Social anxiety and fear of bodily sensations in panic disorder and agoraphobia: A matched comparison

This study tests the hypothesis that social anxiety and fear of bodily sensations are associated with the development of agoraphobic avoidance behavior in panic disorder patients. Twenty patients with panic disorder were compared to 20 patients with panic disorder with agoraphobia, matched by sex and duration of disorder. The two groups did not differ on measures of fear and frequency of assertive social responses. However, the agoraphobics scored higher on measures of interpersonal sensitivity, depression, feelings of inadequacy, and hostility. They also reported higher fear of bodily sensations. Although definitive conclusions need to be postponed until prospective studies have been conducted, there is evidence suggesting that the development of agoraphobia in panic patients is associated with hypersensitivity to bodily sensations and interpersonal situations.This research was supported by Grant 560-268-009 of the Dutch Organization for Scientific Research.     

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.     

Prospective Evaluation of Perceived Control, Predictability, and Anxiety Sensitivity in the Pathogenesis of Panic

Increasing evidence suggests that anxiety sensitivity (AS) may be a premorbid risk factor for the development of anxiety pathology. Perceived control and predictability have also been implicated as factors relevant to the genesis of anxiety. The principal aim of this study was to extend this work to examine independent and interactive effects of perceived control, predictability, and AS in the pathogenesis of panic. A large nonclinical sample of young adults (N = 1296) was prospectively followed over a 5- week highly stressful period of time (i.e., military basic training). Perceived control and predictability did not independently predict panic. However, there was evidence suggesting that AS interacted with perceived control such that high perceived control regarding basic training was protective against panic for individuals with high AS. Similarly, high perceived predictability during basic training reduced anxiety symptoms for individuals with high AS.     

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.     

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.     

Physical activity does not provoke panic attacks in patients with panic disorder: A review of the evidence

Abstract

This paper summarizes the results of published studies in which physical activity has been performed by patients with panic disorder. Several case studies of apparent exercise-induced panic attacks were found. However, in field studies that involved ambulatory monitoring of panic disorder patients only 1 of 91 panic attacks that were monitored actually occurred while the test subject was engaged in moderately intense physical activity. Moreover, only five panic attacks occurred in association with 444 exercise bouts performed by 420 panic disorder patients in laboratory settings despite the fact that exercise induces somatic signs and symptoms of anxiety. Thus, the weight of the published evidence shows that acute physical activity does not provoke panic attacks in panic disorder patients.     

How Do Elements of a Reduced Capacity to Withstand Uncertainty Relate to the Severity of Health Anxiety?

Intolerance of uncertainty (IU)—a multidimensional cognitive vulnerability factor—is associated with a variety of anxiety disorders and health anxiety (HA). To date, few studies have assessed whether IU dimensions (prospective and inhibitory IU) are differentially associated with HA and whether their contributions are independent of anxiety sensitivity (AS). This study addressed these issues using independent community (n = 155; 81% women) and undergraduate (n = 560; 86% women) samples. Results indicated that prospective IU, but not inhibitory IU, had significant positive associations with HA in community dwellers and undergraduate students. AS somatic and cognitive concerns were also significant predictors among both samples. In addition, severity of IU dimensions among individuals reporting elevated HA were compared against individuals diagnosed with generalized anxiety disorder, social anxiety disorder, panic disorder, and obsessive–compulsive disorder. Results indicated minimal differences between those with elevated HA and each of the anxiety disorder diagnoses. Findings lend support to the unique transdiagnostic nature of IU and support commonalities between HA and anxiety disorders.     

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.     

Expectations and Attributions in Social Anxiety Disorder: Diagnostic Distinctions and Relationship to General Anxiety and Depression

Contemporary cognitive models suggest that social anxiety disorder arises from a number of cognitive factors, including tendencies to form pessimistic (rather than optimistic) attributions and expectations for socially-related events. These models also assume that the strengths of such attributions and expectations are more closely linked with social anxiety than with general anxiety or depression. To test these assumptions, a battery of self-report measures was completed by participants with a primary diagnosis of generalized social anxiety disorder (n?=?75), panic disorder with agoraphobia (n?=?44), or post-traumatic stress disorder (n?=?59). To examine differences on these cognitive variables, group comparisons were performed controlling for general anxiety, depression and medication status. Social anxiety disorder, compared with panic disorder with agoraphobia and post-traumatic stress disorder, was characterized by lower expectations for positive social events and higher expectations for negative social events. There was no difference among the groups on expectations for non-social positive or negative events. Stable and global attributions for social negative events were more closely associated with social anxiety disorder than with panic disorder with agoraphobia and post-traumatic stress disorder. Correlational analyses also revealed specific relationships among social-cognitive measures and social anxiety, even after controlling for general anxiety and depression. The results are consistent with cognitive models of social anxiety disorder.     

