Panic attack history and anxiety sensitivity in relation to cognitive-based smoking processes among treatment-seeking daily smokers

INTRODUCTION

Empirical research has found that panic attacks are related to increased risk of more severe nicotine withdrawal and poor cessation outcome. Anxiety sensitivity (AS; fear of anxiety and related sensations) has similarly been found to be related to an increased risk of acute nicotine withdrawal and poorer cessation outcome. However, research has yet to examine the relative contributions of panic attacks and AS in terms of cognitive-based smoking processes (e.g., negative reinforcement smoking expectancies, addictive and negative affect-based reduction smoking motives, barriers to cessation, problem symptoms experienced while quitting).

METHOD

Participants (n = 242; 57.4% male; M (age) = 38.1) were daily smokers recruited as a part of a larger randomized control trial for smoking cessation. It was hypothesized that both panic attacks and AS would uniquely and independently predict the studied cognitive-based smoking processes.

RESULTS

As hypothesized, AS was uniquely and positively associated with all smoking processes after controlling for average number of cigarettes smoked per day, current Axis I diagnosis, and participant sex. However, panic attack history was only significantly related to problem symptoms experienced while quitting smoking.

CONCLUSIONS

Although past research has demonstrated significant associations between panic attacks and certain aspects of cigarette smoking (e.g., severity of nicotine withdrawal; lower abstinence rates, and negative affect reduction motives), the present findings suggest that AS may be more relevant to understanding beliefs about and motives for smoking behavior as well as perceptions of cessation-related difficulties.

Attention training to reduce attention bias and social stressor reactivity: an attempt to replicate and extend previous findings

Cognitive theories suggest that social anxiety is maintained, in part, by an attentional bias toward threat. Recent research shows that a single-session of attention modification training (AMP) reduces attention bias and vulnerability to a social stressor (Amir, Weber, Beard, Bomyea, & Taylor, 2008). In addition, exercise may augment the effects of attention training by its direct effects on attentional control and inhibition, thereby allowing participants receiving the AMP to more effectively disengage attention from the threatening cues and shift attention to the neutral cues. We attempted to replicate and extend previous findings by randomizing participants (N = 112) to a single-session of: a) Exercise + attention training (EX + AMP); b) Rest + attention training (REST + AMP); c) Exercise + attention control condition (EX + ACC); or d) Rest + attention control condition (REST + ACC) prior to completing a public speaking challenge. We used identical assessment and training procedures to those employed by Amir et al. (2008). Results showed there was no effect of attention training on attention bias or anxiety reactivity to the speech challenge and no interactive effects of attention training and exercise on attention bias or anxiety reactivity to the speech challenge. The failure to replicate previous findings is discussed.

Unexpected arousal, anxiety sensitivity, and their interaction on CO₂-induced panic: further evidence for the context-sensitivity vulnerability model

The present experiment tested several predictions derived from the context-sensitivity vulnerability model of panic. Participants (N=79) scoring either high or low in anxiety sensitivity (AS) and with no history of unexpected panic were randomly assigned to one of two instructional sets: expected arousal (EA) or expected relaxation (ER). All participants were administered inhalation of room air and 35% CO(2) in a counterbalanced order. Consistent with theoretical predictions, High-AS participants who received ER instructions showed greater emotional responding compared to High-AS participants who received EA instructions, while instructional set did not affect responding among Low-AS participants. Panic attacks were observed in 52% of the High-AS-ER group compared to 17%, 5%, and 5% in the High-AS-EA, Low-AS-ER, and Low-AS-EA groups respectively. These findings are consistent with the theory's assertion that dispositional tendencies, such as anxiety sensitivity potentiate the panicogenic effects of threat-relevant context variables.

Anxiety sensitivity and marijuana use: an analysis from ecological momentary assessment

BACKGROUND

The cognitive factor of Anxiety Sensitivity (AS; the fear of anxiety and related bodily sensations) is theorized to play a role in cannabis use and its disorders. Lower-order facets of AS (physical concerns, mental incapacitation concerns, and social concerns) may be differentially related to cannabis use behavior. However, little is known about the impact of AS facets on the immediate antecedents of cannabis use.

