Acceptance Mediates the Relationship Between Tinnitus-Related Cognitions and Anxiety Sensitivity.

Running head: TINNITUS, ACCEPTANCE AND ANXIETY SENSITIVITY

Acceptance Mediates the Relationship Between Tinnitus-Related Cognitions and Anxiety Sensitivity John Moring, Ph.D.1 Anne Bowen, Ph.D.2 Jenifer Thomas, Ph.D.3 Jeremy Joseph, Ph.D.1

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University of Texas Health Science Center San Antonio; Department of Psychiatry

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University of Arizona, Department of Psychology

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University of Wyoming, Fay W. Whitney School of Nursing

Corresponding Author John Moring, Ph.D. [email protected] 7550 IH 10 West Suite 1325 San Antonio, TX 78229

This is an author-produced manuscript that has been peer reviewed and accepted for publication in the American Journal of Audiology (AJA). As the “Just Accepted ” version of the manuscript, it has not yet undergone copyediting, proofreading, or other quality controls associated with final published articles. As the publisher and copyright holder, the American SpeechLanguage-Hearing Association (ASHA) disclaims any liability resulting from use of inaccurate or misleading data or information contained herein. Further, the authors have disclosed that permission has been obtained for use of any copyrighted material and that, if applicable, conflicts of interest have been noted in the manuscript.

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Abstract Purpose: Negative cognitions related to tinnitus sensation have been previously shown to impact the level of emotional distress. Anxiety sensitivity is another psychological factor that influences individuals to more closely monitor their own bodily sensations, resulting in increased negative cognitions and negative emotional responses among tinnitus patients. However, increasing acceptance of tinnitus sensation may attenuate emotional distress. The goal of this research was to investigate the relationship between negative tinnitus-related cognitions, acceptance, and anxiety sensitivity. Method: Two hundred sixty-seven participants completed online measures of the Tinnitus Handicap Inventory (THI), Acceptance and Action Questionnaire (AAQ), and the Anxiety Sensitivity Index-3. Results: Hierarchical regression analyses indicated that acceptance fully mediated the relationship between negative tinnitus-related cognitions and anxiety sensitivity. Conclusions: Based on these results, it is suggested that practitioners improve acceptance of tinnitus sensation, duration, and intensity. More research is warranted on the clinical techniques to improve acceptance.


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Acceptance Mediates the Relationship Between Tinnitus-Related Cognitions and Anxiety Sensitivity The perception of tinnitus, often referred to as “ringing in the ears,” is a common experience after exposure to toxic auditory stimuli or noise trauma (Schlee, Mueller, Harmann, Keil, Lorenz, & Weisz, 2009). Approximately 10% of the general U.S. population experience chronic tinnitus that has lasted longer than three months (Vattoth et al., 2010). Of those who experience chronic tinnitus, 1-3% of individuals report that their tinnitus is loud enough to affect quality of life (Eggermont & Roberts, 2004). Quality of life for individuals with chronic tinnitus is negatively impacted by high prevalence of co-occurring psychiatric symptoms. The most frequently reported comorbid disorders associated with tinnitus include anhedonia (Briner, 1995), anxiety (Henry, Dennis, & Schechter, 2005; Hesser & Andersson, 2009; Kaldo et al., 2008), hyperacusis (Sood & Coles, 1988), depression (Henry et al., 2005; Hesser & Andersson, 2009; Kaldo et al., 2008), and insomnia (Hesse, Laubert, Schaaf, & Almeling, 2006). Research has demonstrated that the perceived loudness of tinnitus sensation significantly contributes to annoyance and emotional difficulties (Tyler, Oleson, Noble, Coelho, & Ji, 2007); however, it remains important to assess other factors that contribute to psychological distress, such as acceptance and anxiety sensitivity. A greater understanding of these factors can provide valuable information for the modification of existing therapies and the development of new treatments. Acceptance of tinnitus has been shown to partially mediate the relationship between the loudness of tinnitus experience and tinnitus related psychological distress. Moreover tinnitus has a stronger indirect effect on distress than anxiety (Weise, Kleinstäuber, Hesser, Westin, &


