Emotional responding to biological challenge as a function of panic disorder and smoking

Modifiable risk and protective factors for anxiety disorders among adults: A systematic review

Anxiety disorders are highly prevalent in the general population and associated with high rates of impairment and disability. This burden highlights the need to identify risk factors that individuals can modify without professional intervention. A systematic review was conducted to identify studies that examined modifiable risk and protective factors for anxiety disorders among adults in the general population. Searches were conducted in PubMed, PsycINFO and MEDLINE using medical subject headings and text words related to risk factors, protective factors, and each anxiety disorder. Screening, data extraction, and quality assessment were performed by three study authors. Modifiable risk and protective factors from 19 studies across seven countries were identified. Risk factors identified included cigarette smoking, alcohol use, cannabis use, negative appraisals of life events, avoidance, and occupational factors. Protective factors included social support, coping, and physical activity. Cigarette smoking was the most studied risk factor. Support was found for cigarette smoking as a risk factor for agoraphobia and panic disorder. Mixed results were found for generalized anxiety disorder and specific phobia. Across disorders, smoking frequency was associated with greater risk. Results indicate an important gap in the literature in that few studies have examined modifiable risk factors for anxiety disorders.

Integrated Cognitive Behavioral Therapy for Anxiety and Smoking Cessation

Smokers suffer from high rates of anxiety disorders, presumably because some individuals with anxiety disorders rely on smoking as a maladaptive attempt to manage anxiety. Cognitive behavioral therapy (CBT) is an efficacious smoking cessation treatment, yet outcomes are worse for patients with elevated anxiety. The integration of CBT for smoking cessation with False Safety Behavior Elimination Therapy (FSET) may be useful with anxious smoking cessation patients, as smoking to manage anxiety and associated negative affect can be targeted as a false safety behavior (i.e., behavior aimed at decreasing anxiety in the short-term but which may maintain or exacerbate it in the long-term). Here, we describe the integrated treatment, Treatment for Anxiety and Smoking Cessation (TASC), and the successful use of it with two smoking cessation patients—one with comorbid generalized anxiety disorder (GAD) and one with clinically elevated social anxiety that did not meet diagnostic threshold for an anxiety disorder. Data support the feasibility of TASC as a viable approach to smoking cessation treatment for patients with comorbid anxiety disorder and with elevated anxiety that does not meet diagnostic threshold. Future controlled trials are now warranted to further evaluate the intervention.

Cardiopulmonary and Muscular Interactions: Potential Implications for Exercise (In)tolerance in Symptomatic Smokers Without Chronic Obstructive Pulmonary Disease

Smoking and physical inactivity are important preventable causes of disability and early death worldwide. Reduced exercise tolerance has been described in smokers, even in those who do not fulfill the extant physiological criteria for chronic obstructive pulmonary disease (COPD) and are not particularly sedentary. In this context, it is widely accepted that exercise capacity depends on complex cardio-pulmonary interactions which support oxygen (O₂) delivery to muscle mitochondria. Although peripheral muscular factors, O₂ transport disturbances (including the effects of increased carboxyhemoglobin) and autonomic nervous system unbalance have been emphasized, other derangements have been more recently described, including early microscopic emphysema, pulmonary microvascular disease, ventilatory and gas exchange inefficiency, and left ventricular diastolic dysfunction. Using an integrative physiological approach, the present review summarizes the recent advances in knowledge on the effects of smoking on the lung-heart-muscle axis under the stress of exercise. Special attention is given to the mechanisms connecting physiological abnormalities such as early cardio-pulmonary derangements, inadequate oxygen delivery and utilization, and generalized bioenergetic disturbances at the muscular level with the negative sensations (sense of heightened muscle effort and breathlessness) that may decrease the tolerance of smokers to physical exercise. A deeper understanding of the systemic effects of smoking in subjects who did not (yet) show evidences of COPD and ischemic heart disease - two devastating smoking related diseases - might prove instrumental to fight their ever-growing burden.

The indirect effect of panic disorder on smoking cognitions via difficulties in emotion regulation

Panic disorder (PD) and cigarette smoking are highly comorbid and associated with worse panic and smoking outcomes. Smoking may become an overlearned automatized response to relieve panic-like withdrawal distress, leading to corresponding smoking cognitions, which contribute to its reinforcing properties and difficultly abstaining. Difficulties in emotion regulation (ER) may underlie this relation such that in the absence of adaptive emotion regulatory strategies, smokers with PD may more readily rely upon smoking to manage affective distress. In the current study, the indirect relation between PD status and smoking cognitions through ER difficulties was examined among daily smokers (N=74). We found evidence for an indirect relation between PD status and negative affect, addictive and habitual smoking motives, and anticipating smoking will result in negative reinforcement and personal harm, through self-reported difficulties with ER. Our findings are aligned with theoretical models on anxiety and smoking, and suggest that reports of greater smoking cognitions may be due to ER difficulties.

