Predictors of panic attacks in adolescents

Social anxiety symptoms uniquely predict fear responding to 35% CO(2) challenge

The vast majority of biological challenge studies have focused on panic disorder though there is a small literature suggesting that patients with social anxiety disorder (SAD) show comparable responding. The SAD literature is potentially confounded, however, by the fact that many patients with SAD experience panic attacks. These patients also show elevated negative affect and anxiety sensitivity, factors that are also associated with increased fear responding to challenge. By controlling for these factors, the present report was able to evaluate whether social anxiety symptoms were uniquely associated with fearful responding to a 35% CO(2) challenge. A large nonclinical sample of young adults (N=120) screened for a history of panic attacks completed a 35% CO(2) challenge. Those high (versus low) in social anxiety showed approximately 2.5 times greater risk for experiencing substantial increases in anxiety in response to the challenge. This significant association was maintained after controlling for anxiety sensitivity and general negative affect. These data provide novel evidence suggesting that social anxiety symptoms are uniquely associated with anxious responding to 35% CO(2) challenge and this sensitivity appears to precede the development of panic attacks.

Is anxiety sensitivity a predictor of PTSD in children and adolescents?

OBJECTIVE

Anxiety sensitivity (AS) is the fear of the physical symptoms of anxiety and related symptoms. Longitudinal studies support AS as a vulnerability factor for development of anxiety disorders. This study aimed to investigate AS as a vulnerability factor in the development of childhood posttraumatic stress disorder (PTSD) following traumatic experiences.

METHODS

The study included 81 children 8-15 years of age who experienced the 1999 earthquake in Bolu, Turkey. The earthquake survivors were compared to a randomized group of age- and sex-matched controls 5 years after the earthquake. Both the subject and control groups were administered the Childhood Anxiety Sensitivity Index (CASI), State and Trait Anxiety Inventory for Children (STAI-C), and Child Depression Inventory (CDI), while the PTSD symptoms of the subjects were assessed using the Child Posttraumatic Stress Reaction Index (CPTS-RI).

RESULTS

Subjects and controls did not differ significantly in CASI, STAI-C, or CDI scores. Multiple regression analysis showed that both trait anxiety and CASI scores predicted CPTS-RI scores of the subjects; the prediction by CASI scores was over and above the effect of trait anxiety.

CONCLUSION

The results of this study support the hypothesis that AS may be a constitutional factor, which might increase the risk of PTSD following traumatic experiences.

Anxiety sensitivity as an incremental predictor of later anxiety symptoms and syndromes

Although anxiety sensitivity (AS) has been shown to predict anxiety symptoms and panic, this literature is limited in regard to evaluating AS as an incremental predictor of anxiety psychopathology relative to other established risk factors including sex and negative affect. The present report prospectively evaluated whether AS was predictive of later changes in anxiety symptoms after controlling for potential confounding factors. Consistent with hypothesis, AS was found to be a significant, incremental predictor of anxiety symptoms over time, even after controlling for sex and negative affectivity. These data provide novel evidence for the unique association between AS of the development of anxiety symptoms.

Anxiety sensitivity and perceived control over anxiety-related events: evaluating the singular and interactive effects in the prediction of anxious and fearful responding to bodily sensations

The present investigation examined the singular and interactive effects of anxiety sensitivity and perceived control over anxiety-related events in the prediction of panic symptoms using a CO(2)-enriched air biological challenge. Two hundred and twenty-nine adult participants (M(age)=21.02, SD=7.55, 124 females) were recruited from the greater Burlington, Vermont community. Results indicated that pre-challenge anxiety sensitivity, but not perceived control over anxiety-related events, significantly predicted post-challenge panic attack symptoms, anxiety focused on bodily sensations, and, interest in returning for another challenge (behavioral avoidance). In regard to physiological findings, anxiety sensitivity was significantly related to skin conductance level whereas perceived control over anxiety-related events was related to respiration rate. Neither anxiety sensitivity nor perceived control over anxiety-related events was related to heart rate. There also were no interactive effects between anxiety sensitivity and perceived control over anxiety-related events for any of the studied dependent variables. Results are discussed in relation to multi-risk factor models of cognitive vulnerability for panic psychopathology.

The moderating role of health fear on the relation between smoking status and panic symptoms among adolescents

The present study examined the moderating role of health fear on the concurrent relation between smoking status and panic attack symptoms among 249 adolescents (132 females, M(age)=14.86 years). As hypothesized, youth high in health fear reported elevations in panic attack symptoms, whereas this relation was relatively weak among those low in health fear. Importantly, these associations were significant after controlling for age, gender, negative affectivity, and anxiety sensitivity. Also as expected, health fear did not moderate the association between smoking status and depressive symptoms, supporting model specificity. Results are discussed in terms of implications for the panic-smoking association among youth.

Separation anxiety disorder in childhood as a risk factor for future mental illness

OBJECTIVE

To ascertain the extent to which childhood separation anxiety disorder (SAD) confers risk for the development of psychopathology during young adulthood (ages 19-30).