METHODS

This study used ecological momentary assessment (EMA) to prospectively examine the relations between specific facets of AS, cannabis craving, state anxiety, and cannabis use in the natural environment using real-world data about ad lib cannabis use episodes. Participants were 49 current cannabis users (38.8% female).

RESULTS

AS-mental incapacitation fears were related to significantly greater severity of cannabis-related problems at baseline. During the EMA period, AS-mental incapacitation and AS-social concerns significantly interacted with cannabis craving to prospectively predict subsequent cannabis use. Specifically, individuals with higher craving and either higher AS-mental incapacitation or AS-social concerns were the most likely to subsequently use cannabis. In contrast to prediction, no AS facet significantly moderated the relationship between state anxiety and cannabis use.

CONCLUSIONS

These findings suggest facets of AS (mental incapacitation and social fears) interact with cannabis craving to predict cannabis use. Findings also suggest differential relations between facets of AS and cannabis-related behaviors.

The relative contributions of fear and disgust reductions to improvements in spider phobia following exposure-based treatment

The present study examines the relative contributions of changes in state fear and disgust emotions to improvements in spider phobia observed with exposure-based treatment. Sixty-one treatment-seeking spider fearful individuals underwent a one-session exposure in vivo treatment. Growth curve analyses indicated that treatment was associated with significant improvements in state fear and disgust reactions to a live spider and self-reported trait spider phobia symptoms. Mediation analyses demonstrated that changes over time in state fear and disgust each explained unique variance in improvements in phobic symptoms over time. Examination of the effect size of the mediated pathways suggests that changes in fear and changes in disgust are important to reductions in the severity of spider phobia symptoms during exposure-based treatment. The implications of these findings for conceptualizing the role of fear and disgust emotions in the maintenance and treatment of spider phobia are discussed.

Anxiety sensitivity as a mediator of the relationship between moderate-intensity exercise and coping-oriented marijuana use motives

The present study examined the working hypothesis that moderate-intensity exercise is associated with coping-oriented marijuana use motives through its association with the fear of somatic arousal (ie, anxiety sensitivity). Using data from 146 young adult current marijuana users, we found evidence consistent with this hypothesis. Specifically, moderate-intensity exercise was associated with coping-oriented use motives, even after controlling for frequency of current marijuana use and other co-occurring marijuana use motives. This relationship became nonsignificant after entering anxiety sensitivity as an additional predictor variable, denoting a putative mediational role for this cognitive factor. These findings extend previous work and offer support for the potential utility of moderate-intensity aerobic exercise for the treatment of marijuana use problems.

Smoking Behavior and Alcohol Consumption in Individuals With Panic Attacks

Individuals with anxiety often report greater smoking and drinking behaviors relative to those without a history of anxiety. In particular, smoking and alcohol use have been directly implicated among individuals experiencing panic attacks, diagnosed with panic disorder, or high on panic-relevant risk factors such as anxiety sensitivity. Less is known, however, about specific features of panic that may differentiate among those who do or do not use cigarettes or alcohol. The purpose of the current study was to replicate previous research findings of an association between panic symptomatology, cigarette smoking, and alcohol consumption, as well as extend findings by examining whether specific symptoms of panic attacks differentiated among those who do or do not use cigarettes or alcohol. Participants (n = 489) completed the Panic Attack Questionnaire-IV, a highly detailed assessment of panic attacks and symptoms, as well as self-report measures of smoking history and alcohol use. Consistent with previous research, participants who reported a history of panic attacks (n = 107) were significantly more likely to report current daily or lifetime daily cigarette smoking, and significantly greater hazardous or harmful alcohol use than participants with no panic history (n = 382). Although smoking and hazardous alcohol use were highly associated regardless of panic status, participants with panic attacks showed elevated hazardous alcohol use after controlling for daily or lifetime smoking. Surprisingly, although participants who reported having had at least one panic attack were more likely to smoke, panic attack symptoms, intensity, or frequency did not differentiate panickers who did or did not smoke. Furthermore, panic-related variables were not shown to differentially relate to problematic drinking among panickers. Implications for understanding the complex relationship between panic attacks and smoking and drinking behaviors are discussed.