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Andersson, 2013). Early expression of acceptance during a therapeutic protocol has also been shown to significantly improve tinnitus distress at the end of therapy (Hesser, Westin, Hayes, & Andersson, 2009). Examples of statements that reflect acceptance were, “I can let (tinnitus) be there,” and, “I am willing to experience my tinnitus.” In another study, participants who were assigned to an acceptance condition were significantly better able to focus on an imagery task, compared to individuals assigned to the suppression and control conditions (Westin, Ӧstergren, & Andersson, 2008). These studies demonstrate the effect of tinnitus-specific acceptance on multiple domains of individual functioning. Another factor that contributes to psychological distress among individuals with chronic medical conditions and somatic symptoms, such as tinnitus, is anxiety sensitivity (Asmundson et al., 2000; Asmundson & Norton, 1995; Martin, McGrath, Brown, & Katz, 2007). Anxiety sensitivity is operationally defined as a fear of bodily sensations that mimic physical experiences typically associated with fear of death or losing one’s sanity (Reiss & McNally, 1985). The fear of anxiety sensations influences individuals to monitor their bodily changes (Khalsa, Rudrauf, Sandersara, Olshansky, & Tranel, 2009), which are subsequently, negatively, and falsely misinterpreted as threat and leads to an exacerbation of a fear response (Barlow & Cerny, 1988). Anxiety sensitivity, as measured by the Anxiety Sensitivity Index-3 (ASI-3; Taylor et al., 2007), has been shown to predict panic symptoms in response to biological changes that provoke feared bodily sensations (Rassovsky, Kushner, Schwarze, & Wangensteen, 2000; Rapee et al., 1992). The cyclical nature of anxiety sensitivity and increased symptomotology promotes a fear of anxiety, which provides incentive to avoid physical sensations (McNally, 2002; Shostak & Peterson, 1994). Increased fear of bodily sensations has implications for individuals with tinnitus (Hesser & Andersson, 2009).


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Anxiety sensitivity has been shown to predict tinnitus distress, even when controlling for the amount of time spent masking tinnitus and hearing loss (Andersson & Vretblad, 2000), and when controlling for depression and other psychiatric symptoms (Hesser & Andersson, 2009). One study showed that anxiety sensitivity was significantly related to tinnitus distress and significantly stronger in women than men (Andersson & Vretblad, 2000). Individuals with tinnitus who endorse high anxiety sensitivity may devote significantly more attention to their bodily and auditory sensations, making tinnitus more emotionally and functionally problematic. More research is warranted with regard to the cognitive factors that relate to anxiety sensitivity among individuals with tinnitus. Research has already demonstrated the relationship between distress and dysfunctional and catastrophic thoughts among tinnitus patients (Hallam, 1996; Handscomb, 2006; Henry & Wilson, 1998; Hiller & Goebel, 1992; Newman, Sandridge, & Jacobson, 1998; Sweetow, 1986; Ward & Baumann, 2009). Concurrently, individuals who endorse high anxiety sensitivity may generate additional maladaptive thoughts, which further intensifies fear and anxiety responses (Taylor et al., 2007). However, there is lack of research that investigates the relationships among anxiety sensitivity, acceptance, and negative thought processes, in the context of tinnitus. The goal of this study was to examine the possible direct and mediating effects of acceptance on anxiety sensitivity among individuals with tinnitus. Methods Participants All participants were at least 18 years of age or older. Participants who met inclusion criteria indicated that 1) they experienced ringing, buzzing, or whooshing in one or both ears, 2)