METHOD

A subset of the participants of the Oregon Adolescent Depression Project (n = 816) was used. Subjects provided retrospective reports of lifetime mental illness (including SAD) and concurrent reports of current mental illness at age 16 and were then followed prospectively until age 30. Diagnostic assessments were conducted twice during adolescence and again at ages 24 and 30. Based on diagnosis during childhood/adolescence, the subjects were partitioned into four orthogonal groups: SAD (n = 42), other anxiety disorders (n = 88), a heterogeneous psychiatric disorders control group (n = 389), and a not mentally ill control group (n = 297). Adjusting for demographic variables that were significantly associated with group status and for comorbid disorders prior to age 19, the results were analyzed with hierarchical multiple logistic regression.

RESULTS

SAD was a strong (78.6%) risk factor for the development of mental disorders during young adulthood. The major vulnerabilities were for panic disorder and depression.

CONCLUSIONS

Because SAD creates a major vulnerability for mental disorders during young adulthood, clinicians should be sensitive to the presence of SAD, and children and adolescents with SAD should be treated. Future research should evaluate whether successful treatment of SAD and/or the provision of a preventive intervention during childhood/adolescence reduce the risk for future psychopathology.

Anxiety sensitivity and CO2 challenge reactivity as unique and interactive prospective predictors of anxiety pathology

Emerging evidence suggests that anxiety sensitivity (AS) and CO(2)-induced fear reactivity are associated with panic attacks and anxiety disorders. However, evidence regarding the unique and potentially synergistic effects of these variables is currently lacking. Our primary aims in this study were to determine whether AS and CO(2)-induced fear reactivity are unique and potentially interactive vulnerability factors involved in the pathogenesis of panic attacks and anxiety psychopathology. A large nonclinical sample of young adults (N=404) was prospectively followed over approximately 2 years. AS (i.e., 16-item Anxiety Sensitivity Index total scores) and biological challenge reactivity [i.e., fearful responding to pre- and postchallenge changes in subjective units of distress (SUDS) to a 20-s 20% CO(2) challenge] at study entry served as the primary predictor variables. Consistent with expectation, AS and challenge reactivity correlated only moderately with one another. Challenge reactivity was uniquely associated with the development of spontaneous panic attacks, whereas AS was uniquely associated with anxiety disorder diagnoses, including panic disorder. Moreover, the combination of both risk factors predicted spontaneous panic attacks beyond the effects of either risk factor individually. These data provide novel evidence for the unique and combined effects of AS and CO(2)-induced fear reactivity as risk factors in the development of anxiety and its disorders.

Cognitive development and the interpretation of anxiety-related physical symptoms in 4-13-year-old non-clinical children

The present study examined developmental patterns in children's interpretation of anxiety-related physical symptoms and emotional reasoning (i.e., the tendency to infer danger on the basis of physical response information). A sample of 171 children aged between 4 and 13 years were interviewed after listening to a number of vignettes in which the presence and absence of physical symptoms was systematically varied. Results revealed the expected developmental pattern for anxiety-related interpretations of physical symptoms. More precisely, from age 7, children were increasingly capable of linking physical symptoms to the emotion of anxiety. Furthermore, support was obtained for an emotional reasoning effect. That is, children rated vignettes with physical symptoms as more dangerous than vignettes without such symptoms. While the emotional reasoning effect was present in children of all ages, this phenomenon was more salient among older children. Finally, cognitive development as measured by Piagetian conservation tasks appeared to influence children's anxiety-related interpretations of physical symptoms and emotional reasoning. Altogether, these findings are relevant for researchers who are interested in "physical symptoms-based" theories of childhood anxiety.

Anxiety sensitivity and posttraumatic stress among traumatic event-exposed youth

Total and factor scores of the Childhood Anxiety Sensitivity Index (CASI) were examined in relation to posttraumatic stress symptom levels within a community-based sample of 68 (43 females) traumatic event-exposed youth between the ages of 10 and 17 years (M age=14.74 years). Findings were consistent with hypotheses; global anxiety sensitivity (AS) levels, as well as disease, unsteady, and mental incapacitation concerns, related positively to posttraumatic stress levels, whereas social concerns were unrelated to symptom levels. These results suggest that fears of the physical and mental consequences of anxiety are associated with relatively higher levels of posttraumatic stress subsequent to traumatic event exposure. Findings are discussed in terms of potential implications for the role of AS in developmentally sensitive etiological models of posttraumatic stress disorder (PTSD).

Catastrophic associations predict level of change in anxiety sensitivity in response to cognitive-behavioural treatment for panic

The aim of the present study was to elucidate one of the factors that might be responsible for the maintenance of panic patients' harmful beliefs about anxiety. Specifically, it was hypothesized that harmful beliefs about anxiety, i.e. anxiety sensitivity, is maintained in panic patients by automatic activation of idiographic catastrophic cognitions. To test this prediction, panic patients participated in a one-session cognitive-behavioural treatment of 4-8h to reduce anxiety sensitivity. The strength of automatic catastrophic cognitions in response to idiographic anxiety symptoms, measured with a modified semantic priming task, as well as the strength of the consciously accessible catastrophic meaning of these symptoms were assessed before treatment. In accordance with the hypothesis, stronger automatic catastrophic cognitions predicted a smaller reduction of anxiety sensitivity independently of the strength of conscious catastrophic cognitions. Moreover, in a first exploration, the strength of catastrophic associations was also shown to have an incremental predictive value for change in anxiety sensitivity beyond that of a number of demographic, clinical, treatment and assessment variables. The theoretical and clinical implications are discussed.

