B&m. Rex.Thu. Vol.30,No. 1,pp. 1-5,1992 Printed in Great Britain. All rights reserved
PROBLEMS
0005-7967/92 $5.00+0.00 copyright
0
1991 Pergamon
Press plc
IN RECENT TESTS OF TWO COGNITIVE THEORIES OF PANIC CHARLES G. COSTELLO
Department of Psychology, University of Calgary, Calgary, Alberta, Canada T2N IN4 (Received
14 May 1991)
Summary-Four problems in five recent tests of two cognitive theories of panic arc discussed: (a) the ambiguity and indistinguishability of the ‘body sensations’ and ‘cognitions’ concepts; (b) the uncertain meaning bf ‘meaningfuirelationsgips’; (c) problkms arising from differences in Clark’s (Behaviour Research and Theraov. __ 9.47-59, 1978) ._. 24.461470. 1986) theorv and Goldstein and Chambless’ (Behavior Therapy, theory; (d) the ambiguit; of c&relatibnal data. Some desiderata for future research on these theories are proposed.
In two theories it has been proposed that cognitions play a causal role in panic attacks. Clark (1986) proposed that panic attacks result from the catastrophic misinterpretation of certain body sensations. He gave, as examples of catastrophic misinterpretations, “a healthy individual perceiving palpitations as evidence of impeding heart attack; perceiving a slight feeling of breathlessness as evidence of impending cessation of breathing and consequent death; or perceiving a shaky feeling as evidence of impending loss of control and insanity” (p. 462). Goldstein and Chambless (1978) proposed that panics are due to: (a) a fear of body sensations associated with panic; and (b) maladaptive thoughts about the consequences of becoming anxious. More recently (Chambless & Goldstein, 1988; Chambless, Beck, Gracely & Bibb, 1989), they have modified their theory to include the misinterpretations of somatic cues which do not arise from anxiety and have noted that this has made their theory more consistent with Clark’s theory. The theories are indeed quite similar in many respects. However, there is an important difference in that Goldstein and Chambless’s theory postulates that the causal mechanisms involve the fear of body sensations whereas Clark’s theory refers only to the occurrence of body sensations. This difference will be discussed more fully in a later section. Seligman (1988) and Teasdale (1988) have made some general and cogent criticisms of cognitive theories of panic. In this article I shall focus on five recent tests of these theories, those by Chambless, Beck, Gracely and Bibb (1989), Pollard and Frank (1990), Rachman, Levitt and Lopatka (1987), Street, Craske and Barlow (1989), and Warren, Zgourdides and Englert (1990).* One purpose of each of these studies was to examine the extent to which, during periods when they were panicking (or fearful in the Warren study), Ss would experience pairs of body sensations and cognitions. In all of the studies, except the one by Street where no predictions in this connection were made, it was specifically predicted that the Ss would experience combinations of body sensations and cognitions that could be considered meaningfully related, e.g. the sensations of heart palpitations and the thought that one is going to have a heart attack. However, there are four problems in these five studies which would appear to require attention before further tests of the two theories are conducted. These problems are: (a) the ambiguity and indistinguishability of the ‘body sensations’ and ‘cognitions’ concepts; (b) the uncertain meaning of ‘meaningful relationships’; (c) problems arising from the difference between Clark’s theory and Goldstein and Chambless’s theory; (d) the ambiguity of correlational data. I shall discuss these four problems in turn and, in a concluding section, I shall comment on the lack of consistency in the findings of the five studies and propose some desiderata for further research in this area.
