Progress In Understanding and Treating Anxiety and Related - The Albany Years

The Albany Years Shortly after arriving in Albany, and in a department of psychology rather than a department of psychiatry and associated hospital for the first time, it seemed necessary to create a venue to carry on clinically meaningful research since there was no ready supply of patients. While some psychology departments in those years had established training clinics usually called “psychological service centers” as had Albany, the setup of these training clinics along with their mission made the conduct of clinical research difficult if not impossible beyond simply collecting a few questionnaires etc. Indeed much of the research on going in psychology departments in the 1970’s could be characterized as “analog” research focusing on personality traits or fears mostly in college students. Research from my own dissertation described earlier focusing as it did on modifying relatively normal fears of snakes in college sophomores remained the prototype for clinical research approaches in psychology departments despite the fact that findings from these research paradigms produced few results that were generalizable to more severe psychopathology. Thus, Ed Blanchard and I together initiated the Center for Stress and Anxiety Disorders which grew to become a large federally funded research clinic. This Center was, in turn, organized around the Phobia and Anxiety Disorders Clinic housing my research and the Stress Disorders Clinic for Ed’s research on biofeedback for such conditions as hypertension and migraine headaches. We shared administrative space and a reception area, and over the years flexibly allocated space based on grant portfolios. Here my knowledge of organizing and supervising large outpatient clinics in departments of psychiatry and hospitals came in handy and we purposely set up the Phobia and Anxiety Clinic to serve the general public rather than college students. We also marketed the clinic as offering specialized effective brief psychological treatments for people with anxiety and related disorders, and patients paid for these services. This communicated the fact that the clinic was squarely in the realm of mental health care delivery with a focus on accurate diagnosis and effective treatment (in other words getting people better) rather than a psychology lab where patients paid nothing in return for being a “guinea pig” in a research project. We also saw that the waiting area and offices were comfortable and well appointed and that staff and receptionists dressed and acted professionally. The functioning of this clinic, as it evolved, is described in Barlow (1992, article #8). Treatment was provided by myself and other young faculty members collaborating on setting up clinical research programs such as Rick Heimberg who began a program for social phobia and Gerry O'Brien working in the area of agoraphobia and the newly created disorder (in DSM-III) of panic disorder. Services were also delivered by doctoral students working on the team who were supported by one or more NIH grants focused on developing psychological treatments for anxiety disorders. Despite marketing ourselves as a fully functioning clinic serving the public in order to attract sufficient numbers of patients, we did not lose sight of our principal mission as a center for clinical research. With this structure in place, and taking advantage of every media invitation to make the public aware of our programs, the clinic developed a reputation of providing effective clinical services in a professional manner and positive word of mouth assured steady growth in the number of referrals. This growth necessitated several moves in those first few years to accommodate expansion and by 1983 we finally settled in our own building leased by the university on a busy road just off campus. That year we recruited Wendy Silverman to the faculty and she organized a Child and Adolescent program. When Wendy left for Florida in 1990 a new post-doc, Anne Marie Albano took it over. In 1987 Bonnie Brown, who had been with us in more junior positions became administrator of the anxiety clinic, and when she finished her nursing degree became Nurse-Administrator. Our research focus on anxiety in this center was effectively launched with the awarding of an NIMH contract for a conference on behavioral approaches to anxiety disorders that was held in Albany on April 28th-30th, 1980. This conference, attended by 20 of the leading clinical researchers in the world at that time noted that psychologically based treatments, particularly exposure therapies for phobia, were proving to be an important advance in effective treatment which had been dominated up until that time by pharmacological treatments. But there were sizeable disagreements among clinical investigators on the appropriate directions for research in this area. A report of the consensus conclusions of this conference published in 1981 (Barlow & Wolfe, 1981, article # 4) recommended general research strategies, new approaches to assessment and classification, ideas for fruitful process and outcome research, as well as the beginnings of dissemination strategies. Among the interesting recommendations from the conference participants at that time was that there was no further need for outcome studies utilizing exposure therapies for phobias since these procedures were well established. However, important outcome research should be initiated