Anxiety sensitivity as a moderator of association between smoking status and panic-related processes in a representative sample of adults

The present investigation evaluated a moderational role of anxiety sensitivity (fear of anxiety and anxiety-related states; [McNally RJ. Anxiety sensitivity and panic disorder. Biological Psychiatry 2002; 52:938-946.]) in the relation between smoking status and anxiety/depressive symptoms in a Russian epidemiological sample (n = 390; 197 females, Mean age = 43.55). Consistent with prediction, anxiety sensitivity moderated the association of smoking status with indices of anxiety and depressive symptoms; the effects were evident after controlling for the variance accounted for by alcohol use problems, environmental stress (past month), and gender. These findings are discussed with regard to the role of anxiety sensitivity in etiologic connection between smoking and panic-related processes.

Anxiety sensitivity and affect regulatory strategies: individual and interactive risk factors for anxiety-related symptoms

Studies have shown that anxiety sensitivity (AS) is a risk factor in the development of pathological anxiety. Recent theoretical models emphasize the additional importance of how people handle their anxious experiences. The present study examined whether high AS and being fixated on the control and regulation of unwanted anxious feelings or being unable to properly modulate affect as needed lead to particularly problematic outcomes. We examined the interactive influence of AS and affect regulatory strategies on the frequency and intensity of anxiety symptoms. Questionnaires were completed by 248 young adults in the community. Results showed a general pattern with anxiety symptoms being the most severe when high AS was paired with affect regulatory difficulties. Of participants high in AS, anxious arousal and worry were heightened in the presence of less acceptance of emotional distress; anxious arousal, worry, and agoraphobic cognitions were heightened when fewer resources were available to properly modulate affect; and agoraphobic cognitions were heightened in the presence of high emotion expressiveness. As evidence of construct specificity, an alternative model with anhedonic depressive symptoms as a main effect and interaction effect (with regulatory strategies) failed to predict anxiety symptoms. However, anxiety sensitivity and less acceptance of emotional distress were associated with greater anhedonia. Results are discussed in the context of how and when affect regulatory behavior shifts individuals from normative anxiety to pathology.

Gene-by-environment (serotonin transporter and childhood maltreatment) interaction for anxiety sensitivity, an intermediate phenotype for anxiety disorders

Anxiety sensitivity (AS) is a dispositional characteristic that predisposes to the development of anxiety disorders (eg, panic and post-traumatic stress disorder) and major depression. AS is subject to genetic and environmental influences, the former as yet unidentified and the latter known to include childhood maltreatment. The serotonin transporter gene (SLC6A4) promoter polymorphism (5-HTTLPR) has been associated with depression, but most consistently in the context of environmental stress. We tested the hypothesis that 5-HTTLPR genotype and childhood maltreatment would interact to increase susceptibility to AS in young adults. Subjects were European-American college undergraduates (N=150, median age 18 years) characterized on a measures of AS (Anxiety Sensitivity Index) and retrospective childhood maltreatment (Childhood Trauma Questionnaire [CTQ]). 5-HTTLPR genotypes were obtained from blood-derived DNA. Linear regression was used to model relationships between 5-HTTLPR, childhood emotional abuse, and AS; covariates such as sex, neuroticism, and ancestral proportion scores were incorporated into some models in a larger, ethnically heterogenous sample (N=247) to evaluate robustness of the findings to model assumptions. A statistically signficant interaction was observed between levels of childhood emotional (or physical) maltreatment and 5-HTTLPR genotype. Specifically, S/S individuals with higher levels of maltreatment had significantly higher levels of AS than subjects in other groups. No such relationship was found for neuroticism, attesting to the possible specificity of the findings for AS. Findings were consistently robust to the inclusion of covariates, and were not confounded by population stratification. In conclusion, these results provide evidence of a specific genetic influence on anxiety sensitivity-an intermediate phenotype for anxiety (and depressive) disorders; this effect is modified by severity of childhood maltreatment. These findings are consistent with the notion that 5-HTTLPR operates broadly to moderate emotional responsivity to stress.

What do childhood anxiety disorders predict?

BACKGROUND

Few longitudinal studies of child and adolescent psychopathology have examined the links between specific childhood anxiety disorders and adolescent psychiatric disorder. In this paper we test the predictive specificity of separation anxiety disorder (SAD), overanxious disorder (OAD), generalized anxiety disorder (GAD), and social phobia.

METHODS

Data come from the Great Smoky Mountains Study (GSMS). A representative population sample of children--ages 9, 11, and 13 years at intake--was followed to age 19. Diagnoses of both childhood (before age 13 years) and adolescent psychiatric disorders (age 13 to 19 years) were available from 906 participants.