*In the remainder of this article, these five studies will usually be identified by the name of the senior author. BRT30/!--A
1
CHARLES G. COSTELLO
2
Ambiguity
and indistinguishability
of the ‘body sensations ’ and ‘cognitions ’ concepts
What exactly is being measured by the measures of body sensations and cognitions used in the five studies is not clear. For instance, in Rachman’s study, the Ss had to indicate on two checklists which body sensations and which cognitions they had experienced when they had been placed in a feared situation by the experimenter. The self-reports of body sensations were obtained by means of the list of symptoms in the diagnostic criteria for Panic Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric Association, 1980). These symptoms include items such as ‘dizziness’, which would indeed appear to be a body sensation and ‘fear of dying’ which most people would probably not consider to be a body sensation, not, at least, in the same sense as ‘dizziness’. It is also by no means certain that the measures of body sensations and cognitions are measuring different variables. In Rachman’s study, the self-reports of cognitions were obtained by a lo-item shortened version of the Agoraphobics Cognitions Questionnaire (Chambless, Caputo, Bright & Gallagher, 1984) which included items such as ‘I am going to pass out’ and ‘I am going to suffocate’. Why are these called cognitions? Ss who have been in a fearful situation may check these items in order to indicate that they had experiences of being on the verge of passing out and suffocating. But then would they not simply be wishing to convey that they had experienced certain body sensations rather than certain thoughts? Similarly, in Pollard’s investigation, if someone checks the item, ‘I will faint’ on the cognitions list to indicate that it is an experience they have when they panic and if they also check on the physical symptoms list that the sensation of ‘faintness’ occurs, can they really be said to be referring to two different and related phenomena, one in the physical sensations realm and the other in the realm of cognitions? Is ‘nausea’ in Pollard’s physical symptoms list referring to a different experience than the experience referred to by ‘I am going to throw up’ on the cognitions list? Suspicion that the body sensations and cognition concepts in these studies are indistinguishable is increased when one examines the results of the Chambless study. In a factor analysis of the items of the Agoraphobic Cognitions Questionnaire and Body Sensations Questionnaire (Chambless et al., 1984) which had been administered to 142 agoraphobic outpatients they found that semantically related descriptions of body sensations and cognitions loaded on the same factors. For instance, on Factor 1 the cognition ‘I am going to have a heart attack’ had a high loading as did the body sensations ‘heart palpitations’ and ‘pressure in chest’. On Factor 2, there was a high loading for the cognition ‘I am going to pass out’ and the body sensation ‘dizziness’. On Factor 3, the cognition ‘I am going to throw up’ had a high loading as did the body sensation ‘nausea’. Similar results were found for anxious outpatients without panic disorder and normal volunteers. Chambless and her colleagues interpret their findings as being supportive of theories which postulate that one cause of panic is the catastrophic misinterpretation of body sensations. But a more plausible interpretation is that self-report items such as ‘I am going to throw up’ and ‘nausea’ simply denote the same experience. The uncertain
meaning
of ‘meaninaful
relationships ’
In none of the five studies being discussed has the meaning of a meaningful relationship between body sensations and cognitions been spelled out and in only two of the studies (Chambless and Pollard) have the researchers specifically predicted which pairs of body sensations and cognitions could be considered meaningfully linked and therefore would be significantly correlated. In Rachman’s study it was found that, of the 140 correlations calculated between the 14 bodily sensations and 10 cognitions, 7 (5%) were significant for panic-disorder patients and 17 (12%) for claustrophobic Ss. Rachman and his colleagues noted that “In most instances the relationships between the bodily symptoms and cognitions are meaningful”. But deciding which of the significant correlations presented in their Tables 1 and 3 reflect meaningful links is not an easy task. First of all, there is the question of the appropriateness of one of the cognitions. Of the seven significant correlations for the panic-disorder patients, three of the body sensations are significantly correlated with the cognition ‘I am going to panic’. The legitimacy of including this cognition when it is the cause of panic itself that one is trying to identify is questionable. The cognition ‘I am going to pass out’ was significantly correlated with the body sensations ‘choking’, ‘ faintness’, and ‘depersonalization’. The first two correlations would seem to reflect the strength of a linkage that is meaningful
Two cognitive theories of panic
3
in a common use of the word but there would not seem to be any compelling reason to consider as meaningful the link between depersonalization and ‘I am going to pass out’. The same could be said of another of the seven significant correlations for the panic disorder patients-that between the cognition ‘I am going to lose control’ and the sensation ‘shortness of breath’. Examination of the 17 significant correlations reported for the claustrophic Ss in Table 3 of Rachman’s study suggests that only 5 of them reflect links that are likely to be called meaningful by most people. It is clear that, even if independent measures of body sensations and cognitions could be designed, the problem of which links could be considered ‘meaningful’ and which could not have to be addressed by the development of a firm definition of ‘meaningfulness’ and by studies to ensure that judges could reliably use the definition. Problems arising from the d@erence between Clark’s theory and Goldstein and Chambless’ theory