in the newly conceptualized areas of generalized anxiety disorder, social phobia, and panic disorder. Furthermore, all funded research should be carried out with clinical populations “whether the goal was to uncover basic mechanisms of action of psychological treatment or to pursue future outcome goals” (p. 449). Thus the committee suggested that analogue research had probably run its course and that priority should be given to studies in the context of the more commonly encountered clinical disorders. Recommendations were also made to study the generalization and maintenance of changes as a function of psychological treatments, to study epidemiological and natural histories of the anxiety disorders and, not surprisingly, that a greater use of single case experimental designs teasing out mechanisms should prove fruitful. It is interesting to contrast knowledge of the anxiety disorders as it existed in 1980 represented by the conference recommendations with what we have learned in the past 35 years. In 1981 Peter DiNardo who was on the faculty of nearby SUNY Oneonta joined us for a year-long sabbatical and together we collaborated on writing a much needed semi-structured diagnostic interview focusing exclusively on anxiety and related emotional disorders. Modeled after the Schedule for Affective Disorders and Schizophrenia (SADS) we named this instrument the Anxiety Disorders Interview Schedule (ADIS) which proved to be an extremely useful instrument and became the focus of our new project on classifying anxiety disorders. With a venue in place and the focus squarely on anxiety and related disorders the major themes of my research became more fully elaborated. Early research on the nosology of anxiety and mood disorders resulted in explorations of the reliability of these new DSM-III categories as well as new conceptualizations of generalized anxiety disorder and panic disorder (e.g. Barlow, 1985; Barlow, 1987; Barlow, Blanchard, Vermilyea, Vermilyea, & Di Nardo, 1986). These developments were communicated through my membership on the anxiety disorders work group for DSM-III-R, and later on the Task Force for DSM—IV. Our long running NIMH grant on the classification of anxiety disorders first funded in 1984 and taken over by Tim Brown as Principal Investigator in 2000, continues to this day. At the same time experimental psychopathology research focused on the nature of anxiety as evidenced in men, and later in women, presenting with sexual dysfunction. First funded by NIMH in 1979, the major paradigms used in this grant afforded an easily quantifiable output of the influence of cognitive and affective components of anxiety in the form of psychophysiological measures of sexual arousal which could be manipulated, sometimes without patients’ awareness. This program of research resulted in a model of the process of anxiety manifested in sexual dysfunction (Barlow, 1986a, article # 12). In 1985 Michelle Craske arrived to spend a post-doctoral year after finishing up her PhD at the University of British Columbia with Jack Rachman. During this period my colleagues and I, particularly Michelle and Ron Rapee, also spending a postdoctoral year after getting his degree at the University New South Wales in Sydney developed new treatments for anxiety and related disorders, most notably a new psychological approach to treating panic disorder that was positively evaluated and widely accepted (Barlow, 1986b, article #5; Barlow, Gorman, Shear, & Woods, 2000; Klosko, Barlow, Tassinari, & Cerny, 1990; Barlow & Cerny, 1988). We also extended treatment development efforts to generalized anxiety (e.g. Rapee & Barlow, 1991). Fortunately for me Michelle and Ron ended up staying approximately five years contributing substantially to a very productive period of clinical research. Programmatic research on the nature, classification, and treatment of anxiety and its disorders during the 1980’s resulted in a book integrating basic and applied research on anxiety from a variety of different perspectives (Barlow, 1988). The several years it took to write this book proved to be a crucial step in my research as it deepened and broadened my knowledge of anxiety and I became acquainted with the literature, such as it was, in emotion science. This, in turn, led to the first statement of a transdiagnostic approach to treatment in the emotional disorders based on effective principles of change as described below. By 1990, evidence based psychological treatments had been evaluated positively from emerging clinical trials such that sufficient evidence for efficacy was available for at least some disorders, and around this time we turned our attention to dissemination and implementation. The first step was made possible by the necessity in well conducted clinical trials of writing treatment manuals describing the administration of treatments undergoing evaluation in some detail. This allowed multiple therapists to administer these treatments in a reliable manner thus ensuring the existence of an independent variable. It became apparent to us that these manuals, that had been restricted to internal use among research teams up until that point, would be valuable to clinicians more generally wishing to incorporate these treatments into their practice. Thus, in the late 1980’s Michelle Craske and I wrote up our treatment for panic disorder and selfpublished it through my own publishing company set up for this purpose, Graywind Publications, INC. (Barlow & Craske, 