Brk~t-. Rrs. T/w. Vol. 28. No. I, pp. 83-85. PrInted m Great Britain. All rights reserved
1990 CopyrIght
CASE HISTORIES Anxiety
sensitivity
AND SHORTER
c
0005.7967:90 53.00 + 0.00 1990 Pergamon Press plc
COMMUNICATIONS
and panic attacks in a nonclinical
population
CHRISTINA D. DONNELL and RICHARD J. MCNALLY* Unioersily of Health Sciences/The Chicago Medical School, Department of Psycholog.s, 3333 Green Bay Road, North Chicago. IL 60064-3095, U.S.A. (Received 24 May 1989)
Summary-In
the present study, we administered the Anxiety Sensitivity Index (ASI) and a modified version of the Panic Attack Questionnaire (PAQ) to 425 college students to determine whether high anxiety sensitivity (‘fear of fear’) occurs in the absence of a history of unpredictable (‘spontaneous’) panic attacks, or whether such attacks are a necessary precursor to high anxiety sensitivity. Based on their AS1 scores, subjects were assigned to either the high, medium, or low anxiety sensitivity groups. High anxiety sensitivity subjects more frequently reported both a personal and family history of panic than did subjects in the other groups. Nevertheless, two-thirds of the high anxiety sensitivity subjects had never experienced an unpredictable panic attack. This suggests that the fear of anxiety can be acquired in ways other than through personal experience with panic.
INTRODUCTION Anriety .vensiriri/y refers to fears of anxiety symptoms that are based on beliefs that these symptoms have harmful consequences (Reiss. Peterson, Gursky and McNally, 1986). Thus, a person with high anxiety sensitivity is likely to misinterpret a rapid heart rate as an impending heart attack, whereas a person with low anxiety sensitivity is likely to regard the same symptom as a benign indication of stress. Patients with panic disorder (Rapee, Antis and Barlow, 1988). agoraphobia (McNally and Lorenz, 1987), and posttraumatic stress disorder (McNally. Luedke, Besyner, Peterson, Bohm and Lips, 1987) are characterized by elevated scores on the Anxiety Sensitivity Index (ASI; Peterson and Reiss, 1987; Reiss et al., 1986). Hence, consistent with the ‘fear of fear’ hypothesis (Chambless, Caputo, Bright and Gallagher, 1984), patients who experience panic also express a pronounced fear of anxiety symptoms. It is unclear, however, whether the fear of anxiety is solely a result of panic attacks, or whether it may be acquired indirectly, such as through verbal transmission of misinformation (see Chambless and Goldstein, 1988; Reiss, 1988). If the latter occurs, then pre-existing beliefs about the harmfulness of anxiety symptoms (i.e. anxiety sensitivity) may constitute a cognitive risk factor for the development of panic disorder (McNally and Lorenz, 1987). Indeed, persons with such beliefs should be more likely than others to misinterpret certain bodily sensations catastrophically, and thereby panic (see Clark, 1986). In this study, we administered the ASI and a modified version of the Panic Attack Questionnaire (PAQ; Norton, Dorward and Cox, 1986) to 425 college students to assess anxiety sensitivity and unpredictable (‘spontaneous’) panic attacks. We used normative data (Peterson and Reiss, 1987) to classify Ss on the basis of their ASI scores into three groups: high anxiety sensitivity, medium anxiety sensitivity, and low anxiety sensitivity. We then compared these groups on the basis of panic history. and other variables relevant to the etiology of panic disorder. If high anxiety sensitivity is solely a result of having experienced unpredictable panic attacks, then Ss with elevated anxiety sensitivity with no history of panic should be rare or nonexistent. On the other hand, if the fear of anxiety may be acquired in ways other than through panic, then high anxiety sensitivity Ss with no history of panic should not be uncommon.
METHOD Subjeers The ASI and the PAQ were administered to 425 college students during several group from 17 to 64 yr old (M = 24.2 yr); 64% were women. Ss were unpaid volunteers.
testing sessions.