Anxiety, Substance Use, and Their Co-Occurrence: Advances in Clinical Science

Research and clinical literatures are replete with examples that psychological disorders are related to drug use, abuse, and dependence. The preponderance of scientific work addressing relations among psychopathological processes and drug use, abuse, and dependence has been focused primarily on psychotic disorders, major depression, antisocial personality disorder, and attention deficit hyperactivity disorder. This corpus of empirical work has indicated that there are clinically meaningful relations among particular types of psychopathology and the onset and maintenance of substance use behaviors and disorders and, in turn, that substance use and use-related problems can impact vulnerability for psychopathology. Within this public health context, it is striking that despite the fact that anxiety disorders are one of the most common classes of psychological problems (Kessler et al., 2005), there has been limited programmatic study of the relations between anxiety vulnerability processes and substance use disorders.

Cognitive enhancers for anxiety disorders

Cognitive-behavioral therapy is an effective intervention for anxiety disorders. However, a significant number of people do not respond or only show partial response even after an adequate course of the treatment. Recent research has shown that the efficacy of the intervention can be improved by the use of cognitive enhancers that augment the core learning processes of cognitive-behavior therapy. This manuscript provides a review of the current state of cognitive enhancers for the treatment of anxiety disorders.

Effects of threat context and cardiac sensitivity on fear responding to a 35% CO2 challenge: a test of the context-sensitivity panic vulnerability model

The present study tested several predictions of a context-sensitivity panic vulnerability model emphasizing the interaction between threat context and threat sensitivities. Participants without a history of panic (N=47) completed both global and domain-specific panic relevant sensitivity measures and were then randomized to undergo a 35% CO2 inhalation challenge in the presence or absence of a cardiac defibrillator (threat context). As predicted by the model, cardiac sensitivity (but not trait anxiety or anxiety sensitivity) potentiated the effects of the presence of the defibrillator on CO2 fear responding. Moreover, as predicted by the model, the observed potentiation effects of cardiac sensitivity on CO2 fear responding were mediated by participants' threat appraisals connected to the presence of the defibrillator. Theoretical and clinical implications are discussed.

Psychotropic medication use mediates the relationship between mood and anxiety disorders and obesity: findings from a nationally representative sample

Growing evidence points to a relationship between obesity and both mood and anxiety disorders, but the question of what accounts for this association remains unanswered. The present study examined the use of psychotropic medications as a mediator of the mood/anxiety disorder-obesity relationship. Data came from the public use dataset of the Canadian Community Health Survey Cycle 1.2 (age 15 years and older, N = 36,984). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric diagnoses of 12-month mood disorders (e.g., major depressive disorder, mania) and anxiety disorders (e.g., panic attacks, panic disorder, social phobia, agoraphobia) were examined as was use of psychotropic medications (e.g., antidepressants, antipsychotics, anxiolytics, hypnotics, mood stabilizers) and obesity (defined as body mass index ≥30). A series of multiple logistic regression analyses were completed to test study hypotheses. Covariates in these analyses included sociodemographic factors, physical activity, and physical illness burden. The use of two medication classes, namely antidepressants and antipsychotics, emerged as significant predictors of obesity as well as mediators of the psychiatric diagnosis-obesity relationship after evaluating all psychotropic medication classes simultaneously, while also controlling for other theoretically relevant variables. The use of these two medications accounted for 86% of the relationship between mood disorders and obesity and 32% of the relationship between anxiety disorders and obesity. The study findings guide advances in the theoretical conceptualization of the mechanisms involved in mood/anxiety disorder-obesity relations. Clinical implications are discussed.

Mediation of symptom changes during inpatient treatment for eating disorders: the role of obsessive-compulsive features

The present study examined the relative contributions of changes in obsessive-compulsive symptoms among eating-disorder patients with (n = 254) and without (n = 254) obsessive-compulsive disorder (OCD) to eating-disorder symptom improvement observed with inpatient treatment. Consistent with hypothesis, multilevel mediation analyses revealed that improvements in OCD symptoms over time accounted for significant variance in the improvements in eating-disorder symptoms over time, with stronger mediation evident among eating-disorder patients with comorbid OCD (percent mediated; P(M) = 22.5%) compared to those without OCD (P(M) = 12.2%). However, decreases in eating-disorder symptoms over time fully mediated improvements in OCD symptoms over time, and this mediated pathway did not vary substantially as a function of comorbid OCD status. The theoretical and treatment implications of these findings for conceptualizing the relationship between eating disorders and OCD are discussed.

