Avoidant coping in panic disorder: a yohimbine biological challenge study

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.     

Does coping predict CO2-induced panic in patients with panic disorder?

Patients with panic disorder (PD) show maladaptive coping but the role of coping in the pathogenesis of panic is unclear. This study examined general coping and panic-specific coping as predictors of fear responding to CO2 inhalation. Subjective and physiological responses including panic attacks were assessed in 45 patients with PD and 45 matched nonclinical controls. Measures of coping were the primary predictors used in the analyses. Consistent with other reports, patients with PD reported increased emotion-focused coping and there was an association between emotion-focused coping and subjective reactivity. However, only panic-specific coping predicted panic attacks in response to the CO2 challenge.     

Respiratory symptoms and panic in the National Comorbidity Survey: a test of Klein's suffocation false alarm theory

According to suffocation false alarm theory (Arch. Gen. Psychiatry 50 (1993) 31), respiratory symptoms are the symptoms that best distinguish the panic attacks of individuals with panic disorder (PD) from those of individuals without PD. Using National Comorbidity Survey data from those 609 respondents who had lifetime histories of panic attacks or PD, we tested this prediction. Neither respiratory symptom (smothering; dyspnea) strongly differentiated between respondents with PD and those with only panic attacks. Respiratory symptom endorsement was unrelated to PD when the number of other symptoms endorsed was controlled; furthermore, respiratory symptoms had slight effect sizes and were not included in a multivariate context. In contrast, fear of dying had the largest effect size, an association with PD that persisted after control for other symptom endorsement, and a continuing importance in multivariate analyses. Strikingly, panic attack respondents who reported having had only one panic attack were as likely as PD respondents to report respiratory symptoms during panic. These findings, although based on retrospective self-report and thus subject to recall bias, are inconsistent with the hypothesis that respiratory symptoms during panic have diagnostic significance.     

Sex differences in response to a panicogenic challenge procedure: an experimental evaluation of panic vulnerability in a non-clinical sample

Epidemiological studies show that women are twice as likely as men to develop panic disorder (PD) during their lifetimes. Data from retrospective studies also suggest that women are more distressed by panic and other negative emotional states than men, and that this tendency may precede the development of PD. The present prospective study sought to expand this work by evaluating sex differences in the predisposition to panic in individuals without PD or other forms of psychopathology. Participants (N=96; 52 women) were exposed to 12 panicogenic inhalations of 20% CO2-enriched air while physiological (e.g., heart rate, electrodermal response, Frontalis EMG) and self-report (e.g., subject distress, fear, frequency and severity of DSM-IV panic symptoms) response domains were monitored. As expected, magnitude of autonomic responding failed to reliably discriminate between women and men. Yet, women reported more fear and panic immediately following the challenge procedure relative to men, and this sex difference persisted when assessed again 30 min post-challenge. Implications of these results are discussed broadly in the context of biopsychosocial accounts of sex differences in the clinical presentation of PD.     

Predictors of Self-Reported Anxiety and Panic Symptoms: An Evaluation of Anxiety Sensitivity, Suffocation Fear, Heart-Focused Anxiety, and Breath-Holding Duration

The purpose of this study was to examine the extent to which anxiety-related individual difference variables predict anxious responding when individuals experience aversive bodily sensations. Thus, we explore several psychological and behavioral predictors of response to a single 25-sec inhalation of 20% carbon dioxide-enriched air in 70 nonclinical participants. Predictor variables included anxiety sensitivity, suffocation fear, heart-focused anxiety, and breath-holding duration. Multiple regression analyses indicated that only anxiety sensitivity significantly predicted postchallenge panic symptoms, whereas both anxiety sensitivity and suffocation fear predicted postchallenge anxiety. These data are in accord with current models of panic disorder that emphasize the role of fear of fear in producing heightened anxiety and panic symptoms and help clarify specific predictors of anxiety-related responding to biological challenge.     

