The natural course of anxiety symptoms in early adolescence: factors related to persistence

Background and objectives: Anxiety disorders are the most common mental health problems during childhood and adolescence. This study examined the course of anxiety symptoms in early adolescents from the general population over three phases.

Design: Prospective cohort study.

Methods: Two hundred and forty-two participants (mean-age of 13.52) from a baseline sample of 1514 (mean-age of 10.23) were followed up three times. Of the 1514 children, those with emotional risk and controls without risk constituted the second-phase sample (n?=?562; mean-age of 11.25). The Screen for Child Anxiety Related Emotional Disorders-SCARED was administered in all three phases.

Results: Fifty-six percent and 32% of respondents showed total scores above the SCARED cutoff point at one and three years follow-up, respectively. Eight percent showed fluctuating symptoms. Fifty-five percent of respondents showed high scores for any subtype of anxiety over three years. Social phobia and generalized anxiety symptoms were the most prevalent and persistent. Participants with persistent separation anxiety showed the highest co-occurrence with symptoms of other psychopathological disorders. Participants with persistent anxiety showed lower academic performance. Being male was a protective factor against persistence.

Conclusions: The data support anxiety maintenance during early adolescence. Early adolescence is a critical period which may involve other serious academic, social, and family problems.     

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.     

The moderating role of distress tolerance in the association between anxiety sensitivity physical concerns and panic and PTSD-related re-experiencing symptoms

Abstract

The present investigation evaluated the moderating role of distress tolerance (DT) in the relation between the physical concerns (PC) dimension of anxiety sensitivity (AS–PC) and panic and posttraumatic stress disorder (PTSD)-related re-experiencing symptoms in a nonclinical, undergraduate sample (n = 416; 300 females; M _age=20.3 years, SD = 4.8). Consistent with prediction, there was a significant interactive effect between AS–PC and DT in regard to panic symptoms, such that greater AS–PC and low DT was associated with greater panic symptoms after controlling for the variance accounted for by negative affectivity and the respective main effects. However, contrary to prediction, AS–PC and DT did not significantly interact to predict PTSD-related re-experiencing symptoms. Also consistent with prediction, there was no interactive effect apparent for symptoms of depression or general anxiety, suggesting that the interaction between AS–PC and DT is specific to panic psychopathology.     

Unique contributions of anxiety sensitivity to avoidance: a prospective study in adolescents

Examination of the prospective relation between anxiety sensitivity (AS) and behavioral avoidance is largely absent from the literature. In a longitudinal study of a community sample of 2246 adolescents, participants completed the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally (1986). Behaviour Research & Therapy, 24, 1-8), State-Trait Anxiety Inventory (STAI; Spielberger (1983). STAI: Manual for the Stait-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press), and the Fear Questionnaire (Marks & Matthews (1979). Behaviour Research & Therapy, 17, 263-267) on an annual basis. To stringently test AS's ability to prospectively predict behavioral avoidance, linear regression was used to test whether AS factors predicted variance in follow-up behavioral avoidance scores after controlling for gender, trait anxiety, panic attacks, and baseline avoidance. Results indicted that the mental and physical subscales of the ASI predicted change in behavioral avoidance. The findings of the study are consistent with the view that AS may serve as a precursor to avoidant behavior and that, regardless of whether or not acute panic has been experienced, those who fear autonomic arousal may be more likely to avoid situations in which those sensations may be present.     

Anxiety Sensitivity and Negative Interpretation Biases: Their Shared and Unique Associations with Anxiety Symptoms

Anxiety sensitivity (AS) is a psychological risk factor for anxiety disorders. Negative interpretation biases are a maladaptive form of information-processing also associated with anxiety disorders. The present study explored whether AS and negative interpretation biases make independent contributions to variance in panic and generalized anxiety symptoms and whether particular interpretation bias domains (e.g., of ambiguous arousal sensations) have specific associations with panic and/or generalized anxiety symptoms. Eighty-nine female undergraduates (44 low AS; 45 high AS) completed measures of AS, interpretation biases, and panic and generalized anxiety symptoms. Findings showed that AS and negative interpretation biases both significantly added to the prediction of anxiety symptoms. Negative interpretations of ambiguous arousal sensations were uniquely associated with panic symptoms, while negative interpretations of ambiguous general and social events were uniquely associated with generalized anxiety symptoms. Findings support the conceptual validity of AS and negative interpretation biases and their unique and shared contributions to anxiety symptoms.     

