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.     

Prediction of end-of-life fears in COPD – hoping for the best but preparing for the worst

Objective: The diagnosis of a life-threatening illness can trigger end-of-life fears. Early studies show that end-of-life fears play an important role in chronic obstructive pulmonary disease (COPD). However, predictors of these fears have not yet been identified. This study investigated the relevance of socio-demographic variables, illness severity, psychological distress and disease-specific anxieties as predictors of end-of-life fears in COPD.

Design: A total of 131 COPD patients participated at two time points. Regression and mediation analyses, as well as cross-lagged panel analyses were conducted.

Main outcome measures: The participants completed questionnaires assessing end-of-life fears (Multidimensional Orientation toward Dying and Death Inventory), psychological distress (Hospital Anxiety and Depression Scale), and disease-specific anxieties (COPD Anxiety Questionnaire). Pulmonary function and a 6-min walk test served as measures of illness severity.

Results: Illness severity was not predictive of end-of-life fears. However, gender and psychological distress explained incremental variance. When disease-specific anxieties were included as additional predictors, psychological distress was no longer significant. Cross-lagged panel analyses mostly supported these results. Moreover, disease-specific anxieties mediated the association between psychological distress and end-of-life fears.

Conclusion: Administration and intensity of end-of-life care (especially concerning end-of-life fears) in COPD patients should be based not only on illness severity, but rather on psychological distress and disease-specific anxieties.     

Respiratory function, cognitions, and panic in chronic obstructive pulmonary patients.

The present study investigated the relationship between respiratory function, catastrophic thoughts about anxiety, and panic in 48 Chronic Obstructive Pulmonary Disease (COPD) patients. During a routine office visit which included respiratory function tests (Forced Vital Capacity, FVC; Forced Expiratory Volume--first second, FEV1) patients completed a battery of questionnaires which assessed history of panic, days with shortness of breath, general activity level, agoraphobic cognitions, perception of bodily sensations, anxiety and depression. Thirty-seven percent of the sample reported experiencing a panic attack. Subjects showed a significant impairment in respiratory functioning. Patients with a history of panic did not differ from those who had not experienced panic on demographic, physiologic, or activity variables. Patients who experienced panic reported significantly more agoraphobic cognitions and greater concern with bodily sensations than did patients who did not experience panic.     

Illness perceptions are the main predictors of depression and anxiety symptoms in patients with chronic pain

Depression and anxiety symptoms in chronic pain are associated with adverse clinical outcomes, and appear highly related to patient’s illness perceptions as well as with marital adjustment. This study aimed to investigate the predictive value of pain variables, marital adjustment and illness perceptions on depression and anxiety in patients with chronic pain. Two hundred patients were recruited from a pain unit in a public hospital in the north of Portugal. Patients completed a questionnaire that assessed illness perceptions (IPQ-Brief), marital adjustment (revised dyadic adjustment scale), depression and anxiety symptoms (hospital anxiety depression scale) and pain variables (pain intensity and pain disability index). Depression and anxiety symptoms were associated with pain intensity, pain-related disability, marital adjustment and illness perceptions. Results from hierarchical regression showed that illness perceptions contributed significantly to depression and anxiety symptoms over and above the effects of pain intensity, pain-related disability and marital adjustment, after controlling for gender. In multivariate analyses, pain intensity, pain-related disability and marital adjustment were uniquely related to depression and anxiety symptoms, whereas specific illness perceptions were uniquely related to depression symptoms (identity, treatment control, emotional response and coherence) and to anxiety symptoms (identity, emotional response and concern). Perceptions of greater symptomatology (identity) and of emotional impact, and lesser perceptions of treatment control and understanding of chronic pain (illness comprehensibility) were significantly associated with increased depression symptoms. Perceptions of greater symptomatology (identity), emotional impact and greater concern were associated with anxiety symptoms. These findings indicate that the contribution of illness perceptions was greater than that made by traditional covariates, and may therefore be a useful basis for future psychological interventions.     