1988). When it quickly became apparent that there was considerable demand for this product we published additional materials such as a therapist guide (Craske & Barlow, 1990) as well as programs for treating generalized anxiety disorder (Craske, Barlow, & O'leary, 1992, Zinbarg, Craske, & Barlow, 1993) and began publishing manuals used in other clinical trials by other investigators for a variety of different disorders as well. This was a new concept at that time that did not fit comfortably with traditional publishing companies since we were making available an integrated treatment program to address specific disorders, and it seemed a new and different marketing and dissemination strategy was needed. While this dissemination strategy was effective to a point, it became clear that broader efforts were needed to make these treatments better known and available in order to provide some semblance of choice to people suffering from these disorders most of whom were restricted to available medications from their providers. In 1993 when I was elected President of the Division of Clinical Psychology (now the Society of Clinical Psychology) of the American Psychological Association, I organized a task force (one of the prerogatives of the president each year) and titled it “Promotion and Dissemination of Psychological Interventions”. I was fortunate to have my first choice for chair of this task force, Diane Chambliss, accept this responsibility and, working together we recruited diverse members from research and practice settings. In order to implement promotion and dissemination initiatives it became necessary to first survey the state of the evidence for psychological treatments ascertaining which interventions could be judged to be empirically supported or evidence-based, but no a priori criteria existed for making these determinations. The Task Force settled on a criteria consisting of a minimum number of studies showing efficacy which was admittedly arbitrary but formed a starting point for what proved to be a very important debate on this topic. This was followed by the listing of psychological interventions that met these new criteria, and the active process of communicating the empirical support of psychological treatments to psychologists, other mental health professionals, and the public at large began. These ideas merged with the growing mandate emanating from medicine for evidence based practice and it became clear that this was an idea who’s time had come (Barlow, 1996, 2004). Boston: The Later Years In 1996 after 17 productive and fulfilling years in Albany I was presented with an exciting opportunity to rebuild a clinical psychology program in my hometown, and Beverly and I, after an absence of 30 years, returned to Boston where I became Professor of Psychology and Psychiatry, Director of Clinical Training, and Director of the Center for Anxiety and Related Disorders at Boston University (CARD). CARD was actually the Phobia and Anxiety Disorders Clinic of the Center for Stress and Anxiety Disorders at Albany which, by that time, had grown to approximately 30 people including staff and students, almost all of whom made the trek down the Mass Pike from Albany to Boston. Notable among them were Tim Brown and Stefan Hofmann, who had taken over the Social Phobia Program from Rick Heimberg, David Spiegel, the clinic psychiatrist, and, of course, Bonnie Brown, our Nurse-Administrator. Construction of our new quarters in Kenmore Square, very close to Fenway Park proceeded quickly and we were open for business in the fall of 1996. The design of the new clinic was greatly assisted by David Spiegel who, prior to attending medical school, had completed a degree in engineering, skills he put to good use in designing and adapting space to suit our needs. Shortly after arriving Donna Pincus joined us at CARD and took over the Child and Adolescent program. In the years to follow Pincus, Brown, and Hofmann would all cross over from soft research funded positions to tenured professorships at B.U. CARD was principally a clinical research operation supported by five different NIMH grants in 1996. The complexity of the transfer prompted the Provost to equate efforts to recruit us with the recruitment of a large physics lab. But once again, as had happened at Brown University, one of the principal objectives of my recruitment by the administration at Boston University along with research initiatives was to revitalize the clinical psychology training program. This program, one of the original 12 programs approved by APA in 1948, retained many existing elements from those early years including a very heavy focus on practice and theory. As with most of the early programs, research was not emphasized and training in research methods was introduced only late in the training sequence. There were no existing externally funded research grants in the clinical program and the university made it clear that unless the program became more scholarly and research based they would consider closing it down. Initially, we focused largely on revamping the curriculum, hiring or promoting more research oriented clinical faculty, and making research training an integral part of the clinical program experience beginning in the first year. Very ably assisted by a new graduate of the clinical program, Lynn Bufka who was intimately familiar with the inner workings of the training program, the department, and the university, and with the cooperation of the faculty who