Anxiety sensitivity and history of panic as predictors of response to hyperventilation

In this study, we examined the effects of anxiety sensitivity on the response to hyperventilation in college students with and without a history of spontaneous panic attacks. Reiss et al.'s (Behav. Res. Ther. 24, 1-8, 1986) Anxiety Sensitivity Index and Norton et al.'s (Behav. Ther. 17, 239-252, 1986) Panic Attack Questionnaire were used to select Ss. Following five min of voluntary hyperventilation, high anxiety sensitivity Ss reported more anxiety and more hyperventilation sensations than did low anxiety sensitivity Ss. A history of panic was only associated with enhanced responding to hyperventilation in Ss with high anxiety sensitivity; low anxiety sensitivity Ss who had experience with panic were no more responsive than low anxiety sensitivity Ss who had never had a panic attack. These findings suggest that high anxiety sensitivity may be a crucial determinant of panic attacks provoked by biological challenges (e.g. hyperventilation, sodium lactate infusion).     

Waning of panic sensations during prolonged hyperventilation

Recent theories about panic emphasize that a hyperventilatory positive feedback loop is involved in panic: catastrophic misinterpretation of bodily sensations may trigger anxiety, anxiety may stimulate hyperventilation, hyperventilation may promote the salience of feared sensations etc. Such models leave unexplained how and when panics come to an end. It was hypothesised that panic with hyperventilation may end because pronounced hyperventilation becomes, in the course of time, less powerful in generating perceivable bodily sensations. Twenty healthy subjects hyperventilated forcefully and experienced clear panic symptoms as defined by DSM IIIR. When pCO2 was kept 55% below base line for 90 min, panic symptoms waned. The mean intensity of the symptoms declined as did the number of symptoms occurring. No panic symptoms were observed in the control group (n = 20) who ventilated normally. In so far as hyperventilation is involved in the positive feedback loops that characterize panic, panic attacks may be time-limited because sensations induced by hyperventilation become less salient even if massive hyperventilation continues. As to the explanation of the reported phenomenon, it is suggested that, apart from habituation, local physiological changes due to prolonged hyperventilation may produce a decrease in interoceptive input.     

The hyperventilation syndrome in panic disorder, agoraphobia and generalized anxiety disorder

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.     

The effects of voluntary hyperventilation on patients with chest pain without coronary artery disease

The present investigation was designed to examine panic symptom experience in patients with chest pain of nonorganic etiology, using a hyperventilation provocation procedure. Given the recent focus on panic disorder in patients with nonorganic chest pain, we assessed three indices of physiological arousal, subjective anxiety, and endorsement of DSM-III-R panic symptomatology in response to 3 min of voluntary hyperventilation. Subjects included 23 patients with nonorganic chest pain (CP sample) and matched normal controls (NC sample). The results indicate that hyperventilation produced significant increases in skin conductance, heart rate, and upper trapezious EMG in both CP and NC samples. Despite equivalent levels of physiological arousal and subjective anxiety, the CP sample endorsed a greater number of DSM-III-R panic symptoms relative to the NC sample. Examination of post-hyperventilation symptoms indicated that a greater percentage of the CP sample reported palpitations, nausea, and chest pain when compared with normals. Comparison of CP patients with and without Panic Disorder revealed no significant differences on any measure. The results suggests that hyperventilation plays a role in symptom experience in patients with nonorganic chest pain, although anxiety does not appear central in moderating this effect.     

