Negative interpretations of distress-related information: A novel assessment tool for distress tolerance.

Distress tolerance (DT), defined as the perceived and/or actual behavioral capacity to tolerate negative emotional states, is considered an important risk factor for various externalizing and internalizing disorders. Despite the importance of DT in the development and maintenance of psychopathology, few reliable and valid indicators of DT have been developed. One potentially useful way to assess DT is through interpretation bias (IB) paradigms. The current study sought to examine the convergent validity, reliability, and clinical utility of a DT-focused IB paradigm by directly measuring an individual's interpretations of distressing information. Participants completed a DT-IB task and self-report questionnaires. Results found an association between DTS self-report and an exaggerated DT-IB. Reliability analyses found the word pairings in our DT-IB task to display good internal consistency. In addition, an exaggerated DT-IB was associated with diagnostic status after covarying for negative affect and self-report DTS and DT-IB was associated with increased levels of negative affect above and beyond self-report DTS. This study is the first to identify specific interpretation biases for distress-related information. Given the transdiagnostic nature of DT and the efficacy and accessibility associated with CBM-I protocols for related constructs, the present findings add considerably to a growing body of literature.

The anxiety sensitivity index: item analysis and suggestions for refinement.

Anxiety sensitivity is the fear of anxiety-related sensations, and is measured by the 16-item Anxiety Sensitivity Index (ASI). Despite the popularity and utility of the ASI in research, a number of studies have provided evidence for the inadequacy of several items, and item-to-scale correlations for the ASI have not been published. In this study, a converging set of analyses to evaluate the item adequacy and factor structure of the ASI was used. The results of these multiple analyses converged nicely suggesting that Items 1, 5, 7, 8, and 13 should be considered for removal from the instrument. The impact of removing these problematic items from the scale was explored through the reanalysis of data from 3 previously published studies that compared the original ASI with the new 11-item version (the ASI minus the 5 problematic items). The results of these analyses suggest that the 2 scales function comparably in many respects but that the new version may be a more precise measure of anxiety sensitivity. The 11-item ASI appears to tap 2 primary aspects of anxiety sensitivity: fears of somatic sensations of anxiety and fears of loss of mental control. Suggestions for further development of the ASI are offered.

Evaluating panic-specific factors in the relationship between suicide and panic disorder.

Work during the past decade has suggested an association between panic disorder and suicide (i.e., suicidal ideation and suicide attempts) that cannot simply be accounted for by co-occurring depression symptoms. To clarify the linkage between panic disorder and suicide, the association between panic-specific clinical and cognitive variables and suicide indicators were evaluated in patients with panic disorder (N=146). Analyses predicting the presence of suicidal ideation (positive, negative) after covarying the effects of a current mood disorder diagnosis and depression symptoms indicated a number of significant predictors including: (1) overall anxiety symptoms; (2) level of anticipatory anxiety; (3) avoidance of bodily sensations; (4) attentional vigilance toward bodily perturbations; and (5) phrenophobia (i.e., fear of cognitive incapacitation). Anxiety-specific variables did not account for unique variance in predicting prior history of suicide attempts.

Hopelessness depression as a distinct dimension of depressive symptoms among clinical and non-clinical samples.

Subtyping depression has been an interest of theorists and clinicians for at least four centuries. In this paper, we examined the validity of the symptom cluster component of the hopelessness theory of depression. We used structural equation modeling analyses on large samples of psychiatric outpatients (N=1604, 844, and 680) and Air Force cadets (N=1404) who completed the items of the Beck Depression Inventory (BDI). Findings were supportive of the hopelessness depression cluster as a distinct depressive syndrome. Implications for the nosology of depression and for depression theory were discussed.

Effects of heart-rate feedback on estimated cardiovascular fitness in patients with panic disorder.

Psychological parameters that are believed to affect estimations of cardiovascular fitness were examined in patients with panic disorder and nonclinical controls. Fifty-four participants [panic disorder patients (n = 27) and age- and sex-matched nonclinical controls (n = 27)] completed a cycle ergometer test and were compared on the basis of estimated VO2 max. Participants were randomly assigned to experimental conditions in which they received heart-rate feedback or no feedback during the test. Patients with panic disorder exhibited lower VO2 max and decreased exercise tolerance (i.e., were more likely to discontinue the test) than nonclinical controls. Furthermore, individuals with high anxiety sensitivity (i.e., a fear of autonomic arousal), but not a panic disorder diagnosis per se, achieved significantly lower VO2 max when provided with heart-rate feedback. Moreover, diagnostic status interacted with levels of anxiety sensitivity to predict VO2 max. Patients with panic disorder display poorer cardiovascular fitness after controlling for anxiety and other factors that underestimate performance during fitness testing.

