Epilepsy experts are looking to the future to provide hope for the nearly 3 million Americans suffering from the neurological disease. Researchers claim that developing technologies such as advanced imaging will greatly impact treatment approaches and could eventually lead to a cure. Researchers are beginning look at how epilepsy develops; it has many causes including “abnormal brain development, brain injuries, head trauma, medication, and heredity.” By exploring each avenue of development, experts may find new ways to prevent epilepsy and the seizures it causes. Many agree that simply trying new drugs to combat epilepsy once its presence is established cannot offer sufferers realistic hope. Dozens of medications exist to control epileptic seizures, but many people who live with the disease find the medications do not work for them. When such medications do prevent seizures, people with epilepsy still suffer other symptoms, which often carry socially debilitating implications. A National Health Interview Study (2002) on the matter noted that epilepsy greatly decreases people’s chances to marry, achieve higher education goals, and hold a steady job. According to Baylor College of Medicine’s Ann Berg, a British study revealed that people with epilepsy may also develop “schizophrenia, anxiety, depression, obsessive-compulsive disorders,” and other neuroses. Studies are consistently raising awareness that many epilepsy cases result from head injuries. Of particular interest to our service men and women is evidence from a study of Vietnam war veterans that showed “53 percent of veterans with penetrating head injuries developed epilepsy.” This could indicate that veterans of the war in Iraq face particular susceptibility to epilepsy. Unfortunately, it is difficult to combat the disease in its early stages because it can develop years after the brain is injured—some patients did not show symptoms for 10 years. However, with researchers shifting their focus from treatment to prevention and recognizing who is at risk, they may be able to ensure that veterans and all other head trauma victims can avoid epilepsy-related suffering, while providing those with epilepsy the hope of a cure. Information retrieved from http://www.sciencedaily.com/upi/index. php?feed=Science&article=UPI-1-20070402-22390800-bc-us-epilepsy.xml

A new wind blowing on Capitol Hill is filling the sails of optimism for supporters of a proposed law requiring the insurance industry to achieve mental health parity. Many recent developments raise hopes that insurers will soon be forced to place mental health on a level playing field with physical health. Key supporters of mental health parity are now in leadership positions in the House and Senate, which may put an end to years of parliamentary blocking maneuvers that kept the popular and bipartisan issue from coming to a vote (Elias, 2007; Pierce, 2007; Rovner, 2007). President Bush repeatedly says he favors mental health parity, and he will sign reforms into law if Congress ever passes them (Pugh, Talev, & Hall, 2007; Elias, 2007). Already this year the House leadership is quietly moving the legislation through the process, along with a host of other health-care reforms (Pugh et al., 2007).  With all the momentum, this might seem to be the year that finally recognizes the worth of mental health treatment and gives millions of Americans access to the care they need. But advocates of mental health parity should not pop their corks just yet. All the optimism must be tempered with a dose of political reality: Navigating mental health parity through the labyrinth of Capitol Hill has been a task fraught with peril. Dead-ends often lurked in committees, and the powerful and well-funded health insurance industry wielded its influence to reduce any financial impact of new laws. Only 40 votes in the Senate could bring reform to a crushing halt. A single committee chairperson in either the House or the Senate could delay or stop progress on the legislation. Even if comprehensive mental health legislation becomes law this year, the victory may be only one battle in an ongoing war between economics and mental health care access. Recent history shows the insurance industry exploits loopholes effectively and finds creative ways to reduce benefits to compensate for laws passed by the states and federal government. ◆ ◆ ◆

Cold, Hard Economics Versus Need Mental health treatment has, until recent decades, suffered from a perception that it was incapable of producing hard, empirical evidence of efficacy. Health insurance companies cited their belief that pharmaceutical treatments and talk-based therapy did not always produce dramatic “cures” that could be linked only to the treatments. In justifying decisions not to provide mental health care coverage, insurance companies played up differences of opinion that existed in the mental health care community. An example of the rhetoric against mental health parity can be found on the website of the Health Insurance Association of America (HIAA), which makes these arguments against mental health parity, specifically, and mandates in general: “ . . . Mandates ultimately harm consumers by imposing static clinical procedures and by raising the cost of health insurance, thus contributing to the growing number of uninsured Americans.” “Mandates misallocate resources by requiring consumers (or their employers) to spend available funds on benefits that they would otherwise not purchase.” “Mandates drive up health care costs for consumers and employers and take money and other resources out of the system which could be better used to provide uninsured Americans with access to health care coverage.” “Improving health-care quality by adopting evidence-based medicine into everyday clinical practice, rather than through mandates, would result in health care cost savings.” (HIAA, n. d.) Many who suffer from mental illnesses have either been afraid to turn to a mental health professional or they have been unable to afford the cost of treatment. The general public associates a long-held stigma with mental health treatment, and high costs and insufficient insurance cov erage prevents many others from getting the help they need (President’s New Freedom Commission on Mental Health, 2002). Those factors create a substantial gap between the number of Americans who need mental health treatment and those who actually get it. The evidence is compelling: Studies conclude that a mental disorder can be just as serious as having a heart attack or any disabling physical ailment (Roy-Byrne, 1999). Despite this, 70 percent of Americans think they do not have sufficient access to mental health care (National Comorbidity Survey, 1992). A 2004 survey conducted by the American Psychological Association reported that 87% of Americans say a lack of insurance prevents them from being treated for mental health issues, and 81% cite cost. An overwhelming 85% agree that health insurance should cover mental health services (Chamberlin, 2004). The U.S. Surgeon General’s 1999 report on mental illness concluded that, because there is no effective federal mental health parity mandate, American businesses lose more than $70 billion a year—mostly because of lost efficiency and increased absenteeism (Gilbert, 2007). In 2003, the American Medical Association published a study finding that employers lose $44 billion every year to lost productivity caused by depression alone (Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). Mental conditions affect one in five families, according to a 2001 study reported in the British Journal of Psychiatry (Andrews, Henderson, & Hall, 2001). The President’s 2002 New Freedom Commission on Mental Health Services summed up the condition of America’s mental health-care system: “Today’s mental health care system is a patchwork relic— the result of disjointed reforms and policies. Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities” (Hogan, 2002).