Competitive anxiety responses in the week leading up to competition: the role of intensity,direction and frequency dimensions

Objectives: To investigate the symptom responses associated with competitive anxiety through a fine-grained measurement approach. Incorporating dimensions of intensity, perceptions of direction, and frequency of intrusions, possible time-to-event changes were assessed with respect to the between-subjects variable of skill level.Method: Male athletes (N=82), separated into two skill classifications (club N=45 vs. national N=37), completed the competitive state anxiety inventory-2 (CSAI-2) modified to account for the dimensions of intensity, direction and frequency at five precompetition times (1 week, two days, one day, 2 h, 30 min).Results: Multivariate analysis of variance (skill level×time-to-competition) with follow-up analyses indicated main effects for skill level and time-to-competition with no interactions. For skill level differences, national athletes were more facilitative in their interpretation of the symptoms associated with cognitive and somatic anxiety. For change-over-time effects, intensities of cognitive and somatic anxiety increased and self-confidence decreased between 2 h and 30 min precompetition. Frequencies of cognitive anxiety increased from seven to two days, one day to 2 h and 2 h to 30 min precompetition; frequencies of somatic anxiety increased from seven days to two days and 2 h to 30 min pre-event; frequencies of self-confidence increased from seven to two days.Conclusions: Findings support the notion of measuring the separate dimensions of symptoms associated with competitive anxiety and emphasise the importance of assessing these constructs as processes that unfold over-time.     

Gender differences in mathematics anxiety: An artifact of response bias?

Abstract

Females are more likely than males to report anxiety about mathematics. Hunsley and Flessati (1988) examined two explanations for this difference: the sex-role socialization hypothesis, which states that gender differences occur as a result of differences in socialization, and the math experiences hypothesis, which states that math anxiety is due to previous experiences with mathematics, regardless of gender. They found support only for the math experiences hypothesis, and suggested that the gender difference in math anxiety may be an artifact of response bias.

The present study replicated the Hunsley and Flessati study and included an evaluation of response bias. One hundred and fifty Introductory Psychology students completed a series of questionnaires examining mathematics anxiety, attitudes and mathematical background. The findings of Hunsley and Flessati were replicated, however no evidence was found for a gender-linked response bias. An alternative explanation for the gender difference in math anxiety is proposed based on the finding that females are more self-critical.     

The Effect of a Brief Mindfulness Training on Distress Tolerance and Stress Reactivity

Poor distress tolerance (DT) is considered an underlying facet of anxiety, depression, and a number of other psychological disorders. Mindfulness may help to increase DT by fostering an attitude of acceptance or nonjudgment toward distressing experiences. Accordingly, the present study examined the effects of a brief mindfulness training on tolerance of different types of distress, and tested whether trait mindfulness moderates the effect of such training. Undergraduates (n = 107) naïve to mindfulness completed a measure of trait mindfulness and underwent a series of stress tasks (cold pressor, hyperventilation challenge, neutralization task) before and after completing a 15-minute mindfulness training or a no-instruction control in which participants listened to relaxing music. Participants in the mindfulness condition demonstrated greater task persistence on the hyperventilation task compared to the control group, as well as a decreased urge to neutralize the effects of writing an upsetting sentence. No effect on distress ratings during the tasks were found. Overall trait mindfulness did not significantly moderate task persistence, but those with lower scores on the act with awareness facet of mindfulness demonstrated greater relative benefit of mindfulness training on the hyperventilation challenge. Mediation analyses revealed significant indirect effects of mindfulness training on cold pressor task persistence and urges to neutralize through the use of the nonjudge and nonreact facets of mindfulness. These results suggest that a brief mindfulness training can increase DT without affecting the subjective experience of distress.     

Hyperventilation and anxiety in panic disorder, social phobia, GAD and normal controls

Patients with DSM-III Agoraphobia, Panic Disorder, GAD, Social Phobia and normal controls underwent a series of experimental procedures and measures to determine whether panic attack patients show a greater tendency towards hyperventilation that is independent from their anxiety levels. Contrary to expectations, the Agoraphobia and Panic Disorder patients did not show significantly lower levels of expired pCO2 at rest than the other anxious or non-anxious groups. However, the panic attack patients did show significantly higher levels of anxiety and hyperventilatory symptoms during a hyperventilation test and during breathing 5% CO2 in air. A strong relationship was found between hyperventilatory symptoms and anxiety in all groups of patients and in the controls. On the basis of these results it was concluded that Agoraphobia and Panic Disorder patients do not show a unique tendency toward hyperventilation, but rather that their hyperventilatory symptoms and perhaps intermittent overbreathing episodes are a function of the high levels of anxiety they experience.     