were, for the most part, on board with the necessity of change if not necessarily the specifics of what needed to change, the transition went relatively smoothly. During this transition Lynn performed superbly as Associate Director of Clinical Training with her strong interpersonal skills and the ability to relate to both faculty with whom she was popular and respected, and students who were, after all, just a few years younger than she. Lynn was able to smooth out many of the inevitable bumps in the road during this rebuilding process. This allowed a more complete focus on clinical research at CARD then I had anticipated. By 2004 after eight years of running the clinical program the transitions were complete and I stepped down. As I write this chapter it has now been over 18 years since I arrived in Boston and my program of research and writing has continued to focus on the nature and treatment of anxiety and related disorders of emotion, as well as policy issues involved in dissemination and implementation. In 2004, recognizing the plethora of treatment manuals that had been developed for anxiety and related emotional disorders, each targeting a very narrow slice of psychopathology represented by DSM-IV categories, we returned to the approach first articulated in 1988, identifying a common set of principles of change applicable to all disorders. We referred to this approach as a Unified Transdiagnostic Treatment for Emotional Disorders in the first article on this topic (Barlow, Allen, & Choate, 2004, article # 10). Moving more deeply into this area I began to realize, based on our ongoing research on the classification and nature of emotional disorders with my colleague Tim Brown, that fundamental temperamental aspects underlying anxiety, mood, and related disorders seemed more central to the nature of these disorders than did the symptom presentations that were their defining feature in DSM-IV and DSM-5. In 2009 Tim Brown and I proposed the conceptual outlines of a new hybrid dimensional-categorical classification system based on these shared features and began to spell out implications for assessment and treatment (Brown & Barlow, 2009, article # 16). This led in turn to a greater focus on the underlying temperament of neuroticism along with related temperaments such as positive affect, and a modification of existing models of etiology to encompass the nature and development of neuroticism itself with implications for diagnosis and treatment (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014, article # 17). At the same time we continued to focus on dissemination and implementation with policy based articles outlining the status of some of these fledgling efforts (McHugh & Barlow, 2010 article #19) and a more general update on the status of evidence based psychological treatments with some predictions of necessary future steps (Barlow, Bullis, Comer, & Ametaj, 2013, article #21). By 2009 CARD had morphed into something much more than my laboratory which it had been during the Albany years and the early years in Boston, to a university wide resource that was used for training not only for doctoral level psychology students at BU, but also psychiatric residents, social work students, as well as students from other clinical psychology programs in and around the city of Boston. Research projects and programs have multiplied and CARD is currently staffed with over 70 individuals including a number of principal investigators pursuing different aspects of adult and child emotional disorders. Over 500 patients are admitted to the clinic (after a telephone screen for appropriateness) in a typical year with about half of them triaged into ongoing clinical research projects. The other half, including those who refuse participation in research for one reason or another are assigned to staff and students for treatment. In 2009 I gave up all remaining administrative roles in the department and clinic and a full time director was appointed to administer CARD. In view of the complexities of running this large research and teaching unit the decision was made to appoint someone on a non-tenure-track line who was not also pursuing research. Dr. Lisa Smith, the former clinical director of CARD was appointed and she in turn reports to a steering committee of principal investigators leaving me time to focus more fully on the above mentioned strands of research. With this description of the external influences and contexts that led to the various strands of my program of research now complete, it is time to return once again to the major themes outlined at the beginning of this chapter and to consider briefly the articles I have chosen to illustrate the development of these themes beginning with methodology and clinical research. Methodology and Clinical Research The first paper in this section (Barlow, 1980) represents my presidential address to AABT (now (ABCT). The address was actually delivered in November of 1979 at a time when behavioral and cognitive interventions were beginning to be seen in a more favorable light. This followed a decade ranging through the mid to late 1970’s when behavior modification or behavior therapy received very bad press often described as nothing more than unethical brain washing as famously represented in the popular book and movie of the time Clockwork Orange. This poor image was best represented by a survey of articles in the New York Times during the mid 1970’s demonstrating that approximately 50 