Understanding the Connection Between Posttraumatic Stress Symptoms and Respiratory Problems: Contributions of Anxiety Sensitivity

Respiratory problems and posttraumatic stress disorder (PTSD) are the signature health consequences associated with the September 11, 2001 (9/11), World Trade Center disaster and frequently co-occur. The reasons for this comorbidity, however, remain unknown. Anxiety sensitivity is a transdiagnostic trait that is associated with both PTSD and respiratory symptoms. The present study explored whether anxiety sensitivity could explain the experience of respiratory symptoms in trauma-exposed smokers with PTSD symptoms. Participants (N = 135; M_age = 49.18 years, SD = 10.01) were 9/11-exposed daily smokers. Cross-sectional self-report measures were used to assess PTSD symptoms, anxiety sensitivity, and respiratory symptoms. After controlling for covariates and PTSD symptoms, anxiety sensitivity accounted for significant additional variance in respiratory symptoms (ΔR² = .04 to .08). This effect was specific to the somatic concerns dimension (β = .29, p = .020); somatic concerns contributed significantly to accounting for the overlap between PTSD and respiratory symptoms, b = 0.03, 95% CI [0.01, 0.07]. These findings suggest that the somatic dimension of anxiety sensitivity is important in understanding respiratory symptoms in individuals with PTSD symptoms. These findings also suggest that it may be critical to address anxiety sensitivity when treating patients with comorbid respiratory problems and PTSD.

Morning breathing exercises prolong lifespan by improving hyperventilation in people living with respiratory cancer

Disturbance of oxygen-carbon dioxide homeostasis has an impact on cancer. Little is known about the effect of breath training on cancer patients. Here we report our 10-year experience with morning breathing exercises (MBE) in peer-support programs for cancer survivors.We performed a cohort study to investigate long-term surviving patients with lung cancer (LC) and nasopharyngeal cancer (NPC) who practiced MBE on a daily basis. End-tidal breath holding time (ETBHT) after MBE was measured to reflect improvement in alveolar O2 pressure and alveolar CO2 pressure capacity.Patients (female, 57) with a diagnosis of LC (90 patients) and NPC (32 patients) were included. Seventy-six of them were MBE trainees. Average survival years were higher in MBE trainees (9.8 ± 9.5) than nontrainees (3.3 ± 2.8). The 5-year survival rate was 56.6% for MBE trainees and 19.6% for nontrainees (RR = 5.371, 95% CI = 2.271-12.636, P < 0.001). Survival probability of the trainees further increased 17.9-fold for the 10-year survival rate. Compared with the nontrainees, the MBE trainees shows no significant differences in ETBHT (baseline, P = 0.795; 1-2 years, P = 0.301; 3-4 years, P = 0.059) at baseline and within the first 4 years. From the 5th year onwards, significant improvements were observed in ETBHT, aCO2%, PaCO2, and PaO2 (P = 0.028). In total, 18 trainees (40.9%) and 20 nontrainees (74.1%) developed new metastasis (RR = 0.315, 95% CI = 0.108-0.919, P = 0.031).MBE might benefit for the long-term survival in patients with LC and NPC due to improvement in hyperventilation.

Cigarette Smoking and Panic Psychopathology

The present paper summarizes empirical evidence suggesting that smoking and panic problems often co-occur; that smoking is a risk factor for, and may serve to maintain, panic attacks and panic disorder; and that premorbid panic-specific vulnerability variables and full-blown panic problems are related to coping-oriented smoking motives and perhaps to the maintenance of smoking behavior. An integrative model is offered to stimulate further work on this topic, followed by future directions for research.

Differences in panic psychopathology between smokers with and without asthma

Cigarette smoking is more common among individuals with asthma compared to those without, resulting in increased risk of morbidity and mortality. However, there has been little exploration of psychological factors that differ between smokers with and without asthma. Thus, the aim of the current study was to examine differences between smokers with and without asthma in terms of anxiety sensitivity, panic symptoms, lifetime history of panic attacks, and lifetime history of panic disorder. Participants were 115 smokers with asthma (55.3% male, M_age = 38.4 years, SD = 11.9) and 120 smokers without asthma (70.6% male, M_age = 37.0 years, SD = 12.8) who were administered a structured diagnostic interview and completed self-report measures. As hypothesized, after controlling for the effects of cigarettes per day, gender, race, and education, smokers with asthma reported higher levels of anxiety sensitivity and panic symptoms and were at an increased risk for having a lifetime history of panic attacks (OR = 3.01) and panic disorder (OR = 2.96) compared to smokers without asthma. Further, group differences in anxiety sensitivity and panic symptoms remained even after removing participants with a lifetime history of panic attacks or panic disorder. These findings suggest that smokers with asthma are a particularly 'at-risk' population for panic psychopathology and likely in need of specialized smoking-related prevention and intervention efforts.

A laboratory-based test of the relation between adolescent alcohol use and panic-relevant responding

A burgeoning literature supports a link between alcohol use and panic-spectrum problems (e.g., panic attacks, disorder) among adolescents, but the direction of influence has yet to be properly examined. From a theoretical perspective, panic-spectrum problems may increase risk for problematic drinking via affect regulation efforts (e.g., self-medication), and problematic consumption also may increase or initiate panic-relevant responding (e.g., learning or kindling models). The objective of the current investigation was to examine the role of prior alcohol use in predicting panic-relevant responding, as well as panic symptom history in predicting the desire to consume alcohol, in the context of either a voluntary hyperventilation or a low-arousal task. Participants were community-recruited adolescents aged 12-17 years (n = 92, Mage = 15.42, SD = 1.51; 39.1% girls). Results indicated that prior alcohol use predicted panic-relevant responding among those undergoing the hyperventilation task (but not the low-arousal task), and that this finding was robust to the inclusion of theoretically relevant covariates (i.e., age, sex, negative affectivity). However, panic symptom history did not predict the desire to consume alcohol as a function of either the hyperventilation or low-arousal condition. This work sheds further light on the nature of the relation between panic-spectrum problems and problematic alcohol use in adolescence. Specifically, the current findings suggest that frequent alcohol use may increase panic vulnerability among adolescents, whereas acute panic symptoms may not elicit the immediate (self-reported) desire to drink.