As noted previously, Chambless et al. (1989) consider their revised theory to be similar to Clark’s theory because it recognises the possibility that panic may be caused by the catastrophic misinterpretation of body sensations that are not associated with anxiety. However, whereas Clark simply proposes that panic occurs when the occurrence of certain body sensations is accompanied by catastrophic misinterpretations of those sensations, Goldstein and Chambless propose that panic occurs when there is a fear of certain body sensations accompanied by catastrophic misinterpretations of the sensations. Therefore, Goldstein and Chambless’ theory is a less pure cognitive theory than Clark’s theory in that one component of their theory involves the affective concept of fear. The five studies being reviewed also differ in the degree to which they are pure tests of the cognitive causes of panic. The studies by Rachman and by Pollard are more pure in this sense in that their subjects were simply asked to indicate the extent to which, when they were panicking, certain body sensations and cognitions occurred. In Chambless’ and Warren studies the Ss did simply have to indicate how often the cognitions occurred when they were panicking or anxious. But on the body sensations list they had to indicate how frightened they were by the body sensations when they were panicking or anxious. In Street’s study affective variables appear to be introduced in relation to both body sensations and cognitions in that the Ss had to indicate how frightened they were by the body sensations and how disturbed they were by the cognitions. The problem of the ambiguity of correlational data
Rachman found that: (a) panics that were accompanied by fearful cognitions (i.e. cognitive panics) were also accompanied by more body sensations than were non-cognitive panics; and (b) that, when the researchers selected combinations of 2 or 3 of the most common body sensations and matched them with each of the 10 cognitions, no panics were reported if the combination of sensations occurred without an associated cognition. But even if one had grounds for assuming that the constructs ‘panic’, ‘body sensations’ and ‘cognitions’ are independent ones that are being independently measured, the problem still remains of what is causing what. Rachman and his colleagues appear to believe that fearful cognitions increase the bodily sensations and increase the likelihood of panic occurring. For instance, they wrote “No panics were reported unless there was an associated cognition. When they were associated with a panic cognition. . . (the) combinations of symptoms ended in a panic in most instances. So, for example, the combination of breathlessness and dizziness plus a cognition (pass out, lose control, panic) ended in panic on 11 out of 13 occasions; but in all of the no-panic trials with this combination of symptoms, there was no associated panic cognition” (Rachman et al., 1987, p. 418). But other possible interpretations are obvious. For instance, higher levels of bodily sensations may increase both the likelihood of fearful cognitions and the experience of panic without the cognitions playing any casual role. CONCLUSION
Because the meaning of ‘meaningful relationships’ between body sensations and cognitions has not been clearly defined and because the measurements of body sensations and cognitions are not clearly distinguishable one might have predicted that the conceptual framework for the tests of the
4
CHARLFS G. COSTELLO
catastrophic misinterpretation theories would be loose enough to produce consistency on the findings of the studies. However, there is a surprising lack of consistency in the findings from the five studies reviewed. Not one pair of body sensations and cognitions resulted in a significant correlation in all five studies even when one takes into consideration obviously synonymous items that are differently worded. For instance, the body sensation ‘shortness of breath’ and the cognition ‘I will pass out’ were significantly correlated in Chambless’ study and in Warren’s study and the body sensation ‘difficulty in breathing’ and ‘I will faint’ were correlated in Pollard’s study. But the body sensation ‘shortness of breath’ and the cognition ‘I will pass out’ were not significantly correlated in either Rachman’s study or Street’s study. For these body sensations and cognitions then the correlations were significant in only three of the five studies. But this hit rate might be considered good when one takes into account that only one other body sensation/cognition pair (i.e. the body sensation ‘faintness’ and the cognition ‘I will pass out’ or ‘I will faint’) were significantly correlated in three of the five studies (Rachman, Pollard and Street). Of the 84 pairs of body sensations and cognitions that were significantly correlated in one or other of the five studies, none were significant in all five or even four out of five of the studies; as noted above, two pairs were significantly correlated in three studies, though not the same three studies, 17 pairs were significantly correlated in two studies, though not the same two studies and 65 pairs in only one or other of the five