RESULTS

Childhood SAD predicted adolescent SAD, whereas OAD was associated with later OAD, panic attacks, depression and conduct disorder (CD). GAD was related only to CD. Social phobia in childhood was associated with adolescent OAD, social phobia, and attention-deficit/hyperactivity disorder (ADHD).

CONCLUSIONS

Anxiety disorders in childhood are predictors of a range of psychiatric disorders in adolescence. It appears that children meriting a well-defined diagnosis are missed by the current rules for the diagnosis of GAD. Future studies should examine whether OAD deserves reconsideration as a nosological entity.

Panic disorder, phobias, and generalized anxiety disorder

This chapter provides a review of recent empirical developments, current controversies, and areas in need of further research in relation to factors that are common as well as specific to the etiology and maintenance of panic disorder, phobias, and generalized anxiety disorder. The relative contribution of broad risk factors to these disorders is discussed, including temperament, genetics, biological influences, cognition, and familial variables. In addition, the role that specific learning experiences play in relation to each disorder is reviewed. In an overarching hierarchical model, it is proposed that generalized anxiety disorder, and to some extent panic disorder, loads most heavily on broad underlying factors, whereas specific life history contributes most strongly to circumscribed phobias.

Taxometric and factor analytic models of anxiety sensitivity among youth: exploring the latent structure of anxiety psychopathology vulnerability

This study represents an effort to better understand the latent structure of anxiety sensitivity (AS), a well-established affect-sensitivity individual difference factor, among youth by employing taxometric and factor analytic approaches in an integrative manner. Taxometric analyses indicated that AS, as indexed by the Child Anxiety Sensitivity Index (CASI; Silverman, Flesig, Rabian, & Peterson, 1991), demonstrates taxonic latent class structure in a large sample of youth from North America (N=4,462; M(age)=15.6 years; SD=1.3). Subsequent confirmatory factor analyses indicated that the latent continuous, multidimensional, 4-factor model of AS among youth (Silverman, Goedhart, Barrett, & Turner, 2003) provided good fit for the CASI data among the complement class ("normative form" of AS), but not among the taxon class ("high-risk form" of AS). EFAs supported the prediction that the AS taxon demonstrates a unique, heretofore unexplored latent continuous, unidimensional factor structure among youth. Findings are discussed in relation to refining our understanding of the latent structure of AS and the clinical implications that arise from it.

Personality traits and anxiety symptoms: The multilevel trait predictor model

Investigation of relations between personality traits and mental disorders can inform key issues in psychopathology research. However, it has been hindered by extensive correlations among the traits. Building on studies of affect-psychopathology relations (e.g., the tripartite model), an organizational framework is proposed to solve this problem with respect to anxiety pathology. To test the resulting model, associations between four traits (negative emotionality, positive emotionality, anxiety sensitivity, and negative evaluation sensitivity) and four anxiety symptoms (chronic worry, obsessive-compulsive symptoms, panic, and social anxiety) were examined in an undergraduate sample (N=907). Confirmatory factor analyses supported operationalizations of the constructs in this study. Examination of the trait-symptom links using hierarchical multiple regression analyses supported most of the predicted relations. Specifically, negative emotionality emerged as a general predictor that was significantly related to all four symptom dimensions. In contrast, anxiety sensitivity was specific to panic and worry, whereas negative evaluation sensitivity was specific to social anxiety and worry. Finally, positive emotionality was uniquely related to social anxiety. The model accounted for a substantial amount of variance in the symptoms and almost all of the covariation among them.

Anxiety sensitivity as a prospective predictor of alcohol use disorders

Emerging evidence suggests that elevated anxiety sensitivity (AS) is associated with substance use disorders. However, prospective evidence regarding this association is currently lacking. The primary aim of the present study was to determine whether AS is involved in the pathogenesis of substance-related psychopathology. A large, nonclinical sample of young adults (N = 404) was prospectively followed for approximately 2 years. AS (i.e., 16-item Anxiety Sensitivity Index total scores) at study entry and gender served as the primary predictor variables. Findings indicated that AS was uniquely associated with the later development of alcohol use disorder diagnoses. Data indicated that gender and AS did not act synergistically to predict alcohol use disorders. These data provide novel evidence for the unique effects of AS as a prospective risk factor in the development of alcohol-related disorders.

Introduction to anxiety sensitivity: recent findings and new directions

There has been a long-standing recognition that cognitive factors may play a formative role in anxiety and its disorders (Barlow, 2002). Since the 1980s, there has been great progress made in understanding the nature of cognitive risk for anxiety psychopathology. Within this context, numerous cognitive factors have been implicated and studied as potential risk factors for various anxiety conditions. Perhaps one of the most well-known and promising of these has been anxiety sensitivity (AS; Reiss & McNally,1985). AS is the fear of anxiety-related bodily sensations, which arise from beliefs that the sensations have harmful personal consequences (McNally,2002). To illustrate, people high in AS may be frightened of harmless heart palpitations because they believe the sensations will lead to cardiac arrest,whereas people low in AS do not fear these sensations because they believe them to be harmless. High AS is theorized to enhance anxious and fearful responding to internal cues through associative learning and/or cognitive misinterpretation (McNally, 2002). Numerous studies have indicated that AS is, in fact, related to increased risk of panic attacks (e.g., Hayward, Killen, Kraemer, & Taylor, 2000; Schmidt, Lerew, & Jackson, 1997, 1999) and anxiety disorders (Schmidt, Zvolensky, & Maner, 2006). Although the vast majority of work on AS has been conducted in relation to panic psychopathology (Zvolensky, Schmidt, Bernstein, & Keough, 2006), researchers

