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.     

Does coping predict CO2-induced panic in patients with panic disorder?

Patients with panic disorder (PD) show maladaptive coping but the role of coping in the pathogenesis of panic is unclear. This study examined general coping and panic-specific coping as predictors of fear responding to CO2 inhalation. Subjective and physiological responses including panic attacks were assessed in 45 patients with PD and 45 matched nonclinical controls. Measures of coping were the primary predictors used in the analyses. Consistent with other reports, patients with PD reported increased emotion-focused coping and there was an association between emotion-focused coping and subjective reactivity. However, only panic-specific coping predicted panic attacks in response to the CO2 challenge.     

Increased cardiac awareness in panic disorder.

We investigated cardiac perception in panic disorder with both self-report and objective measures. In Study 1, 120 patients with panic disorder, 86 infrequent panickers, and 38 patients with other anxiety disorders reported greater cardiac and gastrointestinal awareness than 62 normal control subjects. Subjects with panic attacks reported greater cardiac awareness, but not gastrointestinal awareness, than those with other anxiety disorders. Studies 2 and 3 included a test of heart rate perception in which subjects silently counted their heart-beats without taking their pulse. In Study 2, 65 panic disorder patients showed better performance than 50 infrequent panickers, 27 patients with simple phobias, and 46 normal control subjects. No group differences were found in ability to estimate time intervals. In Study 3, 13 patients with panic disorder and 15 with generalized anxiety disorder showed better heart rate perception than 16 depressed patients.     

Emotion regulation difficulties associated with the experience of uncued panic attacks: evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity

Emotion regulation difficulties among nonclinical uncued panickers were examined in two studies. In Study 1, participants with a recent history of uncued panic attacks (n  =  91), compared to a nonpanic sample (n  =  91), reported significantly greater levels of experiential avoidance, lack of emotional acceptance, and lack of emotional clarity. In Study 2, a subset of uncued panickers and nonpanickers from Study 1 (n = 17 per group) viewed positive and negative emotion-eliciting film clips. Despite comparable levels of self-reported distress and physiological arousal, panickers reported using more emotionally avoidant regulation strategies during both film clips. Panic participants also responded with greater negative emotion to the positive emotion-eliciting clip. Results are discussed in terms of their research and clinical implications.     

Physiological and symptom responses to hyperventilation: A comparison of frequent and infrequent panickers

Ten subjects with panic disorder and ten subjects with infrequent panic attacks were assessed during 2 min of voluntary hyperventilation using four measures of physiological arousal (heart rate, upper trapezious EMG, skin conductance, and digital skin temperature). Immediately following hyperventilation, subjects were asked to rate their degree of distress on 13 panic symptoms, derived from DSM-III criteria for panic disorder. Results indicated that frequent panickers had significant overall elevations in trapezious EMG, relative to infrequent panickers, and demonstrated a slight increase in muscle tension following hyperventilation. In contrast, infrequent panickers showed a trend toward greater vasodilation preceding and during hyperventilation, with subsequent vasoconstriction upon resumption of normal breathing. Increases in skin conductance and heart rate were noted for both samples during hyperventilation, as reported in prior research. Symptom distress ratings indicated that the infrequent panickers reported significantly greater distress from dizziness and trembling in response to overbreathing, contrary to prediction. Implications of these findings are discussed in light of current accounts of cognitive and physiological factors in the etiology of panic attacks and panic disorder.This research was supported by Biomedical Research Support Grant #507RR07147, National Institutes of Health.     

The role of anxiety sensitivity and lack of emotional approach coping in depressive symptom severity among a non-clinical sample of uncued panickers

Panic attacks and depression frequently co-occur, and the presence of this co-morbidity is often associated with worse outcomes compared with each disorder alone. Despite this, not everyone who experiences panic attacks also suffers from depression, suggesting that individual difference factors may play a role in this co-morbidity. The purpose of this study was to provide a preliminary investigation of two such individual difference factors, examining the role of anxiety sensitivity and lack of emotional approach coping in depressive symptom severity among a non-clinical sample of uncued panickers. A sample of 79 college students reporting the occurrence of uncued panic attacks within the past year completed a series of questionnaires assessing the lower-order factors of anxiety sensitivity, emotional approach coping, panic attack frequency, panic-related disability, panic symptom severity and depressive symptom severity. Participants with more severe depressive symptoms reported greater anxiety sensitivity, panic attack frequency, panic symptom severity, panic-related disability and lack of emotional approach coping. The particular anxiety sensitivity dimension of fear of cognitive dyscontrol and lack of emotional approach coping emerged as the best predictors of depressive symptom severity. Findings are discussed in terms of their implications for the improved understanding of this co-morbidity, as well as its treatment.     