Smoking to Regulate Negative Affect: Disentangling the Relationship Between Posttraumatic Stress and Emotional Disorder Symptoms, Nicotine Dependence, and Cessation-Related Problems

INTRODUCTION

Posttraumatic stress disorder (PTSD) is associated with various aspects of cigarette smoking, including higher levels of nicotine dependence and cessation difficulties. Affect-regulatory smoking motives are thought to, in part, underlie the association between emotional disorders such as PTSD and smoking maintenance, although few studies have empirically tested this possibility.

METHODS

Data were analyzed from 135 treatment-seeking smokers who were directly exposed to the World Trade Center disaster on September 11, 2001. We modeled the direct effect of 9/11 PTSD symptom severity on nicotine dependence, perceived barriers to smoking cessation, and severity of problematic symptoms experienced during prior cessation attempts. We also examined the indirect effect of PTSD on these outcomes via negative affect reduction smoking motives. Parallel models were constructed for additional emotional disorder symptoms, including panic and depressive symptoms.

RESULTS

PTSD symptom severity was associated with nicotine dependence and perceived barriers to cessation, but not problems during prior quit attempts indirectly via negative affect reduction smoking motives. Panic and depressive symptoms both had significant indirect effects, via negative affect reduction smoking motives, on all three criterion variables.

CONCLUSIONS

Affect-regulatory smoking motives appear to underlie associations between the symptoms of emotional disorders such as PTSD, panic, and depression in terms of smoking dependence and certain cessation-related criterion variables.

IMPLICATIONS

Overall, this investigation suggests negative affect reduction smoking motives help to explain the relationship of PTSD, depression, and panic symptoms to nicotine dependence, severity of problems experienced during prior quit attempts and perceived barriers to cessation. These results highlight the importance of assessing motivations for smoking in the context of cessation treatment, especially among those with emotional disorder symptoms. Future interventions might seek to utilize motivational interviewing and cognitive restructuring techniques to address coping-oriented motives for smoking, in addition to skills for managing negative affect, as a means of improving quit outcomes.

Anxiety, depression, and cigarette smoking: a transdiagnostic vulnerability framework to understanding emotion-smoking comorbidity

Research into the comorbidity between emotional psychopathology and cigarette smoking has often focused upon anxiety and depression's manifest symptoms and syndromes, with limited theoretical and clinical advancement. This article presents a novel framework to understanding emotion-smoking comorbidity. We propose that transdiagnostic emotional vulnerabilities-core biobehavioral traits reflecting maladaptive responses to emotional states that underpin multiple types of emotional psychopathology-link various anxiety and depressive psychopathologies to smoking. This framework is applied in a review and synthesis of the empirical literature on 3 transdiagnostic emotional vulnerabilities implicated in smoking: (a) anhedonia (Anh; diminished pleasure/interest in response to rewards), (b) anxiety sensitivity (AS; fear of anxiety-related sensations), and (c) distress tolerance (DT; ability to withstand distressing states). We conclude that Anh, AS, and DT collectively (a) underpin multiple emotional psychopathologies, (b) amplify smoking's anticipated and actual affect-enhancing properties and other mechanisms underlying smoking, (c) promote progression across the smoking trajectory (i.e., initiation, escalation/progression, maintenance, cessation/relapse), and (d) are promising targets for smoking intervention. After existing gaps are identified, an integrative model of transdiagnostic processes linking emotional psychopathology to smoking is proposed. The model's key premise is that Anh amplifies smoking's anticipated and actual pleasure-enhancing effects, AS amplifies smoking's anxiolytic effects, and poor DT amplifies smoking's distress terminating effects. Collectively, these processes augment the reinforcing properties of smoking for individuals with emotional psychopathology to heighten risk of smoking initiation, progression, maintenance, cessation avoidance, and relapse. We conclude by drawing clinical and scientific implications from this framework that may generalize to other comorbidities.

The role of anxiety sensitivity in the relation between trait worry and smoking behavior

INTRODUCTION

Smoking and anxiety disorders frequently co-occur. Trait worry is a core symptom of anxiety disorders. While research suggests worry processes may be important to certain smoking behaviors, the mechanisms explicating these relations remain unknown.

METHOD

The current study examined anxiety sensitivity (AS) as a potential mediator for the relation between trait worry and number of years being a daily smoker, latency to first cigarette of the day, smoking rate, heaviness of smoking, and nicotine dependence among treatment-seeking daily smokers (N = 376; 47% female; M age = 37.76, SD = 13.46).

RESULTS

Consistent with prediction, AS significantly mediated the relations between trait worry and the studied smoking variables.

CONCLUSION

The present findings suggest it may be useful to clinically address AS among worry-prone, treatment-seeking daily smokers in order to address smoking behavior.

Understanding the relationship between smoking and pain

This review provides an overview of evidence regarding several key mechanisms pertinent to understanding the co-occurrence of smoking dependence and pain, both potentially costly conditions, and highlights treatment implications and future research directions. We describe each of pain and smoking dependence and introduce a revised integrative reciprocal model that explains their co-occurrence. We then provide a selective review of evidence pertinent to direct and indirect pathways between variables postulated in the model. We also provide general recommendations for improving assessment and treatment of smokers with clinically significant pain. We conclude with a targeted agenda for future investigation of the co-occurrence of smoking and pain. Empirical efforts directed at testing postulates of the proposed integrative model may yield a better understanding of the nature of the relationship between these prevalent and costly health conditions as well as evidence-based preventive and treatment strategies for people who experience nicotine dependence and pain-related disability.