Identifying potential barriers to physical activity adherence: anxiety sensitivity and body mass as predictors of fear during exercise

A growing body of work suggests that obese adults are less likely to adhere to exercise than normal-weight adults because they experience greater levels of discomfort and distress during exercise sessions. The present study introduces and provides a preliminary test of the hypothesis that the distress experienced during exercise among persons with elevated body mass index is particularly high among those who fear somatic arousal (i.e. elevated anxiety sensitivity [AS]). Young adults were randomly assigned to complete 20 min of treadmill exercise (at 70% of their age-adjusted predicted maximum heart rate) or 20 min of rest. Body mass, AS, and negative affect were measured at baseline, and fear was measured at 4-min intervals during the experimental phase. Consistent with the authors' hypothesis, there was a significant Exercise x BMI x ASI interaction (sr(2) = .08), suggesting that the greatest fear levels during exercise were observed among participants with high body mass, but only if they also had elevated AS. These findings offer a new approach for identifying specific vulnerable individuals and have clear clinical implications, given that the amplification factor of AS can be modified with clinical intervention.

Negative affect as a mediator of the relationship between vigorous-intensity exercise and smoking

The present cross-sectional study evaluated whether people who engage in vigorous-intensity exercise are better able to regulate negative affective states, thereby changing core maintenance factors of smoking. Participants were a community sample of adults (n = 270) who completed self-report measures of physical activity, cigarette smoking, anxiety sensitivity, and negative affect. Consistent with hypothesis, vigorous-intensity exercise was related to lower levels of cigarette smoking, accounting for 10% of the variance in smoking. Additionally, negative affect mediated the relationship between vigorous-intensity physical activity and cigarette smoking, accounting for about 12% of this relation. Furthermore, these relationships were stronger for individuals with high anxiety sensitivity than for those with low anxiety sensitivity; including anxiety sensitivity as a moderator of the mediated relationship increased the amount of variance accounted for by negative affect to 17%. The findings are discussed in relation to developing further scientific insight into the mechanisms and pathways relevant to understanding the association among vigorous-intensity exercise, smoking, and emotional vulnerability.

Empirically supported treatments for panic disorder

This article provides an empirical review of the elements and efficacy of both pharmacologic and psychosocial treatments for panic disorder. Both monotherapies and combination treatment strategies are considered. The available evidence suggests that both cognitive behavioral therapy (CBT) and pharmacotherapy (prominently, selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors) are effective first-line agents and that CBT offers particular cost efficacy relative to both pharmacotherapy alone and combined pharmacotherapy and CBT. Predictors of non-response and mechanisms of action are considered, as are novel treatment strategies, including the use of memory enhancers to improve CBT outcome.

Extinction retention predicts improvement in social anxiety symptoms following exposure therapy

BACKGROUND

Several researchers have argued that basic research on extinction learning can guide efforts to enhance the efficacy of exposure-based therapy. At the basis of this translational research paradigm is the assumption that extinction retention is important to the outcome of exposure-based therapy. This study is the first to examine the relationship between extinction retention, which comprises the amount of fear reduction that is retained between two exposure sessions and improvement in anxiety symptoms following exposure treatment.

METHODS

Adults (N=90), participating in two separate studies, who received three sessions of repeated exposure to public speaking provided ratings of peak fear during exposure treatment and completed the Liebowitz Social Anxiety Scale Self-Report version, LSAS-SR, Baker et al. [2002: Behav Res Ther 40:701-715] at baseline, posttreatment, and follow-up.

RESULTS

After controlling for within-session extinction, extinction retention accounted for significant variance in the improvement of LSAS-SR scores over time.

CONCLUSIONS

Our findings suggest that the consolidation of extinction learning into long-term memory is associated with improvements in fear and avoidance related to social situations following exposure therapy. Implications for exposure therapy augmentation studies are discussed.

Effects of D-cycloserine administration on weekly nonemotional memory tasks in healthy participants

BACKGROUND

The application of weekly doses of D-cycloserine (DCS) to the enhancement of exposure-based treatments has been a particular achievement of translational research. It is not known, however, whether this enhancement effect can be extended to other forms of learning. In this study, we investigated the relative benefit of DCS versus placebo for enhancing nonemotional verbal and nonverbal memory across weekly trials.