Anxiety sensitivity, conscious awareness and selective attentional biases in children

The current study investigated whether physical anxiety sensitivity (AS) is associated with selective attentional biases to affective stimuli in children. The dot-probe paradigm was used to examine the deployment of attention towards words pertaining to anxiety symptomatology, socially threatening words, and positive words, in samples of 8-10-year-old children. Word pairs were presented under both masked and unmasked conditions. Irrespective of masking, children high in physical AS displayed an attentional vigilance for emotional words relative to neutral words, whereas those low in physical AS displayed a relative avoidance of such material. The results of this study are interesting as they not only suggest the presence of automatic AS-related biases in childhood, but that this is a general emotionality bias rather than one related to specific anxiety-related stimuli.

Anxiety sensitivity and its dimensions across the anxiety disorders

Anxiety sensitivity (AS) refers to the fear of anxiety-related sensations, which is thought to arise from beliefs about their harmful consequences. AS is a multidimensional construct that consists of fears of somatic, social, and cognitive aspects of anxiety. In the present study, we examined the relationship between AS dimensions, assessed by factor-analytically derived subscales of the Anxiety Sensitivity Index-Revised (ASI-R), and anxiety-related psychopathology in a sample of 232 treatment-seeking patients with anxiety disorders. Correlational analyses and comparisons among anxiety disorder patient groups and undergraduate students revealed a specific pattern of relationships between ASI-R subscale scores and anxiety-related psychopathology. In contrast, ASI-R total scores evidenced less discriminant validity. Implications for theoretical models of anxiety and directions for future research are discussed.

Panic and phobic anxiety: associations among neuroticism, physiological hyperarousal, anxiety sensitivity, and three phobias

A dimensional and psychometrically informed taxonomy of anxiety is emerging, but the specific and nonspecific dimensions of panic and phobic anxiety require greater clarification. In this study, confirmatory factor analyses of data from a sample of 438 college students were used to validate a model of panic and phobic anxiety with six content factors; multiple scales from self-report measures were indicators of each model component. The model included a nonspecific component of (1) neuroticism and two specific components of panic attack, (2) physiological hyperarousal, and (3) anxiety sensitivity. The model also included three phobia components of (4) classically defined agoraphobia, (5) social phobia, and (6) blood-injection phobia. In these data, agoraphobia correlated more strongly with both the social phobia and blood phobia components than with either the physiological hyperarousal or the anxiety sensitivity components. These findings suggest that the association between panic attacks and agoraphobia warrants greater attention.

Anxiety sensitivity: prospective prediction of panic attacks and Axis I pathology

Emerging evidence suggests that anxiety sensitivity (AS) predicts subsequent development of anxiety symptoms and panic attacks. However, evidence regarding whether AS serves as a premorbid risk factor for the development of clinical syndromes is lacking. The primary aim of the present study was to determine whether AS acts as a vulnerability factor in the pathogenesis of psychiatric diagnoses. A large nonclinical sample of young adults (N=404) was prospectively followed over two years. The Anxiety Sensitivity Index (ASI: Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy 1986; 24: 1-8.) and trait anxiety served as predictors. Consistent with prior reports, AS predicted the development of spontaneous panic attacks in those with no history of panic. Importantly, AS was found to predict the incidence of anxiety disorder diagnoses and overall Axis I diagnoses in those with no history of Axis I diagnoses at study entry. These are the first data to provide strong prospective evidence for AS as a risk factor in the development of anxiety disorders.

The interactive role of anxiety sensitivity and pubertal status in predicting anxious responding to bodily sensations among adolescents

The present study examined the interaction between pubertal status and anxiety sensitivity (AS) in predicting anxious and fearful responding to a three-minute voluntary hyperventilation challenge among 124 (57 females) adolescents between the ages of 12 and 17 years (Mage = 15.04; SD = 1.49). As predicted, after controlling for baseline anxiety, age, and gender, there was a significant interaction between pubertal status and AS in predicting anxious responding to bodily sensations to the hyperventilation challenge. Specifically, adolescents reporting more advanced pubertal status and higher levels of AS reported the greatest post-challenge self-reported anxiety focused on bodily sensations, whereas pubertal status had relatively less of an effect on low AS adolescents. A test of specificity also was conducted; as expected, the interaction between AS and pubertal status was unrelated to generalized negative affectivity, suggesting the predictor variables interact to confer specific risk for anxious responding to bodily sensations. Finally, exploratory analyses of psychophysiological reactivity to the challenge indicated AS, but not pubertal status, moderated the relation between challenge-related change in heart-rate and post-challenge anxiety such that high AS youth who had experienced a relatively greater heart-rate change reported the most anxious reactivity to the challenge. Results are discussed in relation to theory regarding vulnerability to anxious responding to bodily sensations among adolescents.