Dizziness- and Palpitations-predominant Orthostatic Panic: Physiology,Flashbacks, and Catastrophic Cognitions

In an orthostatic challenge, Cambodian patients with orthostatic panic in the last month (OP patients) sometimes panicked during orthostatic challenge, whereas those without orthostatic panic in the last month (NOP patients) did not. Also, OP patients with primarily dizziness during orthostatic challenge panic (OP_OCP-D) had a less vigorous physiological response than two other groups: (a) OP patients with primarily palpitations during orthostatic challenge panic (OP_OCP-P) and (b) NOP patients who had no symptoms during orthostatic challenge (NOP_NOCP-NS). Among the patients experiencing orthostatic challenge–induced panic (i.e., the OP_OCP-D and OP_OCP-P patients), there were prominent orthostatic challenge–induced flashbacks and catastrophic cognitions, and the severity of orthostatic challenge–induced flashbacks and catastrophic cognitions correlated with the severity of orthostatic panic in the previous month and with the severity of orthostatic challenge–induced panic.     

Symptom Attributions Across the Menstrual Cycle in Women with Panic Disorder

Women with panic disorder are likely to experience greater menstrual-specific symptoms (e.g., headaches, cramps) as well as more panic/anxiety-related symptoms (e.g., dizziness, faintness, chest pain, heart pounding), and may be more likely to experience these symptoms during the premenstrual phase. This study examines the attributions women make about the somatic and affective symptoms they experience during the menstrual cycle. Using a 30-day prospective design, women with and without panic disorder monitored physical and affective symptoms. Participants reported on severity of various symptoms and a primary cause for each symptom (menstrual cycle-related, panic/anxiety related, stress-related, health-related). Women with panic disorder reported more panic attacks during the premenstrual phase compared to other cycle phases. They also reported more severe affective and panic symptoms during the premenstrual phase compared to other phases, but did not significantly differ from the comparison group in menstrual symptom severity across the three cycle phases. Although women with panic disorder attributed more panic/anxiety-related causes for their symptoms across the menstrual cycle, they were able to discriminate between panic/anxiety causes and menstrual cycle-related causes. Women with panic disorder may benefit for therapy that focuses on their exacerbation of panic symptoms during the premenstrual phase.     

The role of anxiety sensitivity and lack of emotional approach coping in depressive symptom severity among a non-clinical sample of uncued panickers

Panic attacks and depression frequently co-occur, and the presence of this co-morbidity is often associated with worse outcomes compared with each disorder alone. Despite this, not everyone who experiences panic attacks also suffers from depression, suggesting that individual difference factors may play a role in this co-morbidity. The purpose of this study was to provide a preliminary investigation of two such individual difference factors, examining the role of anxiety sensitivity and lack of emotional approach coping in depressive symptom severity among a non-clinical sample of uncued panickers. A sample of 79 college students reporting the occurrence of uncued panic attacks within the past year completed a series of questionnaires assessing the lower-order factors of anxiety sensitivity, emotional approach coping, panic attack frequency, panic-related disability, panic symptom severity and depressive symptom severity. Participants with more severe depressive symptoms reported greater anxiety sensitivity, panic attack frequency, panic symptom severity, panic-related disability and lack of emotional approach coping. The particular anxiety sensitivity dimension of fear of cognitive dyscontrol and lack of emotional approach coping emerged as the best predictors of depressive symptom severity. Findings are discussed in terms of their implications for the improved understanding of this co-morbidity, as well as its treatment.     

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.     