A Long and Winding Road Efforts to establish mental health parity in the United States reach back at least 30 years, and they have produced mixed results. Congress and the states often have a difficult time just defining what mental health parity is. Efforts have ranged from a weak provision in the Mental Health Parity act of 1996, which only mandates equal funding in optional insurance plans—to laws that force employers to offer insurance for both medical and mental health purposes (Gilbert, 2007). The momentum for mental health parity started to build decades ago, as researchers in psychiatry and neuroscience began to demonstrate that many mental illnesses have a biological basis. Physicians learned how to better-diagnose depression and other mental disorders and how to more effectively treat them. Success stories became much more frequent, with many patients quickly returning to productive work and full roles in society after treatment. Significant breakthroughs became a powerful argument that mental health treatment was, in fact, “evidence-based” (Otten, 1998). Armed with grim statistics and improved empirical evidence that mental health treatments do work, a coalition of mental health groups denounced as unfair those health insurance policies that fund mental health treatments at much lower levels than physical ailment treatments. Patients and their families stepped forward to tell compelling and, sometimes, horrific stories about terrible results when mental illness sufferers were not treated (Otten, 1998). During the 1970s and 1980s, many states passed health-care insurance mandates that addressed assorted problems. But state mandates cannot apply to selfinsured companies because of the federal government’s Employee Retirement Income Security Act of 1974. Before the act passed, companies that self-insured were mainly big, multi-state operations. To avoid the mandates, smaller businesses also started to self-insure (Otten, 1998). Insurance mandates became so popular that one insurance executive estimated there were close to 1,300 mandates nationwide (Otten, 1998). Proponents of mental health parity began to see real success in the early 1990s, when a few states required full mental health parity from state-regulated employers. Maryland, Minnesota, Maine, New Hampshire, and Rhode Island led the way by requiring mental health benefits to be comparable to other illnesses (Otten, 1998). In the past 15 years, according to the American Psychological Association, 44 states have passed some form of parity coverage (APA, n. d.). Still, in most areas, practices designed to decrease mental health care funding have flourished. Lifetime caps cause patients to exhaust their coverage quickly. In many cases, state and federal government safety- net programs have to pick up the cost (Pierce, 2007). The National Alliance on Mental Illness (NAMI) 2006 report card finds that Connecticut and Ohio offer their residents the most comprehensive access to mental health service (each received a B). The association graded states in 39 areas, and gave a D to the nation as a whole. Eight states flunked: Iowa, Idaho, Illinois, Kansas, Kentucky, Montana, North Dakota, and South Dakota (NAMI, 2006). Because of the limitations that exist on states, Congress took action to pass the Mental Health Parity Act (MHPA) of 1996. The legislation was an effort to force insurance companies to place services for annualbenefit and lifetime-benefit dollar caps on at least equal levels. Insurers compensated for the new law by placing limits on the number of therapy sessions a patient could receive in a given year and by finding other loopholes in the law (APA, n. d.). The Mental Health Parity Act was designed to expire in 2001. Sen. Pete Domenici of New Mexico and Sen. Paul Wellstone of Minnesota co-sponsored the Mental Health Equitable Treatment Act (MHETA) to close loopholes and end discriminatory health services. But by the end of 2001, Congress gave up on the new legislation and instead extended the 1996 act (APA, n. d.). died in a plane crash while campaigning for re-election in 2002. As a tribute to him, Senate Minority Whip Dick Durbin of Illinois sponsored a resolution to honor his memory by passing a stronger mental health parity act. Though the bill attracted broad bipartisan support, some members of the House leadership used their influence to stall the resolution in committee (Roll Call, 2006). The inaction that doomed MHETA may have been at least partially influenced by the powerful insurance lobby. The Center for Responsive Politics (CRP) reports that, since 1990, insurance interests donated about $175 million to the campaign committees of federal candidates. Their direct lobbying efforts are also substantial, with $87 million spent in 2000 alone on influencing Congress and the Executive Branch (CRP, 2007). The stakes are high for psychotherapists and their patients. A study reported by the National Mental Health Information Center (NMHIC) examines the effects of comprehensive mental health parity legislation by studying the aftermath of Vermont’s parity law in 1988 (NMHIC, 2002). The report has both good and bad news for psychotherapists and their clients. Perhaps the most impressive finding is that usage of mental health services rose after passage of the parity law. The most distressing— managed-care insurers responded by limiting the funding of treatment for substance abusers. The findings of the study include: Parity did not cause employers to drop coverage or switch to self-insured products. Access to outpatient mental health services improved with parity. Access to substance abuse treatment was much more restricted (usage down by 51%) after parity. Despite lower consumer cost and higher limits on the use of mental health and substance abuse care, spending on covered services declined after parity. Consumers paid a smaller share of total spending for covered mental health and substance abuse after parity. Managed health care became an important tool that insurance companies used to control costs. The study stated: “The use of managed care made parity affordable by shifting the locus of decision making primarily from the demand side (based on consumer cost sharing and coverage limits) to the supply side (based on the use of provider networks and medical-necessity criteria).” Many consumers didn’t know about the changes (Effects of the Vermont Mental Health and Substance Abuse Parity Law, 2002). Conclusion The Vermont study and the history of parity efforts imply that even if Congress mandates comprehensive mental health parity this year, insurance companies will find ways to cut costs by imposing new restrictions to offset any required increases in spending. Psychotherapists, other mental health professionals, and the groups that support them, must continue efforts for true parity no matter what Congress does. Mental health professionals, advocacy groups, and health-insurance interests play what amounts to a high-stakes game of chess on an ever-changing board. The pressure between establishing profit margins for insurance companies and providing Americans with access to quality health care will continue to exist, if not intensify, whether or not a parity law passes.