Effects of nicotine withdrawal on panic-like response to breath holding: a placebo-controlled, double-blind, crossover patch study

BACKGROUND

Cigarette smoking may increase the likelihood of developing panic disorder. Periods of nicotine withdrawal, in particular, may promote panic in individuals high in anxiety sensitivity. We examined the importance of nicotine withdrawal in the occurrence of smoking and panic.

METHODS

We utilized a placebo-controlled, double-blind, randomized, crossover design. Fifty smokers underwent a breath-holding (BH) challenge after the transdermal administration of nicotine on one test day and a placebo on another test day. Physiological and psychological variables were assessed at baseline as well as directly before and after the challenges.

RESULTS

Nicotine abstinence induced a decrease in heart rate and systolic blood pressure (BP) before the BH procedure (heart rate: 78.80 ± 11.43 under nicotine, 70.88 ± 10.83 under placebo; systolic BP: 124.90 ± 11.34 under nicotine, 121.18 ± 13.44 under placebo) and shorter BH duration relative to the nicotine patch condition. Nicotine abstinence did not, though, increase fear reactivity to the challenge.

CONCLUSIONS

The findings for heart rate and BP are consistent with the stimulant properties of nicotine. The reduced capacity to maintain apnea under placebo might be due to carbon dioxide (CO2 ) hypersensitivity during periods of nicotine abstinence. The negative findings regarding fear reactivity might be due to BH being a relatively weak anxiogen. Future researchers are encouraged to employ CO2 -inhalation procedures to study the relationship between nicotine withdrawal and panic.

The interaction of nicotine withdrawal and panic disorder in the prediction of panic-relevant responding to a biological challenge

The current investigation evaluated nicotine withdrawal symptoms elicited by 12 hours of smoking deprivation on anxious and fearful responding to bodily sensations among daily smokers with and without panic disorder (PD). It was hypothesized that smokers with PD who were experiencing greater levels of nicotine withdrawal would experience the greatest levels of fearful responding to, and delayed recovery from, a 10% carbon dioxide-enriched air (CO₂) biological challenge procedure. Participants were 58 adults who reported smoking 19.72 cigarettes daily (SD = 7.99). Results indicated that nicotine withdrawal and PD status interacted to predict greater postchallenge panic attack symptoms. Also, individuals with PD initially evidenced a quicker decrease in subjective anxiety following the challenge, but their rate of recovery decelerated over time as compared to those without PD. There was, however, no significant interaction for change in subjective anxiety pre- to postchallenge. Results are discussed in relation to the role of nicotine withdrawal in anxious and fearful responding for smokers with PD.

Biological sex and panic-relevant anxious reactivity to abrupt increases in bodily arousal as a function of biological challenge intensity

An emerging pattern of results from panic-relevant biological challenge studies suggests women respond with greater subjective anxiety than men, but only to relatively abrupt and intense challenge procedures. The current investigation examined the relation between biological sex and self-reported anxious reactivity following biological challenges of varying durations and intensity. Participants were 285 (152 females; M(age) = 21.38; SD = 5.92) nonclinical adults who completed one of three protocols: a 3-min voluntary hyperventilation challenge (VH), a 5-min 10% carbon dioxide-enriched air (CO(2)) challenge, or a 25-s 20% CO(2) challenge. As predicted, results indicated that the 20% CO(2) challenge elicited greater self-reported anxiety than the VH and 10% CO(2) challenges. Moreover, women endorsed greater anxious reactivity than men, but only following the 20% CO(2) challenge. Results are discussed in terms of processes likely to account for sex differences in anxious reactivity following relatively abrupt and intense biological challenges.

Spectrum of anxiety disorders: diagnosis and pharmacologic treatment

Nearly 30% of women experience an anxiety disorder at some time during their lives, and there is increasing evidence that anxiety disorders are associated with adverse pregnancy outcomes. Despite increased media coverage regarding anxiety disorders, women are reluctant to discuss signs and symptoms of anxiety with family or health care providers. Additionally, despite ongoing research and improved educational curricula, primary care and women's health care providers find diagnosis and treatment of mental health disorders challenging. This article reviews the diagnostic features and pharmacologic treatment options for the most common anxiety disorders including generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and posttraumatic stress disorder. The impact of anxiety disorders on pregnancy and guidelines for management are presented.

Nicotine withdrawal exacerbates fear reactivity to CO₂-induced bodily sensations among smokers

INTRODUCTION

Independent lines of research suggest that smoking increases the prospective risk of panic disorder. Studies that have examined the hypothesized link between nicotine withdrawal and panic have typically employed light smokers or lacked optimal control groups. Our laboratory team previously found, for example, that smokers who abstained from cigarettes for 12 hr demonstrated greater fear reactivity to a CO(2) rebreathing challenge than nonsmokers. However, the absence of a smoking-as-usual group limited our ability to draw conclusions about the potential role of nicotine withdrawal.

METHODS

We exposed 27 heavy smokers who abstained from smoking for 12 hr and 27 heavy smokers who smoked as usual to a 5-min CO(2) rebreathing challenge.

RESULTS

More intense prechallenge nicotine withdrawal symptoms (regardless of group status) were associated with more severe panicky symptoms and a stronger urge to escape during the challenge, even after we controlled for prechallenge anxiety and daily cigarette use. Unexpectedly, group status did not predict challenge reactivity.

