The effects of voluntary hyperventilation on patients with chest pain without coronary artery disease

The present investigation was designed to examine panic symptom experience in patients with chest pain of nonorganic etiology, using a hyperventilation provocation procedure. Given the recent focus on panic disorder in patients with nonorganic chest pain, we assessed three indices of physiological arousal, subjective anxiety, and endorsement of DSM-III-R panic symptomatology in response to 3 min of voluntary hyperventilation. Subjects included 23 patients with nonorganic chest pain (CP sample) and matched normal controls (NC sample). The results indicate that hyperventilation produced significant increases in skin conductance, heart rate, and upper trapezious EMG in both CP and NC samples. Despite equivalent levels of physiological arousal and subjective anxiety, the CP sample endorsed a greater number of DSM-III-R panic symptoms relative to the NC sample. Examination of post-hyperventilation symptoms indicated that a greater percentage of the CP sample reported palpitations, nausea, and chest pain when compared with normals. Comparison of CP patients with and without Panic Disorder revealed no significant differences on any measure. The results suggests that hyperventilation plays a role in symptom experience in patients with nonorganic chest pain, although anxiety does not appear central in moderating this effect.     

Generalized anxiety and panic disorders: Response to Cox, Cohen, Direnfeld, and Swinson (1996)

Contrary to the contention of Cox, Cohen, Direnfeld and Swinson (1996, Behaviour Research and Therapy, 34, 949–954) that the Beck Anxiety Inventory (BAI; Beck & Steer, 1993, Manual for the Beck Anxiety Inventory) measures primarily symptoms associated with panic attacks rather than anxiety in general, we propose that the higher level of anxiety found in patients with panic disorders not only is not an artifact of the BAI's symptom content, but patients with panic disorders truly have more anxiety than patients with other types of anxiety disorders. Furthermore, the BAI contains symptoms present in other anxiety disorders, besides panic disorder, and specifically includes 11 symptoms of generalized anxiety disorder (GAD). The BAI and revised Hamilton Anxiety Rating Scale (HARS-R; Riskind, Beck, Brown & Steer, 1987, Journal of Nervous and Mental Disease, 175, 474–479) scores of 274 (69%) outpatients with panic disorders and 123 (31%) outpatients with GAD were found to differentiate these two diagnostic groups equally and significantly. The panic disorder outpatients had higher scores on both the BAI and the HARS-R than did the GAD patients. Thus, Cox et al.'s (1996) speculation about the BAI's yielding spuriously high levels of anxiety in patients with panic disorders revives an important issue relevant to the relation of panic disorder to GAD.     

Panic disorder in the families of patients with normal coronary arteries and non-fear panic disorder.

Patients with non-fear panic disorder (NFPD) meet DSM-III-R criteria for panic disorder, but do not report subjective fear or anxiety. Although apparently common in medical settings, this controversial group is in need of further diagnostic validation. This study assessed family history of panic disorder in patients with chest pain and normal coronary arteries (CP/NCA) and either NFPD, panic disorder with fear, or no panic. It was hypothesized that the two panic disorder groups would have similar, elevated rates of panic disorder in their first-degree relatives, compared to patients without panic. The results support the hypothesis; about 17% of the first-degree relatives of both NFPD and panic disorder patients were diagnosable with panic disorder according to proband interviews, whereas only 4.6% of the first-degree relatives of patients without panic were so diagnosable. These results support the diagnostic validity of NFPD in CP/NCA patients, because such patients had a family history of panic disorder similar to patients with a more classical panic disorder presentation. The lack of fear symptoms and behavior in NFPD may cause panic disorder to be overlooked as a potential cause of somatic symptoms in patients with no medical explanation for their condition.     

A Study of Panic Attacks in University Students of Iran

This study examined the parameters of panic, fear, and avoidance among university students in Iran. Data were collected from 347 students using Farsi translations of the Panic Attack Questionnaire, Beck Depression Inventory, Taylor Manifest Anxiety Scale, State-Trait Anxiety Inventory, and Anxiety Sensitivity Index. Thirty-eight percent of participants reported panic attacks in the past year and 21.4% reported panic attacks in the past 4 weeks when prompted by a broad definition of panic. Men and those with unexpected panic reported greater panic severity whereas women with panic attacks reported greater situational fear and avoidance. Panickers who satisfied DSM-III-R panic disorder (PD) criteria reported greater lifestyle restriction and general psychopathology. The findings provide tentative support for cross-cultural similarity in panic phenomenology and the validity of DSM-III-R PD criteria among university students in Iran. The results are discussed by reference to nonclinical panic research and general themes of Iranian culture.     