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.     

The Relationship Between Premenstrual Distress and Anxiety Sensitivity: The Mediating Role of Rumination

Given that premenstrual distress is reported by large numbers of women, research has focused on the identification of biological and psychological factors that influence its severity. Previous research suggests that women who are high in anxiety sensitivity also report greater levels of premenstrual distress and negative affect. According to the menstrual reactivity hypothesis, women who have a tendency to self-focus and catastrophize about physical sensations are more likely to report greater levels of premenstrual distress. Cognitive schemas surrounding the menstrual cycle develop that are influenced by gender roles, cultural stereotypes, and expectations about bodily sensations. Another cognitive process, rumination, may also be linked to increased reports of premenstrual distress. Conceptually, the constructs of anxiety sensitivity and rumination share the tendency to self-focus on internal states. The goal of this study was to investigate how these two constructs relate to the prediction of premenstrual distress in a large sample of healthy undergraduate women (N = 478). Using mediational modeling, support was found for a mediational model; women who reported high levels of rumination and anxiety sensitivity reported the greatest premenstrual distress. These results are discussed within the framework of the menstrual reactivity hypothesis, a diathesis-stress model of premenstrual distress.     

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.     

Anticipation of interoceptive threat in highly anxiety sensitive persons

Anticipatory anxiety plays a major role in the etiology of panic disorder. Although anticipatory anxiety elicited by expectation of interoceptive cues is specifically relevant for panic patients, it has rarely been studied. Using a population analogue in high fear of such interoceptive arousal sensations (highly anxiety sensitive persons) we evaluated a new experimental paradigm to assess anticipatory anxiety during anticipation of interoceptive (somatic sensations evoked by hyperventilation) and exteroceptive (electric shock) threat. Symptom reports, autonomic arousal, and defensive response mobilization (startle eyeblink response) were monitored during threat and matched safe conditions in 26 highly anxiety sensitive persons and 22 controls. The anticipation of exteroceptive threat led to a defensive and autonomic mobilization as indexed by a potentiation of the startle response and an increase in skin conductance level in both experimental groups. During interoceptive threat, however, only highly anxiety sensitive persons but not the controls exhibited a startle response potentiation as well as autonomic activation. The anticipation of a hyperventilation procedure thus seems a valid paradigm to investigate anticipatory anxiety elicited by interoceptive cues in the clinical context.     

Predictors of competitive anxiety direction in male Tae Kwon Do practitioners: a multilevel mixed idiographic/nomothetic interactional approach

Objectives: To examine (a) affective states, proximity of competition and personality traits as predictors of anxiety direction and (b) investigate the role of personality characteristics in moderating the relationship between anxiety direction and proximity of competition and affective states.Method: A multilevel mixed idiographic/nomothetic approach. Intensity and direction of competitive anxiety and positive (PA) and negative affect (NA) were monitored in 22 male Tae Kwon Do practitioners across a week preceding a major competition using the experience sampling method (ESM). The participants were assessed on neuroticism and extraversion. Negative and positive affect and anxiety intensity and direction were measured at three random times a day across 1 week before the competition and 1 hour pre-competition.Results: Multilevel regression analyses revealed that cognitive anxiety intensity, positive affect, proximity to competition and extraversion were significant predictors of cognitive anxiety direction. Significant interaction effects of proximity to competition and neuroticism, and neuroticism and negative affect on cognitive anxiety direction were also observed. Somatic anxiety direction was a function of positive affect, somatic anxiety intensity, proximity to competition and the interaction effects of neuroticism and somatic anxiety intensity and neuroticism and proximity to competition.Conclusions: A multilevel mixed idiographic/nomothetic interactional approach may substantially assist in the explanation of intra- and inter-individual differences in anxiety direction.     

Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis

In the past decade, there have been extensive efforts in the Western world to raise public awareness about mental health problems, with the goal of reducing or preventing these symptoms across the population. Despite these efforts, reported rates of mental health problems have increased in these countries over the same period. In this paper, we present the hypothesis that, paradoxically, awareness efforts are contributing to this reported increase in mental health problems. We term this the prevalence inflation hypothesis. First, we argue that mental health awareness efforts are leading to more accurate reporting of previously under-recognised symptoms, a beneficial outcome. Second, and more problematically, we propose that awareness efforts are leading some individuals to interpret and report milder forms of distress as mental health problems. We propose that this then leads some individuals to experience a genuine increase in symptoms, because labelling distress as a mental health problem can affect an individual's self-concept and behaviour in a way that is ultimately self-fulfilling. For example, interpreting low levels of anxiety as symptomatic of an anxiety disorder might lead to behavioural avoidance, which can further exacerbate anxiety symptoms. We propose that the increase in reported symptoms then drives further awareness efforts: the two processes influence each other in a cyclical, intensifying manner. We end by suggesting ways to test this hypothesis and argue that future awareness efforts need to mitigate the issues we present.     

The influence of exercise duration and cognitions during running on feeling states in an indoor running track environment

Objectives. To examine the influence of different durations of aerobic exercise and cognitions during running on exercise-induced feeling state changes in an indoor running track environment once baseline differences in feeling states were controlled.Method. Physically active females (n=69) participated in one of three experimental conditions: a) a 25 min run at 70% heart rate reserve (HRR), b) a 40 min run at 70% HRR, or c) a 40 min no exercise control. Pre-post feeling states (EFI) were assessed and cognitions during running were recorded with 5 min left in the run.Results. Multilevel modeling analyses revealed that positive engagement and revitalization significantly increased from pre- to post-exercise in comparison to the control condition regardless of exercise duration whereas physical exhaustion was significantly reduced. However, tranquility significantly increased only in the 25 min run condition. Finally, cognitions during exercise moderated the changes in feeling states from pre- to post-exercise above and beyond exercise duration with participants reporting dissociative-external thoughts reporting greater increases in revitalization and decreases in physical exhaustion.Conclusions. Both objective demands of the exercise task (i.e., exercise duration) and subjective intrapsychic phenomena (i.e., cognitions during running) may aid in explaining exercise-induced feeling state changes.     

A model clarifying the role of mediators in the variability of mood states over time in people who stutter

PurposeElevated negative mood states such as social anxiety and depressive mood have been found in adults who stutter. Research is needed to assist in the development of a model that clarifies how factors like self-efficacy and social support contribute to the variability of negative mood states over time.MethodParticipants included 200 adults who stutter. A longitudinal design was employed to assess change in mood states over a period of five months. Hierarchical directed regression (path analysis) was used to determine contributory relationships between change in mood states and self-efficacy, social support, socio-demographic and stuttering disorder variables. Participants completed a comprehensive assessment regimen, including validated measures of mood states, perceived control (self-efficacy) and social support.ResultsResults confirmed that self-efficacy performs a protective role in the change in mood states like anxiety and depressive mood. That is, self-efficacy cushioned the impact of negative mood states. Social support was only found to contribute a limited protective influence. Socio-demographic variables had little direct impact on mood states, while perceived severity of stuttering also failed to contribute directly to mood at any time point.ConclusionsMood was found to be influenced by factors that are arguably important for a person to cope and adjust adaptively to the adversity associated with fluency disorder. A model that explains how mood states are influenced over time is described. Implications of these results for managing adults who stutter with elevated negative mood states like social anxiety are discussed.Educational Objectives: The reader will be able to describe: (a) the method involved in hierarchical (directed) regression used in path analysis; (b) the variability of mood states over a period of five months; (c) the nature of the mediator relationship between factors like self-efficacy and social support and mood states like anxiety, and (d) the contribution to mood states of socio-demographic factors like age and education and stuttering disorder variables like stuttering frequency and perceived severity.     