studies. Perhaps, then, the conceptual framework of the two theories is too loose. The difference between the two theories may be more crucial than it seems and the manner in which the catastrophic misinterpretation idea was tested in the five studies reviewed may not be as comparable as they seem. It would be desirable if further research paid some attention to the following issues: (a) the construct and discriminant validity of self-report measures of body sensations and cognitions must be firmly established; (b) as Seligman (1988) and McNally (1990) have noted what counts as a catastrophic misinterpretation must be established; (c) a clear definition of ‘meaningful relationships’ between body sensations and cognitions must be formulated and evidence should be obtained that judges can reliably use the definition for the classification of relationships; (d) some consideration should be given to the possibility that some of the relationships between body sensations and cognitions will not be meaningful. Pollard and Frank (1990) noted that in their study “Despite the many physical symptoms associated with panic attacks, concern about psychological catastrophe (e.g. ‘I will lose control’ and ‘I will embarrass myself) appears to be a more usual feature of agoraphobic panic than does concern about medical or physical incapacitation” (p, 13). The links between body sensations and thoughts about what Pollard and Frank call psychological catastrophe may not always, or even usually, be meaningful. In Rachman’s study significant correlations were found between: thoughts of ‘losing control’ and each of the following body sensations-‘palpitations’, ‘sweating’, and ‘flushes/chills’; In Street’s study significant correlations were found between thoughts of screaming and each of the following body sensations-‘faintness’, ‘wobbly legs’, ‘sweating’ and ‘knots in stomach’. (e) specific predictions should be made as to which correlations between body sensations and cognitions are expected to be significant. (I) because of the difficulties in arriving at any conclusions concerning causal processes on the basis of correlational data priority should be given to experimental studies in which body sensations and cognitions are manipulated. Whether experimental or non-experimental studies are conducted measurements of body sensations and cognitions should be done concurrently with their occurrence rather than retrospectively; (g) a good understanding of the nature of body sensations may assist us in understanding their role, along with other phenomena such as cognitions, in causing panic and other experiences of fear and anxiety. Therefore, physiological processes should be objectively measured, not to replace the subjective reports of body sensations but to determine the relationship between the objective and subjective measures.
Two cognitive
theories
of panic
5
(h) unless one catastrophic misinterpretation theory of panic emerges the difference between Clark’s theory and Goldstein and Chambless’ theory will have to be kept in mind. This is not always done at present. For instance, Chambless et al. (1989) wrote that one of the purposes of their investigation was to determine, whether, as predicted by Clark (1986), agoraphobics’ self-reported fear of somatic symptoms (by which, presumably, they mean body sensations) would be reliably associated with logically related catastrophic cognitions. But Clark’s theory refers to the occurrence of body sensations and to the fear of such sensations. In general, there appears to be a lot of conceptual tightening-up required before cognitive theories of panic and other experiences of fear and anxiety can be adequately tested. REFERENCES American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd edn). Washington, D.C.: American Psvchiatric Association. Chambless, D. L. & Goldstein, A. J. (1988). Fear of fear: A reply to Reiss. Behaoior Therapy, 19, 85-88. Chambless, D. L., Beck, A. T., Gracely, E. J. & Bibb, J. L. (1989). The relationship of cognitions to fear of somatic symptoms: A test of the cognitive theory of panic. Unpublished manuscript. Chambless, D. L., Caputo, G. C., Bright, P. & Gallagher, R. (1984). Assessment of fear in agoraphobics: The Body Sensations Ouestionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, _ _ 52, 109&1097. Clark, D. M. (1986). A cognitive approach to panic. Eehauiour Research and Therapy, 24, 461470. Goldstein, A. J. & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47-59. McNally, R. J. (1990). Psychological approaches to panic disorder: A review. Psychological Bulletin, 108, 403419. Pollard, C. A. & Frank, M. A. (1990). Catastrophic cognitions and physical sensations of panic attacks associated with agoraphobia. Phobia Practice and Research Journal, 3, 3-18. Rachman, S., Levitt, K. & Lopatka, C. (1987). Panic: The links between cognitions and bodily symptoms-l. Rehauiour Research and Therapy, 25, 411423. Seligman, M. E. P. (1988). Competing theories of panic. In Rachman, S. & Maser, P. D. (Eds), Panic: Psychological perspectives. Hillsdale, N.J.: Erlbaum. Street, L. L., Craske, M. G. & Barlow, D. H. (1989). Sensations, cognitions and the perception of cues associated with expected and unexpected panic attacks. Behauiour Research and Therapy, 27, 189-198. Teasdale, J. (1988). Cognitive models and treatments for panic: A critical evaluation. In Rachman, S. & Maser, J. D. (Eds), Panic: Psychological perspectives. Hillsdale, N.J.: Erlbaum. Warren, R., Zgourides, G. & Englert, M. (1990). Relationship between catastrophic cognitions and body sensations in anxiety disordered, mixed diagnosis and normal subjects. Behauiour Research and Therapy, 28, 355-357.