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the ringing, buzzing, or whooshing lasted longer than three months, and 3) the ringing, buzzing, or whooshing occurred all of the time. Procedure Potential participants were contacted through the American Tinnitus Association (ATA) listserv. Staff of the ATA sent emails that contained information about the nature of the study, eligibility requirements, compensation for participation, and directions for participation. After meeting inclusion criteria, participants in the tinnitus condition provided online consent and completed the survey’s online. Full details regarding recruitment and procedure can be found in Moring, Bowen, and Thomas (2014). Measures Mediator variable Acceptance and Action Questionnaire. The Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) is a nine-item measure and assesses the extent to which individuals engage in experiential avoidant behaviors. Each item on the AAQ is answered by indicating the extent to which individuals endorse the statement on a Likert-scale ranging from 1 to 7. Each number was accompanied by a label to decrease the amount of confusion for participants: 1 (Never True), 2 (Very Rarely True), 3 (Seldom True), 4 (Sometimes True), 5 (Frequently True), 6 (Almost Always True), and 7 (Always True). The AAQ has demonstrated adequate Cronbach’s alpha (α = .70; Hayes et al., 2004). Analyses have also demonstrated adequate convergent validities, significantly correlating with theoretically related measures such as the White Bear Suppression Inventory (r = .50), the Escape-Avoidance subscale of the Ways of Coping Questionnaire (r = .35.38), and the Avoidance subscale of the Post-traumatic Stress Diagnostic Scale (r = .26; Hayes et al., 2004). Cronbach’s alpha reliability for the current study was α = .59 (See Table 1).


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Dependent variable Anxiety Sensitivity Index 3. The Anxiety Sensitivity Index 3 (ASI-3; Taylor et al., 2007) is an 18-item measure and assesses the degree to which individuals believe that their own sensations have detrimental outcomes, such as death, insanity, or rejection from others (Reiss & McNally, 1985). Each item of the ASI is answered by indicating the extent to which individuals endorse the statement. The ASI consists of three subscales with adequate alpha reliabilities: physical concerns (α = .79), cognitive concerns (α = .84), and social concerns (α = .79; Taylor et al., 2007). Convergent validities were also demonstrated by significant correlations of subscales with similar subscales of the original ASI (Taylor et al., 2007). In this study, a five-point Likert scale from 1 to 5 was used for each item, with a possible range of 18 to 90. Each number was accompanied by a label: 1 (Very Little), 2 (A Little), 3 (Some), 4 (Much), and 5 (Very Much). The ASI-3 was conceptualized as the dependent variable in this study due to past research demonstrating the influence of anxiety sensitivity on individual functioning (Asmundson et al., 2000; Martin et al., 2007; Taylor et al., 2007). Cronbach’s alpha reliability for the total ASI-3 in this study was α = .93 (See Table 1). Subscale reliabilities were α = .88 for Physical Concern; α = .90 for Cognitive Concern, and α = .78 for Social Concern (See Table 2). Predictor variable Tinnitus Handicap Inventory. The Tinnitus Handicap Inventory (THI; Newman, Jacobsen, & Spitzer, 1996) consists of 25 items and is an assessment of the impact of tinnitus on individuals. Each item is answered by indicating the extent to which individuals endorse the statement. Multi-item analyses demonstrated adequate convergent validity (r = .90; Baguley, Humphriss, & Hodgson, 2000). In this study, a Likert scale from 1 to 5 (Totally Agree) was used for each item, for a possible range of 25 to 125. Each number was accompanied by a label:


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1 (Totally Disagree), 2 (Disagree), 3 (Neutral), 4 (Agree), and 5 (Totally Agree). Originally, the THI consisted of three subscales (i.e., functional, emotional, and catastrophic); however, more current research suggested that the measure should be regarded as unifactorial (Baguley & Andersson, 2003; Zachariae et al., 2000). Cronbach’s alpha reliability in this study was α = .97 (See Table 1). Analytic Strategy Correlations were first conducted to demonstrate the relationships among variables. Moderate correlations demonstrate that the factors are related, but do not measure the same construct. The definition provided by Baron and Kenny (1986) was used for the meditation analyses in this study. Acceptance would be considered a mediator variable if (Step 1) the independent variable significantly predicts the dependent variable (THIASI), (Step 2) predictor variable significantly predicts the mediation variable (THIAAQ), and (Step 3) mediation variable (AAQ) significantly predicts the dependent variables (AAQASI) while controlling for the independent variable (THI). Results Participants. Three hundred seventy-one individuals began the study, had a mean age of 59.12 years (SD = 11.77), experienced tinnitus for a mean of 175.98 months (SD =175.59), and were mostly male (70.9%). Individuals who completed all measures (N = 267) had a mean age of 57.62 (SD = 12.12), experienced tinnitus for a mean of 176.04 months (SD = 176.30), and were mostly male (68.3%). Correlations. Correlations were conducted to demonstrate the relationships among variables. Very high correlations, such as above .70, indicate that the variables are redundant and inflate the size of error terms in the subsequent regression analyses (Tabachnick & Fidell,