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.     

The structure and correlates of anxiety sensitivity in older adults

Anxiety sensitivity (AS) has been defined as the fear of symptoms of anxiety and panic, and is most frequently assessed with the Anxiety Sensitivity Index (Peterson & Reiss, 1987). To investigate the nature and structure of AS in an older sample, data were collected from a sample of 322 adults aged 65 to 97, with mean age 75. Confirmatory factor analysis indicated a hierarchical structure with three group factors (physical concerns, mental incapacitation concerns, and social concerns), as well as a general factor, consistent with previous investigations. Results suggest that the nature and structure of the AS trait in older adults are highly similar to those of younger adults.     

Prospective evaluation of anxiety sensitivity in the pathogenesis of panic: replication and extension.

Increasing evidence suggests that anxiety sensitivity (AS) may be a premorbid risk factor for the development of anxiety pathology. The principal aim of this study was to replicate and extend a previous longitudinal study evaluating whether AS acts as a vulnerability factor in the pathogenesis of panic (N. Schmidt, D. Lerew, & R. Jackson, 1997). A large nonclinical sample of young adults (N = 1,296) was prospectively followed over a 5-week, highly stressful period of time (i.e., military basic training). Consistent with the authors' initial study, AS predicted the development of spontaneous panic attacks after controlling for a history of panic attacks and trait anxiety, and AS was found to possess symptom specificity with respect to anxiety versus depression symptoms. AS 1st-order factors differentially predicted panic attacks, with the Mental Concerns factor being the best predictor of panic in this sample.     

Anxiety sensitivity in adolescents: factor structure and relationships to trait anxiety and symptoms of anxiety disorders and depression

The current study examined the anxiety sensitivity construct in a large sample of normal Dutch adolescents aged 13-16 years (n=819). Children completed the Childhood Anxiety Sensitivity Index (CASI; Silverman, W. K., Fleisig, W., Rabian, B. & Peterson, R. A. (1991). Journal of Clinical Child Psychology, 20, 162-168) and measures of trait anxiety, anxiety disorder symptoms and depression. Results showed that (1) anxiety sensitivity as indexed by the CASI seems to be a hierarchically organized construct with one higher-order factor (i.e., anxiety sensitivity) and three or four lower-order factors, (2) anxiety sensitivity and trait anxiety were strongly correlated, (3) anxiety sensitivity was substantially connected to symptoms of anxiety disorders (in particular of panic disorder and agoraphobia) and depression, and (4) anxiety sensitivity and trait anxiety both accounted for unique proportions of the variance in anxiety disorder symptoms. Altogether these findings are in agreement with those of previous research in adult and child populations, and further support the notion that anxiety sensitivity should be viewed as an unique factor of anxiety vulnerability.     

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.     

Anxiety symptomatology: the association with distress tolerance and anxiety sensitivity

Research focused on psychological risk factors for anxiety psychopathology has led to better conceptualization of these conditions as well as pointed toward preventative interventions. Anxiety sensitivity (AS) has been well-established as an anxiety risk factor, while distress tolerance (DT) is a related construct that has received little empirical exploration within the anxiety psychopathology literature. The current investigation sought to extend the existing literature by examining both DT and the relationship between DT and AS across a number of anxiety symptom dimensions, including panic, generalized anxiety, social anxiety, and obsessive-compulsive anxiety. Participants (N = 418) completed a number of measures that assessed DT, AS, anxiety symptomatology, and negative affect. Findings indicated that DT was uniquely associated with panic, obsessive compulsive, general worry, and social anxiety symptoms, but that DT and AS were not synergistically associated with each of these symptom dimensions. These findings indicate that an inability to tolerate emotional distress is associated with an increased vulnerability to experience certain anxiety symptoms.     

