Behao.Res.Ther.Vol.29,No.4, pp.361-369, 1991
0005-7967/91 $3.00+O.OO
Printedin GreatBritain.All rightsreserved
Anxiety
CopyrightQ 1991PergamonPressplc
sensitivity
BRIAN J. COX,‘-~ * NORMAN
and nonclinical
panic attacks
S. ENDLER,’ G. RON NORTON’ and RICHARD P. SWINSON~
‘Department of Psychology, York University, 4700 Keele St., Toronto, Ontario, Canada M3J IP3, ‘Department of Psychology, Universiiy of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, Canada R3B 2E9 and ‘Anxiety Disorders Clinic, Clarke Institute of Psychiatry, 250 College St., Toronro, Omario, Canada MST IRS (Received 26 November 1990)
Summary-The present study examined anxiety sensitivity in relation to trait anxiety and the occurrence of nonclinical panic attacks in 265 subjects. Fifty percent of high anxiety sensitivity subjects reported panic attacks (both cued and spontaneous) in the past year. In addition, almost 42% of subjects with high anxiety sensitivity but no history of panic reported a high level of trait anxiety concerning physical danger. The results suggest that anxiety sensitivity is frequently not independent of other forms of anxiety.
A recent study by Donnell and McNally (1990) has investigated the relationship between anxiety sensitivity and nonclinical panic attacks. The purpose of their study was to determine whether anxiety sensitivity, or fear of anxiety symptoms (Reiss, Peterson, Gursky & McNally, 1986), was a result of panic attacks or whether anxiety sensitivity exists independently of panic experiences. The Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1987) and the Panic Attacks Questionnaire (PAQ; Norton, Dorward & Cox, 1986) were administered to 425 college students. The authors found that 32.4% of 68 subjects with high anxiety sensitivity reported at least one panic attack in the past year. Subjects with high anxiety sensitivity were significantly more likely to have concurrent panic attacks than subjects in the medium anxiety sensitivity group. Donnell and McNally concluded that because many subjects with high anxiety sensitivity did not report panic attacks, anxiety sensitivity could be acquired in ways other than panic experiences. The results of this study need to be interpreted with caution, however. First, only the occurrence of spontaneous panic attacks was assessed. The authors claimed this was done because unpredictable panic attacks are hypothesized by some to be important in the development of panic disorder. Yet, this study was conducted to investigate anxiety sensitivity and panic attacks, not panic disorder. Many, if not most, nonclinical subjects experience cued panic (for a review see Norton, Cox & Malan, 1991). Therefore, the prevalence of nonclinical panic was likely underestimated. The second limitation is based on criticisms of the anxiety sensitivity construct in general. Lilienfeld, Jacob and Turner (1989) have suggested that anxiety sensitivity and the AS1 are seriously