References American Psychological Association Help Center (n. d.). Mental Health Parity. Retrieved February 2007 from http://www.apahelpcenter.org/articles/ article.php?id=26 Center for Responsive Politics (2007). Lobbying Database. Retrieved February 2007 from http://www.crp.org/lobbyists/indusclient. asp?code=F09&year=2005 Elias, M. (2007). Supporters renew push for mental health care. USA Today. Retrieved January 2007 from http://www.usatoday.com/news/ health/2007-01-07-mental-health-reform_x.htm Gilbert, G. (2007). Many say they believe in mental health parity, but bills languish. The Oakland Press. Retrieved February 2007 from http://www.theoaklandpress.com/stories/012107/ opi_2007012128.shtml ◆ ◆ Health Insurance Association of America (n. d.). Retrieved February 2007 from http://www.hiaa.org/ content/default.aspx?bc=39|341|315 Hogan, M. (2002). Letter to President Bush presenting final report: Achieving the promise: Transforming mental health care in America. President’s New Freedom Commission on Mental Health, 1. PDF version retrieved February 2007 from http://www.mentalhealthcommission.gov/ reports/FinalReport/downloads/downloads.html National Alliance on Mental Illness (2006). A report on America’s health care system for serious mental illness, 29. PDF version of full report retrieved February 2007 from http://www.nami. org/content/navigationmenu/grading_the_states/ full_report/full_report.htm Otten, A. (1998). Mental health parity: What can it accomplish in a market dominated by managed care? Milbank Memorial Fund. Retrieved February 2007 from http://www.milbank.org/mrparity.html#costs Pierce, O. (2001, January 10). The mental health Congress? United Press International. Retrieved February 2007 from http://www. sciencedaily.com/upi/index.php?feed=Science&articl e=UPI-1-20070110-20433300-bc-us-mentalhealthcongress- analysis.xml Pugh, T., Talev, M., & Hall, K. (2007). Democrats balk at Bush’s health care proposal. McClatchy News Service. Retrieved January 2007 from http://www.mercurynews.com/mld/mercurynews/ news/politics/16537566.htm Roll Call. (2006). Minnesota Pols, Former Colleagues Remember Wellstone on Anniversary of His Death. Retrieved February 2007 from http://www.rollcall. com/issues/1_1/breakingnews/15634-1.html Rovner, J. (2007, January 8) Advocates renew push for mental health ‘parity’ bill. “Morning Edition,” National Public Radio. Retrieved February 2007 from http://www.npr.org/templates/story/ story.php?storyId=6740128 Roy-Byrne, P. P. (1999). Panic disorder in the primary care setting: Comorbidity, disability, service utilization, and treatment. Retrieved from http://www. ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&d b=PubMed&list_uids=10453807&dopt=Citation Stewart, W. Ricci, R., Chee, E. Hahn, S., Morganstein, D. (2003). Cost of lost productive work time among US workers with depression. The Journal of the American Medical Association. Retrieved February 2007 from http://jama. ama-assn.org/cgi/content/abstract/289/23/ lookupType=volpage&vol=289&fp=3135&view= short Effects of the Vermont Mental Health and Substance Abuse Parity Law (2002). Washington, DC: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Center for Substance Abuse Treatment. PDF version of full report retrieved from http://mentalhealth.samhsa.gov/ publications/allpubs/sma03-3822/default.asp

By John  Lechliter By John Lechliter

Panic attacks are reactions to extreme stress or anxiety and are not uncommon. In fact, 9% to 14% of the population has experienced a panic attack (Kleinknecht, 1991). The presence of panic attacks alone is not necessarily indicative of panic disorder. As noted by Barlow and Durand (2005), there are three distinct types of panic attacks. Situationally bound or cued panic attacks occur only when people affected are exposed to specific situations, whereas unexpected or uncued panic attacks are not isolated to specific settings and occur randomly. And, in situationally predisposed panic attacks, certain settings increase the likelihood of an attack, but not always will an attack occur in those settings. Situationally-cued panic attacks are typically related to specific phobia, another anxiety disorder. However, when panic attacks randomly occur on a regular basis they can be symptomatic of a larger problem, panic disorder. The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines a panic attack. “. . . A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself Fear of losing control or going crazy Fear of dying Parathesis (numbness or tingling sensations) Chills or hot flashes (Diagnostic and Statistical Manual of Mental Disorders, 2000) Characteristics Panic disorder is an anxiety disorder in which an individual has panic attacks on a regular, yet seemingly unexplainable basis (Bouton, Mineka, & Barlow, 2001). There are between 3 and 6 million Americans suffering from panic disorder (Beamish, Belcastro, & Granello, 2002). Panic disorder is most likely to occur in individuals between their mid-teens and 40 years of age (Bouton et al.). As noted by Barlow and Durand (2005), there is high comorbidity of panic disorder with other anxiety and depressive disorders. As many as 55% of those with panic disorders also have one or more anxiety,  or depressive disorders. This high comorbidity rate can often affect intervention, which will be discussed later. To be diagnosed with panic disorder, patients must worry persistently about having another attack, worry that the attack is symptomatic of a larger problem, or make some noteworthy change in their behavior, such as avoiding certain people or places. This worry must be present for at least 1 month. The attacks cannot be connected with any drug use, licit or illicit, nor can they be due to any other medical condition. Patients should not be diagnosed with panic disorder if their panic attacks can be correlated with specific stressors. If this is the case, then another mental disorder would most likely be a better fit (APA, 2000). An important issue associated with panic disorder is agoraphobia. Agoraphobia is severe fear or anxiety related to a place or situation from which escape may be difficult (APA, 2000). Often this anxiety is so severe that sufferers will rarely leave the house in an effort to avoid a panic attack (Bouton et al., 2001). This avoidance can be seen as a coping mechanism to help deal with their anxiety. Individuals suffering from panic disorder without agoraphobia tend to cope in other ways, such as drug or alcohol abuse (Bouton et al.). Because so many individuals with panic disorder also have agoraphobia, the American Psychiatric Association has given panic disorder with agoraphobia a diagnostic code separate from panic disorder without agoraphobia. The focus of this paper is panic disorder without agoraphobia.

Etiology

There are several theories regarding the causes of panic disorder, none of which appear to fully explain why it occurs (Jacobs & Nadel, 1999). Some think there is a purely biological explanation, while others posit that panic disorder is a learned behavioral response to stressful situations (Barlow, Brown, & Craske, 1994; Jacobs & Nadel). A third perspective suggests that initial panic attacks are based on the body’s natural fear reaction occurring at an inappropriate time. Following this initial attack a small percentage of individuals develop anxiety based on fear of further attacks (Barlow et al.). As no one theory fully explains panic disorder, it is necessary to examine several theories to better understand panic disorder.

Genetic and Biologic Theories It appears there is at least a moderate case for the heritability of panic disorder. Studies have shown as many as 30% of immediate (first degree) family members share panic disorder (Zal, 1990). However, these data are complicated by shared environment and the opportunity for “vicarious learning” (Bouton et al., 2001). Even with these complicating factors, Kendler, Neale, Kessler, Heath, and Eaves (1992), as reported in Bouton et al., indicated that genetic factors were responsible for 35% to 39% of panic disorder and agoraphobia cases among female twins. Studies also identify specific chemical sensitivities to explain the occurrence of panic disorder. Certain substances can be used to trigger panic in individuals who are vulnerable to their effects (McNally, 1990). Substances that have been used to induce panic include sodium lactate, norepinephrine, isoproterenol, yohimbine, caffeine (McNally), and a mixture of carbon dioxide and oxygen (Lejuez, Eifert, Zvolensky, & Richards, 2000; McNally). Researchers who support this theory think that because of the subjects’ heightened sensitivity to these panic-inducing substances they are biologically predisposed to panic attacks. Critics point to data suggesting that patients with a history of panic attacks do not have any stronger physiological reactions to these stimuli than normal individuals, they simply respond more fearfully to those stimuli. This would suggest a psychological, not biological cause (McNally).

