Unique contributions of anxiety sensitivity to avoidance: a prospective study in adolescents

Examination of the prospective relation between anxiety sensitivity (AS) and behavioral avoidance is largely absent from the literature. In a longitudinal study of a community sample of 2246 adolescents, participants completed the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally (1986). Behaviour Research & Therapy, 24, 1-8), State-Trait Anxiety Inventory (STAI; Spielberger (1983). STAI: Manual for the Stait-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press), and the Fear Questionnaire (Marks & Matthews (1979). Behaviour Research & Therapy, 17, 263-267) on an annual basis. To stringently test AS's ability to prospectively predict behavioral avoidance, linear regression was used to test whether AS factors predicted variance in follow-up behavioral avoidance scores after controlling for gender, trait anxiety, panic attacks, and baseline avoidance. Results indicted that the mental and physical subscales of the ASI predicted change in behavioral avoidance. The findings of the study are consistent with the view that AS may serve as a precursor to avoidant behavior and that, regardless of whether or not acute panic has been experienced, those who fear autonomic arousal may be more likely to avoid situations in which those sensations may be present.     

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.     

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.     

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.     

Associations between emotional avoidance,anxiety sensitivity,and reactions to an observational fear challenge procedure

Research has shown that emotional avoidance and anxiety sensitivity are associated with more self-reported fear and distress in response to laboratory fear challenge procedures. The present study aimed to expand upon this work and examined how emotional avoidance and anxiety sensitivity are related to emotional and physiological responses to an observational fear challenge procedure. To accomplish this aim, a carefully screened, non-clinical sample (N = 43) was administered the Acceptance and Action Questionnaire (AAQ), a measure of emotional avoidance, and the Anxiety Sensitivity Index (ASI). Participants then engaged in an observational fear challenge paradigm. During the fear challenge, participants watched mock panic attacks while emotional (e.g., fear and panic) and skin conductance levels were assessed. Consistent with expectation, emotional avoidance and anxiety sensitivity were positively associated with more self-reported fear and more severe panic symptoms to the challenge procedure. However, anxiety sensitivity was more highly associated with self-reported fear and panic symptoms in response to the challenge procedure than emotional avoidance. Emotional avoidance and anxiety sensitivity were not associated with levels of physiological arousal to the observational fear challenge procedure. Discussion focuses on the interplay between emotional avoidance, anxiety sensitivity, and the development of vicarious fear responses and how these constructs may contribute to the pathogenesis of anxiety disorders.     

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.     

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.     

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.     

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.     

Cross cultural evaluation of smokers risk for panic and anxiety pathology: a test in a Russian epidemiological sample

The present study evaluated the main and interactive effects of level of smoking (cigarettes per day) and anxiety sensitivity (fear of anxiety and anxiety related sensations) in predicting panic and anxiety variables in an epidemiologically-defined sample of smokers from Moscow (n=95). The combination of high levels of anxiety sensitivity and smoking predicted agoraphobic avoidance, but not frequency of panic attacks during the past week. These findings suggest anxiety sensitivity may moderate the relation between level of smoking and prototypical panic psychopathology variables (panic attacks and agoraphobic avoidance) even after controlling for the theoretically-relevant factors of alcohol abuse and negative affect.     

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.     

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.     

Does the Beck Anxiety Inventory measure anything beyond panic attack symptoms?

The Beck Anxiety Inventory (BAI) has become a popular measure in anxiety assessment and the BAI does not overlap in content with measures of depression. There is also some factor analytic evidence to support this distinction. However, an inspection of the BAI's content indicates that many of its items resemble, or are identical to, the symptoms of panic attacks listed in the DSM-IV. Further empirical support for this suspicion is provided from the results of a factor analysis of the BAI items and the individual DSM-IV panic symptoms contained in the Panic Attack Questionnaire, using data from a sample of 157 panic disorder patients. A three-factor model (dizziness related, catastrophic cognitions/fear, cardiorespiratory distress) emerged that replicated a three-factor model of panic symptoms identified in earlier work with another panic disorder sample. All but one of the BAI items loaded highly on the three panic symptom clusters and no separate BAI factor was obtained. The BAI appears to be confounded with, or actually measures, panic attacks rather than anxiety in general. Several implications of this finding are discussed.     