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1996). The THI Total Score was significantly and moderately correlated with the ASI Total Score, r = .45, p < .001 (Figure 1) and the AAQ Total Score, r = .49, p < .001 (Figure 2), and the AAQ Total Score was significantly and moderately correlated with the ASI-3 Total Score, r = .47, p < .001 (Figure 3). Table 3 shows the correlations and significance values. Therefore, multicollinearity will not be problematic for future regression analyses (Cohen, Cohen, West, & Aiken, 2003). Mediation Analyses. Step 1, Regression analysis indicates that negative tinnitus cognitions (THI) significantly predicts anxiety sensitivity (ASI: β = .45, t(265) = 7.45, p < .001) (Table 4). Tinnitus cognitions (THI) also significantly predict acceptance (AAQ: β = .49, t(265) = 9.27, p < .001) (Table 5). Step 3, controlling for tinnitus cognitions (THI), the AAQ significantly predicted anxiety sensitivity (ASI: β = .34, t(2, 266) = 5.60, p = < .001) The significant regression analyses fulfill the criteria for a full mediation model (Table 6). Therefore, acceptance of internal experiences fully mediates the relationship between tinnitus-related cognitions and anxiety sensitivity. Discussion This study demonstrated, as predicted, that the total scale score of the THI predicted scores on the ASI-3 among individuals with tinnitus. Also as hypothesized, the relationship between the THI and the ASI-3 was completely mediated by scores on the AAQ. The findings from this study are consistent with Dauman and Tyler’s (1992) assertion that a variety of factors contribute to distress related to tinnitus. Factors include the magnitude of the perception and intolerance to loud noise, psychological factors that include anxiety as a pre-existing factor and consequence of tinnitus, hearing loss, anatomy of the ear and brain, and chemistry of the ear and brain. Therefore, psychological interventionists should consider these factors and integrate


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educational components, empathy and support for the patient, and encourage cognitive flexibility and behavioral change (Tyler, 2006). This study considered additional psychological factors that could influence tinnitus distress, such as anxiety sensitivity and acceptance. Anxiety sensitivity has been found to significantly predict the development and maintenance of anxiety disorders (Olatunji & Wolitzky-Taylor, 2009; Schmidt et al., 1997). The risk factor promotes fear of anxiety-related physical, social, and cognitive experiences, and subsequently influences individuals to pay closer attention to bodily changes (Reiss et al., 1986). Therefore, individuals with tinnitus who have increased anxiety sensitivity may be more aware of their own tinnitus sensation, and therefore, experience significantly more distress. In other words, the less attention and concern that a person devotes to their tinnitus, emotional reactivity will subside. This study demonstrated that negative cognitive processes increase anxiety sensitivity, but acceptance-based strategies can intervene and prevent the emotionally-distressing cycle. Therefore, interventions that focus on improving acceptance and reducing anxiety sensitivity are warranted. Cognitive behavioral therapies for tinnitus typically begin with psychoeducation, including typical sensations and the genesis and maintenance of the auditory disorder. Later in therapy, automatic thoughts about the phantom perceptions are monitored and identified, along with the associated emotional responses (Greimel & Kröner-Herwig, 2011). The thoughts or cognitions can be challenged by using either Socratic questioning or the “downward arrow” technique. For example, a Socratic approach might challenge the thought, “This tinnitus is driving me crazy,” by asking how they have coped with tinnitus in the past and any evidence to suggest that it will lead to “psychosis.” A balanced cognitive approach to tinnitus is preferred, and an alternative thought might be, “My tinnitus is sometimes annoying, but I’m not crazy


