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.     

Sixteen-item Anxiety Sensitivity Index: confirmatory factor analytic evidence, internal consistency, and construct validity in a young adult sample from the Netherlands

The present investigation examined the factor structure, internal consistency, and construct validity of the 16-item Anxiety Sensitivity Index (ASI; Reiss Peterson, Gursky, & McNally 1986) in a young adult sample (n = 420) from the Netherlands. Confirmatory factor analysis was used to comparatively evaluate two-factor, three-factor, and four-factor models of the anxiety sensitivity construct. Support was found for a hierarchical structure of anxiety sensitivity, with one global higher-order factor and four lower-order factors. Internal consistency for the global and lower-order factors of the 16-item ASI was adequate. Convergent and discriminant associations between the 16-item ASI and general mood and panic-specific variables were consistent with anxiety sensitivity theory. In addition, incremental validity of the anxiety sensitivity construct was established, relative to negative affectivity, for unexpected panic attacks and agoraphobic avoidance.     

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

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

Anxiety Sensitivity Moderates Relations Among Tobacco Smoking,Panic Attack Symptoms,and Bodily Complaints in Adolescents

The present study evaluated associations among smoking and anxiety sensitivity (fear of anxiety and anxiety related sensations) in predicting panic attack symptomatology, somatic complaints, and depressive symptomatology in a community sample of adolescents (ages 12 to 17 years; N=206). As predicted, the combination of high levels of anxiety sensitivity and being a current smoker predicted panic symptomatology and somatic complaints, but not depressive symptomatology. These findings suggest anxiety sensitivity may moderate the relation between smoking and prototypical panic psychopathology variables (panic attacks and somatic complaints) even after controlling for gender and negative affectivity, and that these associations are specific to panic-relevant processes. The primary implication of the study findings is that there may be segments of the adolescent population who are at relatively greater risk for panic-related problems by virtue of individual differences in AS and smoking status.

Smoking and Non-Clinical Panic Attacks: An Initial Empirical Test of Panic-Relevant Cognitive Processes

The present study evaluated panic-relevant cognitive processes in a sample of persons ( n = 70) who met criteria for either: (a) a positive panic attack history and regular smoking (smoking at least 10 cigarettes per day for S 12 months); (2) a positive panic attack history but no history of smoking; or (3) regular smoking history alone (smoking at least 10 cigarettes per day for S 12 months). As hypothesized, participants in group (a) demonstrated significantly greater bodily vigilance and anxiety sensitivity Mental Incapacitation Concerns compared with persons in either groups (b) or (c). Effects involving other dimensions of anxiety sensitivity, suffocation fear and trait anxiety did not discriminate between panickers as a function of smoking status. The observed effects could not be attributed to self-reported physical health status or history of medical problems. The implication of the present findings for understanding the potential role of smoking in panic pathology is discussed.     

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.     

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.     

Mechanisms of change in cognitive behaviour therapy for panic disorder: The role of panic self-efficacy and catastrophic misinterpretations

The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied.     

Physiological and psychological reactivity in women with asthma: the effects of anxiety and menstrual cycle phase.

The relation between menstrual cycle timing, panic attacks, and diagnosis of asthma was explored in this study. Women with or without asthma and with or without a history of panic attacks engaged in a psychophysiological task during either the intermenstrual or premenstrual cycle phase and completed self-report measures of menstrual symptoms and attitudes, general psychological symptoms, and attitudes toward illness. No significant differences were identified for psychological or psychophysiological measures with menstrual cycle phase as a factor. However, women with both asthma and a history of panic attacks reported more general psychological distress than women in the other groups, and more state anxiety than controls. Women in the asthma, asthma and panic, and panic groups reported higher anxiety sensitivity than the control group. After listening to asthma-related scenes, women with asthma exhibited a decrease in peak expiratory air flow, and women with asthma and panic exhibited increased skin conductance response magnitude. Implications for the role of anxiety in lung function are discussed, as well as directions for future research with asthma and anxiety populations.     

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.     

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.     