METHODS

We randomized healthy participants to weekly doses of 50 mg DCS or placebo, with 33 participants completing a 5-week protocol. Participants completed baseline neuropsychological evaluation and then 4 subsequent weeks of repeated learning tasks.

RESULTS

No improvement was found in immediate or delayed memory following single doses of DCS for the memory tasks repeated on a weekly basis. Trends for an advantage of DCS were evident for novel word lists given each week.

CONCLUSIONS

The learning tasks in our study were particularly distinct from the extinction learning paradigms that have shown strong DCS effects, and we were unable to demonstrate useful DCS effects with these nonemotional stimuli. Additional research is needed to elucidate the bounds of DCS augmentation effects on therapeutic learning.

Facilitation of fear extinction in phobic participants with a novel cognitive enhancer: a randomized placebo controlled trial of yohimbine augmentation

Preliminary animal research suggests that yohimbine hydrochloride, a selective competitive alpha2-adrenergic receptor antagonist, accelerates fear extinction and converts ineffective extinction regimens (long intertrial intervals) to effective ones. This randomized placebo controlled study examined the potential exposure enhancing effect of yohimbine hydrochloride in claustrophobic humans. Participants (71% undergraduate students and 29% community volunteers) displaying marked claustrophobic fear (n=24) were treated with 2 1-h in vivo exposure sessions. Participants were randomly allocated to take 10.8mg yohimbine hydrochloride (n=12) or placebo (n=12) prior to each exposure session. Outcome measures included peak fear during a behavioral avoidance task, the Claustrophobia Questionnaire, and the Claustrophobic Concerns Questionnaire. Results showed that both conditions improved significantly at post-treatment with no significant difference between groups. Consistent with prediction the group that took yohimbine hydrochloride prior to exposure sessions showed significantly greater improvement in peak fear at the one-week follow-up behavioral assessment (d=1.68). This was also true across other outcome measures with large to very large effect sizes. These data provide initial support for exposure enhancing effect of single-dose yohimbine hydrochloride in a clinical application.

Cognitive therapy for depressed adults with comorbid social phobia

BACKGROUND

Evidence suggests that comorbid depression influences the outcome of cognitive-behavioral treatment for patients presenting with social phobia. Little is known, however, about the influence of comorbid social phobia on the response to cognitive therapy (CT) for depression among adults presenting with recurrent major depressive disorder (MDD). These analyses seek to clarify this relationship.

METHODS

Patients (N=156) with recurrent DSM-IV MDD entered CT (20% also met DSM-IV criteria for social phobia). Every week during the course of CT, clinicians assessed depressive symptoms and patients completed self-report instruments measuring severity of depression and anxiety.

RESULTS

At presentation, outpatients with comorbid social phobia reported greater levels of depressive symptoms and clinicians rated their impairment as more severe, compared to their counterparts without social phobia. Patients with or without comorbid social phobia did not differ significantly in (1) attrition rates; (2) response or sustained remission rates; (3) time to response or sustained remission; or (4) rate of improvement in symptoms of depression or anxiety.

LIMITATIONS

The lack of domain-specific measures limits inference with respect to the improvements in social anxiety that occur with CT of depression.

CONCLUSIONS

These findings introduce the hypothesis that CT for depression may be flexible enough to treat the depressive symptoms of patients presenting with MDD who also suffer from social phobia.

Reducing anxiety sensitivity with exercise

BACKGROUND

Exercise interventions repeatedly have been shown to be efficacious for the treatment of depression, and initial studies indicate similar efficacy for the treatment of anxiety conditions. To further study the potential beneficial role of prescriptive exercise for anxiety-related conditions, we examined the role of exercise in reducing fears of anxiety-related sensations (anxiety sensitivity).

METHODS

We randomly assigned 60 participants with elevated levels of anxiety sensitivity to a 2-week exercise intervention, a 2-week exercise plus cognitive restructuring intervention, or a waitlist control condition. Assessment of outcome was completed at pretreatment, midtreatment, 1-week posttreatment, and 3-week follow-up.