Psychological Theories One psychological approach to the etiology of panic disorder is cognitive theory. According to cognitive theory, individuals who suffer from panic disorder build their own fear and anxiety through negative thought patterns by focusing on physiological feelings and ascribing their own meaning to them (Bouton et al., 2001). An example of this would be a person who is a little short of breath and readily takes this as evidence that he or she is suffocating. Whether there is a real problem or not, the thoughts create their own anxiety. This anxiety becomes evidence that something really is wrong, which leads to more negative thoughts. This process continues until a panic attack occurs. Support for this theory has been built through clinical experiments in which negative word pairs are read to a subject with the intent of eliciting a panic-like response (Bouton et al.). Problems inherent with cognitive theory are that it does not address the development of the panic reaction, or account for panic attacks that occur in the absence of negative cognition (Bouton et al., 2001; Jacobs & Nadel, 1999). Another theory closely related to cognitive theory is anxiety sensitivity (Bouton et al., 2001). As with cognitive theory, anxiety sensitivity theory hypothesizes that individuals suffer from negative thoughts that can exacerbate their anxiety. With anxiety sensitivity theory, however, the person’s focus is on long-term problems associated with the attacks. They believe that they are doing harm to their overall mental or physical state. For example, cognitive theorists would say that clients are afraid they are having a heart attack, while an anxiety sensitivity theorist would say that clients are fearful that the panic attacks are slowly but surely damaging their heart (Bouton et al.). Anxiety sensitivity theory, like cognitive theory, fails to address the problems of how the panic attacks developed and how they exist in the absence of negative thoughts. A psychological theory that does address the development of the panic reaction is conditioning theory. Conditioning theory suggests that when a stimulus is paired with the physical symptoms of a panic attack, that stimulus is conditioned to elicit the same physiological response the next time it is encountered (Bouton et al., 2001). An example of this would be fear of mice. If a person’s first experience with a mouse elicits strong physiological symptoms, then that person is more likely to experience those same feelings when encountering a mouse again, thereby strengthening the response each time a mouse is encountered. Criticisms of conditioning theory are numerous. One important issue worth discussing is that the anxious reaction (the elicited response) is conditioned by anxiety (Bouton et al.; McNally, 1990). This concept does not appear to have much face validity, as it states that anxiety makes itself stronger. This and other issues have raised much speculation about the usefulness of conditioning theory.

Psychosocial Considerations Race and ethnicity appear to have no direct relationship to panic disorder. However, gender is strongly correlated with panic disorder. Women are two-and-a-half times more likely than men to receive a diagnosis of panic disorder. This gender gap also increases with age (Sheikh, Leskin, & Klein). Women were also found to have more and severer symptoms of panic disorder with agoraphobia than men (Sheikh et al.). Seventy- five percent of all individuals having panic disorder with agoraphobia are female (McNally, 1990). No theories have adequately explained this gender gap; however, according to Herman and Deitch (1986), it has been shown to be steady “across geographic, cultural, and socioeconomic boundaries” (as quoted in Zal, 1990, p. 102). Panic disorder can be triggered by stressful situations. This could include losing one’s job, marital difficulties, substance abuse issues, depression, loss of a loved one, or any other situation that causes excessive amounts of stress for an individual. Between 75% and 91% of patients being seen for panic-related problems had experienced a recent major life stressor (Kleinknecht, 1991). This leads one to believe that the single-most important psychosocial predictor of panic disorder is the perceived stress level of one’s environment.

Summary Panic disorder, with or without agoraphobia, can be debilitating. Most common among women, it leaves the sufferer constantly in fear of another attack and powerless to stop the attack once it has begun. Panic disorder is caused by many complex and unclear interrelated issues, including biology, genetics, behavioral conditioning, cognitive errors, and psychosocial stressors. Hopefully, with continued research and experimentation, we will gain a clearer picture of this devastating disorder. Panic disorder is a pervasive problem affecting 3 to 6 million Americans at any given time (Beamish et al., 2002). Panic disorder is characterized by the occurrence of panic attacks on a regular, seemingly unpredictable basis (Bouton et al., 2001). Often those who suffer from panic disorder turn to drugs or alcohol to help alleviate some of the associated anxiety. Others who suffer from panic disorder with agoraphobia rarely leave the house in an effort to avoid the onset of a panic attack (Bouton et al.). With panic disorder affecting the lives of so many, effective treatment becomes extremely important. For many individuals, successful treatment could mean the difference between a fulfilling, satisfying life and a life filled with constant anxiety, substance abuse, and/or social isolation.

Treatment Approaches: Strengths and Limitations Research on the efficacy of treatment of panic disorder has been hampered by many methodological concerns. As noted by Addis et al. (2004), poorly defined samples render between-study comparisons virtually impossible. Much of the difficulty can be attributed to the high comorbidity of panic disorder with other anxiety and depressive disorders. Also, treatment methods may be poorly defined, reducing the likelihood of replication by subsequent researchers. Nevertheless, some tentative findings have improved understanding of panic disorder. Approaches to the treatment of panic disorder can be separated into three broad categories; pharmacological, psychological (Beamish et al., 2002; Barlow & Durand, 2005; Craske, 1999); and combined approaches (Spiegel & Bruce, 1997).