Prospective evaluation of the etiology of anxiety sensitivity: test of a scar model.

A large body of research has suggested that anxiety sensitivity (AS) acts as a specific vulnerability factor in the development of anxiety pathology. More recently, attention has turned to the etiology of AS per se. The present study represents a specific test of a Scar model of AS. A Scar model posits that the experience of distress will affect the vulnerability factor. We were specifically interested in evaluating the effects of a specific stressor (spontaneous panic) as well as general distress on changes in AS over time. A large nonclinical sample of young adults (N = 1296) was prospectively followed over a five week highly stressful period of time (i.e. military basic training). Findings were consistent with the Scar model and suggested that the specific stressor of experiencing a panic attack as well as general stressors creating significant anxiety symptoms uniquely contributed to increased levels of AS (regardless of prior history of panic). Moreover, the experience of spontaneous panic in the context of generally low levels of distress (both anxiety and depression) appeared to be particularly pernicious in terms of resulting in greater increases in AS. In sum, anxiety-related stressors appear to have the potential to 'scar' individuals in regard to this cognitive vulnerability factor.

Differential roles of depressive and anxious symptoms and gender in defensiveness.

Among a sample of Air Force cadets facing the prospect of basic training (N= 1,190; 1,005 men and 185 women), the influence of a defensive test-taking style on measures of depressive and anxious symptoms was examined. Participants completed the Beck Depression Inventory (Beck & Steer, 1987) and the Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988), as well as the MMPI (Hathaway & McKinley, 1943) L scale. Results supported hypotheses that defensiveness would affect a self-report measure of depression but not a self-report measure of anxiety and would do so more among men than women. Applied implications of the results are discussed.

Dismantling cognitive-behavioral treatment for panic disorder: questioning the utility of breathing retraining.

Cognitive-behavioral treatment (CBT) protocols for panic disorder (PD) consist of a set of interventions that often includes some form of breathing retraining (BR). A controlled outcome study was designed to assess the necessity of BR in the context of a multicomponent CBT protocol. To accomplish this, patients with PD (N = 77) were randomly assigned to receive CBT with or without BR or to a delayed-treatment control. The main study hypothesis was that patients receiving BR would display a less complete recovery relative to the other active-treatment condition given that BR appears to be a more attractive (but less adaptive) option for some patients. Some data suggested that the addition of BR yielded a poorer outcome. However, findings were generally more consistent with treatment equivalence, questioning whether BR produces any incremental benefits in the context of other CBT interventions for PD.

Evaluating gene x psychological risk factor effects in the pathogenesis of anxiety: a new model approach.

The present study evaluated the singular and interactive effects of a functional polymorphism (variation) in the serotonin transporter (5-HTT) gene and a psychological trait (anxiety sensitivity [AS], i.e., fear of arousal symptoms) in predicting subjective and physiological responses to a 35% carbon dioxide (CO2) challenge in a community sample (N = 72). Genotypes were divided into 2 groups in accord with prior research. Findings were partially supportive of the hypothesized risk model. These indicated that the Group L genotype (homozygous for the 1 allele), compared with the Group S genotype (homozygous for the s allele plus heterozygous individuals), predicted greater fearful response to the biological challenge. There was also an AS x Genotype interaction predicting heart rate variability (HRV) in response to the CO2, suggesting that high AS plus Group L status predicts decreased HRV.

The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: quality versus quantity.

Cognitive-behavioral therapy (CBT) is skill based and assumes active patient participation in regard to treatment-related assignments. The effects of patient compliance in CBT outcome studies are equivocal, however, and 1 gap in the literature concerns the need to account for the quality versus the quantity of assigned work. In this study, both quality and quantity of home-based practice were assessed to better evaluate the effects of treatment compliance in patients with panic disorder (N = 48) who participated in a 12-session CBT protocol. Patient estimates of compliance were not significantly associated with most outcome measures. On the other hand, therapist ratings of compliance significantly predicted positive changes on most outcome measures. Moreover, therapist and independent rater estimates of the quality of the participant's work, relative to the quantity of the work, were relatively better predictors of outcome.

Prospective evaluation of anxiety sensitivity in the pathogenesis of panic: replication and extension.