percent of the articles addressing the subject equated behavior modification with such procedures as brainwashing, psychosurgery, sensory deprivation, and Chinese water torture! Nevertheless, by 1980 both the NIMH and the American Psychiatric Association along with Science Magazine and the President’s Commission on Mental Health strongly endorsed further research into behavioral interventions noting preliminary evidence for their efficacy. But what I noted in that address was that our science was becoming shallow. Basically this was due to an overemphasis on broad nomothetic comparisons of a treatment to no treatment with results analyzed in terms of statistical rather than clinical significance “…instead of asking why does a treatment work and what are the ingredients of a given technique that are truly effective, the question is often how much of a chance is there that this package treatment as it currently exists might work with some broadly defined problem. And any probability at all is usually good enough” (pp. 319) In this report, and following the tenets of applied behavioral analysis I advocated for “…a fine grained analysis of an individual’s behavior or a series of individuals’ behavior, with attention to technique building, repeated measurement, and social rather than statistical significance; an approach to science that in its very nature attends to our failures” (p. 322) In this article I go on to hazard some predictions about how this focus on a more idiographic analysis might come about. It is interesting to fast-forward 30 years to the second paper in this section (Barlow & Nock, 2009). The same plea is made, but it is noted that more idiographic single case experimental analyses had not been as widely adopted as I predicted they might be in 1979. The principal reason for this (in retrospect) seemed to be the beginning of the funding of large randomized clinical trials (RCTs) by the National Institute of Mental Health (NIMH). These trials very clearly became the gold standard for establishing the efficacy of treatments and the outcomes deeply influenced healthcare policies and practices. Without questioning the enormous contribution of this methodology, it is interesting to note that the NIMH in its recent policy pronouncements has proposed abandoning large clinical trials that simply compare treatment A to treatment B. Rather, any new trials must undertake a deeper analysis of active mechanisms in these treatments, along with a focus on discerning appropriate targets of any intervention integrating biological and psychological factors that might reflect important causal mechanisms in psychopathology. The NIMH, with its recent launch of the Science of Behavior Change (SOBC) initiative, seems to be pursing the very same objectives noted as desirable in these articles. In Barlow and Nock (2009) we hazard a suggestion as to how this technology can be better integrated into current clinical science initiatives. Treatment of Anxiety and Related Disorders Articles in this section span most of my career and trace an interesting story in the development of our conceptions of treatment predating even exposure as we know it today. The first article in this section, published in 1968 in the Archives of General Psychiatry, but reflecting treatments that occurred a year or two earlier seems naïve in its conception as one might expect from an effort over 40 years old. As a doctoral student at the time I was the therapist for these patients which meant I saw them on a daily basis for a number of weeks during these intensive interventions. These patients suffered from very severe agoraphobia such that they could not leave their homes and had to be transported to the clinical research unit in the hospital via ambulance while heavily sedated. Treatment consisted of setting up a walking course of about a mile in length that proceeded into an ever more crowded area in Burlington, Vermont. Patients would venture out as far as they could away from the hospital and would receive enthusiastic praise (from me) for successfully meeting behavioral targets for the day. The choice of selective positive reinforcement was based on strong results from the operant laboratories as a well established procedure for effecting behavior change. At that time of exposure procedures themselves were not considered central to any therapeutic approach including the new behavioral approaches. Wolpe had been using SD, particularly for specific phobia, in which patients would be gradually exposed in imagination to feared situations along a hierarchy while deeply relaxed based on the idea that relaxation would inhibit anxiety as long as the anxiety was not too intense. So the principal goal was to inhibit or decrease the anxiety. This also reflected a theme present in both psychoanalytic and behavioral theorizing of the day that experiencing intense anxiety could produce a very dangerous outcome up to and including a psychotic break. In psychoanalytic theory the purpose of defense mechanisms was to prevent intense anxiety from happening. In behavioral theorizing based on Pavlov if anxiety was too intense the organism could enter a state of paralysis described by Pavlov “transmarginal inhibition” (Barlow, 1988). So all anxiety reduction procedures of the day were carried out very gradually indeed. That our interventions were successful even with very severe patients was something of a surprise to us, but did engender a number of questions on active mechanisms