The role of illness perceptions in the attachment-related process of affect regulation

Abstract

Based on the predictions of the attachment theory and the Common Sense Model of illness perceptions, the current study focused on the role played by illness perceptions in explaining the path linking attachment orientations to negative affect during recovery from cardiac illness. We predicted two putative mechanisms: (1) illness perceptions would mediate the direct association between attachment-related insecurity (especially attachment anxiety) and levels of distress at follow-up and (2) illness perceptions would interact with attachment orientations (attachment avoidance in particular) in explaining patients' distress. The sample consisted of 111 male patients admitted to the Cardiac Care Unit of the Meir Medical Center, located in the central region of Israel. Patients completed a measure of attachment orientations during hospitalization (baseline). One month later, patients' illness perceptions were measured. Patients' depression and anxiety symptoms were measured at baseline and at the six-month follow-up. The associations between attachment-related anxiety and anxiety symptoms at follow-up were fully mediated by illness perceptions. Attachment-related avoidance was found to interact with illness perceptions in the prediction of depressive symptoms at follow-up. The findings shed light on the possible dynamics among personality, cognitive appraisals, and affect regulation efforts when coping with illness.     

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.     

Depressed and Anxious COPD Patients: Predictors of Psychotherapy Engagement from a Clinical Trial

This study examined patient-level factors associated with engagement in mental health treatment in a sample of medically ill patients with clinically significant symptoms of depression and/or anxiety. A total of 248 patients was enlisted from a randomized controlled trial of cognitive-behavioral therapy for depression and anxiety in patients with chronic obstructive pulmonary disease (COPD). Logistic regression analysis was used to predict mental health engagement, defined as attending at least one intervention session. Results indicated that patient-perceived mastery over COPD was negatively related to mental health engagement. Further, mastery was the only significant predictor of mental health engagement after controlling for patient demographic characteristics, severity of COPD, depression, and anxiety. To improve engagement for medically ill patients with comorbid mental health difficulties, clinicians should explore patients’ attitudes about their mental health within the context of their perceived ability to cope with their medical disease.     

Illness perception patterns in patients with Coronary Artery Disease

The purpose of this study is to identify patterns of illness perception in patients with angiografically verified Coronary Artery Disease. A total of 166 patients (age: 64.4 ± 12.1, 80.7% male) were recruited after angiography. Cluster analysis on the items of the Brief Illness Perception Questionnaire was used to identify patterns of illness perception. The resulting groups were characterized with regard to Quality of Life (MacNew), anxiety and depression (GAD-7 and PHQ-9) and resilience (RS-13). The analysis revealed 4 distinct groups differing with regard to the items covering the perception of the physical and emotional impact of disease. Stronger perceptions in these domains were associated with lower Health Related Quality of Life and higher levels of emotional distress. Group 1 (33.1%) reported the strongest perceptions of the physical and emotional impact of disease and expressed low treatment control, high chronic timeline and significantly higher levels of depression than the other groups. Group 2 (27.7%) was characterized by more moderate perceptions of the emotional and physical impact of disease together with low scores on illness coherence and chronic timeline. Groups 3 (25.3%) and 4 (13.9%) reported smaller physical and emotional impact of illness but differed in chronic timeline. Our results correspond largely to recent findings in patients with other chronic diseases. Further research is needed to explore if stratification of patients according patterns of illness perception can help to inform patient–physician communication strategies.     

