focus on those symptoms and develop fear and anxiety about having those symptoms. So then you're more likely to have those symptoms come on unexpectedly or to have more fears about going out in public or in crowded spaces where you then might have those symptoms.
So sometimes it's just a matter of experiencing some of those discomforts and really keying into those physical cues. Because it's kind of like when you get an itch on your head. This always happens when I'm getting a haircut. So I want to scratch it, but I'm getting a haircut. And so because I can't, I focus on it and it feels more and more intense. So for whatever reason, a person might start to notice those physical sensations and then that feeling like, "How do I control this?" And not being able to fully control it can kind of start that cycle of panic and then lead to agoraphobia as well.
Tori Steffen: Okay. Yeah, that makes good sense as in how it could potentially lead to agoraphobia. So thank you for breaking that down.
Kristy Cuthbert: Sure.
Tori Steffen: And as far as treating agoraphobia and panic disorder, what are some of the common treatments for the two?
Kristy Cuthbert: Yeah, so I'll say the gold standard treatments for panic disorder and agoraphobia are exposure based therapies. And cognitive behavioral therapy more generally. So you can talk about what it means to have a racing heart, and from a cognitive perspective, you might think of other situations where you had a racing heart like when you were working out, and then it was okay. You might think about what it means to feel panic. It means, “I'm out of control.” And you might look for evidence that doesn't support that you're out of control.
For the most part though, we do focus on exposures. And for panic disorder, one of the key types of exposures that we do is called an interoceptive exposure. So these are exposures where we kind of mimic the symptoms of a panic attack. So if one of your main symptoms is hyperventilating, we have you breathe through a coffee stirrer to actually simulate that and to sit with that. I've had patients wear heavy coats and heaters to simulate warmth and sweating, and maybe we will run in place for a couple of minutes to get the heart racing to really try to bring on the simulated symptoms of a panic attack and then to sit with that discomfort until it passes.
Because another thing we know about panic disorder and agoraphobia is that people often have safeties or safety behaviors. So they might carry medications around in their pocket. They might do certain things like bringing friends along with them when they travel so that they don't feel discomfort. So we also ask that, say we're sitting with those panic symptoms, we ask people not to engage in those behaviors. So we're not going to keep an empty bottle of benzodiazepines. We're not going to... We're going to leave that at home, we're not going to take off the coat and crank up the fan to try to combat the symptoms. We're just going to say, what if we leave them alone? And we try not to react to them. And to learn that by not reacting to them, it kind dismantles that false alarm telling you that there's danger.
So for agoraphobia, taking that a step further, we also do what we call situational exposures. So if you're afraid of public transportation, because it gets really crowded here in Boston and because you want to make sure you can escape, whether because you have panic symptoms or for some other reason, we get on the train. We get on the train when it's busy, we ride the train, we resist that urge to escape, we watch for other safety behaviors. Like again, carrying a medication. We may start by doing an exposure together. And then the person I'm working with might start to ride the train or take the bus on their own.
And of course, in more severe cases, this is trying to get them out of the house. So we might start by having them go to a grocery store that's a mile away. And then when they get into the grocery store, making sure they're not using any safeties to try to distract from the discomfort. The idea is that if we face the discomfort, then we'll see that it passes on its own without us having to react and that breaks up that cycle of behavior, and eventually that fear starts to become extinct.
Tori Steffen: Okay. So the goal is to reduce the fear that one would get?
Kristy Cuthbert: Right. And another goal is to learn safety. To be able to say, "I'm in a grocery store and I noticed that I'm having these panic sensations. I noticed the urge to want to escape, and I know that this is a safe place. As far as the world is safe, this is a safe place. And I know that what I'm experiencing is not necessarily a medical emergency. I've had these symptoms before. I recognize them as panic. I'm going to trust what I have learned about these symptoms, which is that I am safe if I just let them pass." So that learning safety is also an important part of it.
Tori Steffen: Okay. Okay. Well, great. And I know we spoke a little bit about how panic disorder and agoraphobia can co-occur pretty frequently. Is it likely for agoraphobia to be comorbid with any other mental health issues as well?
Kristy Cuthbert: Sure. So I talked a little bit about potential precursors. We also see a lot of comorbidity and different disorders that might occur in addition to, or once someone has started to have panic symptoms or agoraphobia. Depending on the severity of agoraphobia, it can be incredibly isolating if people don't go out often, if they have a lot of restrictions about where they can go that they feel safe. So a lot of people with agoraphobia will often have a diagnosis of major depressive disorder and substance use disorders. Because benzodiazepines are often prescribed. And depending on the severity of panic, benzodiazepines can be misused and can be addicted. People also drink or use other substances to try to take the edge off of that anxiety, either when they're feeling panic or if they have to leave the house or go into an uncomfortable situation if they have agoraphobia. So those are two of the particularly important comorbidities that we know of.
Tori Steffen: Okay, that's good to know. And have you worked with any other phobias out there, any that you can name for us?