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Panic attacks and depression frequently co‐occur, and the presence of this co‐morbidity is often associated with worse outcomes compared with each disorder alone. Despite this, not everyone who experiences panic attacks also suffers from depression, suggesting that individual difference factors may play a role in this co‐morbidity. The purpose of this study was to provide a preliminary investigation of two such individual difference factors, examining the role of anxiety sensitivity and lack of emotional approach coping in depressive symptom severity among a non‐clinical sample of uncued panickers. A sample of 79 college students reporting the occurrence of uncued panic attacks within the past year completed a series of questionnaires assessing the lower‐order factors of anxiety sensitivity, emotional approach coping, panic attack frequency, panic‐related disability, panic symptom severity and depressive symptom severity. Participants with more severe depressive symptoms reported greater anxiety sensitivity, panic attack frequency, panic symptom severity, panic‐related disability and lack of emotional approach coping. The particular anxiety sensitivity dimension of fear of cognitive dyscontrol and lack of emotional approach coping emerged as the best predictors of depressive symptom severity. Findings are discussed in terms of their implications for the improved understanding of this co‐morbidity, as well as its treatment.     

Avoidant coping in panic disorder: a yohimbine biological challenge study

Few studies have addressed whether the use of avoidance-oriented coping strategies is related to the development of panic in patients with panic disorder(PD). Self-report, clinician-rated, and physiological data were collected from 42 individuals who participated in a yohimbine biological challenge study, performed under double-blind, placebo-controlled conditions. Participants included 20 healthy controls and 22 currently symptomatic patients who met DSM-IV-TR diagnostic criteria for PD. Consistent with prediction, patients with PD who had higher perceived efficacy of avoidance-oriented strategies in reducing anxiety-related thoughts reported increased severity in panic symptoms during the yohimbine challenge condition as compared to the placebo. Further, patients with PD who had more fear of cognitive dyscontrol, cardiovascular symptoms, and publicly observable anxiety also reported increased severity in panic symptoms during the challenge. Healthy controls who had more fear of cardiovascular symptoms similarly reported increased severity in panic symptoms during the challenge. No effects were found for heart rate response to the challenge agent. These results provide support for the role of avoidance-oriented coping strategies and fear of anxiety-related symptoms as risk and maintenance factors in the development of panic symptoms, particularly within a biological challenge model.     

Avoidant coping in panic disorder: a yohimbine biological challenge study

Abstract

Few studies have addressed whether the use of avoidance-oriented coping strategies is related to the development of panic in patients with panic disorder(PD). Self-report, clinician-rated, and physiological data were collected from 42 individuals who participated in a yohimbine biological challenge study, performed under double-blind, placebo-controlled conditions. Participants included 20 healthy controls and 22 currently symptomatic patients who met DSM-IV-TR diagnostic criteria for PD. Consistent with prediction, patients with PD who had higher perceived efficacy of avoidance-oriented strategies in reducing anxiety-related thoughts reported increased severity in panic symptoms during the yohimbine challenge condition as compared to the placebo. Further, patients with PD who had more fear of cognitive dyscontrol, cardiovascular symptoms, and publicly observable anxiety also reported increased severity in panic symptoms during the challenge. Healthy controls who had more fear of cardiovascular symptoms similarly reported increased severity in panic symptoms during the challenge. No effects were found for heart rate response to the challenge agent. These results provide support for the role of avoidance-oriented coping strategies and fear of anxiety-related symptoms as risk and maintenance factors in the development of panic symptoms, particularly within a biological challenge model.     

Dimensions of Anxiety Sensitivity and Their Relationship to Nonclinical Panic

The goal of the present study was to examine the factor structure of the Anxiety Sensitivity Index (ASI; S. Reiss, R. A. Peterson, D M. Gursky, & R. J. McNally, 1986) and the replicability, reliability, and validity of its dimensions in a nonclinical sample. One-thousand-and-seventy-one undergraduate volunteers completed the ASI and a modified version of the Panic Attack Questionnaire (PAQ; G. R. Norton, J. Dorward, & B. J. Cox, 1986). A principal components analysis, using oblique rotation and parallel analysis, yielded three ASI dimensions that were highly consistent with those reported in previously published studies. Individuals classified as nonclinical panickers scored higher than nonpanickers on the Physical Concerns and Cognitive Concerns subscales of the ASI. Although spontaneous panic attacks were not significantly related to scores on any ASI scale, the occurrence of panic attacks in the past month was related to higher scores on the Cognitive Concerns subscale. The results are discussed in terms of cognitive theories of panic, and limitations of the present study and directions for future research are addressed.     

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.     

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.     

The catastrophic misinterpretation of physiological distress.