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because of it.” Cognitive behavioral therapies are effective at restructuring maladaptive thoughts in relation to tinnitus (Hesser, Weise, Westin, & Andersson, 2011). However, additional strategies to reduce anxiety sensitivity and enhance acceptance are still needed. An alternative therapeutic intervention that capitalizes on acceptance of distressing internal experiences could promote greater attenuation of distress among individuals with tinnitus. More specifically, increased acceptance could disrupt the cycle between negative tinnitus cognitions and anxiety sensitivity. Acceptance is achieved through mindfulness and meditation and is used for the treatment of psychopathology and chronic medical conditions (Hayes, Strosahl, & Wilson, 1999; Kohlenberg et al., 2004). Therapies that incorporate mindfulness and acceptance techniques, such as Acceptance and Commitment Therapy (ACT; Hayes et al., 1999), are designed to affect the context to which problematic behaviors occur, rather than directly changing the events (Hayes, Masuda, & DeMay, 2003). Hayes et al. (2003) explains that changing the perception of one’s symptoms works effectively to resolve psychological distress, as opposed to changing the symptom frequency or intensity, or by actively challenging cognitions. Therefore, Dahl, Wilson, Luciano, and Hayes (2005) proposed that ACT is an especially useful therapy for chronic pain conditions. Acceptance strategies use mindfulness techniques, aimed to promote willingness to make room for difficult internal experiences, such as chronic pain and tinnitus. Studies have shown that mindfulness-based therapies are beneficial in reducing tinnitus-related distress (Hesser et al., 2012; Philippot et al., 2012; Zetterqvist et al., 2011). Additional components to mindfulness-based therapies for tinnitus could possibly offer decreased tinnitus frequency, intensity, and duration. For example, ACT allows for exposurebased exercises, which have been shown to alleviate anxiety sensitivity (Feldner et al., 2008;


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Keough & Schmidt, 2012; Schmidt et al., 2007). These exercises might include actively welcoming tinnitus sensations in a quiet room for extended periods of time, participating in social events despite the discomfort of the tinnitus, and exposure assignments to noise-enriched environments. It is currently unknown whether the combination of exposure, habituation, and mindfulness-based therapies could offer a decrease in the perception of the magnitude of tinnitus, or a decrease in the amount of attention devoted to the phantom auditory perception. Limitations This study contains several limitations. Though the sample size is adequate, the crosssectional design of the study makes it difficult to determine the causality between the cognitive, acceptance, and anxiety sensitivity factors. It is still unknown how these variables interact with one another, over time, to influence distress associated with tinnitus. Future studies can explore causality by measuring these variables before and after psychological treatment for tinnitus. Next, it is still unknown whether individuals with tinnitus exhibit higher levels of anxiety sensitivity, compared to a control group without tinnitus. A separate study should include a control group in order to more accurately assess the extent to which tinnitus patients endorse different levels of anxiety sensitivity. In addition, the alpha reliability estimate of the AAQ was .59, which is marginally acceptable. It may be beneficial to use an acceptance questionnaire, specific to tinnitus, in order to increase alpha reliability estimates and the validity of the data. For example, the Tinnitus Acceptance Questionnaire (TAQ; Westin, Hayes, & Andersson, 2009) has shown to consist of two factors, including the activity engagement subscale and the tinnitus suppression subscale. The overall TAQ has demonstrated adequate alpha reliability (α = .89; Westin et al., 2009). It is suggested that studies regarding acceptance of tinnitus perception use both the AAQ and TAQ to examine differences among tinnitus patients. Lastly, research has