Kristy Cuthbert: Yes. So we also treat specific phobias at the clinic. So I've worked with phobias of vomiting and specific phobias of animals like dogs, blood, injury, and injection phobias, insect phobias, snake phobias. I don't particularly work with snake phobias, but we do treat those at the clinic. And spider phobias. So yeah, a pretty wide range of specific phobias.
Tori Steffen: Yeah, there's definitely a lot out there.
Kristy Cuthbert: Yeah.
Tori Steffen: So yeah, that's very interesting. And how might somebody with a specific phobia typically present? Kind of what's their common experience, I guess?
Kristy Cuthbert: So I would say that from the cognitive behavioral model, we look at everything from this model of our thoughts and our feelings influence our behaviors. So most of the time what we see is a pattern of, and I'll use a dog phobia as an example. Sometimes it comes from having had a negative experience when they were younger. Sometimes it doesn't. It might be that their parents didn't have dogs, didn't like dogs. It might just be that they never had them around so they're just an unknown entity. They can develop for a wide range of reasons.
What tends to happen to maintain it though is... Say I'm going to work, it's important for me to get to work on time, and at around eight o'clock when I'm supposed to be walking through the door every morning, there is a medium-sized dog across the street from me right there next to the door of my office. That thought, feeling and behavior pattern might go something like this. I feel physical sensations, I feel a little bit sweaty, my hands are shaking a little bit. I feel maybe some flip-flops in my stomach, like I'm nervous. And I know that's because I see this dog. So then I think, "That dog might bite me, I'm in danger. I need to get away." And then that leads to the behavior. I don't cross the street. If the dog crosses the street towards me, I walk the other way. I avoid or try to escape the situation.
So what that does though is that says, "Yes, it really is a dangerous situation because you had to get out of it." So it reinforces the fear. So that pattern is something that we see that sort of seeing the object, feeling uncomfortable, labeling it as dangerous and trying to avoid or escape, that's a pretty common pattern.
Tori Steffen: Okay. And that fits so well with the cognitive behavioral therapy outlook. So that's really cool.
Kristy Cuthbert: Exactly. Yep.
Tori Steffen: And have you seen that any phobias are more common than others, in general?
Kristy Cuthbert: You know, it's really tough to say. I know that we do treat a lot of blood, injury, and injection phobias. Having blood drawn, getting medical procedures. I don't know at our particular clinic if those are any more common. And I don't know the prevalence literature off the top of my head. I would say that we do see that a lot, probably because if I am scared of a snake, for example, that's really not impairing my day-to-day life because I don't have to regularly interact with them. Now, if I were a keeper at the zoo and it was my job to take care of the reptiles, then I might come in and say, "I have a snake phobia." Or if I was an avid hiker and I stopped going hiking and kind of lost this thing that I loved, that might warrant treatment for a phobia. Blood, injury, and injection phobias or phobias around medical procedures, these are things that most people need to have done at some point. So we will see those people come in to have those treated.
Tori Steffen: Okay. Yeah, that's an interesting one. For the blood phobia, is it mainly seeing blood and having a fearful reaction to an open wound, is the common experience?
Kristy Cuthbert: So this can be wide-ranging. For some people it is. For others, there's very specifically a fear of having blood drawn, that fear of passing out if they have blood drawn. Some people do have that experience. So that I would say is a little bit of a unique treatment because we often will teach them a technique of tensing and relaxing muscles to make sure the blood is flowing. It increases the blood pressure and can prevent passing out while having blood drawn. So that's something that people can learn and do.
And the rest of it is very, very similar to exposure for panic or agoraphobia. And that we say, "What is it that you're afraid of?" "Well, I'm afraid of having my blood drawn."` So we start wherever a person is ready to start. So it might be, "Watch this video of someone having their blood drawn. Let's go into our medical lab and I'll have you put on the tourniquet and we'll prepare and you can sit with that anxiety." Which is often anticipatory. We also have specific phobias of driving. So for those, we'll start with one stretch of road. And then we talk about trying to see how is that similar to other stretches of road that I might be afraid of? "If I can do this, can I do this highway as well?"
So it's sort of a buildup to eventually having your blood drawn, eventually taking the highway you're most afraid of.
Tori Steffen: Right. Okay. Yeah, that definitely makes sense with gauging where they might be ready to start and starting there. So can all phobias be treated with exposure therapy?
Kristy Cuthbert: So I would say for the most part, there's always something we can do in terms of an exposure. You can be pretty creative, like I said. You can find anything in this day and age on YouTube. There are YouTube videos of just dash cams of people driving on highways. That's an exposure for driving phobia, right? If it's a scenario that you don't often find yourself in, like interviewing for a job with a person in authority. We have what we call confederates come in. It might be our clinic director, it might be one of our professors who's cleared to work in the clinic. But we have them come in, they're doing the interview so that someone starts to get that experience.
And if the situation is one that you can't really recreate, like, "I'm scared of getting the flu and being sick," then we'll do an imaginable exposure. So that's where people write out a script of what is that scenario that you're afraid of? Write it out in as much detail as you can, engage all five senses about what you notice about the situation, and then sit with the discomfort and challenge any sorts of judgments that might be in your write up. So I think it is very versatile. Exposure therapy, I think, is the standard treatment for most phobias. Yes.
