Breathing retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia

The present study investigates the differential effectiveness of three treatment packages for agoraphobia. Patients suffering from panic disorder with agoraphobia (DSM-III-R) received one of three treatments: Breathing Retraining with Cognitive Restructuring (BRCR), graded self-exposure in vivo (EXP), or a combination of BRCR and EXP. Treatments consisted of 8 sessions. Assessments consisted of self-report measures for panic, phobic anxiety and avoidance, depression, general anxiety, somatic complaints and fear of bodily sensations, and of two respiratory measures (respiratory rate and alveolar pCO₂).

The treatments resulted in a reduction in symptomatology on all self-report measures, except panic frequency, and in a decrease in respiratory rate. There was no evidence for a differential efficacy for any of the treatments on any of the variables. Contrary to expectation, and at odds with findings from earlier studies, BRCR had no significant effect on panic frequency. A detailed comparison of sample characteristics of patients in our study and previous studies, did not yield insight into possible causes for the failure to replicate earlier results. The limited effectiveness of breathing retraining in reducing panic, as observed in the present study, leads us to conclude that the role of hyperventilation in panic is less important than previously thought.     

Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS)

Three measures commonly used in assessment of social phobia, the Social Phobia and Anxiety Inventory (SPAI [Turner, S. M., Beidel, D. C. & Dancu, C. V. (1996). Social phobia and anxiety inventory: manual. Toronto, Ont.: Multi-Health Systems Inc.), the Social Phobia Scale (SPS [Mattick, R. P. & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470] and the Social Interaction Anxiety Scale (SIAS [Mattick, R. P. & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470], were compared for their ability to discriminate between social phobia and other anxiety disorders (panic disorder with or without agoraphobia). Participants were 117 patients attending a specialized anxiety disorders unit for treatment. While all three measures were able to detect differences between social phobic patients and patients with panic disorder with or without agoraphobia, a logistic regression analysis showed that the SPAI, but not the SPS and SIAS, was a significant predictor of membership of the social phobia group. Receiver operating characteristic (ROC) analysis also showed that the SPAI was the better measure for discriminating between social phobia and panic disorder with and without agoraphobia. Analysis of the sensitivity, specificity and positive and negative predictive power of the measures at the optimum cutoff scores produced by the ROC analysis are presented.     

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.     

Cognitive factors in panic disorder, agoraphobic avoidance and agoraphobia

There remains a lack of consensus regarding the possibility that especially high levels of panic-related cognitions characterise panic disorder with agoraphobia. We administered the Anxiety Sensitivity Index, the Agoraphobic Cognitions Questionnaire and the Anxious Thoughts and Tendencies Scale as well as measures of agoraphobic avoidance to patients diagnosed with panic disorder with agoraphobia (n=75) and without agoraphobia (n=26). Patients with panic disorder with agoraphobia did not score significantly higher on any of the cognitive variables than did panic disorder patients without agoraphobia. However, most of the cognitive variables showed small to moderate-strength correlations with self-report measures of agoraphobic avoidance. Our findings suggest that anxiety sensitivity, catastrophising of the consequences of panic and a general anxiety-prone cognitive style, although to some extent associated with agoraphobic avoidance, do not discriminate panic disorder with agoraphobia from panic disorder without agoraphobia.     

The hyperventilation syndrome in panic disorder, agoraphobia and generalized anxiety disorder

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.     

The catastrophic misinterpretation of physiological distress.

Cognitive theories of panic disorder suggest that the catastrophic misinterpretation of bodily sensations is the trigger for a panic attack. A challenge to cognitive theories is the suggestion that dyspnea (shortness of breath) is central to the development of panic and that negative cognitions are by-products of panic. To examine these seemingly contradictory theoretical perspectives, the present study investigated panic symptomatology in a sample of patients with chronic shortness of breath (i.e. pulmonary patients). Past studies have shown an increased prevalence of panic in pulmonary patients, a finding that may be useful in elucidating panic etiology. The current sample of pulmonary patients (N = 28) confirmed previous reports of high prevalence rates of panic in this population. Based on self-report of panic symptomatology, a total of nine patients (32%) met DSM-IV criteria that were consistent with panic disorder. Multivariate comparison of participants with and without panic symptomatology revealed that panickers had significantly higher levels of anxiety, depression and agoraphobic cognitions. However, these groups showed no significant differences on physiological measures of pulmonary functioning. The authors conclude that dyspnea alone is inadequate in predicting panic development. High levels of panic symptomatology in pulmonary samples may reflect increased opportunities for these patients to misinterpret bodily sensations and, in particular, their pulmonary symptoms.     

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.     

Avoidance behavior in panic disorder: the moderating influence of perceived control

The relations among anxiety sensitivity, perceived control, and agoraphobia were examined in 239 patients diagnosed with panic disorder (PD). Most patients exhibited agoraphobia accompanying their PD (98% situational avoidance; 90% experiential avoidance; and 80% endorsed interoceptive fear and avoidance). Anxiety sensitivity and perceived emotional control were associated with agoraphobia, and perceived threat control was found to moderate the relationship between anxiety sensitivity and agoraphobia. Lower levels of perceived control were associated with a stronger relationship between anxiety sensitivity and agoraphobia. Results were consistent for self-reported and clinician-rated agoraphobia. Implications for the role of perceived control in agoraphobia development and treatment are discussed.     