Ss ranged
in age
Measures Ansie1.v Sensiririt~~Index (ASI). The ASI is a 16-item questionnaire that measures the fear of anxiety (Reiss et al., 1986). Each item expresses a concern about a possible aversive consequence of anxiety symptoms. Items are rated on a 4-point Likert scale. with total scores ranging from 0 to 64. The normative mean is 17.8 (SD = 8.8; Peterson and Reiss, 1987). There are no sex differences. Patients with panic disorder with or without agoraphobia typically score in the mid-thirties (McNally, Foa and Donnell, 1989). Abundant evidence supports the construct validity of the ASI as a measure of the fear of anxiety and as a measure distinct from trait anxiety. These data are summarized elsewhere (e.g. Donnell and McNally, 1989; Holloway and McNally, 1987; Peterson and Reiss, 1987; Reiss, 1987). Chambless and Gracely (1989) and McNally (1989) have recently reported further data distinguishing the fear of anxiety from trait anxiety (cf. Lilienfeld. Jacob and Turner,
*To whom
all correspondence
should
be addressed. 83
CASE HISTORIES AND SHORTER
84
COMMUNICATIONS
1989). Moreover. although some theorists hold that trait anxiety has more explanatory force than anxiety sensitivity in explammg panic attacks (Lilienfeld ef al.. 1989). the trait anxiety explanation for panic appears circular. That is. it ‘explams’ the tendency for people to experience anxiety attacks by invoking the tendency to experience anxiety in general (i.e. high trait anxiety). In contrast, the anxiety sensitivity hypothesis holds that certain people believe that symptoms associated with anxiety have harmful consequences, and when they experience these symptoms. they tend to panic. Although both trait anxiety and anxiety sensitivity are dispositional constructs, only the latter is embedded in a theory that explains why someone might panic in response to symptoms that are not inherently threatening (Reiss and McNally, 1985: Reiss. Peterson and Gursky, 1988). Panic Allack Quesrionnaire (PAP). The PAQ provides information concerning Ss demographics. frequency and severity of panic symptoms. history of personal treatment for psychopathology, and family history of pamc (Norton, Cairns. Wozney and Malan, 1988; Norton e/ al.. 1986). PAQ validity data are summarized elsewhere (Norton PI al.. 1986). Because we were interested in unpredictable panic attacks, not those triggered by specific external cues, we revised the PAQ description of a panic attack to read as follows: A panick alrack is no apparent reason.
a
sudderl increase in physiological sensations accompanied by fear. that happens for These attacks seem to come ‘out of the blue’. Have you ever had one of these attacks?
Classification qf Ss Using recent normative AS1 data for college students (Peterson and Reiss. 1987). we classified Ss into three groups based on their ASI scores. High anxiefy sensiricity Ss had scores of 27 or higher (i.e. one standard deviation above the normative mean). medium anxiery sensitivity Ss had scores ranging from 10 through 26 (i.e. within one standard deviation either above or below the normative mean), and 10~’ anxiery sensitit,irx Ss had scores of 9 or lower (i.e. one standard deviation below the normative mean). Using PAQ data, we also classified Ss as either patlickers or nonpanickers. Panickers reported experiencing at least one unpredictable panic attack during the past 12 months, and gave intensity ratings of at least two (‘moderate’) on 5-point Likert scales ranging from 0 (‘does not occur’) to 4 (‘very severe’) for at least four of the 14 DSM-III-R panic symptoms (American Psychiatric Association, 1987). Although the PAQ symptom checklist includes other non-DSM-II-R symptoms (e.g. “difficulty concentrating”; Norton ef al., 1986). we disregarded these in our assessment of panic. Nonpanickers reported never experiencing a panic attack. Ss who had experienced panic, but not during the past year. were excluded from the study. Ss who reported a panic attack. but did not meet the symptom frequency or intensity criteria. were also excluded.