PROBLEMS
0005-7967/92 $5.00+0.00 copyright
0
1991 Pergamon
Press plc
IN RECENT TESTS OF TWO COGNITIVE THEORIES OF PANIC CHARLES G. COSTELLO
Department of Psychology, University of Calgary, Calgary, Alberta, Canada T2N IN4 (Received
14 May 1991)
Summary-Four problems in five recent tests of two cognitive theories of panic arc discussed: (a) the ambiguity and indistinguishability of the ‘body sensations’ and ‘cognitions’ concepts; (b) the uncertain meaning bf ‘meaningfuirelationsgips’; (c) problkms arising from differences in Clark’s (Behaviour Research and Theraov. __ 9.47-59, 1978) ._. 24.461470. 1986) theorv and Goldstein and Chambless’ (Behavior Therapy, theory; (d) the ambiguit; of c&relatibnal data. Some desiderata for future research on these theories are proposed.
In two theories it has been proposed that cognitions play a causal role in panic attacks. Clark (1986) proposed that panic attacks result from the catastrophic misinterpretation of certain body sensations. He gave, as examples of catastrophic misinterpretations, “a healthy individual perceiving palpitations as evidence of impeding heart attack; perceiving a slight feeling of breathlessness as evidence of impending cessation of breathing and consequent death; or perceiving a shaky feeling as evidence of impending loss of control and insanity” (p. 462). Goldstein and Chambless (1978) proposed that panics are due to: (a) a fear of body sensations associated with panic; and (b) maladaptive thoughts about the consequences of becoming anxious. More recently (Chambless & Goldstein, 1988; Chambless, Beck, Gracely & Bibb, 1989), they have modified their theory to include the misinterpretations of somatic cues which do not arise from anxiety and have noted that this has made their theory more consistent with Clark’s theory. The theories are indeed quite similar in many respects. However, there is an important difference in that Goldstein and Chambless’s theory postulates that the causal mechanisms involve the fear of body sensations whereas Clark’s theory refers only to the occurrence of body sensations. This difference will be discussed more fully in a later section. Seligman (1988) and Teasdale (1988) have made some general and cogent criticisms of cognitive theories of panic. In this article I shall focus on five recent tests of these theories, those by Chambless, Beck, Gracely and Bibb (1989), Pollard and Frank (1990), Rachman, Levitt and Lopatka (1987), Street, Craske and Barlow (1989), and Warren, Zgourdides and Englert (1990).* One purpose of each of these studies was to examine the extent to which, during periods when they were panicking (or fearful in the Warren study), Ss would experience pairs of body sensations and cognitions. In all of the studies, except the one by Street where no predictions in this connection were made, it was specifically predicted that the Ss would experience combinations of body sensations and cognitions that could be considered meaningfully related, e.g. the sensations of heart palpitations and the thought that one is going to have a heart attack. However, there are four problems in these five studies which would appear to require attention before further tests of the two theories are conducted. These problems are: (a) the ambiguity and indistinguishability of the ‘body sensations’ and ‘cognitions’ concepts; (b) the uncertain meaning of ‘meaningful relationships’; (c) problems arising from the difference between Clark’s theory and Goldstein and Chambless’s theory; (d) the ambiguity of correlational data. I shall discuss these four problems in turn and, in a concluding section, I shall comment on the lack of consistency in the findings of the five studies and propose some desiderata for further research in this area.