Anxiety sensitivity in first-degree relatives of patients with panic disorder

Anxiety sensitivity (AS) has been proposed as a risk factor for the development of panic disorder. Strong familial-genetic influences in panic disorder (PD) have been reported. AS may be familial too. The current study therefore examined whether first-degree relatives of PD patients are more anxiety-sensitive than normals. Twenty-three first-degree relatives of PD patients, 38 PD patients and 30 normals were given the Anxiety Sensitive Index and the Body Sensations Questionnaire. It was found that the first-degree relatives were, indeed, more anxiety-sensitive than the normals, but less so than the PD patients, suggesting that AS runs in families.     

Homotypic Versus Heterotypic Continuity of Anxiety Symptoms in Young Adolescents: Evidence for Distinctions Between DSM-IV Subtypes

Objective: to investigate homotypic and heterotypic longitudinal patterns of symptoms of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), social phobia (SoPh), panic disorder (PD), and obsessive compulsive disorder (OCD) in young adolescents from the Dutch general population. Method: 2,067 individuals (51.4% girls) from a Dutch community sample, who were assessed for the first time when they were aged 10 to 12 years, were followed up across a period of two years. At both assessments, anxiety symptoms were assessed with the RCADS, a self-report questionnaire. Results: Regression analyses indicated that homotypic continuity was relatively high for SAD, GAD, and SoPh symptoms, and for PD in girls. Conclusions: In many studies, anxiety disorders are treated as one group of disorders, and some widely used assessment instruments, such as the Child Behavior Checklist, do not even contain scales that tap different anxiety dimensions. In the present study, evidence for homotypic continuity was found, especially for symptoms of separation, social, and generalized anxiety, and for symptoms of panic disorder in girls, underscoring the usefulness of making distinctions between different anxiety constructs. An erratum to this article can be found at     

Anxiety sensitivity as a predictor of panic disorder symptoms: a prospective 3-year study

Background and Objectives: Anxiety sensitivity (AS) is the fear of anxiety symptoms, a feature proven to be an important vulnerability factor for anxiety pathogenesis. The aim of this study was to examine whether AS (as well as its factors) predicts the onset of panic disorder symptoms when controlling for the contribution of trait anxiety.

Design: We conducted a prospective 3 year follow up study.

Methods: The participants, students at the Humanities and Social Sciences in Zagreb (N?=?1087), completed an Anxiety Sensitivity Index and State-Trait Anxiety Inventory (Trait form) and, after a period of three years, were asked to self-assess criteria for panic disorder (according to the DSM-5).

Results: The predictive validity of AS for the onset of panic disorder symptoms, regardless of trait anxiety, was confirmed. Furthermore, the physical concerns dimension of AS was the only significant predictor of panic disorder symptoms. The optimal cutoff score of 25 on the ASI provides poor to moderate accuracy indices in detecting participants who will manifest panic disorder symptoms in the next three years.

Conclusion: This study contributes to our current understanding of AS as a prospective risk factor for panic disorder symptoms.     

Avoidant coping in panic disorder: a yohimbine biological challenge study

Abstract

Few studies have addressed whether the use of avoidance-oriented coping strategies is related to the development of panic in patients with panic disorder(PD). Self-report, clinician-rated, and physiological data were collected from 42 individuals who participated in a yohimbine biological challenge study, performed under double-blind, placebo-controlled conditions. Participants included 20 healthy controls and 22 currently symptomatic patients who met DSM-IV-TR diagnostic criteria for PD. Consistent with prediction, patients with PD who had higher perceived efficacy of avoidance-oriented strategies in reducing anxiety-related thoughts reported increased severity in panic symptoms during the yohimbine challenge condition as compared to the placebo. Further, patients with PD who had more fear of cognitive dyscontrol, cardiovascular symptoms, and publicly observable anxiety also reported increased severity in panic symptoms during the challenge. Healthy controls who had more fear of cardiovascular symptoms similarly reported increased severity in panic symptoms during the challenge. No effects were found for heart rate response to the challenge agent. These results provide support for the role of avoidance-oriented coping strategies and fear of anxiety-related symptoms as risk and maintenance factors in the development of panic symptoms, particularly within a biological challenge model.     