RESULTS Of the 425 Ss surveyed, 66 (15.50/ o) were panickers. 323 (76.0%) were nonpanickers, and 36 (8.5%) were excluded from the study. Of the 36 excluded Ss, 33 reported limited symptom attacks. and three had experienced panic but not during the past 12 months. Among the 389 Ss who met inclusion criteria, 68 (17.5%) fell into the high anxiety sensitivity category, 262 (67.4%) fell into the medium anxiety sensitivity category. and 59 (15.2%) fell into the low anxiety sensitivity category. The proportion of Ss reporting panic was significantly greater in the high anxiety sensitivity group (32.4%) than in the medium anxiety sensitivity group (15.6%), [x’ (1) = 8.70. P < 0.003. Yates-corrected]. but the proportion of Ss reporting panic in the medium and low (5.1%) anxiety sensitivity groups did not differ, [x’ (1) = 0.72. NS. Yates-corrected]. These data replicate previous findings concerning the close association between anxiety sensitivity and panic (e.g. McNally and Lorenz. 1987). However. as shown in Table I, 46 of the 68 high anxiety sensitivity Ss (67.6%) had never experienced a panic attack. Fifteen of the 68 high anxiety sensitivity Ss had AS1 scores two standard deviations above the normative mean (i.e. at least 36). Of these Ss. nine were panickers and six were nonpanickers. These data demonstrate that the presence of high anxiety sensitivity does not require experience with unpredictable panic. These data also imply that fears of anxiety. like other fears (Rachman. 1977) can be acquired through multiple pathways. The high, medium. and low anxiety sensitivity groups were compared on self-reported treatment for psychopathology and on family history of panic. As shown in Table 2, a significantly greater proportion of high anxiety sensitivity Ss reported treatment for psychopathology than did medium anxiety sensitivity Ss [x’ (I) = 1 I .29. P < 0.0008. Yates-corrected]. No difference was found between medium and low anxiety sensitivity Ss. [x’ (I j = 2.24. P < 0.14, Yates-corrected]. Common treatment problems included stress-related disorders (e.g. ulcers or hypertension), anxiety disorders, depression. and alcohol or drug abuse.
I. Proportron
Table
of Ss reportmg
12 months Anxiety High
sensitivity
Hx
Hx = history.
0.1% The
denommator
tions was 389 (IX.
Table
2. Proportion a familv
Anxietv High
Medium Low
sensitivitv
( 2 27) (10-26)
(.7, 585-596. R&s S. (1988) Interoceptive theory of the fear of anxiety. Behao. 2%~. 19, 8485. Reiss S. and McNally R. J. (1985) Expectancy model of fear. In Theoregicuf &sues in &hat&r Therupy (Edited by Reiss S. and Boot&n R. R.). pp. 107-122. Academic Press. New York. Reiss S., Peterson R. A. and Gursky D. M. (1988) Anxiety sensitivity, injury sensitivity, and individual differences in fearfulness. Behar. Res. Ther. 26. 341-345. Reiss S.. Peterson R. A.. Gursky D. M. and McNally R. J. (1986) Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behar. Res. Ther. 24, l-8.
1990 CopyrIght
CASE HISTORIES Anxiety
sensitivity
AND SHORTER
c
0005.7967:90 53.00 + 0.00 1990 Pergamon Press plc
COMMUNICATIONS
and panic attacks in a nonclinical
population
CHRISTINA D. DONNELL and RICHARD J. MCNALLY* Unioersily of Health Sciences/The Chicago Medical School, Department of Psycholog.s, 3333 Green Bay Road, North Chicago. IL 60064-3095, U.S.A. (Received 24 May 1989)
Summary-In
the present study, we administered the Anxiety Sensitivity Index (ASI) and a modified version of the Panic Attack Questionnaire (PAQ) to 425 college students to determine whether high anxiety sensitivity (‘fear of fear’) occurs in the absence of a history of unpredictable (‘spontaneous’) panic attacks, or whether such attacks are a necessary precursor to high anxiety sensitivity. Based on their AS1 scores, subjects were assigned to either the high, medium, or low anxiety sensitivity groups. High anxiety sensitivity subjects more frequently reported both a personal and family history of panic than did subjects in the other groups. Nevertheless, two-thirds of the high anxiety sensitivity subjects had never experienced an unpredictable panic attack. This suggests that the fear of anxiety can be acquired in ways other than through personal experience with panic.