Cognitive theories of panic disorder suggest that the catastrophic misinterpretation of bodily sensations is the trigger for a panic attack. A challenge to cognitive theories is the suggestion that dyspnea (shortness of breath) is central to the development of panic and that negative cognitions are by-products of panic. To examine these seemingly contradictory theoretical perspectives, the present study investigated panic symptomatology in a sample of patients with chronic shortness of breath (i.e. pulmonary patients). Past studies have shown an increased prevalence of panic in pulmonary patients, a finding that may be useful in elucidating panic etiology. The current sample of pulmonary patients (N = 28) confirmed previous reports of high prevalence rates of panic in this population. Based on self-report of panic symptomatology, a total of nine patients (32%) met DSM-IV criteria that were consistent with panic disorder. Multivariate comparison of participants with and without panic symptomatology revealed that panickers had significantly higher levels of anxiety, depression and agoraphobic cognitions. However, these groups showed no significant differences on physiological measures of pulmonary functioning. The authors conclude that dyspnea alone is inadequate in predicting panic development. High levels of panic symptomatology in pulmonary samples may reflect increased opportunities for these patients to misinterpret bodily sensations and, in particular, their pulmonary symptoms.     

Detection of somatic sensations in panic disorder

Twenty-four panic disorder patients and 25 nonclinical subjects underwent double-breath inhalations of 5, 10, and 20% carbon dioxide (CO₂) or room air. All subjects were blind to inhalation content and were required to guess if the inhalation contained CO₂. There was no significant difference between groups in the accuracy with which they were able to detect CO₂ at any concentration. Similarly, the number of somatic symptoms reported to each inhalation did not differ between groups. The findings question suggestions that individuals with panic disorder are more accurate at detecting changes in physiology than other individuals.     

Selective Processing of Threat Cues in Subjects with Panic Attacks

Abstract

Previous research has demonstrated that patients with generalised anxiety disorder, phobias, and obsessive-compulsive disorder show an attentional bias towards threat cues related to their respective disorders. Two studies are presented that used a modified Stroop colour naming task to assess attentional bias in subjects with panic attacks. In Study 1, 24 panic disorder patients and 24 normal controls were presented three cards containing threat words related to physical harm, separation, or social embarrassment. Colour naming times were compared between these cards and control cards containing matched non-threat words. Reaction time differences in the two groups were in opposite directions, patients tending to be slower in colour naming threat words, and controls, faster. In Study 2, 18 non-clinical panickers and 18 controls were presented cards containing physical threat words, neutral control words, or colour words, respectively. Panickers showed greater interference than controls in colour naming threat words but not in colour naming colour words. The results are consistent with an attentional bias for threat-related material in subjects with panic attacks. Implications for psychophysiological models of 'spontaneous' panic attacks are discussed.     

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.     

Coping skills and exposure therapy in panic disorder and agoraphobia: latest advances and future directions

Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.     

Interoceptive accuracy and panic

Psychophysiological models of panic hypothesize that panickers focus attention on and become anxious about the physical sensations associated with panic. Attention on internal somatic cues has been labeled interoception. The present study examined the role of physiological arousal and subjective anxiety on interoceptive accuracy. Infrequent panickers and nonanxious participants participated in an initial baseline to examine overall interoceptive accuracy. Next, participants ingested caffeine, about which they received either safety or no safety information. Using a mental heartbeat tracking paradigm, participants' count of their heartbeats during specific time intervals were coded based on polygraph measures. Infrequent panickers were more accurate in the perception of their heartbeats than nonanxious participants. Changes in physiological arousal were not associated with increased accuracy on the heartbeat perception task. However, higher levels of self-reported anxiety were associated with superior performance.     

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.     

Body vigilance in nonclinical and anxiety disorder samples: structure, correlates, and prediction of health concerns

The Body Vigilance Scale (BVS) is a measure developed to assess one’s conscious attendance to internal cues. The present report investigated the structure, correlates, and predictive utility of the BVS in nonclinical (N = 442) and anxiety (N = 135) disorder samples. The findings of Study 1 suggest that the BVS is 1-dimensional in a nonclinical sample, and Study 2 replicated the factor structure of the BVS in an anxiety disorder sample. Correlations between the BVS and related (i.e., anxiety sensitivity) and unrelated (i.e., social anxiety) variables were consistent with predictions in both studies. Study 2 also showed that body vigilance is primarily elevated in patients with panic disorder relative to other anxiety disorders. Relative elevations in body vigilance were also observed for patients with hypochondriasis and generalized anxiety disorder. The BVS also demonstrated a specific association with medical utilization and health-related safety-seeking behaviors after controlling for related variables in nonclinical and anxiety disorder samples. The implications of our findings for the nature and measurement of body vigilance as a predictor of health concerns in anxiety disorders are considered.