The role of life events in the onset of panic disorder

Twenty-five panic disorder patients and fifteen obsessive-compulsive patients are compared with regard to a number of Life Events over the last 12 months prior to onset of the disorder and additionally over the total life course up until onset of the disorder. Panic Disorder patients do not differ from obsessive-compulsive disorder patients in terms of the number of life events, they experience during the last year prior to onset of their disorder. However, over the total life course, Panic Disorder patients do seem to be exposed to more Life Events than obsessive-compulsive disorder patients. The findings are discussed in light of the existing literature.     

The Psychophysiology of Orthostatic Panic in Cambodian Refugees Attending a Psychiatric Clinic

Orthostatically triggered panic was examined in female Cambodian refugees. Heart rate, blood pressure (BP), panic, and dizziness responses were assessed during orthostatic challenge in three diagnostic groups: orthostatic panic without comorbid posttraumatic stress disorder (PTSD), orthostatic panic with PTSD, and other mental disorders without orthostatic panic or PTSD. During orthostatic challenge, the panic group without PTSD showed a significant drop, whereas the group with other mental disorders showed an increase in systolic BP. The group with panic and PTSD showed a blunted systolic BP response during orthostasis that fell between the responses of the other groups. Catastrophic, culturally specific cognitions present during orthostatic challenge were significantly correlated with the amount of reported panic upon standing. Some patients recalled previous traumatic events during the orthostatic challenge. The findings suggest that orthostatically induced panic attacks in Cambodian refugees are generated by an interaction of orthostasis physiology, catastrophic cognitions, and trauma associations.     

The hyperventilation provocation test in panic disorder.

Forty-eight patients with DSM-III-R Panic Disorder underwent a hyperventilation provocation Test (HVPT). Twenty-four patients rated the symptoms induced during the HVPT as similar to those occurring during panic attacks in daily life. Contrary to the classical hyperventilation model of panic, no differences were found in respiratory physiology between recognizers and non-recognizers before and during voluntary hyperventilation. Moreover, recognizers and non-recognizers reported comparable levels of panic and hyperventilation symptoms and state anxiety during panic attacks in daily life. Ten of the recognizers also had a panic attack during the HVPT, independent of any differential CO2 alterations. Compared to non-panickers, panickers obtained higher scores for agoraphobia and depression. On the basis of these results, it is concluded that recognizers or panickers do not show a tendency towards hyperventilation, but that reports of severe panic and hyperventilation symptoms are more closely related to the level of anxiety. These results are more consistent with the cognitive model of panic, which emphasizes the patient's tendency to interpret somatic symptoms catastrophically.     

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.     

Women and anxiety disorders: implications for diagnosis and treatment. Proceedings of a conference, November 19-21, 2003, Chantilly, Virginia, USA

Community studies indicate that 19% of men and 31% of women will develop some type of anxiety disorder during their lifetime. The impact of gender is profound in that it increases the likelihood of developing an anxiety disorder by 85% in women compared to men. Sex difference in prevalence rates are apparent as early as age 6, when girls are twice as likely as boys to have an anxiety disorder. In the National Comorbidity Survey, the prevalence rates for panic disorder in women and men were 5% and 2%, respectively. Agoraphobia, which often coexists with panic disorder, has a lifetime prevalence rate of 7% in women and 3.5% in men. Prevalence of trauma is increased in young women as well, and is experienced earlier in life; 62% of sexual assaults are inflicted on females < or = 18 years of age, and 29% occur in children < 11 years of age. Comorbidity of anxiety in women complicates other medical conditions as well. For example, panic disorder is highly comorbid with CHD, which remains the leading cause of death in women in developed countries. Fluctuations in reproductive hormone levels during the female life cycle is thought to be responsible for modulating anxiety. This is often implicated in the later age of onset, the more sudden and acute symptom emergence, and the more episodic course of OCD in women, and in the high prevalence(47.4%) of PMDD. Pregnancy appears to be a protective period for some anxiety disorders, including panic, while for others, such as OCD, it may be associated with onset. Hormonal changes during pregnancy, such as increased prolactin, oxytocin, and cortisol, may contribute to the suppression of stress response that occurs during this period. Despite a large and growing body of literature on anxiety disorders in general, the available data relating to women and girls falls short of informing aspects of diagnosis, treatment, and prevention that may entail sex differences. Additional work is required to understand the biological and psychosocial causes of these differences.     

Neighborhood context, personality, and stressful life events as predictors of depression among African American women

The authors tested neighborhood context, negative life events, and negative affectivity as predictors of the onset of major depression among 720 African American women. Neighborhood-level economic disadvantage (e.g., percentage of residents below the poverty line) and social disorder (e.g., delinquency, drug use) predicted the onset of major depression when controlling for individual-level demographic characteristics. Neighborhood-level disadvantage/disorder interacted with negative life events, such that women who experienced recent negative life events and lived in high disadvantage/disorder neighborhoods were more likely to become depressed than were those who lived in more benign settings, both concurrently and over a 2-year period. Neighborhood disadvantage/disorder can be viewed as a vulnerability factor that increases susceptibility to depression following the experience of negative life events.     

The role of childhood abuse and neglect in the sensitization to stressful life events in adolescent depression

This study examined the role of childhood abuse and neglect in sensitizing adolescents to the effects of proximal stressful life events in a cross-sectional sample of 103 depressed and nondepressed adolescents. Consistent with hypotheses, adolescents with a history of childhood abuse and/or neglect reported a lower level of threat of stressful life events prior to episode onset than that reported by those without. This effect was specific to those on their 1st episode of depression and was specific to independent events (i.e., stressors outside of adolescents' control). Further, this effect was robust when controlling for level of chronic difficulties, which was higher in those with childhood abuse and/or neglect. The authors suggest that childhood abuse and/or neglect may be an important risk factor that sensitizes individuals to the effects of acute independent life events.     