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suggested that the THI does not measure specific factors of tinnitus-related distress, and is instead generalized and unifactorial (Baguley & Andersson, 2003; Zachariae et al., 2000). Other measures of tinnitus are able to measure four primary reactions to tinnitus. For example, the Tinnitus Primary Function Questionnaire (Tyler et al., 2014) assesses the extent to which individuals experience functional impairment in concentration, sleep, hearing, and emotions due to tinnitus. The Tinnitus Primary Function Questionnaire has been shown to be valid, reliable, and sensitive (Tyler et al., 2014), and should be used to comprehensively measure different aspects of tinnitus impairment. Future research should properly classify participants’ tinnitus. Dauman and Tyler (1992) recommended a comprehensive method of classification based on whether tinnitus is normal versus pathological, acceptable versus unacceptable, temporary or permanent, middle ear or sensorineural, and the etiological classification. More in depth assessment concerning individuals’ tinnitus is warranted, and analyses should account for these differences. It is possible that acceptance, anxiety sensitivity, and cognitive factors interact differently depending on the specific tinnitus classification, which has implications for tailored therapeutic interventions. Conclusion Chronic subjective tinnitus has been shown to negatively affect quality of life in several different domains. Individuals with tinnitus have decreased cognitive and emotional functioning (Andersson, Eriksson, Lundh, & Lyttkens., 2000; Henry et al., 2005; Hesse et al., 2006), which can lead to significant disability. Therefore, it remains important to investigate the psychological factors that are associated with the auditory disorder, such as anxiety sensitivity. Anxiety sensitivity has been studied in tinnitus populations previously, and results indicate that increased anxiety sensitivity leads to more tinnitus-related distress (Andersson & Vretblad, 2000; Hesser &


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Andersson, 2009). Our study demonstrated that there is a significant relationship between negative tinnitus-related cognitions and anxiety sensitivity. Moreover, this relationship is fully mediated by acceptance of distress, measured by the Acceptance and Action Questionnaire. It is suggested that future studies focus on improving individuals’ acceptance of tinnitus, in order to adequately target anxiety sensitivity and alleviate distress. Acceptance and Commitment Therapy (ACT) is one approach that utilizes acceptance and mindfulness, and has preliminarily shown to be beneficial for tinnitus patients (Westin et al., 2009). It is suggested that additional studies examine specific factors and techniques of ACT, such as exposure exercises and habituation approaches that can be specifically applied for tinnitus patients, as well as the relationship among acceptance, anxiety sensitivity, and distress. Acknowledgements The authors would like to thank the American Tinnitus Association for the support of this research and the assistance in participant recruitment.


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Table 1. Scale Reliabilities Scale

Number

Mean

of Items

Std Deviation

Possible Range Low

High

Obtained Range Low

High

Alpha

Acceptance and Action Questionnaire (AAQ)*

9

33.98

7.23

9

63

13

55

.59

18

34.76

14.00

18

90

18

90

.93

25

70.32

25.17

25

125

25

125

.97

Anxiety Sensitivity Index (ASI)** Tinnitus Handicap Inventory (THI)*** Note.

*

N = 271; ** N = 268; *** N = 303. Alphas range from marginally acceptable (AAQ p = .59) to excellent (THI p = .97).



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Table 2. Subscale Reliabilities of the ASI-3 Scale

Number

Mean

of Items

Std Deviation

Possible Range Low

High

Obtained Range Low

Alpha

High

ASI Physical Concerns

6

11.39

11.39

6

30

6

30

.88

Cognitive Concerns

6

10.66

10.66

6

30

6

30

.90

Social Concerns

6

5.07

12.71

6

30

6

30

.78

Note. N = 268. Alphas range from good (ASI Social Concerns p = .78) to excellent (ASI Cognitive Concerns p = .90).



