Panic disorder in the families of patients with normal coronary arteries and non-fear panic disorder.

Patients with non-fear panic disorder (NFPD) meet DSM-III-R criteria for panic disorder, but do not report subjective fear or anxiety. Although apparently common in medical settings, this controversial group is in need of further diagnostic validation. This study assessed family history of panic disorder in patients with chest pain and normal coronary arteries (CP/NCA) and either NFPD, panic disorder with fear, or no panic. It was hypothesized that the two panic disorder groups would have similar, elevated rates of panic disorder in their first-degree relatives, compared to patients without panic. The results support the hypothesis; about 17% of the first-degree relatives of both NFPD and panic disorder patients were diagnosable with panic disorder according to proband interviews, whereas only 4.6% of the first-degree relatives of patients without panic were so diagnosable. These results support the diagnostic validity of NFPD in CP/NCA patients, because such patients had a family history of panic disorder similar to patients with a more classical panic disorder presentation. The lack of fear symptoms and behavior in NFPD may cause panic disorder to be overlooked as a potential cause of somatic symptoms in patients with no medical explanation for their condition.     

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.     

Chest pain without coronary artery disease: An exploratory comparison with panic disorder

Recent reports have indicated similarities between patients with persistent chest pain of nonorganic origin and patients with panic disorder. In order to explore this association further, we administered a structured interview and three self-report measures (State-Trait Inventory, Beck Depression Inventory, and SCL90-R) to three subject groups: (1) a sample with persistent chest pain (CP; n=14) who had been screened and found to have normal coronary arteries, (2) a sample of patients with panic disorder (PD; n=14), and (3) a sample of matched normals (n=14). CP patients were considered to be free of coronary artery disease (CAD) following normal cardiac catheterization and/or normal thallium stress tests and were not diagnosed initially with panic disorder. PD patients were diagnosed with a standardized psychiatric interview and were free of organic causes of panic. Using an exploratory data analytic approach, the results indicated that both CP and PD samples reported increased levels of state and trait anxiety (p <.0001), depression (p <.01), and somatization (p <.0001) compared with normals. CP patients differed from PD patients in their less frequent use of anxiolytic medication (p <.01) and lower levels of reported panic anxiety and phobic avoidance (p <.0001). These data suggest that persistent chest pain in the absence of CAD shares some features with panic disorder, yet differs from panic in key ways as well. The results are discussed in light of the role of anxiety in contributing to symptom labeling.This research was supported by Grant 86G-491 from the American Heart Association, Texas Affiliate, to J.G.B. H.T. is the recipient of USPHS Research Career Development Award K04-HL-0122246.     

Anxiety sensitivity and auditory perception of heartbeat

Anxiety sensitivity (AS) is the fear of sensations associated with autonomic arousal. AS has been associated with the development and maintenance of panic disorder. Given that panic patients often rate cardiac symptoms as the most fear-provoking feature of a panic attack, AS individuals may be especially responsive to cardiac stimuli. Consequently, we developed a signal-in-white-noise detection paradigm to examine the strategies that high and low AS individuals use to detect and discriminate normal and abnormal heartbeat sounds. Compared to low AS individuals, high AS individuals demonstrated a greater propensity to report the presence of normal, but not abnormal, heartbeat sounds. High and low AS individuals did not differ in their ability to perceive normal heartbeat sounds against a background of white noise; however, high AS individuals consistently demonstrated lower ability to discriminate abnormal heartbeats from background noise and between abnormal and normal heartbeats. AS was characterized by an elevated false alarm rate across all tasks. These results suggest that heartbeat sounds may be fear-relevant cues for AS individuals, and may affect their attention and perception in tasks involving threat signals.     