Self-regulatory efficacy's role in the relationship between exercise identity and perceptions of and actual exercise behaviour

Identity theory posits that when people endorse an identity they maintain or alter their behaviour in order to behave consistently with that identity. This assertion is supported in the exercise context where strength of exercise identity relates to exercise behaviour. Less is known about self-regulatory constructs that may aid individuals in behaving consistently with their exercise identity. Self-regulatory efficacy may mediate the relationship between exercise identity and exercise given the influence of this variable on exercise self-regulation; this relationship has not been examined. Exercise identity research has focused on the relationship between identity and behaviour; yet, identity theory recognizes perceptions of identity-behaviour consistency as theoretically important. Through influencing how identity-relevant information is processed, self-regulatory efficacy may also mediate the relationship between exercise identity and perceptions of identity-behaviour consistency.ObjectiveIdentity and social cognitive theories were used to examine self-regulatory efficacy as a mediator between exercise identity and i) exercise behaviour and ii) perceptions of identity-behaviour consistency.Method/designUndergraduate students (n = 311) were followed for 8 weeks. At baseline, participants completed demographic, exercise identity and exercise measures. After 4 weeks they reported their self-regulatory efficacy and after 8 weeks they reported their perceptions of identity-behaviour consistency and their exercise behaviour.ResultsConsistent with theory, self-efficacy mediated the relationship between exercise identity and both outcomes.ConclusionsFindings extend the exercise identity literature by providing empirical support for self-regulatory efficacy as a mechanism through which exercise identity strength leads to exercise behaviour and the perception of behavioural consistency with exercise identity meanings.     

‘It was all intertwined’: Illness representations and self-management in patients with cancer and anxiety/depression

Objective: Cancer and anxiety/depression frequently co-occur, leading to poorer outcomes for these illnesses. However, the majority of existing research investigates how participants view single illnesses alone. This study aimed to explore the content of individuals’ multimorbid representations and how these relate to their coping behaviours and self-management strategies for cancer and anxiety/depression.

Design: A semi-structured qualitative research design with theoretical thematic analysis.

Main Outcome Measures: Multimorbid illness representations, coping behaviours, and self-management strategies.

Results: In interviews with 21 participants multimorbid representations varied, three participants viewed cancer and anxiety/depression as unrelated, five participants were uncertain about the relationship between cancer and anxiety/depression, and the majority of participants perceived cancer and anxiety/depression as related. This third group of participants often described relationships as causal, with representations having both positive and negative influences on coping behaviours and self-management strategies. Representations were shown to change over the course of the cancer experience, with fear of cancer recurrence and the influence of participants’ most challenging illness also discussed.

Conclusions: People hold multimorbid illness representations that can influence self-management. An awareness of these representations by researchers, health professionals, and patients is important for the creation of future interventions that aim to improve and maintain patient wellbeing.     

Hospitalization of Children with Cystic Fibrosis Adversely Affects Mothers’ Physical Activity,Sleep Quality,and Psychological Status

Having a child with a chronic disease can cause anxiety and depression, which may impair the sleep quality of mothers. The aim of this study was to compare physical activity level, sleep quality, anxiety and depression in mothers of hospitalized cystic fibrosis patients, cystic fibrosis outpatients and healthy controls. Twenty-three of the patients were hospitalized and 38 were outpatients and 37 age-matched healthy children served as controls. The mothers’ fatigue levels, sleep disturbances, stress levels and perceptions of their child’s disease severity were assessed with a Visual Analog Scale. The International Physical Activity Questionnaire, Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale were administered to the mothers of children. Mothers of hospitalized and outpatient cystic fibrosis children had significantly higher fatigue severity, sleep disturbance, and stress level according to Visual Analog Scale than mothers of healthy controls. All of International Physical Activity Questionnaire scores were significantly lower in cystic fibrosis patients’ mothers than healthy controls’. Hospital Anxiety and Depression Scale depression score, Pittsburgh Sleep Quality Index subdomains and total scores of hospitalized patients’ mothers were higher than those of the other two groups (p?<?0.05). Chronic illness in children with cystic fibrosis may impair the physical activity level, sleep quality and psychological state of their mothers, especially during hospitalization period.     

Relationship between anxiety and dyspnea on exertion in patients with chronic obstructive pulmonary disease

Abstract

Dyspnea limits exercise in patients with chronic obstructive pulmonary disease (COPD) and is known to induce anxiety. Little is known whether anxiety contributes to exercise-induced dyspnea, which in turn might influence the outcome of diagnostic tests. The aim of the present study was to examine the relationship between general anxiety and dyspnea on exertion in patients with COPD.