Habituation or Normalization? Experiential and Respiratory Recovery From Voluntary Hyperventilation in Treated Versus Untreated Patients With Panic Disorder

Psychophysiological theories postulate respiratory dysregulation as a mechanism contributing to panic disorder (PD). Additionally, symptomatic and respiratory recovery from voluntary hyperventilation (HVT-recovery) have been shown to lag in PD and it is unclear if HVT-recovery normalizes with treatment. Thirty-seven panic disorder patients were randomized to hypoventilation therapy (TX, n = 20) or waitlist control (WL, n = 17) (Meuret et al., 2008). In a secondary analysis, their HVT-recovery was analyzed at pre- and post-TX/WL, compared to 29 healthy controls (HC). HVT included three phases: 5-min baseline, 3-min hyperventilation, and 8-min recovery. HVT-elicited symptom severity and anxiety were rated following each phase, and end-tidal PCO₂ and respiratory rate (RR) were recorded throughout. Treatment, compared to WL, was highly effective in reducing PD pathology (d = 2.21, Meuret et al., 2008). At pre-TX/WL, PD demonstrated delayed HVT-recovery PCO₂ and higher RR. Treated patients demonstrated normalization of HVT-recovery for PCO₂ and RR; however, improvements of HVT-recovery for symptom severity and anxiety did not differ between TX and WL. Results replicate pretreatment HVT respiratory recovery abnormalities in PD and further demonstrate normalization, comparable to HC, following successful treatment. The results provide support for respiratory dysregulation as a feature of PD and demonstrate the utility of HVT respiratory recovery as treatment outcome measure for respiration-based PD therapy.     

Balanced states of mind in psychopathology and psychological well-being

The balanced states of mind (BSOM) model proposes that coping with stress and psychological well-being is a function of the BSOM ratio of positive thoughts to the sum of positive and negative thoughts. Based on different BSOM ratios, different BSOM categories are constructed to quantitatively differentiate levels of coping with stress and psychological well-being. The cognitive content-specificity hypothesis states that there are unique themes of semantic content in self-reported automatic thoughts particular to depression or anxiety. This study investigated the BSOM model and its cognitive content-specificity for depression, anxiety, anger, stress, life satisfaction, and happiness, based on negative and positive automatic thoughts. Three hundred and ninety-eight college students from Singapore participated in this study. First, BSOM ratio and positive automatic thoughts were positively correlated with life satisfaction and happiness, and negatively correlated with stress, anxiety, depression, and anger. In contrast, negative automatic thoughts were positively correlated with stress, anxiety, depression, and anger, and negatively correlated with life satisfaction and happiness. Second, levels of psychopathology and psychological well-being were statistically differentiable among the BSOM categories for depression, happiness, perceived stress, and life satisfaction; and less statistically differentiable among the BSOM categories for anxiety and anger, as expected based on the BSOM model and cognitive content-specificity hypothesis. Third, the results were more supportive of the BSOM model for depression, followed by happiness, perceived stress, life satisfaction, anxiety, and anger in terms of percentage of variance accounted for by BSOM categories, as expected based on the cognitive content-specificity hypothesis. Taken together, the results suggested that the more moderately positive thoughts one has (balanced by negative thoughts), the better mental health outcomes one has. Implications and limitations of these findings are discussed.     

Panic disorder: A product of classical conditioning

Contrary to the common view that all panic attacks have a single etiology, it is shown that a distinction must be made between initial attacks, for which there are many causes, and recurrent attacks (panic disorder) which have a common basis. Most initial panic attacks are attributable to the physiological effects of hyperventilation resulting from severe and prolonged anxiety. It has been claimed that the attacks are due to such symptoms as dyspnea, tachycardia and dizziness being misattributed to deadly illness or incipient insanity. We reject this view on several grounds, and in particular because of a pilot study that showed that such attributions follow the onset of panic. Apart from some biological cases, the common initial panic is an unconditioned response to a bizarre stimulus complex produced by excessive hyperventilation, and panic disorder is the result of contiguous stimuli, especially endogenous stimuli, being conditioned to the elicited anxiety. Treatment accords with principles of conditioning.