*In the remainder of this article, these five studies will usually be identified by the name of the senior author. BRT30/!--A
1
CHARLES G. COSTELLO
2
Ambiguity
and indistinguishability
of the ‘body sensations ’ and ‘cognitions ’ concepts
What exactly is being measured by the measures of body sensations and cognitions used in the five studies is not clear. For instance, in Rachman’s study, the Ss had to indicate on two checklists which body sensations and which cognitions they had experienced when they had been placed in a feared situation by the experimenter. The self-reports of body sensations were obtained by means of the list of symptoms in the diagnostic criteria for Panic Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric Association, 1980). These symptoms include items such as ‘dizziness’, which would indeed appear to be a body sensation and ‘fear of dying’ which most people would probably not consider to be a body sensation, not, at least, in the same sense as ‘dizziness’. It is also by no means certain that the measures of body sensations and cognitions are measuring different variables. In Rachman’s study, the self-reports of cognitions were obtained by a lo-item shortened version of the Agoraphobics Cognitions Questionnaire (Chambless, Caputo, Bright & Gallagher, 1984) which included items such as ‘I am going to pass out’ and ‘I am going to suffocate’. Why are these called cognitions? Ss who have been in a fearful situation may check these items in order to indicate that they had experiences of being on the verge of passing out and suffocating. But then would they not simply be wishing to convey that they had experienced certain body sensations rather than certain thoughts? Similarly, in Pollard’s investigation, if someone checks the item, ‘I will faint’ on the cognitions list to indicate that it is an experience they have when they panic and if they also check on the physical symptoms list that the sensation of ‘faintness’ occurs, can they really be said to be referring to two different and related phenomena, one in the physical sensations realm and the other in the realm of cognitions? Is ‘nausea’ in Pollard’s physical symptoms list referring to a different experience than the experience referred to by ‘I am going to throw up’ on the cognitions list? Suspicion that the body sensations and cognition concepts in these studies are indistinguishable is increased when one examines the results of the Chambless study. In a factor analysis of the items of the Agoraphobic Cognitions Questionnaire and Body Sensations Questionnaire (Chambless et al., 1984) which had been administered to 142 agoraphobic outpatients they found that semantically related descriptions of body sensations and cognitions loaded on the same factors. For instance, on Factor 1 the cognition ‘I am going to have a heart attack’ had a high loading as did the body sensations ‘heart palpitations’ and ‘pressure in chest’. On Factor 2, there was a high loading for the cognition ‘I am going to pass out’ and the body sensation ‘dizziness’. On Factor 3, the cognition ‘I am going to throw up’ had a high loading as did the body sensation ‘nausea’. Similar results were found for anxious outpatients without panic disorder and normal volunteers. Chambless and her colleagues interpret their findings as being supportive of theories which postulate that one cause of panic is the catastrophic misinterpretation of body sensations. But a more plausible interpretation is that self-report items such as ‘I am going to throw up’ and ‘nausea’ simply denote the same experience. The uncertain
meaning
of ‘meaninaful
relationships ’
In none of the five studies being discussed has the meaning of a meaningful relationship between body sensations and cognitions been spelled out and in only two of the studies (Chambless and Pollard) have the researchers specifically predicted which pairs of body sensations and cognitions could be considered meaningfully linked and therefore would be significantly correlated. In Rachman’s study it was found that, of the 140 correlations calculated between the 14 bodily sensations and 10 cognitions, 7 (5%) were significant for panic-disorder patients and 17 (12%) for claustrophobic Ss. Rachman and his colleagues noted that “In most instances the relationships between the bodily symptoms and cognitions are meaningful”. But deciding which of the significant correlations presented in their Tables 1 and 3 reflect meaningful links is not an easy task. First of all, there is the question of the appropriateness of one of the cognitions. Of the seven significant correlations for the panic-disorder patients, three of the body sensations are significantly correlated with the cognition ‘I am going to panic’. The legitimacy of including this cognition when it is the cause of panic itself that one is trying to identify is questionable. The cognition ‘I am going to pass out’ was significantly correlated with the body sensations ‘choking’, ‘ faintness’, and ‘depersonalization’. The first two correlations would seem to reflect the strength of a linkage that is meaningful
Two cognitive theories of panic
3
in a common use of the word but there would not seem to be any compelling reason to consider as meaningful the link between depersonalization and ‘I am going to pass out’. The same could be said of another of the seven significant correlations for the panic disorder patients-that between the cognition ‘I am going to lose control’ and the sensation ‘shortness of breath’. Examination of the 17 significant correlations reported for the claustrophic Ss in Table 3 of Rachman’s study suggests that only 5 of them reflect links that are likely to be called meaningful by most people. It is clear that, even if independent measures of body sensations and cognitions could be designed, the problem of which links could be considered ‘meaningful’ and which could not have to be addressed by the development of a firm definition of ‘meaningfulness’ and by studies to ensure that judges could reliably use the definition. Problems arising from the d@erence between Clark’s theory and Goldstein and Chambless’ theory