Optimism and pessimism as predictors of change in health after death or onset of severe illness in family.

The authors prospectively examined changes in health after a major life event (death or onset of severe illness in family) among 5,007 employees (mean age=44.8 years) whose optimism and pessimism levels were assessed in 1997 and major life events in 2000. Health was indicated by sickness absence days during a period covering 36 months prior to the event and 18 months after the event. Increase in sick days after the event was smaller and returned to the prevent level more quickly among highly optimistic individuals than among their counterparts with low optimism. Parallel changes were not observed in relation to pessimism. These findings suggest that optimism may reduce the risk of health problems and may be related to a faster recovery after a major life event.     

Stress Generation in Adolescent Depression: The Moderating Role of Child Abuse and Neglect

The present study examined the role of childhood abuse and neglect and depression recurrence in moderating the generation of stressful life events in adolescent depression. Maltreatment history and stressful life events were assessed using two rigorous contextual interviews and rating systems. In a sample of 59 community depressed adolescents we found significantly higher rates of interpersonal events in the 3-month period immediately following depression episode onset versus the 3-month period immediately preceding onset in adolescents with a history of childhood maltreatment. By contrast, rates of events remained constant over a matched period in a control group of non-maltreated adolescents. Furthermore, the generation of interpersonal events only held among those on a first onset of depression. These results suggest that a history of childhood abuse and neglect exacerbates the psychosocial dysfunction associated with the onset of depression, particularly in the very first episode.     

Presleep attributions about arousal during sleep: nocturnal panic

This study examined the role of presleep attributions about physiological events during sleep in nocturnal panic attacks. Patients who regularly experienced nocturnal panic were physiologically monitored as audio signals were presented during sleep. They were randomly assigned to 1 of 3 conditions: expected, in which signals of intense physiological changes were expected; unexpected, in which signals of intense physiological changes were not expected; or control, involving distinctly different signals unrelated to physiological responses. The unexpected condition led to substantially more self-reported distress and panic attacks. The experimental conditions did not elicit different autonomic reactions, but those who panicked showed stronger physiological responses than those who did not panic. The findings are consistent with a cognitive model of nocturnal panic attacks.     

Risk Factors for Isolated Sleep Paralysis in an African American Sample: A Preliminary Study

Isolated sleep paralysis (ISP) is a temporary period of involuntary immobility that can occur at sleep onset or offset. It has previously been reported in association with both panic disorder (PD) and posttraumatic stress disorder (PTSD). The current study examined the association between ISP and several possible risk factors—anxiety sensitivity, trauma exposure, life stress, and paranormal beliefs—in a sample of African American participants with and without a history of ISP. Significant between-group differences were found for PD and PTSD diagnoses, anxiety sensitivity, life stress, and certain aspects of paranormal belief, with the ISP group being higher on all of these indices. No differences were found with regard to trauma exposure. Hierarchical regression analyses indicated that PD, anxiety sensitivity, and life stress each contributed unique variance to ISP cognitive symptoms, whereas PTSD and paranormal beliefs did not. These results provide preliminary support for an association between ISP and anxiety sensitivity and corroborate previous reports of ISP's association with PD and life stress. The current trauma/PTSD findings are mixed, however, and warrant future research.     

Autobiographical memories and self-schemata

Self-schemata associated with dependency were assessed in a group of nine adults. Subjects subsequently kept diary-type records of the three most memorable events occurring in their daily lives during a 3-week period. Free and cued recall memory tests for reported events were given approximately 5½ weeks after the completion of record keeping. A priori assessments of self-schemata were correlated with the kinds of daily events reported: independent subjects evaluated their events as more independent than did dependent subjects, and vice-versa. Free recall results suggested that the degree of schematicity found in assessment, and the nature of reported events, were correlated with memory. In cued recall no significant memory differences were found between independent and dependent subjects for schema-consistent or inconsistent events. Self-schemata apparently function as an effective retrieval environment in the absence of observable mnemonics. The data support the view that autobiographical recollections are reconstructions driven, in part, by self-schemata derived from life experiences.     

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.     

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.     

Sociotropy/autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders

Followed samples of unipolar and bipolar patients for a 6-month period, with independent assessment of symptoms and life events. Patients were initially categorized into subtypes using Beck's Sociotropy/Autonomy Scale, with the prediction that onset or exacerbation of symptoms, as well as more total symptoms, would occur for sociotropic individuals experiencing more negative interpersonal events than achievement events, and for autonomous-achievement patients experiencing more achievement events than interpersonal events. Results were confirmed for unipolars, indicating that the course of disorder was associated with the occurrence of personally meaningful life events, but not for bipolars. Further research is recommended to examine whether the effect is equally robust for both subtypes of unipolars, whether longer study duration may be required for bipolars, and whether a cognitive self-schema mechanism may account for the specific vulnerability to a subset of stressful events.     

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.     

A prospective study of stressful life events and schizophrenic relapse

In this prospective, longitudinal study, 11 recent-onset schizophrenic outpatients who met criteria for psychotic relapse or significant psychotic exacerbation during a 1-year period of standardized maintenance medication, and 19 patients who did not relapse during this follow-up period, were interviewed monthly regarding life events. As hypothesized, for relapsing patients, a significantly higher number of independent life events (those not the result of symptomatology or personal influence) occurred in the month preceding relapse. This increase was apparent relative to either the analogous month of a "nonrelapse" period in the same patient or the average number of independent events per month during a 1-year standardized medication period for nonrelapsing patients. The methodological advances of this design as well as the consistency of these findings with those of previous retrospective studies supports the hypothesis that life events may sometimes "trigger" schizophrenic episodes.     

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.     

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.     

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.