Pharmacological Approach The pharmacological approach is based on the assumption that there is a biological cause to panic disorder (Beamish et al., 2002). This approach focuses on the use of either benzodiazepines or anti-depressants, including SSRI’s and tricyclics, to control the body’s responses to internal, exaggerated panic cues (Beamish et al.; Craske, 1999). Both drug categories have their advantages and disadvantages. Benzodiazepines are frequently prescribed because they have been shown to quickly and effectively alleviate the symptoms of panic attacks (Beamish et al.; Barlow & Durand, 2005). The most attractive quality of benzodiazepines is the speed with which they work, having no need to build in the system (Beamish et al.; Barlow & Durand). The most frequently prescribed benzodiazepines are Xanax (alprazolam) and Klonopin (clonazepam), due to their high potency (Beamish et al.). Major side effects that can occur with the use of benzodiazepines include sedation and problems with motor skills or coordination. It is also important to note that benzodiazepines are addictive and may be difficult to stop taking because of psychological dependence and physical withdrawal (Beamish et al., 2002; Barlow & Durand, 2005). Another important group of drugs used to treat panic disorder is anti-depressants. There are two categories of anti-depressants used in the treatment of panic disorder, serotonin specific reuptake inhibitors (SSRI’s) and tricyclics (Beamish et al., 2002). A third group, monoamine oxidase inhibitors (MAOI’s), is used infrequently today because of extreme side effects and drug interactions (Beamish et al., 2002). SSRI’s (Prozac & Paxil) have become the more popular option among the anti-depressants in recent years (Barlow & Durand, 2005; Craske, 1999). This is because of an extremely low risk of overdose, and a reduced level of side effects compared with other options (Beamish et al., 2002). Side effects from SSRI’s are even less of an issue when they are used in treating panic disorder, because the drug is effective at much lower doses than when used to treat other disorders (Beamish et al.). The major side effect associated with SSRI’s is sexual dysfunction, which is experienced by as many as 75% of all users (Barlow & Durand). Tricyclics are the second most popular group of anti-depressants used to treat panic disorder; however, results are mixed and side effects can be many (Beamish et al., 2002; Barlow & Durand, 2005). Among the tricyclics, only imipramine (Tofranil) and clomipramine (Anafril) have been proved to be truly beneficial, while others such as desipramine (Norpramin), notriptlyine (Pamelor), and amitriptyline (Elavil) have not been thoroughly tested, and still others, specifically matprotiline (Ludiomil) and amoxapine (Asendin), have been shown to be ineffective (Beamish et al.). Another drawback to tricyclics is that they take as long as 8 weeks to reach an effective therapeutic level (Beamish et al.). Side effects of tricyclics can include dry mouth, constipation, blurred vision, memory difficulties, weight gain, drowsiness, inhibition of sexual functioning, light-headedness, and skin rash. Tricyclics also carry a risk of overdose. Given that as many as 20% of patients suffering from panic disorder attempt suicide, this can be a serious risk (Beamish et al.). Pharmacological treatment of panic disorder is an important and complex treatment issue. Advantages of pharmacological treatment include rapid symptom reduction and a variety of treatment options (Spiegel & Bruce, 1997). In addition, medications used to treat panic disorder are common and widely available. Those with limited access to other treatment options could benefit from medical intervention in the absence of other treatment options. Despite these advantages, there are some concerns with pharmacological interventions and panic disorder. For example, SSRI’s have been shown to have sexual side effects for as many as 75% of all patients, and Benzodiazepines can have powerful sedative and addictive qualities (Barlow & Durand, 2005). As suggested by Otto, Pollack, and Maki (2000), when medications are discontinued, most people see symptoms return. Some have argued that medication reduces the likelihood that patients will learn skills to cope with panic without medication, thereby rendering them dependent upon medication (Spiegel & Bruce, 1997). Thus, medication may produce short-term gains, but long-term gains with medication are questionable. As such, pharmacological treatments are expensive because removal of medication typically leads to symptom resurgence (Otto et al.). When addressing medication, it is always necessary to weigh the positive outcomes of the treatment against the potentially harmful effects of medication.

Cognitive-Behavioral Treatment Studies show Cognitive-behavioral theory is an extremely effective treatment for panic disorder, with as many as 70% of all patients showing considerable reduction of panic and anxiety (Barlow & Durand, 2005). Cognitive-behavioral treatment is based on the premise that people suffering from panic disorder cognitively misinterpret normal physiological responses, such as a rapid heartbeat or heavy breathing, as signs that something dangerous is happening; thereby activating their fight or flight response and causing them to panic (Beamish et al., 2002). Through the use of cognitive-behavioral treatments, therapists attempt to alter clients’ perceptions of their bodies’ physiological responses (Beamish et al.). As suggested by Smits, Powers, Cho, and Telch (2004), reduction in the fear-offear response (the overreaction to benign bodily sensations) is a necessary component in cognitive treatment of panic disorder. Cognitive-behavioral therapy for panic disorder typically encompasses four basic areas—panic education, cognitive restructuring, respiratory control, and exposure (Addis et al., 2004; Beamish et al., 2002 Craske, 1999). Panic education involves educating the client on the differences between what they think and what they feel (Beamish et al.; Craske). By giving a physiological explanation for where the body’s panic response is originating, the client should understand that these are normal body functions, not catastrophic events (Craske, 1999; Beamish et al., 2002). After panic education takes place, cognitive restructuring can begin. Cognitive restructuring involves changing the way clients think about the things that feed into their panic response (Beamish et al., 2002; Craske). An example of this might be a client who thinks he or she is having an asthma attack because his or her heart rate is a little fast. Clients are taught to question their interpretations of the way they feel and gather evidence that supports a more realistic picture of the things they fear (Addis et al., 2004; Beamish et al., 2002; Craske). These skills must be built so that they can carry into the final stages of therapy and beyond (Craske). The next stage in cognitive-behavioral therapy is respiratory control, or breathing retraining (Beamish et al., 2002; Craske). This stage focuses on explaining the physiology of hyperventilation and teaching proper breathing techniques. These techniques can be used all the time, and are thought to be helpful in times of anxiety or panic (Craske). By learning appropriate breathing methods the client is helping eliminate one of the biggest body cues that can lead to a panic attack. However, controlled breathing has received criticism (Schmidt et al., 2000). Some have argued that controlled breathing is a “false safety aid.” As noted by Schmidt et al., false safety aids may actually maintain panic reaction by preventing (or distracting) the person from experiencing anxiety and thereby learning skills to cope with anxiety. They further suggest that successfully coping with anxiety is a superior skill when compared to distraction techniques, of which controlled breathing is considered. Nevertheless, some research indicates that controlled breathing can be useful for some who experience panic attacks. Additional research is needed to determine who benefits and who does not benefit from controlled breathing training. After respiratory control, the client will work on exposure to feared stimuli or feared body responses (Beamish et al., 2002; Craske). Barlow and Durand (2005) refer to this as panic control treatment. In a controlled situation, clients will attempt to induce a panic response by hyperventilating, or elevating their heart rate, or by using any of the other physiological cues that have led to panic attacks in the past (Barlow & Durand; Craske). By allowing these panic sensations to occur, but not reacting to them, the client is, in effect, breaking the link between the stimulus and the panic response (Barlow & Durand; Beamish et al.; Craske). Cognitive-behavioral treatment can be used in either an individual or a small group approach; however, it is important that all members of a group are given large amounts of individual attention. Craske (1999) recommends individual treatment or, at most, groups of three to five with an extra therapist present and extra time allotted. Treatment should also be intensive, with two sessions a week to begin with and one session a week later in the treatment process (Craske). Despite the apparent high success rate of cognitive behavioral treatment and panic disorders, there are some areas of concern. As noted by Spiegel and Bruce (1997), cognitive behavioral approaches may take longer to achieve tangible results than pharmacological treatments. Also, treatment compliance can be problematic for those receiving cognitive behavioral treatment for panic disorder. Schmidt and Woolaway- Bickel (2000) noted that most cognitive behavioral interventions rely heavily on homework assignments and/or practice exercises apart from actual treatment sessions. Clients who fail to complete homework may not succeed in treatment. Client motivation becomes a variable in treatment success. While cognitive behavioral treatment creates long-term gains, initially it may be more taxing on clients and require more time to produce tangible results for clients than pharmacological interventions.