Increasing evidence suggests that anxiety sensitivity (AS) may be a premorbid risk factor for the development of anxiety pathology. The principal aim of this study was to replicate and extend a previous longitudinal study evaluating whether AS acts as a vulnerability factor in the pathogenesis of panic (N. Schmidt, D. Lerew, & R. Jackson, 1997). A large nonclinical sample of young adults (N = 1,296) was prospectively followed over a 5-week, highly stressful period of time (i.e., military basic training). Consistent with the authors' initial study, AS predicted the development of spontaneous panic attacks after controlling for a history of panic attacks and trait anxiety, and AS was found to possess symptom specificity with respect to anxiety versus depression symptoms. AS 1st-order factors differentially predicted panic attacks, with the Mental Concerns factor being the best predictor of panic in this sample.

Evaluation of psychological risk factors: prospective prediction of psychopathology during basic training.

OBJECTIVE: Three theoretically derived cognitive risk factors were evaluated to determine whether they predicted the development of stress responding in the context of Basic Cadet Training (BCT). METHOD: A large sample of cadets (N = 1,401) was prospectively followed for the 5-week BCT period. RESULTS: All risk factors were found to significantly and independently predict the development of psychopathology and impairment as well as changes in symptoms during basic training. Risk factors conveyed approximately two to five times greater likelihood of experiencing clinically significant levels of symptoms at the end of BCT. CONCLUSIONS: These data provide strong evidence for three psychological risk factors in the development of anxiety and mood symptoms. Implications for screening and primary prevention are discussed.

Physiological hyperarousal: construct validity of a central aspect of the tripartite model of depression and anxiety.

Physiological hyperarousal (PH) is an understudied component of the tripartite model of depression and anxiety. This study contributes to the literature on PH, the tripartite model, and anxiety and its disorders, using data from psychotherapy outpatients (n = 2,448), air force cadets (n = 1,335), and undergraduates (n = 284). Psychometrics and exploratory and confirmatory factor analyses showed that PH is a reliable, cohesive, discriminable, and valid construct. Compared with subjective anxiety, PH was more associated to panic versus mood disordered status, and to panic versus generalized anxiety disordered status. As hypothesized, an aspect of anxiety sensitivity (i.e., fear of body sensations) was particularly related to subjective anxiety in the presence of PH. Results support the PH construct as replicable, valid, and clinically important and support the utility of the tripartite and related models for understanding the relation of depressive and anxious syndromes.

Effects of anxiety sensitivity on anxiety and pain during a cold pressor challenge in patients with panic disorder.

Fear of anxiety symptoms, or anxiety sensitivity (AS), has been extensively studied in anxiety disorders and more recently has been linked to other psychopathological conditions including pain. Asmundson and colleagues have suggested that AS may act as a risk factor for chronic pain and several studies have demonstrated an association between AS, avoidance behaviors and pain. The present study assessed whether AS levels would be predictive of pain and anxiety during a brief pain induction task. Clinical participants meeting DSM-IV criteria for panic disorder (n = 22) were age and sex matched with nonclinical controls (n = 22) and exposed to a 2-min cold pressor challenge. Diagnostic status and AS were significantly predictive of pain and anxiety during the cold pressor task. Moreover, AS appears to mediate the relationship between diagnostic status and pain. However, AS appears to be only indirectly associated with pain through its contribution to anxiety.

Factor structure of a measure of anxiety sensitivity in children.

Anxiety sensitivity (i.e., the disposition to react to autonomic arousal with fear) has taken a central role in recent conceptualizations of anxiety. However, questions regarding the dimensional nature of anxiety sensitivity remain. In particular, the factor structure of anxiety sensitivity is unexplored in nonadult populations. The factor structure of the Anxiety Sensitivity Index for Children (ASIC) was examined in three studies. Study 1 (N = 95) used a sample of school children in Grades 4-8 to investigate the reliability of items and factor structure. Items with weak psychometric properties were eliminated, and subsequent analyses revealed that the ASIC was best viewed as a hierarchical scale with a higher order factor (Anxiety Sensitivity) and two first-order factors (Fear of Physiological Arousal and Fear of Mental Catastrophe). Study 2 (N = 112) and Study 3 (N = 144) used more distressed samples of youngsters, and they also found the ASIC to be a hierarchical scale. These findings add a developmental perspective to the Anxiety Sensitivity Index factor analytic discussion and are highly consistent with emergent thinking in the adult anxiety sensitivity literature.

Excessive reassurance-seeking predicts depressive but not anxious reactions to acute stress.