of change. It was not long before we discovered that the exposure procedures themselves, particularly in vivo exposure as was happening in this study was the principal and most powerful mechanism of change, and that reinforcement simply motivated this new behavior (Barlow, 1988). Other articles in this section detail the accumulation of knowledge over the decades as we developed ever more successful treatments. The aforementioned NIH conference that occurred at SUNY, Albany in 1980 summarized the state of the art at that time (article #4). By the mid 1980’s we had conceptualized a new approach to treating panic attacks based on the notion that these attacks represented the conditioning of anxiety to internal somatic (interoceptive) cues and that the required treatment would involve the “twist” of directly exposing patients suffering from panic attacks to these interoceptive cues in a procedure that came to be called interoceptive exposure (Barlow, 1988). This early conceptualization is presented in Barlow (1986b, article #5). In 1988, and as noted above, while attempting to integrate everything we knew about anxiety and its disorders at the time, I wrote a chapter “The process of fear and anxiety reduction: Affective therapy” (Barlow, 1988, p. 285-318, article #6). I called it “affective therapy” since I drew on principals of emotion science as the basis for new and continuing developments in treating disorders of emotion. Particularly important strategies gleaned from this analysis included changing action tendencies associated with pathological emotions, along with interoceptive exposure and altering attributions and appraisals about the emotional experience. This was actually the first statement of what would develop 15 years later into an integrative transdiagnostic treatment for emotional disorders. In the meantime clinical trials and had already become the gold standard for evaluating treatment efficacy and our clinic benefited from a number of NIMH grants supporting trials for one disorder or another. One of my students, Janet Klosko with support from what was then the Upjohn Pharmaceutical Company conducted the first direct comparison of our new treatments for panic disorder incorporating interoceptive exposure with the most popular drug of the day Alprazolam (Xanax) a high potency benzodiazepine (Klosko, Barlow, Tassinari, & Cerny, 1990, article #7). The somewhat surprising result was that what we then called “panic control treatment” actually outperformed the drug, an outcome quite surprising to many. “Surprising” because there was little evidence at that time for the efficacy of psychological interventions for what was thought by many, particularly biological psychiatrists, to be a biologically based disorder. But this finding led directly to a large multisite clinical trial finally published in 2000 in JAMA comparing panic control treatment with the tricyclic antidepressant imipramine as well as their combination (Barlow, Gorman, Shear, & Woods, 2000, article #9) This study broke new ground at NIMH since they had not yet had an application for a study from multiple principal investigators acting independently at four different sites (as opposed to one site subcontracting to another). This forced the NIMH to create a new grant mechanism to accommodate this collaboration which included two sites with a pharmacological approach to anxiety and panic (Gorman and Woods) and two sites better known for a psychological approach (Barlow and Shear). This innovation, intended to handle the obvious confound of allegiance effects at any one site, was widely praised and, given the success in obtaining funding, widely imitated in years to come. The activities ongoing in our anxiety disorders clinic in the 1990’s referred to above in the discussion of “the Albany years” are detailed in a brief article published in 1992 (Barlow, 1992, article #8). Finally, as a logical extension of thinking detailed in my 1988 book on “Affective Therapy” we published in 2004 the first statement describing a Unified Transdiagnostic Treatment for Emotional Disorders consisting of five core therapeutic procedures thought to be widely applicable to all anxiety, mood, and related disorders (Barlow, Allen, & Choate, 2004, article #10). In many ways this was a culmination of work begun back in the 60’s that reflected our deepening understanding of the nature of anxiety and its disorders and the development of effective psychological interventions targeting these underlying mechanisms. It certainly will not be the last statement since clinical science will continue to advance, but it does form the current focus of our efforts in the twilight of my career. The Nature, Diagnosis and Etiology of Anxiety and Related Disorders Upon arriving at SUNY Albany in the fall of 1979 two NIMH grants were simultaneously awarded; the first focused on the treatment of agoraphobia and panic disorder with a particular emphasis on including a significant other, usually the spouse, in the treatment process (see Barlow, O'Brien, & Last, 1984). The second was focused on elucidating the nature of anxiety and arousal in sexual dysfunction (as mentioned above and described below). In 1982 a third NIMH sponsored clinical trial began focused on evaluating new treatments for generalized anxiety disorder. As the principal investigator (PI) on three NIMH awards we discussed with NIMH staff the desirability of applying for a Center grant that would support the infrastructure of the