Health Perceptions and Anxiety Sensitivity in Patients with Panic Disorder

Separate lines of research indicate that patients with panic disorder display negative perceptions of physical health and elevated fear of autonomic arousal. Because health perceptions and anxiety sensitivity may be related, the present study evaluated the degree to which these constructs can be distinguished in patients meeting DSM-IV criteria for panic disorder (N = 44). Perceived health, anxiety sensitivity, and the clinical features of panic disorder were assessed at pretreatment and following 12 sessions of cognitive–behavioral treatment. Findings consistently indicated that perceived health and anxiety sensitivity can be meaningfully differentiated. Perceived physical health was only moderately associated with anxiety sensitivity, and each was uniquely associated with pretreatment symptomatology and posttreatment end-state functioning. Perceived physical health appears to be a clinically useful index in the overall evaluation of panic disorder and is readily distinguishable from anxiety sensitivity.     

Computer‐Aided Psychotherapy for Anxiety Disorders: A Meta‐Analytic Review

Computer‐aided psychotherapy (CP) is said to (1) be as effective as face‐to‐face psychotherapy, while requiring less therapist time, for anxiety disorder sufferers, (2) speed access to care, and (3) save traveling time. CP may be delivered on stand‐alone or Internet‐linked computers, palmtop computers, phone‐interactive voice response, DVDs, and cell phones. The authors performed a meta‐analysis of 23 randomised controlled studies (RCTs) that compared CP with non‐CP in anxiety disorders: phobias, n = 10; panic disorder/agoraphobia, n = 9; PTSD, n = 3; obsessive–compulsive disorder, n = 1. Overall mean effect size of CP compared with non‐CP was 1.08 (95% confidence interval: 0.84–1.32). CP and face‐to‐face psychotherapy did not differ significantly from each other (13 comparisons, d = ?0.06). Much caution is needed when interpreting the findings indicating that outcome was unrelated to type of disorder, type of comparison group, mode of CP delivery (Internet, stand‐alone PC, palmtop), and recency of the CP system and that effect size decreased when more therapist time was replaced by the computer. Because CP as a whole was as effective as face‐to‐face psychotherapy, certain forms of CP deserve to be integrated into routine practice.     

A New CBT Model of Panic Attack Treatment in Comorbid Heart Diseases (PATCHD): How to Calm an Anxious Heart and Mind

Treating anxiety comorbid with heart disease is challenging due to (a) diagnostic overlap between anxiety and heart disease, (b) the high risk associated with ignoring chest pain symptoms and delaying seeking medical attention, (c) that cognitive-behavioral therapy based on catastrophic misinterpretation of bodily symptoms requires adaption to incorporate the element of risk, and (d) that certain interoceptive symptom induction experiments may be harmful and are therefore fraught with liability. We describe Panic Attack Treatment in Comorbid Heart Diseases (PATCHD) that is based on enhancing coping skills, performing safe interoceptive exposures and supervised exercise, and countering avoidance to reduce panic attack frequency. Pre- and posttreatment data from 18 patients shows a significant reduction in cardiovascular hospital admissions and length of stay, panic attacks, general anxiety, and depression (all p < .05). Because of the complex nature of panic disorder comorbid with heart disease, health professionals should familiarize themselves with several necessary CBT adaptions.     