INTRODUCTION Anriety .vensiriri/y refers to fears of anxiety symptoms that are based on beliefs that these symptoms have harmful consequences (Reiss. Peterson, Gursky and McNally, 1986). Thus, a person with high anxiety sensitivity is likely to misinterpret a rapid heart rate as an impending heart attack, whereas a person with low anxiety sensitivity is likely to regard the same symptom as a benign indication of stress. Patients with panic disorder (Rapee, Antis and Barlow, 1988). agoraphobia (McNally and Lorenz, 1987), and posttraumatic stress disorder (McNally. Luedke, Besyner, Peterson, Bohm and Lips, 1987) are characterized by elevated scores on the Anxiety Sensitivity Index (ASI; Peterson and Reiss, 1987; Reiss et al., 1986). Hence, consistent with the ‘fear of fear’ hypothesis (Chambless, Caputo, Bright and Gallagher, 1984), patients who experience panic also express a pronounced fear of anxiety symptoms. It is unclear, however, whether the fear of anxiety is solely a result of panic attacks, or whether it may be acquired indirectly, such as through verbal transmission of misinformation (see Chambless and Goldstein, 1988; Reiss, 1988). If the latter occurs, then pre-existing beliefs about the harmfulness of anxiety symptoms (i.e. anxiety sensitivity) may constitute a cognitive risk factor for the development of panic disorder (McNally and Lorenz, 1987). Indeed, persons with such beliefs should be more likely than others to misinterpret certain bodily sensations catastrophically, and thereby panic (see Clark, 1986). In this study, we administered the ASI and a modified version of the Panic Attack Questionnaire (PAQ; Norton, Dorward and Cox, 1986) to 425 college students to assess anxiety sensitivity and unpredictable (‘spontaneous’) panic attacks. We used normative data (Peterson and Reiss, 1987) to classify Ss on the basis of their ASI scores into three groups: high anxiety sensitivity, medium anxiety sensitivity, and low anxiety sensitivity. We then compared these groups on the basis of panic history. and other variables relevant to the etiology of panic disorder. If high anxiety sensitivity is solely a result of having experienced unpredictable panic attacks, then Ss with elevated anxiety sensitivity with no history of panic should be rare or nonexistent. On the other hand, if the fear of anxiety may be acquired in ways other than through panic, then high anxiety sensitivity Ss with no history of panic should not be uncommon.
METHOD Subjeers The ASI and the PAQ were administered to 425 college students during several group from 17 to 64 yr old (M = 24.2 yr); 64% were women. Ss were unpaid volunteers.
testing sessions.
Ss ranged
in age
Measures Ansie1.v Sensiririt~~Index (ASI). The ASI is a 16-item questionnaire that measures the fear of anxiety (Reiss et al., 1986). Each item expresses a concern about a possible aversive consequence of anxiety symptoms. Items are rated on a 4-point Likert scale. with total scores ranging from 0 to 64. The normative mean is 17.8 (SD = 8.8; Peterson and Reiss, 1987). There are no sex differences. Patients with panic disorder with or without agoraphobia typically score in the mid-thirties (McNally, Foa and Donnell, 1989). Abundant evidence supports the construct validity of the ASI as a measure of the fear of anxiety and as a measure distinct from trait anxiety. These data are summarized elsewhere (e.g. Donnell and McNally, 1989; Holloway and McNally, 1987; Peterson and Reiss, 1987; Reiss, 1987). Chambless and Gracely (1989) and McNally (1989) have recently reported further data distinguishing the fear of anxiety from trait anxiety (cf. Lilienfeld. Jacob and Turner,
*To whom
all correspondence
should
be addressed. 83
CASE HISTORIES AND SHORTER
84
COMMUNICATIONS
1989). Moreover. although some theorists hold that trait anxiety has more explanatory force than anxiety sensitivity in explammg panic attacks (Lilienfeld ef al.. 1989). the trait anxiety explanation for panic appears circular. That is. it ‘explams’ the tendency for people to experience anxiety attacks by invoking the tendency to experience anxiety in general (i.e. high trait anxiety). In contrast, the anxiety sensitivity hypothesis holds that certain people believe that symptoms associated with anxiety have harmful consequences, and when they experience these symptoms. they tend to panic. Although both trait anxiety and anxiety sensitivity are dispositional constructs, only the latter is embedded in a theory that explains why someone might panic in response to symptoms that are not inherently threatening (Reiss and McNally, 1985: Reiss. Peterson and Gursky, 1988). Panic Allack Quesrionnaire (PAP). The PAQ provides information concerning Ss demographics. frequency and severity of panic symptoms. history of personal treatment for psychopathology, and family history of pamc (Norton, Cairns. Wozney and Malan, 1988; Norton e/ al.. 1986). PAQ validity data are summarized elsewhere (Norton PI al.. 1986). Because we were interested in unpredictable panic attacks, not those triggered by specific external cues, we revised the PAQ description of a panic attack to read as follows: A panick alrack is no apparent reason.
a
sudderl increase in physiological sensations accompanied by fear. that happens for These attacks seem to come ‘out of the blue’. Have you ever had one of these attacks?