RESULTS

We found that both exercise conditions led to clinically significant changes in anxiety sensitivity that were superior to the waitlist condition, representing a large controlled effect size (d=2.15). Adding a cognitive component did not facilitate the effects of the exercise intervention. Consistent with hypotheses, changes in anxiety sensitivity mediated the beneficial effects of exercise on anxious and depressed mood.

CONCLUSIONS

We discuss these findings in terms of the potential role of exercise as an additional psychosocial intervention for conditions such as panic disorder, where anxiety sensitivity is a prominent component of pathology.

Evaluative conditioning of fear and disgust in blood-injection-injury phobia: specificity and impact of individual differences in disgust sensitivity

The present study examines whether the repeated pairing of neutral facial expressions with phobic-relevant stimuli differentially influences evaluative ratings of fear and disgust between analogue blood-injection-injury (BII) phobic (n=40) and non-phobic (n=40) participants. Consistent with prior research, BII phobics reported greater disgust sensitivity than non-phobic participants even after controlling for between group differences in anxiety symptoms. Results from the evaluative conditioning experiment indicated that pre- to posttest increases in fear ratings were only marginally greater for phobic compared to non-phobic participants. However, increases in disgust from pre- to posttest were greater for phobic compared to non-phobic participants and greater for neutral expressions that were paired with threat-relevant stimuli compared to stimuli not paired with threat-relevant stimuli. Subsequent analysis also indicated that pre- to posttest increases in disgust ratings of neutral expressions that were paired with threat-relevant stimuli was moderated by disgust sensitivity levels among phobic and non-phobic participants. Heightened fear and disgust ratings were subsequently reduced by an extinction procedure. Implications of present findings in understanding the role of fear and disgust in BII phobia are discussed.

A meta-analytic review of the effects of psychotherapy control conditions for anxiety disorders

BACKGROUND

Little is known about the magnitude of improvement associated with psychotherapy control conditions for adult anxiety disorders. This information is important for the design of psychosocial treatment efficacy studies.

METHOD

We performed a computerized search of treatment outcome studies of anxiety disorders conducted between the first available year and 1 March 2007. In addition, we examined the reference lists from identified articles and asked international experts to identify eligible studies. We included studies that randomly assigned adult patients suffering from anxiety disorders to either cognitive-behavioral treatment or psychotherapy control condition. For each study, the two authors independently selected psychometrically sound measures of anxiety disorder severity. In addition, we collected data on attrition and treatment response.

RESULTS

Of the 1165 studies that were initially identified, 19 studies (454 patients) met inclusion criteria and were included in the analyses. The random effects analysis yielded a pre- to post-treatment Hedges' g effect size of 0.45 (95% confidence interval 0.35-0.46, z=8.50, p<0.001). The mean weighted response and attrition rates were 25.0% and 14.2%, respectively. There was no evidence for publication bias, nor was there a significant relationship between the effect size and diagnostic group, study year or number of treatment sessions.

CONCLUSIONS

Psychotherapy control conditions are associated with significant improvements when administered to adults suffering from anxiety disorders. In addition, they are associated with a relatively low attrition rate. These findings can inform the design of future psychotherapy outcome studies.

The effects of acute exercise on CO(2) challenge reactivity

The present study examined the effects of acute exercise on anxiogenic responding to 65% O(2)/35% CO(2) challenge. Participants (N=92) were 51 female and 41 male volunteers ranging in age from 17 to 24 (M=19.43, SD=1.31). Participants had no history of panic attacks and were randomized to moderate treadmill exercise (i.e., 70% of HR(max)) or quiet rest prior to taking a single vital capacity inhalation of 35% CO(2)/65% O(2). Gender and measures of negative affectivity and anxiety sensitivity were included in the design as control variables. Results indicated participants who exercised prior to challenge showed significantly reduced reactivity compared to their counterparts who rested prior to challenge. Importantly, the effect sizes for the advantage of exercise over rest remained in the medium to large range (i.e., partial eta(2)>.07) after controlling for the effects of gender, anxiety sensitivity, and negative affectivity. These findings are the first to demonstrate that the anti-panic effects of exercise are unique from, and cannot be better explained by, established risk factors of CO(2) challenge reactivity.