Book Reviews

Panic attacks and depression frequently co‐occur, and the presence of this co‐morbidity is often associated with worse outcomes compared with each disorder alone. Despite this, not everyone who experiences panic attacks also suffers from depression, suggesting that individual difference factors may play a role in this co‐morbidity. The purpose of this study was to provide a preliminary investigation of two such individual difference factors, examining the role of anxiety sensitivity and lack of emotional approach coping in depressive symptom severity among a non‐clinical sample of uncued panickers. A sample of 79 college students reporting the occurrence of uncued panic attacks within the past year completed a series of questionnaires assessing the lower‐order factors of anxiety sensitivity, emotional approach coping, panic attack frequency, panic‐related disability, panic symptom severity and depressive symptom severity. Participants with more severe depressive symptoms reported greater anxiety sensitivity, panic attack frequency, panic symptom severity, panic‐related disability and lack of emotional approach coping. The particular anxiety sensitivity dimension of fear of cognitive dyscontrol and lack of emotional approach coping emerged as the best predictors of depressive symptom severity. Findings are discussed in terms of their implications for the improved understanding of this co‐morbidity, as well as its treatment.     

Response patterns to repeated CO2 inhalation in individuals with high anxiety sensitivity.

The present report extends previous work which has documented two distinct response patterns to repeated presentation of interoceptive cues (using CO2 inhalation) in PD patients [Beck, J. G. & Shipherd, J. C. (1997). Repeated exposure to interoceptive cues: does habituation of fear occur in panic disorder patients? Behaviour Research and Therapy, 35, 551-557]. We were interested in determining if these two patterns of fear habituation and sensitization would be noted in panic-naive individuals who reported high levels of Anxiety Sensitivity. A second aspect of this report examined whether attention to bodily sensations versus to neutral material would impact fear habituation and sensitization. Participants included 43 panic-naive individuals who scored at least 1 standard deviation above norms on the Anxiety Sensitivity Index. Results indicated that 37% of the sample reported habituation of fear, 47% reported fear sensitization and 16% demonstrated relatively stable fear levels across 12 inhalations of CO2 during session 1. The attentional manipulation did not exert a pronounced influence on anxiety, panic symptom severity, skin conductance, or heart rate in either Habituators or Sensitizers during session 2. These results are discussed in light of their relevance in understanding fundamental psychopathological processes underlying Panic Disorder.     

Anxiety sensitivity and perceived control over anxiety-related events: evaluating the singular and interactive effects in the prediction of anxious and fearful responding to bodily sensations

The present investigation examined the singular and interactive effects of anxiety sensitivity and perceived control over anxiety-related events in the prediction of panic symptoms using a CO(2)-enriched air biological challenge. Two hundred and twenty-nine adult participants (M(age)=21.02, SD=7.55, 124 females) were recruited from the greater Burlington, Vermont community. Results indicated that pre-challenge anxiety sensitivity, but not perceived control over anxiety-related events, significantly predicted post-challenge panic attack symptoms, anxiety focused on bodily sensations, and, interest in returning for another challenge (behavioral avoidance). In regard to physiological findings, anxiety sensitivity was significantly related to skin conductance level whereas perceived control over anxiety-related events was related to respiration rate. Neither anxiety sensitivity nor perceived control over anxiety-related events was related to heart rate. There also were no interactive effects between anxiety sensitivity and perceived control over anxiety-related events for any of the studied dependent variables. Results are discussed in relation to multi-risk factor models of cognitive vulnerability for panic psychopathology.     

Role of cognitive appraisal in panic-related avoidance

The present study examined several dimensions of panic cognitions to test whether panic appraisals predict phobicity among panic sufferers. Thirty-five patients meeting DSM-III-R criteria for panic disorder with minimal or no phobic avoidance were compared to 40 patients meeting DSM-III-R criteria for panic disorder with agoraphobia (severe). The two groups looked strikingly similar on measures of panic symptoms, panic frequency and panic severity. As expected, patients diagnosed as having panic disorder with agoraphobia reported significantly more depression and phobic avoidance than patients with PD. Striking differences emerged on each of the following panic appraisal dimensions: (a) anticipated panic, (b) perceived consequences of panic, and (c) perceived self-efficacy in coping with panic. In each case, patients with panic disorder and agoraphobia reported significantly more dysfunctional panic appraisals than patients with panic disorder and no avoidance. Of those panic appraisal dimensions studied, anticipated panic emerged as the most potent correlate of agoraphobic avoidance. These findings support the hypothesis that cognitive appraisal factors may play an important role in the genesis or maintenance of phobic avoidance among panic patients.     