confounded with trait anxiety. Donnell and McNally (1991) did not report using a trait anxiety measure in their study so this alternate hypothesis remains untested. The present study was designed to further investigate the relationship between anxiety sensitivity and nonclinical panic attacks and address the limitations of the Donnell and McNally study. Accordingly, both spontaneous and cued panic attacks were assessed using the PAQ. The trait form of the Endler Multidimensional Anxiety Scales (EMAS-T; Endler, Edwards & Vitelli, 1990) was chosen as the measure of trait anxiety. There is strong evidence, based on a factor analysis of over 2000 subjects’ responses (Endler, Parker, Bagby & Cox, 1991), that trait anxiety is multidimensional. The EMAS-T assesses four facets of trait anxiety: social evaluation, physical danger, ambiguous or novel situations, and daily routines (neutral). Because anxiety sensitivity is defined as a fear of anxiety symptoms based on the belief that they have harmful consequences, the trait anxiety subscale hypothesized to correspond with anxiety sensitivity was the Physical Danger (PD) subscale. Reiss and McNally (1985) originally hypothesized that anxiety sensitivity would interact with danger expectancy, among other factors, in the development of anxiety disorders. METHOD Subjects
Two hundred and sixty-five college students (105 females, 160 males) voluntarily completed a series of self-report measures for a study on clinical and nonclinical panic attacks (Cox, Endler & Swinson, 1991). The subjects’ mean age was 22.2 years (SD = 4.8). Materials
and procedures
All subjects completed the ASI (Peterson & Reiss, 1987), the EMAS (Endler, Edwards & Vitelli, 1991) and the PAQ (Norton et a/., 1986). Subjects were classified into high, medium, and low anxiety sensitivity groups using the same cutoff score criteria as Donnell and McNally (1990). Subjects were classified as nonclinical panickers if they reported at least one DSM-III-R (APA, 1987) defined panic attack in the past year with four or more DSM-III-R symptoms and were not currently receiving treatment for their panic. The percentage of subjects who reported spontaneous panic was also assessed using the PAQ as was the anticipation of spontaneous panic where 0 = never and 4 = very likely. Fourteen subjects were removed from the study because of incomplete information or limited symptom attacks and two subjects were removed because they were currently receiving treatment. This left a final N of 265 subjects for the analyses. *To whom all correspondence
should be addressed 361
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:“‘J’(-J