Panic disorder

Panic disorder is a common mental disorder that affects up to 5% of the population at some point in life. It is often disabling, especially when complicated by agoraphobia, and is associated with substantial functional morbidity and reduced quality of life. The disorder is also costly for individuals and society, as shown by increased use of health care, absenteeism, and reduced workplace productivity. Some physical illnesses (eg, asthma) commonly occur with panic disorder, and certain lifestyle factors (eg, smoking) increase the risk for the disorder, but causal pathways are still unclear. Genetic and early experiential susceptibility factors also exist, but their exact nature and pathophysiological mechanisms remain unknown. Despite an imprecise, although increased, understanding of cause, strong evidence supports the use of several effective treatments (eg, pharmacological, cognitive-behavioural). The adaptation and dissemination of these treatments to the frontlines of medical-care delivery should be urgent goals for the public-health community.

Affect intensity: association with anxious and fearful responding to bodily sensations

The present investigation evaluated affect intensity in regard to anxious and fearful responding to a voluntary hyperventilation paradigm. Participants were 90 young adults without a history of Axis I psychopathology or nonclinical panic attacks. The incremental validity of affect intensity was examined relative to gender, negative affectivity, anxiety sensitivity, and anticipatory anxiety. As hypothesized, affect intensity significantly and incrementally predicted the perceived intensity of post-challenge panic-relevant physical and cognitive symptoms but not physiological arousal. Findings are discussed in relation to better understanding the role of affect intensity as a potential risk factor for panic-related problems.

Risk-factor research and prevention programs for anxiety disorders: A translational research framework

The aim of the present essay is to discuss the interconnection between risk-factor research and prevention program development for panic-spectrum psychopathology. We argue that prevention of panic-spectrum psychopathology specifically, and anxiety disorders more generally, is likely to be best advanced through active, systematic translation of basic, risk-factor research. After operationalizing key terminology, we present some exemplar risk-factor candidates for panic-spectrum psychopathology, summarize research related to their role as risk-factors for panic problems, and link this discussion to risk-factor nomenclature. We then present a translational framework for extrapolating extant knowledge on these and other potential risk-factors for panic-spectrum psychopathology with respect to the development of preventative interventions. The proposed translational framework is intended to describe a forward-feeding process by which risk-factor research could be used by clinical researchers to inform prevention programs; and reciprocally, how such prevention knowledge could be most effectively utilized to drive new, clinically focused risk-factor research.

Anxiety sensitivity-physical concerns as a moderator of the emotional consequences of emotion suppression during biological challenge: an experimental test using individual growth curve analysis

Anxiety-related responding to, and recovery from, a 5-min 10% carbon dioxide-enriched air presentation among 80 participants with no history of psychopathology was examined. Half of participants were instructed to suppress challenge-induced emotional responses, whereas their matched counterparts were instructed to observe such responses. Responding from immediately post-challenge through a 10-min recovery period was analyzed as a function of Anxiety Sensitivity-Physical Concerns and experimental condition using individual growth curve modeling. Anxiety Sensitivity-Physical Concerns moderated the effect of suppression only on emotion valence during recovery. In terms of main effects, suppression resulted in increased heart rate during recovery and Anxiety Sensitivity-Physical Concerns was positively associated with post-challenge self-reported anxiety. Results are discussed in terms of the potential role of inhibition-oriented affect regulation processes in the etiology of panic disorder.

Personality and anxiety disorders

Personality traits and most anxiety disorders are strongly related. In this article, we review existing evidence for ways in which personality traits may relate to anxiety disorders: 1) as predisposing factors, 2) as consequences, 3) as results of common etiologies, and 4) as pathoplastic factors. Based on current information, we conclude the following: 1) Personality traits such as high neuroticism, low extraversion, and personality disorder traits (particularly those from Cluster C) are at least markers of risk for certain anxiety disorders; 2) Remission from panic disorder is generally associated with partial "normalization" of personality traits; 3) Anxiety disorders in early life may influence personality development; 4) Anxiety disorders and personality traits are usefully thought of as spectra of common genetic etiologies; and 5) Extremes of personality traits indicate greater dysfunction in patients with anxiety disorders.

Anxiety sensitivity interacts with marijuana use in the prediction of anxiety symptoms and panic-related catastrophic thinking among daily tobacco users

The present investigation evaluated whether anxiety sensitivity interacted with marijuana use in relation to the prediction of panic-relevant variables among young adult tobacco smokers (n=265). Approximately 73% of the sample was composed of current marijuana smokers, with 78.5% of this sub-sample using marijuana more than once per week. As expected, after covarying cigarettes per day, alcohol use, and negative affectivity, the interaction between marijuana use and anxiety sensitivity predicted anxiety symptoms and agoraphobic cognitions. Partially consistent with prediction, the interaction between frequency of marijuana use and anxiety sensitivity predicted only anxiety symptoms. These results are discussed in relation to better understanding the potential role of regular marijuana use and anxiety sensitivity for panic-relevant emotional vulnerability among regular tobacco smokers.