anxiety clinic making each of the treatment outcome grants less expensive. Due to fluctuations in policies regarding Center grants at that time this particular application was not encouraged, but working with NIMH we decided that an additional grant application focused on detailed assessment, diagnosis and classification of all patients coming into the clinic would serve the same purpose. That is, all patients could then be worked up in considerable detail and triaged to the appropriate clinical trial focused on treatment outcomes thereby saving the clinical trials the expense of this initial screening. The grant, titled “Classification of Anxiety Disorders” was funded in April of 1984. In September of 2000 after relocating to Boston the PI status was transferred to Tim Brown and this grant is now in its 31st year of continual funding. The first article in this section “The phenomenon of panic” (Barlow, Vermilyea, Blanchard, Vermilyea, DiNardo, & Cerny, 1985, article #11) emanating from early work on this project provides detailed descriptive data on patients coming into our clinic. In this article it was demonstrated for the first time that panic attacks were a ubiquitous process occurring across all of the anxiety disorders and depression, and therefore from a nosological point of view could not be restricted to what was then called panic disorder. We also developed in this article for the first time a scheme for categorizing panic attacks based on whether triggers or cues for the panic attack were recognized by the patient (as in a phobic situation) or not and whether the attack was expected or unexpected. A panic attack categorized as uncued, and unexpected by the patient was meant to replace the prevailing more biologically based conception of a “spontaneous” panic attack, a term that was judged to be unscientific since nothing was truly “spontaneous” in nature. We also made clear that whether the attacks were cued and expected or not was a construction of the patient rather than a biologically based phenomenon since the different types of attacks presented all but identically in terms of symptom clusters etc. This terminology and the ubiquity of panic attacks then began to make its way to the DSM process beginning with DSM-III-R published in 1987. The second article on “Causes of sexual dysfunction: The role of anxiety in cognitive interference” (Barlow, 1986a, article # 12), ultimately provided the theoretical underpinning for a new conception of the nature of anxiety described in more detail in my book Anxiety and its Disorders published in 1988. The gist of this article was a fundamental refutation of the then widely accepted notion from Masters and Johnson that anxious arousal was the cause of sexual dysfunction. What was demonstrated in this article was that introducing anxiety in the form of shock threat while “normal” males (and later females) without sexual dysfunction were watching erotic content not only did not diminish sexual arousal objectively measured in the form of changes in penile circumference, but actually enhanced sexual arousal. Indeed, what seemed to differentiate sexually functional from dysfunctional males in this paradigm was the type and focus of cognitive activity in an erotic context, and the extent to which this sexual arousal was perceived to be under the participants control. A sense of control became a major theoretical underpinning in my conceptions of anxiety (and later neuroticism itself) and the origins of perceptions of uncontrollability and anxiety were traced to early developmental experiences first in 1988 (Barlow, 1988) and then, in considerably more detail, in a Psychological Bulletin article first authored by one of my students at the time, Bruce Chorpita, (Chorpita & Barlow, 1998, article #14). In 1991, anticipating later work attempting to identify common underpinnings of all emotional disorders and building on theoretical work developed in Barlow (1988), I published an article “Disorders of Emotion” (Barlow, 1991, article #13) extending our conceptions of the etiology of panic disorder to other emotional disorders such as depression, stress and anger, and mania (excitement). Ten years later during a very productive year at the Center for Advanced Study and Behavioral Sciences with my colleagues Mark Bouton, and Sue Mineka, we wrote a paper updating in some detail the theory of the etiology of panic disorder integrating new findings from cognitive science and neuroscience (Bouton, Mineka, & Barlow, 2001, article # 15). By that time DSM-5 was already in the works as noted above, and Tim Brown and I began speculating on what new findings from the classification of anxiety disorders grant would portend for classification in DSM-5 and beyond. Taking a unified transdiagnostic perspective, we published in 2009 an invited paper proposing a new hybrid dimensional- categorical classification system based on the shared features of anxiety and mood disorders (Brown & Barlow, 2009, article # 16). This work continues to be the major focus of the classification grant under Tim’s direction. Finally, and as also mentioned briefly above, following the substantial honor of being awarded the James McKeen Cattell award from the Association for Psychological Science in 2012 our team fashioned a paper based on portions of my award address entitled “The Nature, Diagnosis, and Treatment of Neuroticism: Back to the Future” in which we proposed that earlier ideas from Barlow (1988) on the origins of