Ninety patients with stable COPD participated; 44 men, mean age 61 (standard deviation (SD) 10.4), and mean forced expiratory volume in 1 second (%pred.) 40.5 (SD 16.9). All participants performed pulmonary function tests and an incremental cycle ergometry. The Modified Borg Scale was used to measure the level of dyspnea on exertion. Anxiety symptoms were assessed with the Hospital Anxiety and Depression Scale. Data were analyzed using Spearman's correlations and multivariate regression. Dyspnea on exertion was correlated with general anxiety (r=.31), age (r=–.30), and exercise capacity (r=.27). Regression analysis showed that general anxiety was associated with dyspnea on exertion, adjusted for sex, age, baseline dyspnea, and exercise capacity. Consequently, it is reasoned that results of exercise training and activities in daily living may be influenced negatively by anxiety-worsened dyspnea. Attention should be given to anxiety management in patients with COPD to optimize exercise training.     

En experimentell prövning av aktivt lyssnande som tröst för sm[acaron] barn som gr[acaron]ter

The procedural validity of the Composite International Diagnostic Interview - short form (CIDISF) administered via an Internet web-page was examined and compared with an in-person interview (Structured Clinical Interview for DSM-IV Axis I Disorders, research version; SCID) for 7 DSM-IV mental disorders: major depression, generalized anxiety, specific phobia, social phobia, agoraphobia, panic attack and obsessive-compulsive disorder. The 53 participants completed a computerized interview (CIDI-SF) via a web page 2 days before the scheduled in-person interview (SCID). The agreement between CIDI-SF and SCID was generally low (Cohens Kappa <0.40). However, if the panic disorder module from the long version of CIDI is used instead, the Kappa is fair (K = 0.48) with an agreement of 75%. Practical applications and future directions are discussed.     

In this together: Psychological wellbeing of foreign workers in the United Arab Emirates during the COVID-19 pandemic

The COVID-19 pandemic and the associated infection prevention and control measures (e.g. quarantine, lockdown and isolation), have had an adverse impact on mental health. To date, the mental health status and challenges of foreign workers during the pandemic have been neglected in the literature. This cross-sectional web-based survey assessed levels of post-traumatic stress, depression, anxiety and insomnia among an international sample of foreign workers (n = 319) resident in the United Arab Emirates (UAE). The majority of participants were female (76%), European (69%) and highly educated (83% had a bachelor's or higher degree). Results indicate high rates of post-traumatic stress, depression, anxiety, and insomnia, especially among women, younger individuals, and those with a previous diagnosis of a psychological disorder. Additionally, foreign workers' perceptions of pandemic severity in their home nations (mild, moderate, severe) were positively correlated with their symptom levels of depression, anxiety and insomnia. Overall, these findings may help inform future public mental health strategy and pandemic preparedness plans with reference to safeguarding the psychological wellbeing of foreign workers.     

Anxiety Sensitivity and Disabling Chronic Health Conditions State of the Art and Future Directions

Anxiety sensitivity (AS) is a construct that denotes an individual difference in fear of anxiety. Most research into the AS construct has focused on its association with panic attacks, panic disorder and several other psychiatric disorders. There has been growing interest recently in AS as an important factor in the maintenance and exacerbation of morbidity associated with some disabling chronic health conditions (e.g. gastrointestinal dysfunction, asthma, vestibular dysfunction and chronic pain). The purposes of this paper are (a) to provide a brief overview of the theoretical framework within which the AS and chronic health condition literature can be synthesized, (b) to review the existing literature regarding AS and chronic health conditions and (c) to offer recommendations for assessment and treatment. Theoretically and practically relevant directions for future investigation are provided throughout the review.     

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.     