The gulf war: Distressful reactions to scud missiles attacks

This study investigated the relationships among coping strategies, trait anxiety and distressful reactions (State anxiety and fears and symptoms) of Israeli civilians under missile attack during the 1991 Gulf war. During the war sixty-six subjects (46 females and 20 males) completed a questionnaire that measured their distressful reactions and included fears in various situations (e.g., during the night, in the sealed room) and various symptoms (e.g., sleep disturbances, sensitivity to noise). In addition each subject completed the Coping Inventory for Stressful Situations (CISS, Endler & Parker, 1990a), a multidimensional self-report measure of coping which measures three major coping strategies: task-oriented, emotion-oriented and avoidance-oriented. Subjects also completed the State and Trait anxiety scales of the Endler Multidimensional Anxiety Scales (EMAS, Endler, Edwards, & Vitelli, 1991). The state anxiety scales measure two components of the individual's state anxiety, cognitive worry and autonomic emotional reactions. The trait anxiety scales measure the individual's predisposition to experience anxiety in four different situations: social evaluation, physical danger, ambiguous situations and daily routines. The results showed that individuals who used emotion-oriented coping more frequently, experienced more state anxiety and symptoms and fears, (i.e., experienced greater distress) during the war. Task-oriented and avoidance-oriented coping were not related to the distressful reactions. It was further found that subjects high on physical danger trait anxiety and social evaluation trait anxiety experienced greater fears and more symptoms (i.e., experienced greater distress) during the war. Persons high on social evaluation trait anxiety also experienced great cognitive-worry state anxiety. The results are discussed within the framework of the multidimensional model of stress, anxiety and coping (Endler, 1988; Endler & Parker, 1990a, 1990b) and the special characteristics of the Gulf war situation.     

Negative beliefs about breathlessness increases panic for patients with chronic respiratory disease

Breathlessness is a multidimensional symptom of respiratory disease and is associated with the experience of panic. Patients with panic disorder have increased mortality, morbidity and healthcare utilisation that is unrelated to their disease severity. Our qualitative study aimed to appraise respiratory patients' experiences of breathlessness and whether their cognitions were associated with panic aetiology. The self-regulatory theory was utilised to develop the framework for the semi-structured interview schedule. Twelve individuals with respiratory disease at a U.K. cardiothoracic centre participated and their data were analysed using interpretative phenomenological analysis. Perceived control over the disease, symptoms and panic emerged as the core theme with three related belief systems; (1) Perceived consequences of panic and disease; (2) Illness and symptom coherence; and (3) Emotional adaptation. Panic symptoms were most prevalent in participants with low perceived control over symptoms and the disease, negative beliefs about the life-limiting consequences of unpredictable breathless attacks and by those using emotional coping strategies such as denial and avoidance. The experience of panic for respiratory patients can be explained through the cognitive-behavioural model of anxiety, which highlights the contributory role of catastrophic beliefs about the control and consequences of symptoms and disease as a significant contributory factor for the prevalence and maintenance of panic. The mortality and morbidity of respiratory patients is significantly affected by a co-morbid diagnosis of panic disorder and so it is critical to patients' long-term healthcare that their psychological experiences are assessed. Healthcare services must enhance patients' understanding about their disease to improve their confidence to control symptoms. Recent evidence suggests that cognitive-behavioural interventions that increase problem-solving coping will reduce catastrophic misinterpretations about the perceived consequences of breathlessness and improve emotional adaption to respiratory disease.     