Stress and stress management at the workplace

Anxiety sensitivity (AS), the fear of anxiety-related symptoms, is strongly implicated in the development of anxiety disorders and is associated with other types of psychopathology. Little is known, though, about the processes through which AS might precipitate distress. As a preliminary step in understanding mechanisms, the mediational role of stress perception was evaluated in a nonclinical sample using a cross sectional design. We conducted a comparison between trait anxiety (TA) and AS to test whether any observed relations were specific to fear of anxiety (AS) or whether associations could be explained by the more general construct. Perceived stress mediated the relation between AS, and specific AS components, and panic symptoms and depression; but not in analyses where TA was statistically controlled. Perceived stress was not found to mediate the relation between TA and panic symptoms or depression, although TA, perceived stress and depression were highly correlated. Although incremental validity was not demonstrated in the present study, stress perception may be an important process through which AS amplifies reactivity to demanding life circumstances and further study is warranted.     

Test of a Factor Mixture-Based Taxonic-Dimensional Model of Anxiety Sensitivity and Panic Attack Vulnerability among University and Clinical Samples in Mexico City

The aim of the present study was to evaluate a factor mixture-based taxonic-dimensional model of anxiety sensitivity (AS) (Bernstein et al. Behavior Therapy 41:515-521, 2010), as measured by the ASI-3 (Taylor et al. Psychological Assessment 19:176-188, 2007), in regard to panic attacks, anxiety symptoms, and behavioral impairment among a university sample (N = 150, n _females  = 107, M _age = 21.3 years, SD = 4.3) and a clinical sample (N = 150, n _females  = 102, M _age = 39.0 years, SD = 12.0) from Mexico City, Mexico. Findings demonstrated cross-national support for the conceptual and operational utility of the AS taxonic-dimensional hypothesis (Bernstein et al. Journal of Anxiety Disorders 20:1-22, 2007b). Specifically, (1) the FMM-based AS taxon class base rate was significantly greater among the clinical relative to the university sample; (2) risk for panic attacks was significantly greater among the AS taxon class relative to the AS normative class; and (3) continuous individual differences in AS physical and psychological concerns, within the AS taxon class, were associated with level of risk for panic attacks, as well as panic attack severity and anxiety symptom levels. Similar AS taxonic-dimensional effects were observed in relation to degree of behavioral impairment across domains of functioning. The study results are discussed with respect to their implications for better understanding the nature of AS-related cognitive vulnerability for panic and related anxiety psychopathology.     

Anxiety sensitivity and daily cigarette smoking in relation to sleep disturbances in treatment-seeking smokers

ABSTRACT

Although the association between anxiety and sleep disturbance is well-documented, the underlying mechanisms are less clear. Anxiety sensitivity (AS), the fear of physiological arousal and bodily sensations, is a risk factor for anxiety and poor sleep. Smoking also contributes to poor sleep and may compound the effects of AS on sleep quality. This study evaluated the main and interactive effects of AS and cigarettes/day on sleep quality among smokers. Participants (n = 190) were adult treatment-seeking daily smokers who completed a baseline assessment as part of a larger smoking cessation trial. Sleep quality was self-reported. Results indicated that AS was significantly correlated with greater disturbance in sleep duration, subjective sleep quality, sleep onset latency, sleep disturbance, daytime dysfunction, and sleep medication use. There was a significant interaction between AS and cigarettes/day in terms of sleep onset latency, but not other sleep quality indices. AS was associated with significantly longer sleep onset latency minutes among heavier smokers, but not lighter smokers. Specifically, the association between AS and sleep onset latency was significant for those who smoked ≥ 33 cigarettes/day. AS is a psychological factor that may contribute to poor sleep quality, especially in heavy smokers, and thus may be a promising intervention target.     

Health Anxiety: Latent Structure and Associations with Anxiety-related Psychological Processes in a Student Sample

Although currently classified as a somatoform disorder, cognitive-behavioral models conceptualize hypochondriasis (HC) as a severe form of health anxiety. The Short Health Anxiety Inventory (SHAI) is a measure derived from this conceptualization that measures health anxiety symptoms across the range of severity. Previous studies have reported inconsistent findings regarding this measure’s factor structure, but these studies employed factor analytic tools that did not account for the categorical nature of SHAI items. The present psychometric study was designed to address these inconsistencies using categorical factor analysis. Using data from a large student sample we found that the SHAI had two factors: Illness Likelihood and Illness Severity. We also examined the relationship between these domains and cognitive variables associated with other anxiety disorders. Results suggested that the psychological processes present in obsessive-compulsive disorder and panic disorder are also associated with health anxiety. Implications for the conceptualization and classification of severe health anxiety are discussed.     