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.d!ysluapnls epeue330 [!aunoD ysJeasax [ea!pam e Kq palioddns sf1oqlv.Elsiyaq.J_--tuaura8p+uou~>v ,tzuaruouaqd Kla!xue[ea!u![3uou 30 sur~o3Jaqlo WOJJ luala#!pK[anb!unpue 30 iuapuadapu!s! Kl!A!$!suas Kla!xue.~aq~aq~uo lqnop autos~$83s1lnsa.I asaqJ ,la%ep [ED!sKqdlaho Kla!XU!2 ly~]Jo s[ana[q%!q pue s43elltr a!ued lualln3uo3~J!M pale!aosstz KpuanbaJ3 SZ?MKl!h!l!suas Kla!xueq&q ltzqlpun03 Kpnls IuasaJdaq) 'uo!sn[Duoau[ .&n!l!suasKia!xua01 uo!iqaJ u! suo~~~puosIeXparu sno!leAssasse01 palaal!paq p[no3 qaleasaJaJntna .saq%zpeaquo!sua$10 au@$u 1031uarulsa.r) lsedpaUoda2 (o/,s.oz) aAy ‘Kla!xua yeqo s[aAa[ qS!q JO 3!ued30 K~o~srqou lnq K@qfSUaS K$a!XW yi$y ql!~ s]>arqns ps_aql30 :%I!MO[[OJ aq$ pa[zaAale$ep asaql30 S!SK[eUy WtauxF2a~~[e%pauIlsed atuos~03 rs![xzq~e u!e$uo3saop I!1nq K[aA!sua)xa K;rols!q [e3!paur ssassz10u saop avd au .(auroJpuKs [a.Moqa[qEt+q ~%.a)suo!~!puo~~~lEUIosoq3Ksd 01 pariqaraq oqe Xew &n!l!suasK$a!xue$ey$a[q!ssods!$!‘K[~e[!ut!s ~!sK[eueluasa.td aqt U! apn[au!olala[duro3u!ool a~aMslaya!uEd:doldwKs-pal!lu![ uoe~epaq~‘K[a~eunyo3un '(0&5['[qspu'ale)I)sasuodsal Kia!xut: aJaAasOS[EaJl!q~!q~ serene 3!uBd uroldurbs-pal!ur![ aAvq KeuI s)safqnsKl!A!]!suas K$a!xueqZ!q leyla[q!ssodos[esf$1 '&86[ ‘Ja%aq[a!ds) KloluaAuIKla!xuy lp?JJ-alels aq, se q3ns Kla!xuel!es 30 alnseazu[auo!suaunp!unI!ql!.kt anI1p[oq IOU Keru s%u!puy asaqlpue Kla!xue~!e~ljoalnsuatu[euo!suauup!l[nuI e uIol3 a[easqnsB palaa[as Kpn)sluasa.xd aql lv!yl palou aq plnoqs I[.Kla!xutz ~!a~$30s[aAa[ q%q JO/PUP syaelle3!utd pallodalos[e si3acqns Kl!A!l!suasKla!xue q%q30 %[L lsouqe‘snqL.laFhp ["D!sKqd8u!uJa3uo3Kia!xue~!e~l~os[aaa[ q&q pallodalsy~iie a!ued30 Klo%s!qou $nq Kl!~!$!suas Kla!xueq%q qI!M slaacqns30%zp ~souqv .uop!sodolds!qi01 $.roddns autospua[sl[nsal S,dpn$S luasaxdaqlpUeKla!xueI!~~13ouo!punJeaq os[eKeurKl!ntl!suasKla!xut,lEtqlpa~sa8lns a,~eq(686[)'Iulap[a3ua![!? *sWcqns [E~!u![~uou u! syjeUE s!ued q~fhtpa@!aosse Kpuanbag s!d~!~p!suas &a!xue leg aP?3!pu! sj[nsal asaqA ~&!n!l!suas Xla!xuassa[pavodal oqM s$sacqns01 paxedruo3sqs~e 3!ued snoaualuods alnin3arzdp!iue0% K[axy a2or.U alaM sWqns Klla!l!suas Kla!xw q&q teqlpun03 Kpnls luasa.td ayl ‘IaAamoq ‘s%upuy l!aq$03 ~e[!ur!s X~XW 3!ued snoaueluods ~fl!rn SlDaFqnspapn[Xq K[uo oqM (0661)K[[~NDR pue [[auuoa Kq pallodal%~ZE aql ueql 3aql!qs! aJn8y s!q~ 'leadaed aq] u! S~~EJJE D!uad pallodadKpnis s!qlu! Kl!A!lysuas Kla!xue@q ql!m WaCqns 30 luaxad K135
.a[eDsqns Kla!xueJ!WI s!qluo (UC) ueazu a[drues[["Jaaoaql aAoqe uo!r+ap pn?pueis au0 lsea[ le paJo% sy~$$equadjo hrols!you mq K+t!l!suas K$a!xuey%!q Q!M(~&‘[@) SW~qnS 1930 L[ 'X[[e~y!%ds'sv~s aq$30 a[eDsqnsKla!xueJ!EJ$ .ta%uea[e+%qd aqr uo dnoB Kl!A!l!suas Kta!xw q%!q aql30 sasuodsalayl pau!uIexaaAt‘Kla!xue j!tzi Kq ~03 paluno33eaq *ql!uiQAyisuas .Qa!xuejeyluopsaX?ns (686[)5‘7vla p[~3ua![!~ Isalo& ,ct!ued snoauEluods30 a3uaJJnz?ao aql uo JO iea.4lsed aql u! J!uEd uo 'ay!p K[lue3y@!s IOU p!p sMa[qns K+++suas K:a!xueMO[ pur!uirnpam ,D!uedsnoaueluodsjo aXsai.xn330 ayl uo la&~!p ~[)UKJI@!S IOU p!pSl3a[qnS &i!l!SUaS &a!XUt! unupaur pu~q~!H'pa~aallo:,Kl!nU!~UO~'PO'O > d'e$+ =(1)ZX‘SqaWe3!uBd snoaueluods a.xnln3 %uped!a!lueK[alslapowIseal)u se pay!sse[a aJaM (o/,s'gz) slaafqnsKl!A!l!SUaS Kla!xueunuparu aqi 01 paleduroa(~~9.19)slz$qns Kl!A!l!suas Kla!xutz q$!q30 uo!llodoJdJaq8!qK[~uesy@$s v ~xa~lleD!ued pa)lodaJKl!A!