Discomfort with space and motion: A possible marker of vestibular dysfunction assessed by the situational characteristics questionnaire

Space and motion discomfort (SMD) refers to the situational specificity of symptoms occurring in some patients with vestibular dysfunction, such as those with balance disorders and some with panic disorder. SMD occurs in situations characterized by inadequate visual or kinesthetic information for normal spatial orientation. We report the results of two studies of the construct validity of the Situational Characteristics Questionnaire (SitQ), which has two subscales, both of which measure SMD: the SMD-I and SMD-II. In Study 1, the SitQ was administered to members of a self-help group for balance disorders, a psychiatric sample consisting of patients with panic disorder, nonpanic anxiety disorders, depression, and a sample of normals. SMD levels were the highest in the self-help balance group, next to the highest in the panic groups, and lowest in the remaining groups. In Study 2, the SitQ was administered to otolaryngological patients with vestibular dysfunction and to patients with hearing loss. SMD levels were higher in the vestibular patients. Data on internal consistency, test-retest reliability, and convergent and discriminant validity are presented. The SitQ, particularly the SMD-II, is recommended for quantifying space and motion discomfort in patients with anxiety and/or balance disorders.Study 1 was funded by MH 40757. Study 2 was funded by a grant from the Upjohn Company and MH 19816.     

Peritraumatic and persistent panic attacks in acute stress disorder

This study examined the prevalence of peritraumatic and persistent panic symptoms following trauma. Survivors of civilian trauma (n=30) with either acute stress disorder (ASD) or no acute stress disorder (non-ASD) were administered the Panic Module of the Structured Clinical Interview for DSM-IV (SCID). Participants also completed the Impact of Event Scale, Acute Stress Disorder Scale, Beck Depression Inventory, Beck Anxiety Inventory, and the Anxiety Sensitivity Index. Panic attacks were experienced by 77% of participants during their trauma, and 47% reported recurrent panic attacks post-trauma. ASD participants demonstrated more panic symptoms during and after their trauma than non-ASD participants. Posttraumatic panic was most strongly associated with anxiety sensitivity. These findings are discussed in terms of cognitive factors that may mediate posttrauma panic and treatment implications for managing posttraumatic anxiety.There is increasing evidence that panic attacks play a role in psychopathological response to trauma. A significant proportion of people with panic disorder report a history of trauma (). Moreover, two-thirds of trauma survivors report panic attacks within the previous 2 weeks (). There is also evidence that people with posttraumatic stress disorder (PTSD) display elevated levels of anxiety sensitivity (). Recent attention has focused on acute panic reactions because of proposals that panic during trauma may condition trauma-related cues to subsequent panic (). There is evidence that panic attacks occur in 53-90% of trauma survivors during the traumatic experience (). Further, people with acute stress disorder (ASD) are more likely to report peritraumatic panic attacks than non-ASD individuals. ASD is a useful framework in which to investigate the role of panic in posttraumatic stress because ASD describes acute responses to trauma that are strongly predictive of chronic PTSD ().This study investigated the relationship between peritraumatic panic and ongoing panic attacks following trauma. Specifically, we indexed panic attacks during trauma and subsequent to trauma in trauma survivors with and without ASD. We also indexed the extent to which distorted interpretations about somatic sensations may be associated with panic attacks following trauma. We considered that the strong evidence that maladaptive appraisals of somatic sensations mediate panic () is directly relevant to posttraumatic panic. We hypothesized that ASD participants would report more peritraumatic and persistent panic than non-ASD participants, and that this panic would be associated with dysfunctional interpretations about somatic stimuli.     

Health Anxiety: Latent Structure and Associations with Anxiety-related Psychological Processes in a Student Sample

Although currently classified as a somatoform disorder, cognitive-behavioral models conceptualize hypochondriasis (HC) as a severe form of health anxiety. The Short Health Anxiety Inventory (SHAI) is a measure derived from this conceptualization that measures health anxiety symptoms across the range of severity. Previous studies have reported inconsistent findings regarding this measure’s factor structure, but these studies employed factor analytic tools that did not account for the categorical nature of SHAI items. The present psychometric study was designed to address these inconsistencies using categorical factor analysis. Using data from a large student sample we found that the SHAI had two factors: Illness Likelihood and Illness Severity. We also examined the relationship between these domains and cognitive variables associated with other anxiety disorders. Results suggested that the psychological processes present in obsessive-compulsive disorder and panic disorder are also associated with health anxiety. Implications for the conceptualization and classification of severe health anxiety are discussed.     