CONCLUSION

Smokers who regularly experience intense withdrawal symptoms, regardless of length of smoking abstinence, may be at heightened risk for experiencing panic attacks.

The interplay between physical activity and anxiety sensitivity in fearful responding to carbon dioxide challenge

OBJECTIVE

Physical activity may confer protective effects in the development of anxiety and its disorders. These effects may be particularly strong among individuals who have elevated levels of anxiety sensitivity (AS; i.e., the fear of somatic arousal), an established cognitive-based risk factor for anxiety and its disorders. The present study performed a laboratory test of the interplay between physical activity and AS.

METHODS

The participants were adults free of Axis I psychopathology (n = 145) who completed measures of physical activity and AS before undergoing a recurrent 20% carbon dioxide-enriched air (CO(2)) challenge.

RESULTS

Consistent with the hypothesis, physical activity was significantly related to CO(2) challenge reactivity among persons with elevated levels of AS, at high levels of physical activity (p < .001) but not at low levels of physical activity (p = .90). Also consistent with hypothesis, irrespective of the level of physical activity, physical activity did not relate significantly to CO(2) challenge reactivity among persons with normative levels of AS (p = .28).

CONCLUSIONS

These findings provide novel empirical insight into the role that physical activity may play in terms of resiliency for the development of anxiety disorders. Specifically, the protective effects of physical activity may only be evident at higher doses and among persons who are at increased risk of developing anxiety disorders because they have elevated AS.

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.

Panic-Relevant Cognitive Processes Among Smokers

To further understand the frequent co-occurrence of smoking and panic disorder (PD), we examined panic-relevant cognitive processes among heavy smokers, half of whom were in 12-hour withdrawal, and nonsmokers. All participants (N = 85) underwent a 5-minute carbon dioxide rebreathing challenge. Prior to the challenge, participants completed questionnaires on reasons for smoking, anxiety sensitivity, and suffocation fear. Results are consistent with a model in which smokers with predisposing risk factors (high anxiety sensitivity and high suffocation fear) misappraise bodily sensations and experience panicky symptoms. No evidence was found that being in acute withdrawal heightened this risk. Overall, findings highlight (a) cognitive vulnerabilities that may place smokers at elevated risk for developing PD and hence (b) potential targets for intervention.

Uni-morbid and co-occurring marijuana and tobacco use: examination of concurrent associations with negative mood states

The aim of the current investigation was to examine uni-morbid and co-occurring tobacco and marijuana use in relation to the negative emotional symptoms of anxiety and depression. Participants were 250 adult individuals (132 women; mean age = 22.43 years, standard deviation = 9.00 years) who were divided into one of four non-overlapping substance use categories: tobacco use only (n = 39), marijuana use only (n = 62), co-occurring tobacco and marijuana use (n = 82), and neither tobacco nor marijuana use (n = 67). Results revealed three key findings. First, tobacco-only using individuals reported significantly greater negative affectivity than any of the other groups. Second, tobacco-only users reported greater anxious arousal symptoms than either the marijuana or non-substance use groups, but not the combined group. Third, tobacco-only users reported greater levels of depressive symptoms than either marijuana users or non-substance users. These findings provide novel information about tobacco and marijuana use and how these variables relate to the experience of general and specific types of negative emotional symptoms.

Cigarette smoking and 35% CO(2) induced panic in panic disorder patients

BACKGROUND

A disproportionately large number of persons with panic disorder (PD) smoke cigarettes compared to people in the general population and individuals with other anxiety disorders. Clinical and epidemiological data suggest that cigarette smoking increases the risk for the development and maintenance of PD. The carbon dioxide (CO(2)) challenge is well established as experimental model for panic. The present study seeks to examine whether cigarette smoking has an influence on laboratory elicited panic in PD patients.

METHODS

In total 92 subjects (46 smokers and 46 non-smokers) with PD, according to the DSM-IV criteria, were compared. All subjects received a baseline clinical assessment and underwent a 35% CO(2) challenge. Response to the challenge was evaluated via the Panic Symptom List and the Visual Analogue Fear Scale.

RESULTS

The two samples did not differ on baseline anxiety level. Smokers had a significantly higher increase in panic symptoms in response to the challenge compared to non-smokers (p=0.04).

LIMITATIONS

This type of study does not provide information concerning the underlying mechanisms of the link between smoking and panic. Study limitations include lack of formal assessment of personality and of inter-rater reliability.

CONCLUSIONS

The present findings are consistent with the idea that smoking facilitates panic in PD subjects. This may have clinical implications, as quitting smoking could become one of the relevant steps in the treatment of PD patients.

An evaluation of pain-related anxiety among daily cigarette smokers in terms of negative and positive reinforcement smoking outcome expectancies

The present investigation sought to evaluate the unique explanatory relevance of pain-related anxiety in relation to negative and positive reinforcement smoking outcome expectancies among 135 (40.7% female; M(age) = 26.11, SD = 11.23) adult daily cigarette smokers. As predicted, pain-related anxiety was significantly related to greater expectancies that smoking will decrease negative affect, and lesser expectancies that smoking will result in positive outcomes. The observed effects were evident above and beyond the variance accounted for by gender, current level of non-specific bodily pain, daily cigarette use, relations with non-criterion outcome expectancies, and shared variance with anxiety sensitivity. Results suggest that there may be segments of the smoking population who are at relatively greater risk for certain expectancies for tobacco smoking by virtue of individual differences in pain-related anxiety.