Classification qf Ss Using recent normative AS1 data for college students (Peterson and Reiss. 1987). we classified Ss into three groups based on their ASI scores. High anxiefy sensiricity Ss had scores of 27 or higher (i.e. one standard deviation above the normative mean). medium anxiery sensitivity Ss had scores ranging from 10 through 26 (i.e. within one standard deviation either above or below the normative mean), and 10~’ anxiery sensitit,irx Ss had scores of 9 or lower (i.e. one standard deviation below the normative mean). Using PAQ data, we also classified Ss as either patlickers or nonpanickers. Panickers reported experiencing at least one unpredictable panic attack during the past 12 months, and gave intensity ratings of at least two (‘moderate’) on 5-point Likert scales ranging from 0 (‘does not occur’) to 4 (‘very severe’) for at least four of the 14 DSM-III-R panic symptoms (American Psychiatric Association, 1987). Although the PAQ symptom checklist includes other non-DSM-II-R symptoms (e.g. “difficulty concentrating”; Norton ef al., 1986). we disregarded these in our assessment of panic. Nonpanickers reported never experiencing a panic attack. Ss who had experienced panic, but not during the past year. were excluded from the study. Ss who reported a panic attack. but did not meet the symptom frequency or intensity criteria. were also excluded.
RESULTS Of the 425 Ss surveyed, 66 (15.50/ o) were panickers. 323 (76.0%) were nonpanickers, and 36 (8.5%) were excluded from the study. Of the 36 excluded Ss, 33 reported limited symptom attacks. and three had experienced panic but not during the past 12 months. Among the 389 Ss who met inclusion criteria, 68 (17.5%) fell into the high anxiety sensitivity category, 262 (67.4%) fell into the medium anxiety sensitivity category. and 59 (15.2%) fell into the low anxiety sensitivity category. The proportion of Ss reporting panic was significantly greater in the high anxiety sensitivity group (32.4%) than in the medium anxiety sensitivity group (15.6%), [x’ (1) = 8.70. P < 0.003. Yates-corrected]. but the proportion of Ss reporting panic in the medium and low (5.1%) anxiety sensitivity groups did not differ, [x’ (1) = 0.72. NS. Yates-corrected]. These data replicate previous findings concerning the close association between anxiety sensitivity and panic (e.g. McNally and Lorenz. 1987). However. as shown in Table I, 46 of the 68 high anxiety sensitivity Ss (67.6%) had never experienced a panic attack. Fifteen of the 68 high anxiety sensitivity Ss had AS1 scores two standard deviations above the normative mean (i.e. at least 36). Of these Ss. nine were panickers and six were nonpanickers. These data demonstrate that the presence of high anxiety sensitivity does not require experience with unpredictable panic. These data also imply that fears of anxiety. like other fears (Rachman. 1977) can be acquired through multiple pathways. The high, medium. and low anxiety sensitivity groups were compared on self-reported treatment for psychopathology and on family history of panic. As shown in Table 2, a significantly greater proportion of high anxiety sensitivity Ss reported treatment for psychopathology than did medium anxiety sensitivity Ss [x’ (I) = 1 I .29. P < 0.0008. Yates-corrected]. No difference was found between medium and low anxiety sensitivity Ss. [x’ (I j = 2.24. P < 0.14, Yates-corrected]. Common treatment problems included stress-related disorders (e.g. ulcers or hypertension), anxiety disorders, depression. and alcohol or drug abuse.
I. Proportron
Table
of Ss reportmg
12 months Anxiety High
sensitivity
Hx
Hx = history.
0.1% The
denommator
tions was 389 (IX.
Table
2. Proportion a familv
Anxietv High
Medium Low
sensitivitv
( 2 27) (10-26)
(.7, 585-596. R&s S. (1988) Interoceptive theory of the fear of anxiety. Behao. 2%~. 19, 8485. Reiss S. and McNally R. J. (1985) Expectancy model of fear. In Theoregicuf &sues in &hat&r Therupy (Edited by Reiss S. and Boot&n R. R.). pp. 107-122. Academic Press. New York. Reiss S., Peterson R. A. and Gursky D. M. (1988) Anxiety sensitivity, injury sensitivity, and individual differences in fearfulness. Behar. Res. Ther. 26. 341-345. Reiss S.. Peterson R. A.. Gursky D. M. and McNally R. J. (1986) Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behar. Res. Ther. 24, l-8.