Combined Approaches As the name implies, combined approaches use cognitive behavioral treatment in conjunction with pharmacological treatment (Otto et al., 2000). Several advantages for treatment of panic disorder with combined approaches have been noted. For those with severe symptoms resulting in debilitation, starting with medications can be helpful in providing immediate symptom reduction. This may also be true for those with comorbid depressive and anxiety disorders. Once the client is stabilized with medication, cognitive behavioral treatment can be introduced to teach coping skills. The intention of the added cognitive behavioral treatment would be to facilitate tapering of pharmacological treatment (Siegel & Bruce, 1997). As clients acquire skills, medication can be accordingly adjusted until it can be discontinued. As previously noted, cognitive behavioral treatment requires active participation by clients. For those severely affected by panic disorder, medication can be used to increase active participation in cognitive behavioral treatments. Similarly, those who start with cognitive behavior treatment and have little success, pharmacological intervention can improve efficacy of cognitive behavioral treatment. This is especially true with the exposure component of cognitive behavioral treatment. When clients are exposed to panic-producing stimuli, they may have a strong, adverse reaction causing them to leave treatment prematurely. The use of medication during the initial stages of exposure therapy may be effective in reducing anxiety associated with exposure to panicproducing stimuli. Opponents of combined approaches (Spiegel & Bruce, 1997) suggest that medications can interfere with cognitive learning. Depending on the medications used, clients may have difficulty retaining cognitive content. Furthermore, motivation to learn coping skills can be compromised. Because medication yields desired symptom reduction with very little effort from clients some may be content with taking medication rather than learning to cope without medications. Though these are compelling arguments, combined methods have been useful long term treatment of panic disorders. Additional research is needed to evaluate the overall efficacy of combined treatments.

Treatment Selection: Clinical Considerations Given the array of treatments available, selection of the appropriate treatment or treatments for panic disorder can be complex. Several factors influence treatment selection. These include comorbidity with other disorders, frequency and intensity of panic attacks, client motivation for treatment, treatment availability, client preference, client characteristics, and cost. As noted earlier, the presence or absence of comorbid conditions with an identified panic disorder can influence treatment selection and outcome of treatment. Thorough initial assessment of clients before the start of treatment may facilitate identification and treatment of panic disorder and comorbid conditions, if present (Barlow & Durand, 2005). Failure to identify and treat comorbid conditions can adversely affect treatment outcomes. For those with severe, frequently occurring, and debilitating panic symptoms, it may be necessary to begin with pharmacological intervention (Spiegel & Bruce, 1997). The goal would be to stabilize initial symptoms and prepare clients for skill acquisition, thereby eliminating the need for medication. Those with mild to moderate, infrequent panic attacks may respond to cognitive behavioral treatment because they recognize their symptoms are manageable without medications. Mild and moderate panic-attack clients may also have greater motivation and are more readily able to complete homework and other activities compared to those with severe panic attacks. Client motivation is a key factor in treatment methods that require active client participation. Clients with low motivation may easily accept pharmacological treatment because it is more passive and requires less client-generated activity than cognitive behavioral treatment (Schmidt & Woolaway-Bickel, 2000). Treatment availability is also a contributing factor in treatment selection. Those with few options may be forced to use the treatment available regardless of personal preference. In some areas, there may be few clinicians with cognitive behavioral training sufficient to treat moderate and severe panic disorder (Barlow & Durand, 2005). In such instances, pharmacological treatment may become the default treatment. It has been noted by some (Otto et al., 2000), that pharmacological treatments are more costly than cognitive behavior treatments. Clients with limited resources may opt for cognitive behavioral treatment because it is time-limited (12 sessions or less) and produces long-term results with less relapse than pharmacological treatments. Despite cost-effectiveness associated with cognitive behavioral approaches, those with severe symptoms and debilitation may require pharmacological treatment. Unfortunately, those with few personal resources may be excluded from cost-prohibitive pharmacological treatments. Client characteristics can influence client preface of treatment (Otto et al., 2000). Most ethnic and cultural groups seem to experience panic disorder equally; however, they do not experience the same symptoms of panic, or at least do not describe them in the same manner (Barlow & Durand, 2005). Therefore, it is important for therapists to treat panic disorder on an individualized basis. Treatment plans must be tailored to the client’s specific needs and preferences (Barlow & Durand, 2005; Beamish et al., 2002; Craske, 1999). Educating clients on the array of treatments available, the strengths and limitations of treatment options, and the overall effectiveness of treatment approaches increases active participation in the treatment process. Client comfort with treatment options can positively impact client involvement and motivation.

Conclusion Panic disorder is a problem that transcends socioeconomic status, gender, and many other characteristics. It can be debilitating for all those who suffer from it, leaving them constantly with the fear that another panic attack may occur at any moment. Fortunately, there are effective treatments for this disorder. Cognitive behavioral interventions have been demonstrated as the most effective long-term treatment for panic disorder, while pharmacological treatments have proved effective in rapid symptom reduction of panic disorders. Combined approaches may be used when there is comorbid anxiety or depressive disorders and/or the frequency of panic attacks create debilitation for those afflicted. The key is selecting the right intervention for the right client for the right reasons. Through medication, cognitive-behavioral therapy, or a combination of the two, many of those who suffer with panic disorders can lead happier, more meaningful lives.