Anxiety sensitivity and panic attacks in a nonclinical population

In the present study, we administered the Anxiety Sensitivity Index (ASI) and a modified version of the Panic Attack Questionnaire (PAQ) to 425 college students to determine whether high anxiety sensitivity ('fear of fear') occurs in the absence of a history of unpredictable ('spontaneous') panic attacks, or whether such attacks are a necessary precursor to high anxiety sensitivity. Based on their ASI scores, subjects were assigned to either the high, medium, or low anxiety sensitivity groups. High anxiety sensitivity subjects more frequently reported both a personal and family history of panic than did subjects in the other groups. Nevertheless, two-thirds of the high anxiety sensitivity subjects had never experienced an unpredictable panic attack. This suggests that the fear of anxiety can be acquired in ways other than through personal experience with panic.     

Sensations, cognitions and the perception of cues associated with expected and unexpected panic attacks

Panic attacks may be perceived by patients as either cued or uncued (spontaneous) and either expected or unexpected. The purpose of the present study was to examine the prevalence and characteristics of these types of panic. Twenty-six panic disorder patients with mild avoidance and 18 with moderate or severe avoidance were instructed to complete a questionnaire during or immediately following each of three consecutive naturally occurring panic attacks they experienced. They were asked to rate the extent to which they expected the panic attack to occur, whether they felt it was associated with an external panic "cue" (e.g. a shopping mall), whether they would expect to panic again in similar circumstances, their mood, present level of life stress, and fear and severity of their body sensations and disturbing cognitions. Results indicated that from a sample of 92 questionnaires, each representing a separate panic, nearly 70% of panic attacks were rated as cued-expected and only one panic was rated as uncued-expected. The other two categories each comprised about 15% of all panic attacks. There were few reported differences in body sensations and cognitions reported as a function of type of panic and no differences with regard to extent of agoraphobic avoidance. Expected panic was associated with a higher expectation of future panic in similar circumstances.     

Panic symptoms during trauma and acute stress disorder

This study investigated the role of panic symptoms that occur during trauma and subsequent acute stress disorder (ASD). Civilian trauma (N=51) survivors with either acute stress disorder (ASD), subclinical ASD, or no acute stress disorder (non-ASD) were administered the Acute Stress Disorder Scale, Impact of Event Scale, Beck Anxiety Inventory, Beck Depression Inventory, and the Anxiety Sensitivity Index (ASI). Participants also completed the Physical Reactions Scale to index panic symptoms that occurred during their trauma. Overall, 53% of participants reported panic attacks during their trauma. ASD and subclinical ASD participants reported more peritraumatic panic symptoms, and higher ASI scores, than non-ASD participants. These findings are consistent with the notion that peritraumatic panic may be related to subsequent posttraumatic stress, and suggest that modification of maladaptive beliefs about physical sensations should be addressed in posttraumatic therapy.     

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.     

Factors influencing drinking behavior in alcoholic panickers and non-panickers

Male alcoholics who (a) experienced panic attacks prior to abusing alcohol, (b) experienced panic attacks subsequent to abusing alcohol, and (c) had not experienced panic attacks were compared on three sets of measures: the Panic Attack Questionnaire, the Restrained Drinking Scale, and the Inventory of Drinking Situations. The results showed that two groups of Ss who experienced panic attacks were more likely than non-panickers to use drugs other than alcohol, began drinking at an earlier age, had a greater proportion of parents with panic and alcohol related problems, had higher drinking restraint scores, and drank in more situations. The Ss who experienced panic attacks prior to abusing alcohol were more likely than the other groups to drink in situations similar to those related to agoraphobic fears. It was postulated that alcoholics who experience panic attacks, especially those who experienced panic attacks prior to abusing alcohol may be using alcohol to reduce anxiety or fear related to panic attacks.     

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.     

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.