As noted previously, Chambless et al. (1989) consider their revised theory to be similar to Clark’s theory because it recognises the possibility that panic may be caused by the catastrophic misinterpretation of body sensations that are not associated with anxiety. However, whereas Clark simply proposes that panic occurs when the occurrence of certain body sensations is accompanied by catastrophic misinterpretations of those sensations, Goldstein and Chambless propose that panic occurs when there is a fear of certain body sensations accompanied by catastrophic misinterpretations of the sensations. Therefore, Goldstein and Chambless’ theory is a less pure cognitive theory than Clark’s theory in that one component of their theory involves the affective concept of fear. The five studies being reviewed also differ in the degree to which they are pure tests of the cognitive causes of panic. The studies by Rachman and by Pollard are more pure in this sense in that their subjects were simply asked to indicate the extent to which, when they were panicking, certain body sensations and cognitions occurred. In Chambless’ and Warren studies the Ss did simply have to indicate how often the cognitions occurred when they were panicking or anxious. But on the body sensations list they had to indicate how frightened they were by the body sensations when they were panicking or anxious. In Street’s study affective variables appear to be introduced in relation to both body sensations and cognitions in that the Ss had to indicate how frightened they were by the body sensations and how disturbed they were by the cognitions. The problem of the ambiguity of correlational data
Rachman found that: (a) panics that were accompanied by fearful cognitions (i.e. cognitive panics) were also accompanied by more body sensations than were non-cognitive panics; and (b) that, when the researchers selected combinations of 2 or 3 of the most common body sensations and matched them with each of the 10 cognitions, no panics were reported if the combination of sensations occurred without an associated cognition. But even if one had grounds for assuming that the constructs ‘panic’, ‘body sensations’ and ‘cognitions’ are independent ones that are being independently measured, the problem still remains of what is causing what. Rachman and his colleagues appear to believe that fearful cognitions increase the bodily sensations and increase the likelihood of panic occurring. For instance, they wrote “No panics were reported unless there was an associated cognition. When they were associated with a panic cognition. . . (the) combinations of symptoms ended in a panic in most instances. So, for example, the combination of breathlessness and dizziness plus a cognition (pass out, lose control, panic) ended in panic on 11 out of 13 occasions; but in all of the no-panic trials with this combination of symptoms, there was no associated panic cognition” (Rachman et al., 1987, p. 418). But other possible interpretations are obvious. For instance, higher levels of bodily sensations may increase both the likelihood of fearful cognitions and the experience of panic without the cognitions playing any casual role. CONCLUSION
Because the meaning of ‘meaningful relationships’ between body sensations and cognitions has not been clearly defined and because the measurements of body sensations and cognitions are not clearly distinguishable one might have predicted that the conceptual framework for the tests of the
4
CHARLFS G. COSTELLO
catastrophic misinterpretation theories would be loose enough to produce consistency on the findings of the studies. However, there is a surprising lack of consistency in the findings from the five studies reviewed. Not one pair of body sensations and cognitions resulted in a significant correlation in all five studies even when one takes into consideration obviously synonymous items that are differently worded. For instance, the body sensation ‘shortness of breath’ and the cognition ‘I will pass out’ were significantly correlated in Chambless’ study and in Warren’s study and the body sensation ‘difficulty in breathing’ and ‘I will faint’ were correlated in Pollard’s study. But the body sensation ‘shortness of breath’ and the cognition ‘I will pass out’ were not significantly correlated in either Rachman’s study or Street’s study. For these body sensations and cognitions then the correlations were significant in only three of the five studies. But this hit rate might be considered good when one takes into account that only one other body sensation/cognition pair (i.e. the body sensation ‘faintness’ and the cognition ‘I will pass out’ or ‘I will faint’) were significantly correlated in three of the five studies (Rachman, Pollard and Street). Of the 84 pairs of body sensations and cognitions that were significantly correlated in one or other of the five studies, none were significant in all five or even four out of five of the studies; as noted above, two pairs were significantly correlated in three studies, though not the same three studies, 17 pairs were significantly correlated in two studies, though not the same two studies and 65 pairs in only one or other of the five studies. Perhaps, then, the conceptual