Cognitive-affective characteristics of smokers with and without posttraumatic stress disorder and panic psychopathology

The present study evaluated differences among daily smokers with posttraumatic stress disorder (PTSD), panic disorder (PD), panic attacks (PA), and no axis I psychopathology (past 6 months) in terms of several cognitive-affective variables implicated in both the onset and maintenance of anxiety psychopathology and cigarette smoking. The sample consisted of 123 daily smokers (62% women: M(age)=29.7, SD=11.9). Compared to the PA and no psychopathology groups, the PTSD group reported significantly higher levels of anxiety sensitivity, discomfort intolerance, negative affectivity, anxious arousal, and anhedonic depression; and, the PTSD group reported significantly lower levels of perceived control over anxiety-related events than the PA group. The PD group, compared to those in the PA and no psychopathology groups, reported significantly higher levels of anxiety sensitivity, negative affectivity, and anxious arousal; and significantly lower levels of perceived control over anxiety-related events. No significant differences were evident between the PTSD and PD groups. Theoretical and clinical implications of the present findings are discussed in terms of smoking and emotional vulnerability.

Anxiety sensitivity and panic reactivity to bodily sensations: relation to quit-day (acute) nicotine withdrawal symptom severity among daily smokers making a self-guided quit attempt

The current investigation explored the main and interactive effects of panic attacks in response to laboratory-induced bodily sensations and anxiety sensitivity in predicting acute nicotine withdrawal symptoms among daily smokers making a self-guided quit attempt. Participants were 99 daily smokers (58% women; M(age) = 28.4 years, SD = 11.7) who completed a battery of questionnaires, a voluntary hyperventilation challenge, and a measure of nicotine withdrawal symptoms 12 hr after making a self-guided quit attempt. Results indicated that the interaction of anxiety sensitivity and panic responsivity to the challenge predicted quit-day nicotine withdrawal symptom severity above and beyond the main effects (p < .05). The form of the interaction indicated that the relationship between postchallenge panic attack status and acute nicotine withdrawal was more robust among individuals who were low in anxiety sensitivity. Individuals who did not experience a panic attack posthyperventilation who were also low in anxiety sensitivity reported the lowest levels of nicotine withdrawal. Results suggest that anxiety sensitivity may be less relevant with regard to acute nicotine withdrawal severity among individuals with panic-related problems.

Laboratory test of a novel structural model of anxiety sensitivity and panic vulnerability

The current study evaluated a novel latent structural model of anxiety sensitivity (AS) in relation to panic vulnerability among a sample of young adults (N=216). AS was measured using the 16-item Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986), and panic vulnerability was indexed by panic attack responding to a single administration of a 4-minute, 10% CO(2) challenge. As predicted, vulnerability for panic attack responding to biological challenge was associated with dichotomous individual differences between taxonic AS classes and continuous within-taxon class individual differences in AS physical concerns. Findings supported the AS taxonic-dimensional hypothesis of AS latent structure and panic vulnerability. These findings are discussed in terms of their theoretical and clinical implications.

The Role of Mindful Attention in Regard to the Relation Between Negative Affect Reduction Outcome Expectancies and Emotional Vulnerability Among Adult Cigarette Smokers

The present investigation examined the role of mindful attention in regard to the relation between negative affect reduction smoking outcome expectancies and anxious arousal and anhedonic depression symptoms and difficulties with emotion regulation among 174 (46% women; M _age = 25.32 years, SD = 10.51) daily cigarette smokers. As predicted, there was a significant interaction for negative affect reduction smoking outcome expectancies and mindful attention in relation to anxious arousal symptoms and emotion regulation difficulties. Individuals endorsing both higher levels of negative affect reduction outcome expectancies and lower levels of mindful attention reported the greatest anxious arousal symptoms and difficulties with emotion regulation, while those reporting both lower levels of negative affect reduction expectancies and higher levels of mindful attention were associated with lesser anxious arousal symptoms and the least difficulties with emotion regulation. There was no interactive effect for anhedonic depression symptoms. Findings are discussed in relation to better understanding the clinically meaningful interplay between mindful attention and negative affect reduction outcome expectancies among cigarette smokers in terms of affective vulnerability.

Anxiety sensitivity and CO2 challenge anxiety during recovery: differential correspondence of arousal and perceived control

The relations between changes in arousal and perceived control with changes in anxiety-related distress during a 10-min recovery period after exposure to 10% CO(2)-enriched air was examined among community participants (N=47) high (n=23) and low (n=24) in anxiety sensitivity (AS). Rate of decline in arousal was significantly positively associated with rate of decline in anxiety among high and low AS participants when controlling for valence. Rate of increase in perceived control was significantly negatively related to rate of decline in anxiety in the high AS group but not in the low AS group when controlling for valence. These findings suggest that associations between arousal, perceived control, and anxiety-related recovery from a panic-relevant episode of abrupt increases in bodily arousal differ as a function of pre-existing fears of anxiety-related symptoms (i.e., AS). Implications of these findings for disorders associated with elevated AS are discussed.