Panic symptoms in asthma and panic disorder: a preliminary test of the dyspnea-fear theory.

Ley's (Behaviour Research and Therapy, 27, 549-554, 1989) dyspnea-fear theory was tested on three groups of subjects: 10 with panic disorder, 24 with asthma, and 12 who were nonanxious and nonasthmatic, using measures of pulmonary function, muscle tension; and self-report measures of generalized anxiety, dyspnea, and psychopathology. Results are supportive of dyspnea-fear theory for asthmatics but not for individuals with panic disorder. Differences between groups on panic/fear measures were explained by a combination of general anxiety and dyspnea. Within-group regression analyses showed that only generalized anxiety symptoms contributed significantly to scores on the Asthma Symptom Checklist scale of panic/fear within the panic disorder group; while only dyspnea contributed to panic/fear among asthmatics. Additional results show that panic disorder subjects performed normally on pulmonary function tests but reported respiratory symptoms as severe as did asthmatics. Compared with normal subjects, both patient groups displayed lower correlations between self-rated symptoms of bronchoconstriction and objective pulmonary measures. Panic disorder subjects showed a negative relationship between pulmonary function and hyperventilation symptoms, suggesting a heightened sensitivity to, and discomfort with, sensations associated with normal pulmonary function. Asthmatics displayed a significant relationship between degree of airway obstruction and both trapezius surface EMG and ratings of hyperventilation symptoms.     

Agoraphobic avoidance and panic frequency as predictors of laboratory induced panic reactions

This study examined the importance of agoraphobic avoidance and frequency of panic as predictors of psychological and physiological responses of panic sufferers to a laboratory based provocation procedure. Psychophysiologic comparisons were made between 22 panic disorder patients and 15 controls, at baseline and across three periods of carbon dioxide gas inhalations (1, 3, 5%; balance oxygen). Subjective measures of anxiety, frightening cognitions and body sensations were obtained across the phases. Physiological measures of minute ventilation, breathing rate, tidal volume, end tidal CO₂ and heart rate were also obtained. Between group comparisons revealed significant differences between the groups on the subjective measures with no significant differences occurring on the physiological measures. Within group analyses revealed that pre-session questionnaire measures of agoraphobia avoidance and panic frequency predicted the degree of anxiety, frightening sensations and cognitions during baseline and 5% CO₂ inhalation. The results indicated that both self-reported agoraphobic avoidance and panic frequency are strong clinical predictors of psychological reactions of panic sufferers during laboratory provocation.     

Cognitive therapy versus interoceptive exposure as treatment of panic disorder without agoraphobia

Cognitive therapy (CT) and interoceptive exposure (IE) as treatments of panic disorder without agoraphobia were compared in a sample of 69 patients, randomly allocated to condition. There were no significant differences between treatments as to reductions in panic frequency, daily anxiety levels and a composite questionnaire score, at posttest after the 12-session treatment, and at both follow-ups (4 weeks, 6 months). In both conditions, high percentages of patients were panic free at post and follow-up tests (range 75-92%). Although the reduction in idiosyncratic beliefs about the catastrophic nature of bodily sensations was equally strong in both conditions, post-treatment beliefs correlated strongly with symptoms at post and follow-up tests in the CT condition, but not in the IE condition. Reduction of beliefs may be essential in CT, but not in IE. This suggests that the two treatments utilize different change mechanisms.     

Evaluating panic-specific factors in the relationship between suicide and panic disorder

Work during the past decade has suggested an association between panic disorder and suicide (i.e., suicidal ideation and suicide attempts) that cannot simply be accounted for by co-occurring depression symptoms. To clarify the linkage between panic disorder and suicide, the association between panic-specific clinical and cognitive variables and suicide indicators were evaluated in patients with panic disorder (N=146). Analyses predicting the presence of suicidal ideation (positive, negative) after covarying the effects of a current mood disorder diagnosis and depression symptoms indicated a number of significant predictors including: (1) overall anxiety symptoms; (2) level of anticipatory anxiety; (3) avoidance of bodily sensations; (4) attentional vigilance toward bodily perturbations; and (5) phrenophobia (i.e., fear of cognitive incapacitation). Anxiety-specific variables did not account for unique variance in predicting prior history of suicide attempts.     

Bodily maps of emotions across child development

Different basic emotions (anger, fear, disgust, happiness, sadness, and surprise) are consistently associated with distinct bodily sensation maps, which may underlie subjectively felt emotions. Here we investigated the development of bodily sensations associated with basic emotions in 6‐ to 17‐year‐old children and adolescents (n = 331). Children as young as 6 years of age associated statistically discernible, discrete patterns of bodily sensations with happiness, fear, and surprise, as well as with emotional neutrality. The bodily sensation maps changed from less to more specific, adult‐like patterns as a function of age. We conclude that emotion‐related bodily sensations become increasingly discrete over child development. Developing awareness of their emotion‐related bodily sensations may shape the way children perceive, label, and interpret emotions.     