framework of the two theories is too loose. The difference between the two theories may be more crucial than it seems and the manner in which the catastrophic misinterpretation idea was tested in the five studies reviewed may not be as comparable as they seem. It would be desirable if further research paid some attention to the following issues: (a) the construct and discriminant validity of self-report measures of body sensations and cognitions must be firmly established; (b) as Seligman (1988) and McNally (1990) have noted what counts as a catastrophic misinterpretation must be established; (c) a clear definition of ‘meaningful relationships’ between body sensations and cognitions must be formulated and evidence should be obtained that judges can reliably use the definition for the classification of relationships; (d) some consideration should be given to the possibility that some of the relationships between body sensations and cognitions will not be meaningful. Pollard and Frank (1990) noted that in their study “Despite the many physical symptoms associated with panic attacks, concern about psychological catastrophe (e.g. ‘I will lose control’ and ‘I will embarrass myself) appears to be a more usual feature of agoraphobic panic than does concern about medical or physical incapacitation” (p, 13). The links between body sensations and thoughts about what Pollard and Frank call psychological catastrophe may not always, or even usually, be meaningful. In Rachman’s study significant correlations were found between: thoughts of ‘losing control’ and each of the following body sensations-‘palpitations’, ‘sweating’, and ‘flushes/chills’; In Street’s study significant correlations were found between thoughts of screaming and each of the following body sensations-‘faintness’, ‘wobbly legs’, ‘sweating’ and ‘knots in stomach’. (e) specific predictions should be made as to which correlations between body sensations and cognitions are expected to be significant. (I) because of the difficulties in arriving at any conclusions concerning causal processes on the basis of correlational data priority should be given to experimental studies in which body sensations and cognitions are manipulated. Whether experimental or non-experimental studies are conducted measurements of body sensations and cognitions should be done concurrently with their occurrence rather than retrospectively; (g) a good understanding of the nature of body sensations may assist us in understanding their role, along with other phenomena such as cognitions, in causing panic and other experiences of fear and anxiety. Therefore, physiological processes should be objectively measured, not to replace the subjective reports of body sensations but to determine the relationship between the objective and subjective measures.
Two cognitive
theories
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(h) unless one catastrophic misinterpretation theory of panic emerges the difference between Clark’s theory and Goldstein and Chambless’ theory will have to be kept in mind. This is not always done at present. For instance, Chambless et al. (1989) wrote that one of the purposes of their investigation was to determine, whether, as predicted by Clark (1986), agoraphobics’ self-reported fear of somatic symptoms (by which, presumably, they mean body sensations) would be reliably associated with logically related catastrophic cognitions. But Clark’s theory refers to the occurrence of body sensations and to the fear of such sensations. In general, there appears to be a lot of conceptual tightening-up required before cognitive theories of panic and other experiences of fear and anxiety can be adequately tested. REFERENCES American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd edn). Washington, D.C.: American Psvchiatric Association. Chambless, D. L. & Goldstein, A. J. (1988). Fear of fear: A reply to Reiss. Behaoior Therapy, 19, 85-88. Chambless, D. L., Beck, A. T., Gracely, E. J. & Bibb, J. L. (1989). The relationship of cognitions to fear of somatic symptoms: A test of the cognitive theory of panic. Unpublished manuscript. Chambless, D. L., Caputo, G. C., Bright, P. & Gallagher, R. (1984). Assessment of fear in agoraphobics: The Body Sensations Ouestionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, _ _ 52, 109&1097. Clark, D. M. (1986). A cognitive approach to panic. Eehauiour Research and Therapy, 24, 461470. Goldstein, A. J. & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47-59. McNally, R. J. (1990). Psychological approaches to panic disorder: A review. Psychological Bulletin, 108, 403419. Pollard, C. A. & Frank, M. A. (1990). Catastrophic cognitions and physical sensations of panic attacks associated with agoraphobia. Phobia Practice and Research Journal, 3, 3-18. Rachman, S., Levitt, K. & Lopatka, C. (1987). Panic: The links between cognitions and bodily symptoms-l. Rehauiour Research and Therapy, 25, 411423. Seligman, M. E. P. (1988). Competing theories of panic. In Rachman, S. & Maser, P. D. (Eds), Panic: Psychological perspectives. Hillsdale, N.J.: Erlbaum. Street, L. L., Craske, M. G. & Barlow, D. H. (1989). Sensations, cognitions and the perception of cues associated with expected and unexpected panic attacks. Behauiour Research and Therapy, 27, 189-198. Teasdale, J. (1988). Cognitive models and treatments for panic: A critical evaluation. In Rachman, S. & Maser, J. D. (Eds), Panic: Psychological perspectives. Hillsdale, N.J.: Erlbaum. Warren, R., Zgourides, G. & Englert, M. (1990). Relationship between catastrophic cognitions and body sensations in anxiety disordered, mixed diagnosis and normal subjects. Behauiour Research and Therapy, 28, 355-357.