Expectations and Attributions in Social Anxiety Disorder: Diagnostic Distinctions and Relationship to General Anxiety and Depression

Contemporary cognitive models suggest that social anxiety disorder arises from a number of cognitive factors, including tendencies to form pessimistic (rather than optimistic) attributions and expectations for socially-related events. These models also assume that the strengths of such attributions and expectations are more closely linked with social anxiety than with general anxiety or depression. To test these assumptions, a battery of self-report measures was completed by participants with a primary diagnosis of generalized social anxiety disorder (n?=?75), panic disorder with agoraphobia (n?=?44), or post-traumatic stress disorder (n?=?59). To examine differences on these cognitive variables, group comparisons were performed controlling for general anxiety, depression and medication status. Social anxiety disorder, compared with panic disorder with agoraphobia and post-traumatic stress disorder, was characterized by lower expectations for positive social events and higher expectations for negative social events. There was no difference among the groups on expectations for non-social positive or negative events. Stable and global attributions for social negative events were more closely associated with social anxiety disorder than with panic disorder with agoraphobia and post-traumatic stress disorder. Correlational analyses also revealed specific relationships among social-cognitive measures and social anxiety, even after controlling for general anxiety and depression. The results are consistent with cognitive models of social anxiety disorder.     

Understanding Chest Pain: What Every Psychologist Should Know

Chest pain is one of the most frequent presenting complaints in Emergency Rooms and other medical settings. A considerable number of these patients do not have significant coronary artery disease. This led to plausible alternative explanations for these presenting symptoms and these patients tend to have unremarkable cardiac outcomes. Nevertheless, many studies have also documented that symptoms and related disability persist in the face of reassurances about benign cardiac status. Given the implied threat of chest pain (e.g., myocardial infarction) and the presence of chest pain symptoms in other noncardiac conditions (including anxiety and panic), it is not surprising that many of these patients present with considerable emotional distress. Consequently, chest pain symptoms represent diagnostic and treatment dilemmas for physicians and psychologists alike. The extent to which cardiac and noncardiac factors contribute to all forms of chest pain remains unknown. The function of this review is to provide mental health professionals with a primer on relevant clinical issues in chronic chest pain. We examine several common medical and psychiatric causes of chronic chest pain and selectively review (1) the relevant medical and psychiatric diagnostic and treatment considerations for chest pain and (2) the hypothetical biobehavioral mechanisms relevant to psychological intervention, (3) while expanding on existing conceptual models for understanding chest pain, and (4) offering some suggestions for future research.     

The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain

Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.     

Psychopharmacological investigation of panic disorder by means of lactate infusion

The contribution of research with lactate infusion to an understanding of agoraphobia, generalized anxiety disorder, and panic disorder (PD) was reviewed. Lactate-induced panic seems to differentiate panic disorder from generalized anxiety disorder. Panic disorder seems to have important links to depression; both respond to tricyclic antidepressant drugs and neither responds well to the benzodiazepine antianxiety drugs. Response to pharmacotherapy, epidemiological surveys, and familial studies support the distinction between panic disorder and generalized anxiety disorder and the overlap between major depression and panic disorder. Understanding the mechanism of lactate-induced attacks may provide a better understanding of the pathophysiology of naturally occurring panic.     

The Role of Cardioprotective Avoidance Beliefs in Noncardiac Chest Pain and Associated Emergency Department Utilization

This study examined cardioprotective avoidance beliefs and general panic/agoraphobia variables among 45 Emergency Department patients with a primary complaint of noncardiac chest pain (NCCP) in the absence of coronary artery disease or other medical explanation. Cardioprotective beliefs about the dangerousness of work and physical activity were assessed with the Fear-Avoidance Beliefs Questionnaire (FABQ). Additional measures assessed complaints of cardiac distress and panic, anxiety sensitivity, panic-related beliefs, agoraphobic avoidance, and depressive symptoms. Hierarchical regression analysis indicated that cardiac distress symptoms are a function of panic symptoms and cardioprotective beliefs concerning both physical activity and work, with 62% of the total variance explained. The predictors also explained 57% of the variance in Emergency Department utilization, which was significantly related to cardiac distress symptoms, number of illnesses, and work-avoidance beliefs. Neither outcome was related to demographics, depression symptoms, general anxiety sensitivity, general panic cognitions, or agoraphobic avoidance. Results suggest that current behavioral understandings of NCCP might be advanced by further examination of cardiac-specific avoidance beliefs and behavior and the potential role these factors play in both symptom experience and medical utilization.