Psychological predictors for health-related quality of life and disability in persons with chronic obstructive pulmonary disease (COPD)

Objective: Individuals with chronic obstructive pulmonary disease (COPD) exhibit low physical and mental health-related quality of life (HRQL) and high susceptibility to disability. We investigated the influence of psychological factors on HRQL and disability in COPD individuals recruited from the general population. In line with Leventhal’s common sense model, we expected psychological factors to be associated with HRQL and disability even after controlling for medical status.

Methods: Individuals with COPD (n = 502; 59.7 years old; GOLD grades were I: 3%, II: 17%, III: 34%, IV: 46%) were assessed through an online survey administered via COPD patient organisations in Germany. Individuals filled in the Short Form Health Survey (SF-12), COPD Assessment Test, Patient Health Questionnaire (modules: GAD-2, PHQ-15, PHQ-9), Brief Illness Perception Questionnaire, a questionnaire that assesses causal illness attributions, and the internal illness-related locus of control scale of the ‘KKG questionnaire for the assessment of control beliefs about illness and health’. Multiple linear regressions were calculated.

Results: The investigated factors explained high variances (disability = 56%, physical HRQL = 28%, mental HRQL = 63%, p ≤ .001). Better mental health, more optimistic illness perceptions, attribution to psychological causes, and stronger internal locus of control were associated with lower disability and better HRQL. Comorbid somatic symptoms contributed to high disability and low quality of life.

Conclusion: Psychological factors, such as illness perception, attribution and internal locus of control, were associated with disability and HRQL. These factors should be considered when designing treatments for individuals with COPD, and adequate interventions should be provided to enhance illness understanding and self-management skills.     

The role of self-regulation strategies and self-efficacy perceptions in successful weight loss maintenance

Abstract

The purpose of this study was to identify the self-regulatory strategies which people use to lose, maintain, or manage their weight, and to assess their self-efficacy perceptions to implement these strategies. Thirty-three (N = 33) undergraduate college students were divided into three groups based on their past weight loss experience and confirmed by their current Body Mass Index: (a) overweight participants who tried but failed to lose weight, (b) participants who used to be overweight but lost significant weight and kept it off for at least six months, and (c) participants with an optimal weight. All participants were interviewed using a structured questionnaire. Data were analyzed using a one-way ANOVA and correlation analyses. Participants who used self-regulatory strategies such as goal-setting, self-monitoring, self-evaluation, environmental structuring, time management, social assistance and information seeking were better able to maintain or lose weight. Overweight participants reported significantly less strategy use than participants who had lost weight or who had a healthy weight. In addition, overweight participants had lower self-efficacy perceptions about implementing strategies than did healthy weight participants or participants who had successfully lost weight. Finally, a path analysis revealed that participants who reported high self-efficacy perceptions and applied their strategies persistently in the face of difficulties were more likely to successfully manage their weight.     

The relation of illness perceptions to stress,depression, and fatigue in patients with chronic lymphocytic leukaemia

Objective: Chronic lymphocytic leukaemia (CLL) is the most prevalent adult leukaemia and is incurable. The course and treatment of CLL is unique and characterised by repeated cycles of treatment, stable disease and relapse. Utilising a Self-Regulatory Model framework, we examined the relationship between patients’ illness perceptions and cancer-specific stress, depressive symptoms and fatigue. Our aim was to test illness perceptions as predictors of these outcomes when variance due to disease and treatment variables was controlled.

Design: Data were collected on 147 patients with relapsed/refractory CLL as they entered a phase II clinical trial of an investigational medication at a university affiliated, National Cancer Institute designated comprehensive cancer center.

Main outcome measures: Cancer-specific stress, depressive symptoms and fatigue interference.

Result:. Hierarchical multiple regression was used. Consequences and emotional representation were related to all outcomes (ps?p?p?Conclusion: Illness perceptions are related to cancer-specific stress, depressive symptoms and fatigue interference in relapsed/refractory CLL. Interventions targeted at restructuring maladaptive illness perceptions may have clinical benefit in this population.     

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.