$!suas K]a!xuBMO[ ql!~ sloafqns 0~1 L[uo 'pal3allos K]!nuyuoD‘[ooo'or d ‘~()'zz ==(I)$ ‘maA lsedaq1 II! S~X?W z!uedpa)lodaJ (%woz) slDa[qnsKl!ay!suas Ala!xuvunuparu aql 01 paJeduro3 (~0~0s) slaafqnsKl!A!l!suas K$a!xueq&q 30 uo!llodoJd laql!qK[JUEDY$~!S v .Kl!A!i!suas K$a!xut? 30 s[aAa[aq$ 03 uo!le[aJu! sy%$re.D!uad 30 aaua[zAaJdaql sluasaid[ a[qaA 2+@2ue aqj uf pau!qtuoaalaM sa[eutaj pun sa[eur‘~sv aql uo aaua3ag!p 3apU& lUe3ylU%!S ou SEM araQ asnz3a~ ‘[o&)'o> d '~L'LL=(I&% ‘SyZe~$\! D!ued Ilodal 01 K[ay![a;louiK[~U~~y~U~~S ara.ttsa[eucrd 'saJo3s Klatxua~psla%ut?a["3!sKqdlo[sv uo sa~ua~a~!p3apua~JUB~~!U@ ou aJa& aJaqJ,.dnoB K~!n!t!suas Kla!xuE MO[ aql uf s$sa{qns($48'9)8[pue ‘dnol%Kl!A!l!suas Aja!xueruntpam aql UC slaacqns(%E'zg)s9[ ‘dno& Kl!.q!suas Kla!xuEq&q aql u! suafqns (~~6'0~)28 am+ alaqL Q[.o[ =a~) 8p.z~SZM a[dLuasal!luaaqi 103 axons[sv ueazu au
89E
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
369
Norton, G. R., Cox, B. J. & Malan, J. (1991). Nonclinical panic attacks: A critical review. Clinical Psychology Review. In press. Norton, G. R., Dorward, J. & Cox, B. J. (1986) Factors associated with panic attacks in nonclinical subjects. Behavior Therapy, 17, 239-252. Peterson, R. A. & Reiss, S. (I 987). Test manual for fhe anxiety sensitivity index. Orland Park, Ill.: International Diagnostic Systems. Reiss, S. & McNally, R. J. (1985). The expectancy model of fear. In Reiss, S. & Bootzin, R. R. (Eds), Theorefical issues in behavior therapy. New York: Academic Press. Reiss, S., Peterson, R. A., Gursky, D. M. & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy, 24, l-8. Spielberger, C. C. (1983). Manualfor the sfate-fruit anxiety inuentory (Form V). Palo Alto, Calif.: Consulting Psychologists Press.
0005-7967/91 $3.00+O.OO
Printedin GreatBritain.All rightsreserved
Anxiety
CopyrightQ 1991PergamonPressplc
sensitivity
BRIAN J. COX,‘-~ * NORMAN
and nonclinical
panic attacks
S. ENDLER,’ G. RON NORTON’ and RICHARD P. SWINSON~
‘Department of Psychology, York University, 4700 Keele St., Toronto, Ontario, Canada M3J IP3, ‘Department of Psychology, Universiiy of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, Canada R3B 2E9 and ‘Anxiety Disorders Clinic, Clarke Institute of Psychiatry, 250 College St., Toronro, Omario, Canada MST IRS (Received 26 November 1990)
Summary-The present study examined anxiety sensitivity in relation to trait anxiety and the occurrence of nonclinical panic attacks in 265 subjects. Fifty percent of high anxiety sensitivity subjects reported panic attacks (both cued and spontaneous) in the past year. In addition, almost 42% of subjects with high anxiety sensitivity but no history of panic reported a high level of trait anxiety concerning physical danger. The results suggest that anxiety sensitivity is frequently not independent of other forms of anxiety.