Responses to symptom induction exercises in panic disorder

Exposure to panic symptoms (interoceptive exposure) is often included as part of treatment for panic disorder (PD), although little is known about the relative effects of particular symptom induction exercises. This study describes responses of individuals with PD and nonclinical controls to 13 standard symptom induction exercises and 3 control exercises. Generally, individuals with PD responded more strongly to symptom induction exercises than did controls. The exercises producing the most fear included spinning, hyperventilation, breathing through a straw, and using a tongue depressor. This study also reports findings regarding specific symptoms triggered by each exercise, the percentage of participants reporting fear during each exercise, and predictors of fear.     

Coping with Missile Attack: Resources, Strategies, and Outcomes

ABSTRACT The coping process was examined in a group of Israeli subjects experiencing SCUD missile attacks during the Persian Gulf War. We were interested in examining the relationship of coping resources, optimism, perceived control, and coping strategies, to anxiety, to physical symptoms, and to cognitive functioning during a real crisis. Data were gathered via structured questionnaires in the midst of the Persian Gulf War (February 1991) on a sample of 261 adult respondents residing in northern Israel. Although people reported a mixture of palliative and active coping strategies, it was the use of palliative coping efforts that predicted greater anxiety and physical symptoms. Subjects with greater coping resources used more palliative and active coping strategies and had higher cognitive functioning. However, active coping did not predict any of the negative stress reactions (i.e., anxiety and physical symptoms). People who perceived being in control of the situation reported using less palliative coping and fewer symptoms. That active coping did not predict negative stress reactions may have been a function of the severity of the stressor, and the resultant high levels of anxiety that were engendered. Overall, these findings do point to a different coping process in a grave and ongoing disaster situation than that reported in reaction to more normal life events.     

Nonclinical panic in college students: an investigation of prevalence and symptomatology

This article presents data on the prevalence and symptomatology of panic attacks and panic disorder (PD) in a large nonclinical sample (n = 2,375) of college students. Results showed that approximately 12% of the sample had experienced at least one unexpected panic attack and that 2.36% met DSM-III-R criteria for panic disorder. Although there were no sex differences in overall panic attack prevalence, men reported significantly more panic-related worry than women, and women reported a higher panic frequency than men. Compared to subjects who met DSM-III-R criteria for PD, infrequent panickers presented with fewer panic symptoms, fewer panic episodes, less panic-related worry, lower anxiety sensitivity, and less panic-related avoidance. Moreover, compared with PD subjects, the infrequent panickers were much less likely to report fears of dying, going insane, and derealization during a panic attack. The findings provide preliminary support for the role of anxious apprehension as a psychological vulnerability factor in the pathogenesis of panic disorder.     

Discomfort intolerance: evaluation of a potential risk factor for anxiety psychopathology

Discomfort intolerance, defined as an individual difference in the capacity to tolerate unpleasant bodily sensations, is a construct recently posited as a risk factor for panic and anxiety psychopathology. The present report used a biological challenge procedure to evaluate whether discomfort intolerance predicts fearful responding beyond the effects of trait anxiety and a well-established psychological vulnerability factor (i.e., anxiety sensitivity). Nonclinical community participants (N=44) with no history of panic attacks or any Axis I condition completed a 35% CO(2) challenge. Results are consistent with our hypothesis suggesting that discomfort intolerance incrementally predicts increased subjective reactivity to the challenge. Moreover, there was some suggestion that discomfort intolerance interacted synergistically with anxiety sensitivity to increase anxiety-related symptoms. These findings add to a small but growing literature suggesting that discomfort intolerance may play a role in the development of anxiety problems.     

Situations and specific coping strategies associated with clinical and nonclinical panic attacks.

The present paper reports the results of further comparisons between clinical and nonclinical panickers. Both panic disorder patients and nonclinical panickers reported a variety of situational contexts associated with panic attacks, and differed markedly in their attempts to cope with panic. Nonclinical panickers tended to use more 'positive' coping strategies in response to panic. Conversely, one of the most commonly used and subjectively effective coping strategies reported by panic disorder patients was to escape the situation.