Heart-beat perception, panic/somatic symptoms and anxiety sensitivity in children

There is considerable evidence implicating heart-beat perception (HBP) accuracy and anxiety sensitivity (AS) in the development of panic in adults. However, to date there have been no studies exploring the association between HBP, AS and childhood panic/somatic symptoms. Seventy-nine children aged 8 to 11 years completed a mental tracking paradigm (Psychophysiology 18 (1981) 483) to assess HBP, the Children's Anxiety Sensitivity Index (J Clin Chil Psychol 20 (1991) 162) and the Screen for Childhood Anxiety Related Emotional Disorders (J Am Acad Child Adoles Psych 38 (1999) 1230). Those with good HBP (n = 7, 9%) had significantly higher panic/somatic symptoms (t = -1.71, P < 0.05), and AS (t = -2.16, P < 0.02) than those with poor HBP. There were no effects of age, sex or BMI on HBP. Those with high levels of panic/somatic symptoms were seven times more likely to have good HBP and had AS scores 1 S.D. higher than the remainder of the sample. Multivariate analyses revealed that these two phenotypes had independent associations with high panic/somatic symptoms. These results extend the literature on HBP and panic and suggest that in children, as in adults, increased panic/somatic symptoms are associated with enhanced ability to perceive internal physiological cues, and fear of such sensations.     

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.     

A Study of Panic Attacks in University Students of Iran

This study examined the parameters of panic, fear, and avoidance among university students in Iran. Data were collected from 347 students using Farsi translations of the Panic Attack Questionnaire, Beck Depression Inventory, Taylor Manifest Anxiety Scale, State-Trait Anxiety Inventory, and Anxiety Sensitivity Index. Thirty-eight percent of participants reported panic attacks in the past year and 21.4% reported panic attacks in the past 4 weeks when prompted by a broad definition of panic. Men and those with unexpected panic reported greater panic severity whereas women with panic attacks reported greater situational fear and avoidance. Panickers who satisfied DSM-III-R panic disorder (PD) criteria reported greater lifestyle restriction and general psychopathology. The findings provide tentative support for cross-cultural similarity in panic phenomenology and the validity of DSM-III-R PD criteria among university students in Iran. The results are discussed by reference to nonclinical panic research and general themes of Iranian culture.     

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.     

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.     

Panic-Related fears in persons reporting a family history of panic disorder

Abstract We administered the Body Sensations Questionnaire, Health Hardiness Index, Panic Attack Questionnaire, and the Symptom Checklist 90-R to college students (n=71) who either reported or did not report a family history of panic disorder. Participants who reported a family history of panic disorder reported significantly less perceived control over their health status, a greater fear of bodily arousal, and greater frequency of unexpected panic attacks compared to participants without such a history, although no significant group differences were detected for Symptom Checklist-90-R scales that measure negative emotional experiences. After controlling for personal history of panic, differences between the positive family history group remained only for the control over health measure. We discuss the results as preliminary evidence that certain cognitive responses are overrepresented in self-classified first-degree relatives of persons with panic disorder.     

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.     

Anxiety sensitivity, panic, and depressed mood: a reanalysis teasing apart the contributions of the two levels in the hierarchial structure of the Anxiety Sensitivity Index

Anxiety sensitivity (AS) has been defined as the fear of anxiety and anxiety-related sensations, and evidence suggests that AS plays an important role in the psychopathology of panic. It is entirely unclear whether the relation between AS and panic should be attributed to one (or more) of the AS group factors, the general AS factor, or to factors at both levels of the AS hierarchy. The authors reanalyzed data presented earlier by R. M. Rapee, T. A. Brown, M. A. Antony, and D. H. Barlow (1992) to tease apart the contributions of the different levels of the AS hierarchy to fear responses to hyperventilation and 5.5% carbon dioxide challenges. The results demonstrated that AS-Physical Concerns is the only one of the three AS group factors that contributes to relations with fear responses to these two challenges. However, AS-Mental Incapacitation Concerns had a stronger positive linear association with depressed mood than did AS-Physical Concerns.     

Response to hyperventilation and inhalation of 5.5% carbon dioxide-enriched air across the DSM-III-R anxiety disorders.