References Addis, M. E., Hatgis, C., Crasnow, A., Jacob, K., Bourne, L., & Mansfield, A. (2004). Effectiveness of cognitive–behavioral treatment for panic disorder versus treatment as usual in a managed care setting. Journal of Consulting and Clinical Psychology, 72(4) 625–635. Barlow, H. D., Brown, T. A., Craske, M. G. (1994). Definitions of panic attacks and panic disorder in the DSM-IV: Implications for research. Journal of Abnormal Psychology, 103(3), 553-564. Barlow, H. & Durand, M. (2005). Abnormal Psychology: An Integrative Approach (4th Edition). Belmont, CA: Thomson/Wadsworth. Beamish, P. M., Granello, D. H., & Belcastro, A. L. (2002). Treatment of panic disorder: Practical guidelines. Journal of Mental Health Counseling, 24(3), 224–246. Retrieved February 9, 2005, from database at http://www.questia.com Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108(1), 4–32. Diagnostic and statistical manual of mental disorders (4th ed., Rev. ed.). (2000), Washington, DC: American Psychiatric Association. Jacobs, W. J., & Nadel, L. (1999). The first panic attack: A neurobiological theory. Canadian Journal of Experimental Psychology, 53(1), 92–107. Kleinknecht, R. A. (1991). Mastering anxiety: The nature and treatment of anxious conditions. New York: Insight Books. Lejuez, C. W., Eifert, G. H., Zyolensky, M. J., & Richards, J. B. (2000). Preference between onset predictable and unpredictable administrations of 20% carbon-dioxide-enriched air: Implications for better understanding the etiology and treatment of panic disorder. Journal of Experimental Psychology: Applied, 6(4) 349–358. McNally, R. J. (1990). Psychological approaches to panic disorder: A review. Psychological Bulletin, 108, 403–419. Otto, M. W., Pollack, M. H., & Maki, K. M. (2000). Empirically supported treatments for panic disorder: Costs, benefits, and stepped care. Journal of Consulting and Clinical Psychology. 2000, 68(4), 556–563. Schmidt, N. B., & Woolaway-Bickel, K. (2000). The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: Quality versus quantity. Journal of Consulting and Clinical Psychology, 68(1), 13–18. Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, Julie, K., Margaret, & Cook, Jeff (2000). Dismantling cognitive-behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417–424. Sheikh, J. I., Leskin, G. A., & Klein, D. F. (2002). Gender differences in panic disorder: Findings from the national comorbidity survey. American Journal of Psychiatry, 159(1), 55–58. Smits, J. A., Powers, M. B., Cho, Y., & Telch, M. J. (2004). Mechanism of change in cognitive– behavioral treatment of panic disorder: Evidence for the fear of fear mediational hypothesis. Journal of Consulting and Clinical Psychology, 72(4) 646–652. Stuart, G. L., Treat, T. A., & Wade, W. A. (2000). Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting: 1-year follow-up. Journal of Consulting and Clinical Psychology, 68(3), 506–512. Zal, H. M. (1990). Panic disorder: The great pretender. New York: Insight Books.

About the authors James L. Whalen is a graduate student in the School of Social Work at Western Michigan University. He is a graduate assistant for the field instruction office.

Robin E. McKinney is an assistant professor of Social Work at Western Michigan University and a clinician at Catholic Family Services in Bay City Michigan Dr. McKinney has written many mental health-related articles. He is a Licensed Social Worker and Licensed Professional Counselor in Michigan. He is also a Diplomate of the American Psychotherapy Association of which he has been a member for 3 years.