Cognitive factors in panic disorder, agoraphobic avoidance and agoraphobia

There remains a lack of consensus regarding the possibility that especially high levels of panic-related cognitions characterise panic disorder with agoraphobia. We administered the Anxiety Sensitivity Index, the Agoraphobic Cognitions Questionnaire and the Anxious Thoughts and Tendencies Scale as well as measures of agoraphobic avoidance to patients diagnosed with panic disorder with agoraphobia (n=75) and without agoraphobia (n=26). Patients with panic disorder with agoraphobia did not score significantly higher on any of the cognitive variables than did panic disorder patients without agoraphobia. However, most of the cognitive variables showed small to moderate-strength correlations with self-report measures of agoraphobic avoidance. Our findings suggest that anxiety sensitivity, catastrophising of the consequences of panic and a general anxiety-prone cognitive style, although to some extent associated with agoraphobic avoidance, do not discriminate panic disorder with agoraphobia from panic disorder without agoraphobia.     

Differences in panic psychopathology between smokers with and without asthma

Cigarette smoking is more common among individuals with asthma compared to those without, resulting in increased risk of morbidity and mortality. However, there has been little exploration of psychological factors that differ between smokers with and without asthma. Thus, the aim of the current study was to examine differences between smokers with and without asthma in terms of anxiety sensitivity, panic symptoms, lifetime history of panic attacks, and lifetime history of panic disorder. Participants were 115 smokers with asthma (55.3% male, M_age = 38.4 years, SD = 11.9) and 120 smokers without asthma (70.6% male, M_age = 37.0 years, SD = 12.8) who were administered a structured diagnostic interview and completed self-report measures. As hypothesized, after controlling for the effects of cigarettes per day, gender, race, and education, smokers with asthma reported higher levels of anxiety sensitivity and panic symptoms and were at an increased risk for having a lifetime history of panic attacks (OR = 3.01) and panic disorder (OR = 2.96) compared to smokers without asthma. Further, group differences in anxiety sensitivity and panic symptoms remained even after removing participants with a lifetime history of panic attacks or panic disorder. These findings suggest that smokers with asthma are a particularly ‘at-risk’ population for panic psychopathology and likely in need of specialized smoking-related prevention and intervention efforts.     

The Interactive Contributions of Perceived Control and Anxiety Sensitivity in Panic Disorder: A Triple Vulnerabilities Perspective

Within the triple vulnerabilities model of anxiety disorders, a genetic contribution to the development of anxiety and negative affect (i.e., generalized biological vulnerability), a diminished sense of perceived control over aversive events and emotional experiences (i.e., generalized psychological vulnerability), and elevated levels of anxiety sensitivity (i.e., specific psychological vulnerability) are posited to increase the risk of developing and maintaining panic disorder (Barlow American Psychologist 55(11):1247–1263, 2000). The purpose of the present study was to investigate the direct and interactive effects of perceived control and anxiety sensitivity on panic disorder symptom severity. Structural equation models (SEM) were conducted in data derived from a sample of 379 adults with panic disorder participating in a multi-site randomized controlled trial. Findings indicated that both perceived control and anxiety sensitivity uniquely predicted panic disorder symptoms. A moderation model examining the interactive effects of perceived control and anxiety sensitivity on panic symptoms indicated that the effect of anxiety sensitivity on panic symptoms increased with greater deficits in perceived control. The present findings suggest that deficits in perceived control and elevated levels of anxiety sensitivity exert unique and shared effects on panic disorder symptoms, thereby illustrating the relationship between putative vulnerability factors and panic disorder symptoms as predicted by the triple vulnerabilities model.     

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.     

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.     

Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report

Trauma‐related exposure therapy is a useful but not universally effective treatment for post‐traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post‐traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma‐related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician‐Administered Post‐traumatic Stress Disorder Scale, a self‐report measure of post‐traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post‐traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1‐ and 3‐month follow‐up. Symptoms of anxiety sensitivity and post‐traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post‐traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma‐related exposure therapy as a means of boosting treatment efficacy.     