Emotional vulnerability as a function of physical activity among individuals with panic disorder

This investigation evaluated the association between physical inactivity and emotional vulnerability in panic disorder. Participants were 39 adults (69% females) with a primary diagnosis of panic disorder (with or without agoraphobia), recruited through the community. Consistent with prediction, current physical inactivity was significantly associated with greater levels of anxiety sensitivity and severity of panic disorder. Results are discussed in relation to the importance of better understanding the role of physical inactivity in panic disorder.

Air hunger and ventilation in response to hypercapnia: Effects of repetition and anxiety

We investigated the effects of anxiety on the intensity of air hunger during gradually increasing levels of CO2 until the end-tidal fractional concentration of CO2 was 7.9% or air hunger was intolerable. Normal high and low (trait) anxious participants (N=23) went through three rebreathing trials (15 min interval). Breathing behaviour was continuously monitored and air hunger was rated every 12 s. The threshold for responding to the increased CO2 was always lower for the subjective rating than for the ventilatory response. Habituation across trials was observed for both the ventilatory response and the air hunger rating regardless of anxiety. However, beyond the threshold, the slope in air hunger ratings decreased across trials in low anxious persons and tended to increase in high anxious persons (interaction P<0.05). No differences occurred in the slopes of the breathing responses. The findings documented uncoupling of the physiological and subjective responses during CO2-induced air hunger.

Taxonicity of anxiety sensitivity: a multi-national analysis

Taxometric coherent cut kinetic analyses were used to test the latent structure of anxiety sensitivity in samples from North America (Canada and United States of America), France, Mexico, Spain, and The Netherlands (total n = 2741). Anxiety sensitivity was indexed by the 36-item Anxiety Sensitivity Index--Revised (ASI-R; [J. Anxiety Disord. 12(5) (1998) 463]). Four manifest indicators of anxiety sensitivity were constructed using the ASI-R: fear of cardiovascular symptoms, fear of respiratory symptoms, fear of publicly observable anxiety reactions, and fear of mental incapacitation. Results from MAXCOV-HITMAX, internal consistency tests, analyses of simulated Monte Carlo data, and a MAMBAC external consistency test indicated that the latent structure of anxiety sensitivity was taxonic in each of the samples. The estimated base rate of the anxiety sensitivity taxon differed slightly between nations, ranging from 11.5 to 21.5%. In general, the four ASI-R based manifest indicators showed high levels of validity. Results are discussed in relation to the conceptual understanding of anxiety sensitivity, with specific emphasis on theoretical refinement of the construct.

Anxiety responses to CO2 inhalation in subjects at high-risk for panic disorder

BACKGROUND

A number of reports have shown that patients with panic disorder have greater anxiety responses to the inhalation of enhanced carbon dioxide mixtures than do well controls or patients with other psychiatric illnesses. Three earlier studies have shown that well individuals who have first-degree relatives with panic disorder also experience more anxiety following CO(2) than do controls without such a family history. The following was undertaken to confirm and extend these findings.

METHODS

Well subjects at high risk for panic disorder (HR-P, n=132) had a first-degree family member with treated panic disorder but no personal history of panic attacks. Low-risk subjects (LR-C, n=85) had no such family history. All underwent a diagnostic interview with the SADS-LA and completed a battery of self-rating scales before undergoing two CO(2) challenges. One involved a single vital capacity breath of air and then of 35% CO(2) and the other 5 min of air and then 5 min of 5% CO(2).

RESULTS

In comparison to the LR-C group, HR-P subjects had higher scores on various self-ratings of anxiety and depression and were more likely to have a lifetime diagnosis of MDD or of an anxiety disorder. NEO neuroticism and a history of MDD were the most important of these measures in separating the high-risk and low-risk groups. As predicted, the HR-P subjects experienced more anxiety following 35% CO(2) exposure. The removal of individuals with lifetime diagnosis of MDD or of an anxiety disorder eliminated the relationship of neuroticism to CO(2)-induced anxiety and strengthened the relationship between the CO(2) response and a family history of panic disorder. Five minutes of 5% CO(2) produced much lower increases in anxiety than did the 35% exposure, but a dose by group interaction suggested that increasing exposure increased anxiety preferentially in the high-risk subjects.

CONCLUSION

The results confirm earlier findings in indicating that a family history of panic disorder conveys a liability to experience anxiety with CO(2) exposure. They also suggest that this anxiety may reflect several discrete diatheses of relevance to the heritability of panic disorder.

Anxiety sensitivity taxonicity across gender among youth

The present investigation comparatively evaluated the latent class structure and parameters of anxiety sensitivity (AS) among female and male youth using the Childhood Anxiety Sensitivity Index. Participants were 4462 adolescents (2189 females) in grades 7-12 (M(age)=15.6 years). Consistent with prediction, taxometric analyses indicated the latent structure of AS was taxonic in both males and females, demonstrating the taxonic latent structure of AS is similarly observed across gender. Also consistent with prediction, the base rate of the AS taxon differed between genders -- higher for females (12%) compared to males (7%). These findings are discussed in terms of their implications for the study of AS and panic vulnerability among youth.