A recent study by Donnell and McNally (1990) has investigated the relationship between anxiety sensitivity and nonclinical panic attacks. The purpose of their study was to determine whether anxiety sensitivity, or fear of anxiety symptoms (Reiss, Peterson, Gursky & McNally, 1986), was a result of panic attacks or whether anxiety sensitivity exists independently of panic experiences. The Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1987) and the Panic Attacks Questionnaire (PAQ; Norton, Dorward & Cox, 1986) were administered to 425 college students. The authors found that 32.4% of 68 subjects with high anxiety sensitivity reported at least one panic attack in the past year. Subjects with high anxiety sensitivity were significantly more likely to have concurrent panic attacks than subjects in the medium anxiety sensitivity group. Donnell and McNally concluded that because many subjects with high anxiety sensitivity did not report panic attacks, anxiety sensitivity could be acquired in ways other than panic experiences. The results of this study need to be interpreted with caution, however. First, only the occurrence of spontaneous panic attacks was assessed. The authors claimed this was done because unpredictable panic attacks are hypothesized by some to be important in the development of panic disorder. Yet, this study was conducted to investigate anxiety sensitivity and panic attacks, not panic disorder. Many, if not most, nonclinical subjects experience cued panic (for a review see Norton, Cox & Malan, 1991). Therefore, the prevalence of nonclinical panic was likely underestimated. The second limitation is based on criticisms of the anxiety sensitivity construct in general. Lilienfeld, Jacob and Turner (1989) have suggested that anxiety sensitivity and the AS1 are seriously confounded with trait anxiety. Donnell and McNally (1991) did not report using a trait anxiety measure in their study so this alternate hypothesis remains untested. The present study was designed to further investigate the relationship between anxiety sensitivity and nonclinical panic attacks and address the limitations of the Donnell and McNally study. Accordingly, both spontaneous and cued panic attacks were assessed using the PAQ. The trait form of the Endler Multidimensional Anxiety Scales (EMAS-T; Endler, Edwards & Vitelli, 1990) was chosen as the measure of trait anxiety. There is strong evidence, based on a factor analysis of over 2000 subjects’ responses (Endler, Parker, Bagby & Cox, 1991), that trait anxiety is multidimensional. The EMAS-T assesses four facets of trait anxiety: social evaluation, physical danger, ambiguous or novel situations, and daily routines (neutral). Because anxiety sensitivity is defined as a fear of anxiety symptoms based on the belief that they have harmful consequences, the trait anxiety subscale hypothesized to correspond with anxiety sensitivity was the Physical Danger (PD) subscale. Reiss and McNally (1985) originally hypothesized that anxiety sensitivity would interact with danger expectancy, among other factors, in the development of anxiety disorders. METHOD Subjects
Two hundred and sixty-five college students (105 females, 160 males) voluntarily completed a series of self-report measures for a study on clinical and nonclinical panic attacks (Cox, Endler & Swinson, 1991). The subjects’ mean age was 22.2 years (SD = 4.8). Materials
and procedures
All subjects completed the ASI (Peterson & Reiss, 1987), the EMAS (Endler, Edwards & Vitelli, 1991) and the PAQ (Norton et a/., 1986). Subjects were classified into high, medium, and low anxiety sensitivity groups using the same cutoff score criteria as Donnell and McNally (1990). Subjects were classified as nonclinical panickers if they reported at least one DSM-III-R (APA, 1987) defined panic attack in the past year with four or more DSM-III-R symptoms and were not currently receiving treatment for their panic. The percentage of subjects who reported spontaneous panic was also assessed using the PAQ as was the anticipation of spontaneous panic where 0 = never and 4 = very likely. Fourteen subjects were removed from the study because of incomplete information or limited symptom attacks and two subjects were removed because they were currently receiving treatment. This left a final N of 265 subjects for the analyses. *To whom all correspondence
should be addressed 361
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