anxiety required refocusing to higher order dimensions of temperament, specifically neuroticism itself (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014, article # 17). We note in that article that neuroticism may be more malleable than previously thought and would ideally be the target of direct therapeutic intervention. This constitutes the very heart of our research approach at the current time. The Ascendance of Evidence-Based Psychological Treatments As mentioned in the section describing the Albany years, I served as president of the Society for Clinical Psychology (Division 12 of the American Psychological Association) in 1993 and created a task force on the “Promotion and Dissemination of Psychological Interventions”. This initiative grew out of efforts in the late 1980’s alluded to above when it had become very clear from a public policy point of view that the prevailing pharmacological approaches to mental disorders were being widely adopted and recommended in emerging health care policy statements. Most of these policies were targeting accountability under the relatively new concept of evidence based practice while at the same time addressing the spiraling cost of health care. These policies often took the form of clinical practice guidelines. As noted above, medications were deemed the treatment of choice for panic disorder despite the fact that our data had already indicated that new psychological interventions were at least as effective if not more effective (e.g. Klosko, Barlow, Tassinari, & Cerny, 1990; Barlow & Cerny, 1988). Since these treatments were not readily available to clinicians or the public, and there were no efforts to make them available other than the occasional workshop, we formed a small company “Graywind Publications, INC.” to disseminate new treatments. With unbridled optimism and a firmly established illusion of control over how easy this was going to be, we incorporated our company, invested money in printing several hundred copies of our treatment for panic disorder entitled “Mastery of Your Anxiety and Panic” and set up shop in the basement of our house in 1988 with my wife Beverly running the show. After obtaining several mailing lists and testing the waters the initial investment was recouped in the first month and the company became profitable. The company expanded quickly, was moved into commercial space, and additional employees were hired. This experience convinced us that the demand existed for these programs, and that the problem was little or no infrastructure for dissemination. After five years the business required an infusion of substantial cash for expansion, a much advanced computer system for fulfillment, and a CEO to actually run the business, all steps that neither Beverly nor I were willing to take due to other commitments and a bit of fatigue from the very long hours and inevitable set of problems involved in any rapidly growing business. So we sold the business with it ultimately ending up in the hands of Oxford University Press where the series is known as “Treatments that Work”. But these early experiences made apparent the necessity of further promoting the existence of what we then called “empirically validated treatments” and exploring methods of dissemination and implementation In the first article in this section published in 1996 (Barlow, 1996, article # 18), I identified emerging policies, the status of research, and the necessity of responding to developing clinical practice guidelines such as they were at that time. By 2010 dissemination and implementation had become its own field of endeavor with appropriate funding mechanisms and emerging methodologies. Along with my student at the time, Kate McHugh, we detailed the status of those efforts offering judgments on where the field was lacking and what additional research was needed (McHugh & Barlow, 2010, article # 19). This topic was expanded into a book published in 2012 (McHugh & Barlow, 2012) and in 2013 our team once again updated emerging directions in research on evidence based psychological treatments with suggestions for more broad based future efforts (Barlow, Bullis, Comer, & Ametaj, 2013, article # 21). To improve dissemination, one of those recommendations focused on taking advantage of the power of direct to consumer marketing of psychological interventions, a strategy that has proved enormously successful for the large pharmaceutical companies. Initial demonstrations of the potential of this strategy for psychological interventions were detailed in a special series (Santucci, McHugh, & Barlow, 2012, article # 20). Notably, another of my students Katlin Gallo, conducted an important dissertation on this topic only recently published (Gallo, Comer, & Barlow, 2013; Gallo, Comer, Clarke, Antony, & Barlow, in press). Thus, the articles in this last section representing as they do substantial advances in policy is perhaps one of the more remarkable developments over the course of my career since we literally began with nothing . From that humble beginning we have now reached a point, detailed in some of the above publications, where governments and health care policy makers around the world including the National Health Care System in the U.K. and the Veterans Health Administration in the United States are spending billions of dollars to make evidence based psychological treatments more readily available. While we have a very long way to go, I believe we can all be gratified by this progress.