Effects of aerobic exercise on anxiety sensitivity

Anxiety sensitivity is a known precursor to panic attacks and panic disorder, and involves the misinterpretation of anxiety-related sensations. Aerobic exercise has been shown to reduce generalized anxiety, and may also reduce anxiety sensitivity through exposure to feared physiological sensations. Accordingly, 54 participants with elevated anxiety sensitivity scores completed six 20-min treadmill exercise sessions at either a high-intensity aerobic ( n = 29 ) or low-intensity ( n = 25 ) level. Self-ratings of anxiety sensitivity, fear of physiological sensations associated with anxiety, and generalized anxiety were obtained at pre-treatment, post-treatment, and one-week follow-up. Results indicated that both high- and low-intensity exercise reduced anxiety sensitivity. However, high-intensity exercise caused more rapid reductions in a global measure of anxiety sensitivity and produced more treatment responders than low-intensity exercise. Only high-intensity exercise reduced fear of anxiety-related bodily sensations. The implications of these findings are discussed.     

What Is the Core Fear in Social Phobia? A New Model to Facilitate Individualized Case Conceptualization and Treatment

What, exactly, do individuals with social phobia fear? Whereas fear of anxiety-related bodily sensations characterizes and defines panic disorder, is there a fundamental focus of anxiety that unifies individuals under the diagnostic category of social phobia? Current conceptualizations of social phobia suggest several possible candidates, including the fear of negative evaluation, embarrassment, and loss of social status. However, it is argued here that these conceptualizations are fundamentally flawed and confusing, and the lack of clarity with respect to this question has hampered our ability to conceptualize and treat patients with social phobia in a manner that is tailored to individual differences in symptom presentation. In the present article, I will propose a novel conceptualization of core fear in social phobia, demonstrate how this conceptualization can be used to classify individuals with social phobia in a manner that eliminates confusion and accounts for symptom heterogeneity, and illustrate its potential utility for both clinical practice and research.     

Anxiety sensitivity within the anxiety disorders: disorder-specific sensitivities and depression comorbidity

The tendency to perceive anxious states as aversive and harmful is hypothesized to confer vulnerability to the development of anxiety disorders. The most commonly used measure of anxiety sensitivity, the Anxiety Sensitivity Index [ASI; Reiss, S., Peterson, R.A., Gursky, D.M., & McNally R.J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behavior Research and Therapy, 24, 1-8], is composed of multiple lower-order factors, assessing fear of physical symptoms, fear of publicly observable anxious symptoms, and fear of cognitive dyscontrol. This study examined the convergent validity of the lower-order anxiety sensitivity dimensions in DSM-IV diagnosed anxiety disorders. Participants with primary diagnoses of panic disorder with agoraphobia, social phobia, and generalized anxiety disorder (GAD) completed the ASI and measures of anxiety and depression severity. Support was found for the convergent validity of all ASI dimensions in reference to thematically related anxiety disorders and in the identification of patients presenting with and without secondary major depressive disorder (MDD). The ASI-fear of cognitive dyscontrol dimension displayed strong and nonredundant associations with GAD, dimensional depression scores, and secondary diagnoses of MDD. The conceptual implications of the shared importance of fear of cognitive dyscontrol in GAD and MDD are discussed.     

Perfectionism and self-consciousness in social phobia and panic disorder with agoraphobia.

Social phobics were compared to patients with panic disorder with agoraphobia and normal controls on perfectionism and self-consciousness. On concern over mistakes and doubts about action, social phobics scored higher than patients with panic disorder. Social phobics also demonstrated a higher level of public self-consciousness than patients with panic disorder and when this difference was controlled for the significant differences on perfectionism disappeared. Within each patient group, however, perfectionism was more robustly related to social anxiety than was public self-consciousness, which replicates the findings of Saboonchi and Lundh [Saboonchi, F. & Lundh, L. G. (1997). Perfectionism, self-consciousness and anxiety. Personality and Individual Differences, 22, 921-928.] from a non-clinical sample. The results are discussed in terms of public self-consciousness being a differentiating characteristic of the more severe kind of social anxiety which is typical of social phobia.     

Preliminary Examination of the Relationship Between Anxiety Disorders in Adults and Self-Reported History of Teasing or Bullying Experiences

This preliminary study examined the relationship between anxiety disorders and self-reported history of teasing or bullying experiences, comparing individuals with social phobia, obsessive compulsive disorder, and panic disorder with or without agoraphobia. Given that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated, we hypothesized that the social phobia group would have a higher rate of self-reported teasing history than would the obsessive compulsive disorder or panic disorder groups. Consistent with this hypothesis, a relationship between reported history of teasing and diagnosis was found. A significantly greater percentage of participants in the social phobia group (92%) reported a history of severe teasing experiences compared with the obsessive compulsive disorder (50%) and panic disorder (35%) groups. History of teasing experiences was also significantly related to an earlier age of onset for all 3 anxiety disorders, and to a greater number of self-reported additional problems in childhood. These findings suggest further directions for research in this area and highlight the significant link between perceptions of teasing in childhood and social phobia.     

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.