John Douglas, former head of the FBI’s Investigative Support Unit, has hunted some of the most notorious and sadistic criminals of our time: the “trailside killer” in San Francisco, the “Atlanta child murderer,” the “Tylenol poisoner,” the man who hunted prostitutes for sport in the woods of Alaska, and a case that nearly ended his own life—Seattle’s “Green River Killer.” Despite the FBI’s original lack of support and attempts to ignore his pioneering techniques and methods, he developed the first psychological profile of the Unabomber. He confronted, interviewed, and studied dozens of serial killers and assassins— including Charles Manson, Sirhan Sirhan, Richard Speck, John Wayne Gacy, David Berkowitz (Son of Sam), and James Earl Ray—to understand their motives and get inside their minds. He identifies with both predator and prey. He examines a crime scene and creates profiles of the perpetrators, describing their habits and predicting their next moves. He is a renowned figure in law enforcement and the model for the Scott Glenn character in the movie, The Silence of the Lambs. As chief of the FBI’s Investigative Support Unit—the team that tackles the most baffling and senseless of unsolved violent crimes—Douglas ushered in a new age in behavioral science and criminal profiling. He retired after 25 years of eventful service, and now he can finally tell his unique and compelling story. You can hear Douglas present his workshop as a optional one-day addition to the 2007 APA National Conference in Kansas City, Missouri. Expanding on his national bestsellers, Obsession, Mind Hunter, and Unabomber: On the Trail of America’s Most Wanted Serial Killer, Douglas’ presentation will be a fascinating inside look at some of the most intriguing criminal cases of our time. His most recent book, The Anatomy of Motive, analyzes such notorious criminal minds as Lee Harvey Oswald, Theodore Kaczynski, and Timothy McVeigh. It will help you learn how to anticipate potential violent behavior before it is too late. Drawing from his long and extraordinary career, Douglas will take you inside the cat-and-mouse struggle between his elite squad of investigators and a chilling rogues gallery of assailants, a sort of surreal chess game with life-and-death consequences. Annals of the American Psychotherapy Association interviewed Douglas about his career and his upcoming presentation at the 2007 National APA Conference. You are well known for your exceptional career in criminal profiling. Please tell our readers about your background and how you became a famous FBI profiler. As a child, I watched a popular television show called The FBI starring Efrem Zimbalist Jr., who played the part of Inspector Erskine. This show was on television for 9 years (1965–74) and had 240 episodes based on the work of Inspector Erskine, who was all business. He didn’t laugh, didn’t love, and didn’t play. He worked every type of case and flew in a private jet to wherever the action was. In truth, this type of position was non-existent at the time. An FBI agent was, and still is, assigned to 1 of 59 field offices and generally remains in that office unless transferred. Little did I know in 1970, when I joined the FBI, that one day I would actually create a position within the FBI based on Inspector Erskine that would have me traveling throughout the United States and abroad providing on-site consultations in the form of crime analysis and criminal profiling. As a young FBI agent I enjoyed investigations of interpersonal violence—cases where the subjects were attempting to avoid prosecution or confinement—and cases where the subjects were fugitives from justice. Though the investigations and arrests were fun, I was really interested in learning something about who the subjects were and why they perpetrated their crimes, particularly violent crimes, against innocent people. I received graduate degrees in educational psychology, guidance and counseling, and adult education. I enrolled in many abnormal and clinical psychology courses —but, though I found the classes interesting, they never addressed the question of motive. Perhaps it was because the professors teaching those courses had little, if any, experience with the criminal element. In 1977, when I was promoted and transferred to the Behavioral Science Unit at the FBI Academy, I hoped I would learn more about the motives behind criminal behavior. The students (law enforcement officers enrolled in the criminal psychology classes taught at the FBI Academy) and I found the classes entertaining and sometimes humorous, and the instructors received the highest praises each semester from their students. Yet, I still felt there was something missing. None of the instructors had actually gone into prisons and personally asked violent offenders about the specifics of their crimes. I wanted to know about the offenders’ pre-offense behaviors, victim selections, personal backgrounds, motivations, and post-offense behaviors and how they were identified so I could apply that information to present-day cases. By the early 1980s, another colleague and I received a federal grant to conduct research on serial murderers. It seemed obvious to me that to learn from the “experts,” it was necessary to speak with them. I’ve had three personal mantras in all my books: To understand the artist, look at the artwork. Behavior reflects personality. The crime is a reflection of the offender. The above seemed obvious, so I was surprised and amused when some people and organizations began praising this enlightenment into the criminal mind. But not everyone agreed—especially people in mental health, parole, and corrections (see later question for more information). During your career, the criminal profiling profession made important advancements. Can you describe your position as an FBI profiler and your role in implementing the expansion of this field? In 1977, when I was transferred to the FBI Academy as a criminal psychology instructor, the criminal profiler position did not exist. After first conducting the research and then passing on what I learned in classes, we began to receive cases for analysis. In 1981, I began creating a criminal profiling program within the FBI’s Behavioral Science Unit. During the first year we received 54 cases, and every subsequent year the caseload expanded. By the time I retired from the FBI in 1995, we were analyzing more than 1,000 cases a year. When I retired, I had 43 employees in my unit. Only 12 of those employees profiled, so it was very stressful for all of us. We had to deal with life-and-death situations with very short deadlines. Even today, there are many people who think the FBI only profiles serial murder cases. In reality, the majority of cases are single homicides, and every type of violent crime has been researched and analyzed by profilers. Profiling is not the only investigative tool available. For example, there are some cases where profiling an unknown offender would not be suitable because of the high risk-level of the victim. What could possibly still be provided are proactive techniques: research-based probable cause for search warrants, interview and interrogation techniques, prosecution and defense counseling, and possibly expert testimony. Criminal profiling is a rough line of work. Please describe some of the more difficult aspects of the job. The very nature of profiling violent crimes makes for a highly stressful job. One must be able to identify with both the subject and victim in order to answer the investigative formula of why + how = who. It has been my experience that if a profiler uses the defense mechanism of “isolation of affect,” he or she will not be successful. When I train profilers I tell them they must walk in the shoes of both the subject and victim. You have to experience the feelings and emotions of both. There is danger in this technique. In 1983, I nearly died in Seattle while working on the Green River murder case. I was found in a coma in my hotel room because I had a body temperature between 104 and 107 degrees. After 5 days in the coma, I woke up and found myself paralyzed on my left side. I had viral encephalitis, and doctors attributed my weakened immune system to high stress levels. I was later treated for post-traumatic stress disorder. Please describe the most fascinating case you have tackled. There have been many interesting and personally rewarding cases in my career. Most recently I was able to interview Dennis Rader, the “BTK Strangler,” whose murders resurfaced after 30 years. I did the original profile in 1979 and later updated it with my colleagues. I briefly wrote and profiled the BTK Strangler in my book, Obsession. Rader told me he read Obsession and personally critiqued my analysis. He said my analysis was very good, but his identification, arrest, and conviction were not attributed to it. In August 2007, Jossey-Bass will be publishing my book on BTK, and during the 2007 APA National Conference, I will be presenting this case along with many others. Do you think mental-health professionals receive enough training in how to recognize warning signs of violent behavior? Some therapists question at what point, or even whether, they should intervene. What is your advice? I’ve given presentations to mental health professionals, and some have told me that they do not want to look at crimes perpetrated by the offender, because—if they did—it may prejudice their evaluation. They would instead rely on self-reporting, which to me is worthless because rarely will offenders tell you the truth. They will test you to see whether you know their case. Once they know you have no clue, be ready to be shoveled a lot of manure. To understand the artist you must look at the artwork. If you want to understand the criminal, you MUST look at the crime because the crime is a reflection of who he really is. When I hear about the patient-therapist relationship, Charles Whitman comes to mind. Also known as the “Texas Tower Sniper,” Whitman was seeing a therapist at the time he decided to shoot dozens of people. He even told the therapist of his desire to go up in the University of Texas tower and shoot people. The therapist never advised law enforcement, and the rest is tragic history. Do you think that becoming a criminal profiler is a viable option for today’s mental health professionals? The best way is to work in law enforcement in the capacity of a psychologist and saddle up next to detectives and learn their job. Most medium-to-large police departments and agencies have behavioral science units dealing primarily with police stress and problems from their jobs, which subsequently spills into their personal lives. There is nothing stopping the psychologist from creating a new position, i.e. criminal profiler. I did. What are the most common warning signals that mental health professionals must know to head off a potentially violent threat? The warning signals first surface in early childhood and are first observed by teachers, who in most cases are ill-prepared to handle the angry or defiant child. Signs such as firesetting, animal cruelty, bed-wetting, destructive behavior, and being a school bully are a few early indicators. I rarely see a violent offender who came from a family where there were loving, supportive parents. What else will you teach at the 2007 APA National Conference? Profiling, in the right hands and with good training, can be a viable investigative tool. The seminar will give a better appreciation and understanding of the overall profiling process. Criminal profiling is not accurately portrayed in the movies or on television. Attendees will learn the process of criminal profiling, and I will demonstrate that criminal investigative analysis is very similar to a physician’s actof diagnosing a patient with an unknown illness or disease. Both the medical doctor and criminal profiler can be wrong at times. We are only as good as the information provided to us for analysis. Unfortunately, not every case investigated is a perfect one, but it is important to recognize the imperfections and consider them in the overall analysis. How will your conference presentation relate to all attendees’ professions? I’ve spoken to college students, physicians, lawyers, school teachers, nurses, stockbrokers, sales personnel, and to people in many other occupations. At the very least the audience will be entertained in a forensic area with which most are not intimately familiar. The seminar will have direct application to their forensic specialty. I hope that everyone attending the seminar takes the information, digests it, and then applies it, not only to their work, but also to their lives.

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