Discomfort intolerance: evaluation of incremental validity for panic-relevant symptoms using 10% carbon dioxide-enriched air provocation

The present investigation examined the relation between discomfort intolerance and panic-relevant symptoms among 216 (117 women) young adults who participated in a biological challenge procedure. Partially consistent with hypotheses, after covarying for anxiety sensitivity, negative affectivity, and emotional acceptance, the intolerance subscale of the Discomfort Intolerance scale [DIS; Schmidt, N. B., Richey, J. A., & Fitzpatrick, K. K. (2006). Discomfort intolerance: development of a construct and measure relevant to panic disorder. Journal of Anxiety Disorders, 20, 263-280] was significantly incrementally related to increased post-challenge anxiety focused on bodily sensations, physical panic symptoms, and behavioral avoidance, but not cognitive panic symptoms. Inconsistent with prediction, the avoidance subscale of the DIS was not significantly related to any of the dependent variables. Results are discussed in relation to better understanding the role of discomfort intolerance as a unique explanatory factor in the context of panic psychopathology.

Evaluation of anxiety sensitivity among daily adult smokers using item response theory analysis

The present investigation applied Item Response Theory (IRT) methodology to the 16-item Anxiety Sensitivity Index (ASI) [Reiss, S., Peterson, R. A., Gursky, M., & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8] for a sample of 475 daily adult smokers (52% women; M(age)=26.9, S.D.=11.1, range=18-65). Using non-parametric item response analysis, all 16 ASI items were evaluated. Evaluation of the option characteristic curves for each item revealed 4 poorly discriminating ASI items (1: "It is important not to appear nervous;" 5: "It is important to me to stay in control of my emotions;" 7: "It embarrasses me when my stomach growls;" 9: "When I notice my heart beating rapidly, I worry that I might be having a heart attack"), which were dropped from analysis. Upon repeat analysis, the remaining items appeared to make adequate separations within levels of anxiety sensitivity in this sample. Graded response modeling data indicated important differences in ASI items' capacity to discriminate between, and provide information about, latent levels of anxiety sensitivity. Specifically, three items best discriminated and provided the most information regarding latent levels of AS-items 3, 15, and 16. Items 1, 5, 7, and 9 were omitted due to their limited capacity to discriminate between latent levels of anxiety sensitivity; items 8, 12, and 13 also performed poorly. Overall, current findings suggest that evaluation of anxiety sensitivity among adult smokers using the 16-item ASI may usefully choose to focus on items that performed well in these IRT analyses (items: 2, 3, 4, 6, 10, 11, 14, 15, and 16).

An evaluation of anxiety sensitivity, emotional dysregulation, and negative affectivity among daily cigarette smokers: relation to smoking motives and barriers to quitting

The present investigation evaluated the relations between anxiety sensitivity and motivational bases of cigarette smoking, as well as barriers to quitting smoking, above and beyond concurrent substance use, negative affectivity, and emotional dysregulation among a community sample of 189 daily cigarette smokers (46% women; M(age)=24.97 years, SD=9.78). Results indicated that anxiety sensitivity was significantly related to coping, addictive, and habitual smoking motives, as well as greater perceived barriers to quitting. These effects were evident above and beyond the variance accounted for by concurrent tobacco, alcohol, and marijuana use and discernable from shared variance with negative affectivity and emotional dysregulation. Emotional dysregulation was significantly related to stimulation, habitual, and sensorimotor smoking motives and greater perceived barriers to quitting, whereas negative affectivity was only significantly related to smoking for relaxation. These findings uniquely add to a growing literature suggesting anxiety sensitivity is an important and unique cognitive factor for better understanding clinically-relevant psychological processes related to cigarette smoking.

Biological challenge procedures used to study co-occurring nicotine dependence and panic disorder

A wide array of biological challenge procedures - including carbon dioxide inhalation, hyperventilation, and breath holding - have been used to model panic in laboratory settings. Originally used to study developmental processes in panic disorder (PD), these procedures, along with nicotine patch administration and self-administered smoking, have recently been applied to help understand the etiology of co-occurring nicotine dependence and PD. The goals of the present paper are to review studies that have employed biological challenges to study the comorbid condition, identify the advantages and limitations of the various procedures, describe desirable outcome measures for use in biological challenges, and present recommendations for future challenge studies in this field. We argue that biological challenges, though in need of standardization, are useful for studying the development, maintenance, prevention, and treatment of comorbid nicotine dependence and PD.

Evaluation of smoking characteristics among community-recruited daily smokers with and without posttraumatic stress disorder and panic psychopathology

The present investigation compared 123 community-recruited daily smokers with posttraumatic stress disorder (PTSD), panic disorder (PD), nonclinical panic attacks (PA), or no current Axis I psychopathology (controls; C) in terms of nicotine dependence, smoking rate, quit history, severity of symptoms during past quit attempts, and motivation for and expectancies about smoking. No differences were observed between groups in regard to smoking rate or nicotine dependence. The PTSD group reported making more lifetime quit attempts than the other groups, and the PTSD and PD groups perceived more severe symptoms during past quit attempts. The PD and PTSD groups reported greater motivation to smoke to reduce negative affect. Individuals with PTSD endorsed a stronger expectation that smoking would alleviate negative mood states and would produce negative consequences. Overall, results suggest that smokers with PD or PTSD differ from other smoking groups in a number of clinically significant ways.