25

Table 3. Intercorrelations Among Variables THI Total AAQ Total ASI-P .49*

ASI-C

ASI-S

.31**

.50**

.35**

.45***

.31***

.46***

.47***

.47***

.63***

.58***

.86**

.65***

.88***

THI Total

1.00

AAQ Total

-

1.00

ASI Physical

-

-

1.00

ASI Cognitive

-

-

-

1.00

ASI Social

-

-

-

-

1.00

ASI Total

-

-

-

-

-

ASI Total

.85*** 1.00

Note *N = 270; **N = 267; ***N = 268; All correlations are significant at the p < .01



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Table 4. Summary of Simple Regression Analysis of Negative Thoughts Predicting Anxiety Sensitivity Variable

B

Constant

17.07

2.29

.25

.03

THI Total Adjusted R2

SE B

β

.45*

.20

F for change in R2 66.86* Note: *p < .001. Each added point on the THI Total Score increases the expected score on the ASI by .45, a significant effect in the model.



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Table 5. Summary of Simple Regression Analysis of Tinnitus Negative Thoughts Predicting Acceptance Variable

B

Constant

23.99

1.15

.34

.02

THI Total Adjusted R2

SE B

β

.49*

.24

F for change in R2 85.93* Note: *p < .001. Each added point on the THI Total Score increases the expected score on the AAQ by .49, a significant effect in the model.



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Table 6. Summary of Hierarchical Regression Analysis for Variables Predicting Anxiety Sensitivity Model 1 Variable THI Total

B .25

SE B .03

Model 2 β

B

.45*

.16

.03

.28*

.64

.12

.34*

AAQ Total Adjusted R2

.20

SE B

β

.28

F for change in R2 66.86* 31.39* * Note: p < .001. Model 1 demonstrates that for each added point on the THI Total Score, the expected score on the ASI significantly increases by .45 points. Model 2 demonstrates that when controlling for THI Total Score, each added point on the AAQ significantly increases the ASI score by .34 points.



Figure 1 Scatter Plot Showing the Relationship Between the THI and ASI-III.


29


Figure 2 Scatter Plot Showing the Relationship Between the THI and AAQ.


30


Figure 3 Scatter Plot Showing the Relationship Between the AAQ and ASI-III.


31

Self-acceptance mediates the relationship between mindfulness and perceived stress.

Anxiety sensitivity mediates relations between emotional disorders and smoking.

Decomposing the Relationship Between Anxiety Sensitivity and Alcohol Use.

Anxiety sensitivity as a moderator of the relationship between trait anxiety and illicit substance use.

Anxiety Mediates the Relationship between Perfectionism and Insomnia Symptoms: A Longitudinal Study.

The mediating role of depression in the relationship between anxiety sensitivity and alcohol dependence.

Relationship between anxiety and guilt.

The Relationship between Infant Facial Expressions and Food Acceptance.

Sleep cognitions associated with anxiety and depression in the elderly.

Relationship between death anxiety and demographic variables.

Drinking-and-Driving-Related Cognitions Mediate the Relationship Between Alcohol Demand and Alcohol-Impaired Driving.

Relationship between anxiety and premenstrual syndrome.

Relationships between catastrophic cognitions and body sensations in anxiety disordered, mixed diagnosis, and normal subjects.

The relationship between fear and death and anxiety.

The Temporal Relationship Between Faulty Gambling Cognitions and Gambling Severity in Young Adults.

Psychological inflexibility mediates the effects of self-efficacy and anxiety sensitivity on worry.

The relationship between psychological and physiological measures of anxiety.

Dimensional structure of bodily panic attack symptoms and their specific connections to panic cognitions, anxiety sensitivity and claustrophobic fears.

Relationship Satisfaction Mediates the Link Between Partner Aggression and Relationship Dissolution: The Importance of Considering Severity.

Elucidating the relationship between noise sensitivity and personality.

The relationship between perceived stress and cue sensitivity for alcohol.

The relationship between taste sensitivity to phenylthiocarbamide and anhedonia.

Interplay of dysphoria and anxiety sensitivity in relation to emotion regulatory cognitions of smoking among treatment-seeking smokers.

Anxiety sensitivity facets in relation to tobacco use, abstinence-related problems, and cognitions in treatment-seeking smokers.