A Meta-analytic Review of the Role of Child Anxiety Sensitivity in Child Anxiety

Conflicting findings exist regarding (1) whether anxiety sensitivity (AS) is a construct distinct from anxiety in children and (2) the specific nature of the role of AS in child anxiety. This study uses meta-analytic techniques to (1) determine whether youth (ages 6–18 years) have been reported to experience AS, (2) examine whether AS differentiates anxiety disordered youth from youth without diagnoses, and (3) ascertain whether AS distinguishes youth with panic disorder from those with other anxiety disorders. The weighted mean effect size analyses included 15 studies and 6,579 participants. Results suggested positive correlational relationships between AS and anxiety for children (r = 0.26) and adolescents (r = 0.36) and higher levels of AS for anxiety disordered youth than non-clinical youth (d = 0.64). Findings tentatively suggested higher levels of AS for youth with panic disorder than youth diagnosed with other anxiety disorders. Implications and future directions in the research of child AS are discussed.     

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

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

Anxiety symptom interpretation in high-anxious,defensive high-anxious,low-anxious and repressor sport performers

Abstract

For the first time in a sport setting this study examined the intensity and direction of the competitive state anxiety response in collegiate athletes as a function of four different coping styles: high-anxious, defensive high-anxious, low-anxious and repressors. Specifically, the study predicted that repressors would interpret competitive state anxiety symptoms as more facilitative compared to high-anxious, defensive high-anxious, and low-anxious performers. Separate Multivariate Analyses of Variance (MANOVA) were performed on the intensity and direction subscales of the modified Competitive State Anxiety Inventory-2 (CSAI-2). A significant main effect was identified for trait worry revealing that low trait anxious athletes reported lower intensities of cognitive and somatic anxiety and higher self-confidence and interpreted these as more facilitative than high trait anxious athletes. The prediction that performers with a repressive coping style would interpret state anxiety symptoms as more facilitative than performers with non-repressive coping styles was not supported.     

Laboratory Test of a Novel Structural Model of Anxiety Sensitivity and Panic Vulnerability

The current study evaluated a novel latent structural model of anxiety sensitivity (AS) in relation to panic vulnerability among a sample of young adults (N = 216). AS was measured using the 16-item Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986), and panic vulnerability was indexed by panic attack responding to a single administration of a 4-minute, 10% CO₂ challenge. As predicted, vulnerability for panic attack responding to biological challenge was associated with dichotomous individual differences between taxonic AS classes and continuous within-taxon class individual differences in AS physical concerns. Findings supported the AS taxonic-dimensional hypothesis of AS latent structure and panic vulnerability. These findings are discussed in terms of their theoretical and clinical implications.     

Attentional biases to threat in social anxiety disorder: time to focus our attention elsewhere?

Background: Cognitive models propose that attentional biases to threat contribute to the maintenance of social anxiety disorder (SAD). However, the specific characteristics of such biases are still object to debate.

Objectives: The current study aimed to disentangle effects of trait and state social anxiety on attention allocation towards social stimuli.

Methods: Participants with SAD (n?=?67) and healthy controls (n?=?62) completed three visual search tasks while their eye movements were recorded. Half of the participants in each group were randomly assigned to a state anxiety induction.

Results: Contrary to our predictions, neither trait nor state social anxiety was associated with a facilitated attention to or a delayed disengagement from threat. However, participants with SAD did show reduced fixation durations for threatening stimuli, indicating an avoidance of threat. Induction of state anxiety led to an increased distractibility by threat.

Conclusions: We suggest that attention allocation in SAD is characterized by an avoidant rather than a vigilant attentional bias. Accordingly, our results contradict previous results that associate SAD with facilitated attention to threat and existing approaches to modify attentional biases, that aim to decrease attention towards threatening stimuli.