Diathesis stress model for panic-related distress: a test in a Russian epidemiological sample

To investigate a cognitive diathesis-stress model, the present study evaluated the main and interactive effects of anxiety sensitivity (AS) and exposure to aversive conditions (past month) in predicting theoretically relevant panic vulnerability variables in an epidemiologically defined sample from Russia (N = 390). Consistent with expectation, findings suggested that the combination of high levels of exposure to aversive conditions and high AS physical concerns predicted panic attacks (past week) and agoraphobic avoidance above and beyond the variance accounted for by negative affect. These findings are discussed in relation to biopsychosocial theories of panic disorder, which emphasize the importance of both a cognitive diathesis and stress component in the pathogenesis of the disorder.     

Brief treatment with alprazolam and behavioral guidance in panic disorder

Abstract

Thirty-two patients with panic disorder, with or without agoraphobic limitations, were treated with alprazolam (mean dose 3.5 mg/d) plus brief behavioral guidance in an open study during eight weeks. The sample had a notorious severity in the frequency of panics and phobic avoidance but was only mildly depressed. Before starting treatment the presence of demoralized mood and extensive avoidance were significant indicators of clinical severity, whereas the presence of dizziness as a relevant somatic complaint was not related to higher severity. After eight weeks of treatment a clinical improvement equal to or exceeding 80% of change was obtained in all cases (29) who completed treatment. Ninety-two percent of the patients were panic free at the end of treatment. There were significant reductions in all the scales with comparable declines in the subgroups formed according to the presence or absence of agoraphobic avoidance and demoralization. The data suggested that moderate doses of alprazolam could be a quick and effective treatment for panic-agoraphobic patients in the short term. The behavioral guidance probably helped in reducing agoraphobic avoidance and in obtaining global good effectiveness although this awaits controlled tests. Finally, the similarity in the response to treatment regardless of the presence of extensive avoidance or demoralized mood argues in favor of not considering the different variants of panic-agoraphobic syndrome differently, at least in samples with similar severity to the present one.     

Anticipatory anxiety and avoidance in panic disorder with agoraphobia

The present study utilized the responses of 34 patients with panic disorder with agoraphobia to investigate the occurrence and anticipation of panic attacks in relation to the avoidance of specific situations from the Fear Questionnaire [Marks & Mathews (1979) Behaviour Research and Therapy, 17, 263-267]. Results indicated that self-reports of avoidance of specific situations were often significantly correlated with the anticipation of panic but rarely with the occurrence of panic. The occurrence and anticipation of panic were also frequently associated with social phobic situations in addition to agoraphobic situations.     

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.     

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.     

Health perception is a unique predictor of anxiety symptoms in non-clinical participants

This study evaluated the role of perceived health in predicting anxiety symptoms, bodily vigilance and agoraphobic cognitions among 71 individuals (30 females; mean age 19.9 years, SD=3.1) without a psychiatric history, including non-clinical panic attacks. Results indicated that, relative to anxiety sensitivity, perceived health was a distinct construct that incrementally predicted bodily-oriented catastrophic thinking (8% of unique variance) and heart-focused anxiety (13% of unique variance). Moreover, perceived health significantly incrementally predicted anxious arousal symptoms (9% of unique variance). Results are discussed in relation to the role of perceived health as a cognitive vulnerability factor for anxiety-related problems.     

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.     

Responses to false physiological feedback in individuals with panic attacks and elevated anxiety sensitivity

Participants with elevated anxiety sensitivity and a history of panic attacks were compared to a low anxiety comparison group with respect to physiological and subjective reactivity to false heart-rate feedback and reactivity to a priming procedure. Whereas accurate heart-rate feedback elicited minimal responses, participants across groups showed significant physiological and subjective responses to false feedback. High risk and low risk participants did not differ in heart-rate responses to false feedback, though panic attack frequency did predict physiological and subjective reactions to false feedback in the high risk group. Self-reported nonspecific anxiety was significantly higher in high risk female participants than in low risk female participants, while males did not different in general subjective anxiety. However, high risk participants reported more panic-specific symptoms during the false feedback task than low risk participants, regardless of the sex of the participant. Therefore, although the experimental paradigm appeared to trigger nonspecific anxiety in high risk female participants, panic attack symptoms in reaction to the task were specific to risk group, not sex, and consistent with hypotheses. Surprisingly, the priming procedure did not influence physiological or subjective responses to false feedback in either group. These results raise additional questions regarding the process and impact of interoception in individuals with panic attacks, and suggest that false perception of internal changes may contribute to risk for panic disorder when exposed to believable cues.     

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.