Tori Steffen: Right. And how effective would you say that exposure therapy is in treating a wide range of phobias?
Kristy Cuthbert: Yeah, so you can really generalize this concept. And there are trans diagnostic approaches like the unified protocol that treat a wide range of anxiety and mood disorders based on these same concepts. So much like we avoid driving or avoid dogs, we can sometimes avoid uncomfortable emotions. So sometimes exposure is exposure to an uncomfortable emotion and being able to tolerate that emotion. Sometimes if we're feeling depressed and we don't want to be up and active, the exposure is being active. Depression tends to make us feel like we don't get a lot of pleasure out of activities. The problem then is that we stop doing the activities that might make us happy.
So taking that same approach, it's entering into those situations and saying, "I might not cure my depression today by going for a walk, but if I do this every day it's going to be really hard to hang on to that inertia and that heaviness that can come with depression." Likewise, interoceptive exposures, the ones where you simulate the physical symptoms of panic, you can do that with depression. The heaviness of depression, for example. There are ankle weights and arm weights that you can put on to kind of simulate heaviness. So it really does touch on a wide range of anxiety and mood disorders.
Tori Steffen: Wow, that's really interesting. Yeah, I'd never heard the examples for depression as well, so that's great to know that it can also help with that. Well, awesome. Well, while treatment options are best and ideally done under the guidance of the licensed mental health professional, are there any things that individuals can do on their own to potentially reduce the symptoms of panic or agoraphobia?
Kristy Cuthbert: So I would say a starting point is to be willing to say, "What is my panic look like?" I think one of the scary things about panic is your body is physically reacting. And so it's really hard to know is this a medical emergency? Because it feels so uncomfortable. Obviously you're having a physical reaction. It's hard to know. I would say that over time, panic attacks though, you can get to know them. And you can say, “I know what this is,” and to approach it with a familiarity, which I think can prevent the urge to, for example, Google your symptoms or to say, "Should I go to the ER to get this checked out?" If you start to understand what your panic is, that's a first step. Of course. I always give the caveat, make sure you're aware of what your physical conditions really are so you do know what to look out for. And also really balance that with saying, "I also know what my panic feels like and it feels like this."
And I would say the other thing is to think about the story you tell yourself. So I say this a lot with patients, and this really gets at the cognitive piece. So two things about the story you tell yourself. First of all, if you're telling yourself that, "Yes, I'm scared of having my blood drawn and I did it today, but I was scared the whole time." Well that kind of discounts this big achievement, you did something that was important to do. And it also can create a bunch of fear around it. It's almost like the expectation is that I should be able to have my blood drawn with no fear or you know what, I should be able to drive over a really high bridge with no anxiety. That is a really high expectation. And I would say that sometimes I drive over bridges and I'm like, "Wow, this is a really high bridge."Or I have a pretty healthy level of anxiety in busy traffic, because you're watching a lot and you're vigilant.
So don't see anxiety as a thing you want to eradicate. Just kind of learn to get more comfortable with it and learn when it's kind of out of proportion to what you think you're experiencing and give yourself credit for victories that you do achieve. If you get across a bridge because you have somewhere to go, pat yourself on the back for that if you're afraid of driving across a bridge. And the other thing is to picture going into it. What do you tell yourself about that bridge? “I'm going to drive over this bridge, I'm going to lose control and drive the car off the bridge.” And then ask yourself, “What is making me think this? What evidence do I have for it?” Sometimes the one thing that gets in the way is the story that we tell ourselves. Even before an exposure, if you're telling yourself that story, it's going to amp up the fear. And part of the fear is going to come anyway. And the story we tell ourselves can make that fear feel stronger.
Tori Steffen: Right. That makes a lot of sense, and that's great advice for just kind of starting off and getting introspective about what's really going on. Well, Dr. Cuthbert, do you have any final words of advice or anything else that you'd like to share with the listeners today?
Kristy Cuthbert: Not that I can think of. I think other than to say above and beyond the things that people can do on their own, it's okay to ask for help, to see someone who specializes in different types of therapy. If you feel like you're afraid of something and you're not quite ready to do exposures, there are other types of therapy where you kind of explore the root causes or where you focus on approaches that have you live your life in spite of your fears. And eventually it might mean facing your fears. And it's all about looking at your values and living according to those values. If you feel like anything, any specific fear, panic symptoms or fear of certain situations, if you feel like that's getting in the way of living a life according to your values, it's okay to seek help from someone to help get you through it. Some of these treatments can be completed in as few as 12 to 16 sessions. So it is worth the investment and the time that it takes.
Tori Steffen: Yeah, I would have to agree. That's great advice. So thanks so much for sharing that, and thanks for chatting today. It was really great speaking with you about this. And I hope you have a great rest of your day.
Kristy Cuthbert: Thanks, you too.
Tori Steffen: Thank you. And thank you everybody for joining.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.