Anxiety disorder patients (n = 198; under criteria of the Diagnostic and Statistical Manual of Mental Disorders; rev. 3rd ed.; American Psychiatric Association, 1987) and nonanxious control subjects (n = 25) underwent challenges of 90 s of voluntary hyperventilation and 15 min of 5.5% carbon dioxide in air. Panic disorder subjects showed a greater subjective response to both challenges than did subjects with other anxiety disorders, who in turn responded more than did control subjects. Furthermore, subjects with panic disorder as an additional diagnosis tended to report more subjective response than did anxiety disorder subjects without panic disorder. The best prechallenge predictor of response to each procedure was a measure of fear of physical symptoms. The findings support previous results that have pointed to a greater fear or anxiety-inducing effect of these challenge procedures in panic disorder patients, as compared with other subjects.     

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.     

Intolerance of Uncertainty as a Contributor to Fear and Avoidance Symptoms of Panic Attacks

Panic disorder symptoms are persistent for 50–80% of cases even after treatment, resulting in experiences of disability and dissatisfaction in life. Previous research has focused on anxiety sensitivity (AS) and its dimensions as contributing to symptoms of panic disorder; however, recent research has suggested that intolerance of uncertainty (IU)—the tendency for a person to consider the possibility of a negative event occurring as threatening, irrespective of the actual probability of its occurrence—may also play a critical role. The current study was designed to assess the specific relationships between dimensions of IU (i.e. prospective IU and inhibitory IU) and the fear and avoidance symptoms associated with panic disorder. Participants included 122 community members (81% women) with a history of at least one panic attack who participated in a larger study on fear. Participants completed measures of AS, IU, and panic disorder symptoms. Correlation and regression analyses supported a significant and substantial relationship between AS, inhibitory IU, and panic disorder symptoms. Inhibitory IU accounted for relatively more variance in avoidance symptoms related to panic disorder than did the fears of physical sensations dimension of AS. As such, further investigation of the role of IU in panic disorder symptoms appears warranted. Comprehensive results, implications, and directions for future research are discussed.     

Physical symptoms and illness attributions in agoraphobia and panic.

The cognitive model of panic disorder proposes that panic patients interpret physical symptoms in a catastrophic way, thus precipitating panic attacks. This study describes the development of a questionnaire measure designed to assess beliefs about the health implications of various symptoms. Two groups, agoraphobics and normals, were compared on a variety of measures. Agoraphobics showed much higher panic frequency, fear of anxiety, and prevalence of frightening cognitions when anxious, but did not score higher than normals when assessing seriousness of symptoms. The implications of these results are considered.     

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.     

A modern learning theory perspective on the etiology of panic disorder

Several theories of the development of panic disorder (PD) with or without agoraphobia have emerged in the last 2 decades. Early theories that proposed a role for classical conditioning were criticized on several grounds. However, each criticism can be met and rejected when one considers current perspectives on conditioning and associative learning. The authors propose that PD develops because exposure to panic attacks causes the conditioning of anxiety (and sometimes panic) to exteroceptive and interoceptive cues. This process is reflected in a variety of cognitive and behavioral phenomena but fundamentally involves emotional learning that is best accounted for by conditioning principles. Anxiety, an anticipatory emotional state that functions to prepare the individual for the next panic, is different from panic, an emotional state designed to deal with a traumatic event that is already in progress. However, the presence of conditioned anxiety potentiates the next panic, which begins the individual's spiral into PD. Several biological and psychological factors create vulnerabilities by influencing the individual's susceptibility to conditioning. The relationship between the present view and other views, particularly those that emphasize the role of catastrophic misinterpretation of somatic sensations, is discussed.     

Panic disorder: A cognitive-behavioural approach to treatment

The present study investigated the relationship between panic disorder and cognitive-behavioural therapy in a sample of 27 panic disorder patients who were randomly assigned to either a Treatment (six weeks of cognitive-behavioural therapy) or a Control group. Panic disorder was operationalized using three subjective and three physiologic indices. Results indicated that six weeks of cognitive-behavioural therapy were effective in decreasing panic disorder, as measured by three report measures: the Anxiety Sensitivity Index (catastrophic thoughts), State-Trait Anxiety Inventory (trait anxiety), and number of panic attacks, for the Treatment group relative to the Control group. In contrast, cognitive—behavioural therapy was ineffective in decreasing physiologic arousal as defined by blood pressure, pulse rate, and finger temperature. Implications of these results are discussed.     

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.