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.     

The Role of Cardioprotective Avoidance Beliefs in Noncardiac Chest Pain and Associated Emergency Department Utilization

This study examined cardioprotective avoidance beliefs and general panic/agoraphobia variables among 45 Emergency Department patients with a primary complaint of noncardiac chest pain (NCCP) in the absence of coronary artery disease or other medical explanation. Cardioprotective beliefs about the dangerousness of work and physical activity were assessed with the Fear-Avoidance Beliefs Questionnaire (FABQ). Additional measures assessed complaints of cardiac distress and panic, anxiety sensitivity, panic-related beliefs, agoraphobic avoidance, and depressive symptoms. Hierarchical regression analysis indicated that cardiac distress symptoms are a function of panic symptoms and cardioprotective beliefs concerning both physical activity and work, with 62% of the total variance explained. The predictors also explained 57% of the variance in Emergency Department utilization, which was significantly related to cardiac distress symptoms, number of illnesses, and work-avoidance beliefs. Neither outcome was related to demographics, depression symptoms, general anxiety sensitivity, general panic cognitions, or agoraphobic avoidance. Results suggest that current behavioral understandings of NCCP might be advanced by further examination of cardiac-specific avoidance beliefs and behavior and the potential role these factors play in both symptom experience and medical utilization.     

Anxiety induced by cardiac perceptions in patients with panic attacks: a field study

In panic disorder bodily sensations appear to play an important role as a trigger for anxiety. In our psychophysiological model of panic attacks we postulate the following vicious circle: individuals with panic attacks perceive even quite small increases in heart rate and interpret these changes as being catastrophic. This elicits anxiety and a further increase in heart rate. To evaluate this model we conducted a field study of 28 subjects with panic attacks and 20 healthy controls. A 24 hr ambulatory ECG was recorded and the subjects were instructed to report any cardiac perceptions during this period and to rate the anxiety elicited by these perceptions. The incidence of cardiac perceptions was about the same in both groups, but only subjects with panic attacks reported anxiety associated with such perceptions. Analysis of the ECGs revealed that in both groups heart rate accelerations preceded cardiac perceptions. Following cardiac perceptions, the healthy controls showed a heart rate deceleration, whereas the subjects with panic attacks had a further acceleration. This heart rate increase after cardiac perceptions was positively related to the level of anxiety elicited by the perceptions. These results provide clear evidence in support of the vicious circle model of panic attacks.     

Delineating generalized anxiety: A preliminary investigation

The present study examined the nature of generalized anxiety, which was defined as the constellation of symptoms listed as diagnostic criteria for generalized anxiety disorder in DSM-III-R. Generalized anxiety was assessed by means of a questionnaire that was especially constructed for this study. Although multidimensional scaling of symptoms reported by a clinically anxious sample produced orthogonal anxiety and panic dimensions, many symptoms were common to both dimensions. Whereas worry was found to be the cardinal feature of generalized anxiety, respiratory symptoms were found to associate closely with panic. These dimensions were replicated in a student sample. It is argued that while generalized anxiety symptoms constitute a unique dimension in the field of anxiety disorders, both panic and generalized anxiety may be linked with a basic anxiety response system. The findings also indicated that worry associated more closely with generalized anxiety than did apprehensive expectations. The heuristic value of the findings are discussed in light of the issue relating to an anxiety-panic continuum.     

Predictors of Self-Reported Anxiety and Panic Symptoms: An Evaluation of Anxiety Sensitivity, Suffocation Fear, Heart-Focused Anxiety, and Breath-Holding Duration

The purpose of this study was to examine the extent to which anxiety-related individual difference variables predict anxious responding when individuals experience aversive bodily sensations. Thus, we explore several psychological and behavioral predictors of response to a single 25-sec inhalation of 20% carbon dioxide-enriched air in 70 nonclinical participants. Predictor variables included anxiety sensitivity, suffocation fear, heart-focused anxiety, and breath-holding duration. Multiple regression analyses indicated that only anxiety sensitivity significantly predicted postchallenge panic symptoms, whereas both anxiety sensitivity and suffocation fear predicted postchallenge anxiety. These data are in accord with current models of panic disorder that emphasize the role of fear of fear in producing heightened anxiety and panic symptoms and help clarify specific predictors of anxiety-related responding to biological challenge.