Panic reactions to terrorist attacks and probable posttraumatic stress disorder in adolescents

A number of factors, including subjective reactions and appraisal of danger, influence one's reaction to a traumatic event. This study used telephone survey methodology to examine adolescent and parent reactions to the 2001 World Trade Center attacks 6 to 9 months after they occurred. The prevalence of probable posttraumatic stress disorder (PTSD) in adolescents was 12.6%; 26.2% met study criteria for probable subthreshold PTSD. A probable peri-event panic attack in adolescents was strongly associated with subsequent probable PTSD and probable subthreshold PTSD. This study suggests that the early identification of peri-event panic attacks following mass traumatic events may provide an important gateway to intervention in the subsequent development of PTSD. Future studies should use longitudinal designs to examine the course and pathogenic pathways for the development of panic, PTSD, and other anxiety disorders after exposure to disasters.

Unique contributions of anxiety sensitivity to avoidance: A prospective study in adolescents

Examination of the prospective relation between anxiety sensitivity (AS) and behavioral avoidance is largely absent from the literature. In a longitudinal study of a community sample of 2246 adolescents, participants completed the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally (1986). Behaviour Research & Therapy, 24, 1-8), State-Trait Anxiety Inventory (STAI; Spielberger (1983). STAI: Manual for the Stait-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press), and the Fear Questionnaire (Marks & Matthews (1979). Behaviour Research & Therapy, 17, 263-267) on an annual basis. To stringently test AS's ability to prospectively predict behavioral avoidance, linear regression was used to test whether AS factors predicted variance in follow-up behavioral avoidance scores after controlling for gender, trait anxiety, panic attacks, and baseline avoidance. Results indicted that the mental and physical subscales of the ASI predicted change in behavioral avoidance. The findings of the study are consistent with the view that AS may serve as a precursor to avoidant behavior and that, regardless of whether or not acute panic has been experienced, those who fear autonomic arousal may be more likely to avoid situations in which those sensations may be present.

Neuroticism moderates the effect of maximum smoking level on lifetime panic disorder: a test using an epidemiologically defined national sample of smokers

The present study evaluated a moderational model of neuroticism on the relation between smoking level and panic disorder using data from the National Comorbidity Survey. Participants (n=924) included current regular smokers, as defined by a report of smoking regularly during the past month. Findings indicated that a generalized tendency to experience negative affect (neuroticism) moderated the effects of maximum smoking frequency (i.e., number of cigarettes smoked per day during the period when smoking the most) on lifetime history of panic disorder even after controlling for drug dependence, alcohol dependence, major depression, dysthymia, and gender. These effects were specific to panic disorder, as no such moderational effects were apparent for other anxiety disorders. Results are discussed in relation to refining recent panic-smoking conceptual models and elucidating different pathways to panic-related problems.

A contemporary learning theory perspective on the etiology of anxiety disorders: it's not what you thought it was

The authors describe how contemporary learning theory and research provide the basis for perspectives on the etiology and maintenance of anxiety disorders that capture the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the shortcomings of earlier overly simplistic behavioral approaches, which sometimes have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term outcomes of experiences with stressful events. They also demonstrate how contextual variables during and following stressful learning events affect the course of anxiety disorder symptoms once they develop. This range of variables can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.

10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II. Developmental epidemiology

OBJECTIVE

To describe the growth of developmental epidemiology in the past decade and to illustrate it with examples of recent studies.

METHOD

A review of publications on developmental epidemiology in the past 10 years and a discussion of some key examples.

RESULTS

The authors describe how the interaction between developmental psychopathology and psychiatric epidemiology has produced developmental epidemiology, the study of patterns of distribution of psychiatric disorders in time as well as in space. They give two examples of the kinds of questions that developmental epidemiology can help to answer: (1) Is the prevalence of autism increasing? Does the use of vaccines explain the increase? (2) Is there an epidemic of child and adolescent depression? Finally, they describe two areas of science that are beginning to inform developmental epidemiology: molecular genetics and the use of biological measures of stress.

CONCLUSIONS

While child and adolescent psychiatric epidemiology continues, as described in the first of these reviews, to address questions of prevalence and burden, it has also expanded into new areas of research in the past decade. In the next decade, longitudinal epidemiological data sets with their rich descriptive data on psychopathology and environmental risk over time and the potential to add biological measures will provide valuable resources for research into gene-environment correlations and interactions.

Vulnerability factors for anxiety disorders in children and adolescents

With the maturation of community studies of adults in the past decade, there has been growing awareness of the importance of the magnitude and impact of anxiety disorders in the general population. The convergence of findings from adult and child epidemiology reveals that the onset of anxiety disorders occurs in childhood, and a substantial proportion of youth with anxiety continues to manifest lifelong problems with anxiety and other mental disorders. In this article, the major risk factors for the development of anxiety disorders in childhood and adolescence are reviewed.

Separation anxiety disorder, panic disorder, and school refusal

Studies attest to the chronic nature of anxiety in youth. Consequently, there is a growing literature examining causative pathways to these disorders and efficacious treatments for them. This review examines separation anxiety disorder, a commonly occurring childhood anxiety disorder, and panic disorder, a more rare anxiety disorder in youth. Finally, school refusal, which may be tied to an internalizing or externalizing disorder or no disorder at all, is examined.