The authors hypothesized that excessive reassurance-seeking would prospectively predict changes in depressive symptoms, even controlling for changes in anxious symptoms, and would not predict changes in anxious symptoms controlling for changes in depressive symptoms. This prediction was supported in a study of 1,005 air force cadets. Participants completed measures of excessive reassurance-seeking and depressive and anxious symptoms before basic training, and completed symptom measures again following basic training. This study, together with others, demonstrates that excessive reassurance-seeking is an important depression-related variable that deserves serious attention as a potential vulnerability factor.

Anxiety sensitivity and the pathogenesis of anxiety and depression: evidence for symptom specificity.

Expectancy theory posits that anxiety sensitivity (AS) acts as a specific risk factor for the development of anxiety pathology (Reiss, 1991). Previous work suggests that AS is a risk factor for anxiety but several reports have found that AS is also related to depression. The principal aim of the present study was to determine whether anxiety sensitivity acts as a specific vulnerability factor in the pathogenesis of anxiety and depression in both a large nonclinical sample (N = 1401) as well as a patient sample (N = 53). A covariance analytic strategy indicated that AS possesses symptom specificity with respect to anxiety but is not predictive of depression when accounting for changes in anxiety symptoms. Component analyses suggest, however, that one first-order factor (phrenophobia) is likely to account for the association between AS and depression because it is non-specific (i.e. associated with unique aspects of both anxiety and depression). It is concluded that much of the general association noted between anxiety sensitivity and depression is likely to be due to covariation among symptoms of anxiety and depression.

Extinction of panicogenic effects of a 35% CO2 challenge in patients with panic disorder.

Inhalations of high concentrations of carbon dioxide (CO2) reliably produce panic attacks in patients with panic disorder. The present study evaluated whether cognitive-behavioral treatment (CBT) for panic disorder would extinguish CO2-induced panic and whether changes in panic and arousal-related cognitions were associated with the induction of panic. Patients with panic disorder (N = 54) were assigned to 1 of 3 experimental conditions: CBT with respiratory training (CBT-R), CBT without respiratory training (CBT), or delayed treatment. Participants received 5 repeated vital-capacity inhalations of 35% CO2/65% O2 prior to and following either 12 treatment sessions or a 12-week waiting period. During pretreatment assessments, 74% of patients experienced a panic attack during at least 1 inhalation. At posttreatment, only 20% of treated participants (CBT-R = 19%, CBT = 22%), compared with 64% of untreated participants, panicked. Forty-four percent of treated participants, compared with 0% of untreated participants, reported no anxiety during all posttreatment inhalations. Anxiety sensitivity as well as panic appraisals regarding the likelihood of panic and self-efficacy with coping with panic were significantly related to fearful responding to the CO2 challenge.

The role of anxiety sensitivity in the pathogenesis of panic: prospective evaluation of spontaneous panic attacks during acute stress.

Expectancy theory posits that anxiety sensitivity may serve as a premorbid risk factor for the development of anxiety pathology (S. Reiss, 1991). The principal aim of the present study was to determine whether anxiety sensitivity acts as a specific vulnerability factor in the pathogenesis of anxiety pathology. A large, nonclinical sample of young adults (N = 1,401) was prospectively followed over a 5-week highly stressful period of time (i.e., military basic training). Anxiety sensitivity was found to predict the development of spontaneous panic attacks after controlling for a history of panic attacks and trait anxiety. Approximately 20% of those scoring in the upper decile on the Anxiety Sensitivity Index (R. A. Peterson & S. Reiss, 1987) experienced a panic attack during the 5-week follow-up period compared with only 6% for the remainder of the sample. Anxiety sensitivity also predicted anxiety symptomatology, functional impairment created by anxiety, and disability. These data provide strong evidence for anxiety sensitivity as a risk factor in the development of panic attacks and other anxiety symptoms.

Body vigilance in panic disorder: evaluating attention to bodily perturbations.

Body vigilance, consciously attending to internal cues, is a normal adaptive process. The present report investigated whether body vigilance is exaggerated among those with panic disorder, a condition characterized by intense fear and worry regarding bodily sensations. The Body Vigilance Scale is validated in nonclinical and anxiety disorder samples. Study 1 suggests that body vigilance is normally distributed in a nonclinical sample (n = 472) but vigilance is related to a history of spontaneous panic attacks, anxiety symptomatology, and anxiety sensitivity. Study 2 suggests that body vigilance is elevated in panic disorder patients (n = 48) relative to social phobia patients (n = 18) and nonclinical controls (n = 71). During cognitive-behavioral treatment, panic disorder patients show substantial reductions in body vigilance associated with reductions in anxiety symptomatology. Anxiety sensitivity was found to be related to body vigilance and to predict changes in body vigilance during treatment.