An integrated approach to panic prevention targeting the empirically supported risk factors of smoking and anxiety sensitivity: theoretical basis and evidence from a pilot project evaluating feasibility and short-term efficacy

Consistent with a risk reduction model of targeted prevention, the present investigation piloted and empirically evaluated the feasibility and short-term efficacy of a first-generation panic prevention program that targeted two malleable risk factors for panic development-anxiety sensitivity and daily cigarette smoking. Members of a high risk cohort, defined by high levels of anxiety sensitivity and current daily smoking (n=96), were randomly assigned to either (1) a one session intervention focused on proximally increasing motivation to quit smoking and reducing anxiety sensitivity to distally prevent the development of panic or (2) a health information control condition of comparable length. Participants were followed for 6 months. Consistent with hypotheses, those in the treatment condition showed reduced anxiety sensitivity and this effect was maintained across the follow-up period. Limited evidence also suggested the intervention increased motivation to quit smoking. We discuss how this prevention protocol can be modified in the future to enhance its effects as part of second-generation larger-scale outcome evaluations.

Panic reactivity to voluntary hyperventilation challenge predicts distress tolerance to bodily sensations among daily cigarette smokers

The present investigation examined the extent to which panic reactivity to bodily sensations is related to distress tolerance (DT) among daily smokers. It was hypothesized that panic reactivity to an initial voluntary hyperventilation (i.e., whether participants met criteria for a DSM-IV panic attack; PA) would predict the relative degree of task persistence on a second hyperventilation trial (DT) above and beyond the variance accounted for by anxiety sensitivity (AS), negative affectivity (NA), cigarette smoking rate, and self-reported discomfort intolerance (DI). Participants were 95 daily smokers (58% women; M-sub(age) = 29.0, SD = 12.2) who completed a battery of questionnaires and two voluntary hyperventilation procedures. Results indicated PA status significantly predicted DT, above and beyond the theoretically relevant covariates of AS, NA, cigarettes per day, and DI ( p < .05). Such a result is consistent with theoretical models and empirical findings on emotional reactivity that suggest panic responsivity to internal cues may represent a key explanatory construct in terms of level of DT to interoceptive stimuli.

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.

Anxiety sensitivity as a moderator of the association between smoking status and anxiety symptoms and bodily vigilance: replication and extension in a young adult sample

The present investigation evaluated the moderational role of the physical concerns dimension of anxiety sensitivity (fear of anxiety and anxiety-related states) in the relation between smoking status and panic-relevant symptoms in a young adult sample (n=222; 123 females; M(age)=22.45 years, SD=8.08). Consistent with prediction, anxiety sensitivity physical concerns moderated the association of smoking status with body vigilance and anxious arousal symptoms, such that greater anxiety sensitivity physical concerns was associated with greater panic symptoms among smokers. The observed effects were evident even after controlling for the variance accounted for by alcohol use problems and gender. Also consistent with prediction, there was no interactive effect apparent for depressive symptoms, providing evidence of explanatory specificity with respect to the anxiety variables examined. Findings are discussed with regard to the role of anxiety sensitivity in the relation between smoking and panic processes.

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.

Interaction between smoking rate and anxiety sensitivity: relation to anticipatory anxiety and panic-relevant avoidance among daily smokers

The aim of the present investigation was to evaluate the moderating role of anxiety sensitivity (AS) in the relation between smoking rate and panic vulnerability variables, both concurrently and prospectively (3 months), among a community-based sample of 125 daily smokers (60 females; M(age) =26.02 years, S.D. =10.98). Consistent with prediction, the interaction between AS and smoking rate significantly predicted concurrent agoraphobic avoidance (3.2% of unique variance) and change in levels of anticipatory anxiety during the 3-month follow-up period (4.7% unique variance). Smokers high in AS who also smoked at greater rates reported the highest levels of avoidance and greatest increase in anticipatory anxiety. Overall, these data suggest that AS is an important individual difference factor that, when coupled with higher rates of smoking, is associated with greater levels of avoidance and anticipatory anxiety among daily smokers.

Incremental validity of anxiety sensitivity in relation to marijuana withdrawal symptoms

The present investigation examined the relation between anxiety sensitivity (AS) and marijuana withdrawal severity among 84 (47 female) young adult marijuana smokers. As expected, after covarying for the theoretically-relevant variables of frequency of past 30-day marijuana use, number of cigarettes smoked per day, volume of alcohol consumed, and anxious arousal as well as anhedonic depressive symptoms, both the global AS factor and the AS-mental incapacitation concerns factor were significantly related to the severity of retrospectively reported marijuana withdrawal symptoms. Results are discussed in relation to better understanding cognitive-emotional variables related to the marijuana withdrawal.

Discomfort intolerance: evaluation of a potential risk factor for anxiety psychopathology

Discomfort intolerance, defined as an individual difference in the capacity to tolerate unpleasant bodily sensations, is a construct recently posited as a risk factor for panic and anxiety psychopathology. The present report used a biological challenge procedure to evaluate whether discomfort intolerance predicts fearful responding beyond the effects of trait anxiety and a well-established psychological vulnerability factor (i.e., anxiety sensitivity). Nonclinical community participants (N=44) with no history of panic attacks or any Axis I condition completed a 35% CO(2) challenge. Results are consistent with our hypothesis suggesting that discomfort intolerance incrementally predicts increased subjective reactivity to the challenge. Moreover, there was some suggestion that discomfort intolerance interacted synergistically with anxiety sensitivity to increase anxiety-related symptoms. These findings add to a small but growing literature suggesting that discomfort intolerance may play a role in the development of anxiety problems.

Perceived health moderates the association between smoking rate and panic vulnerability variables among daily smokers

Our aim in this investigation was to evaluate the moderating role of perceived health in the relation between smoking rate and panic variables in a community-based sample of 220 daily smokers (98 females; M(age)=23.76 years, SD=8.76). As hypothesized, the interaction between smoking and perceived health incrementally predicted anxiety sensitivity (fear of anxiety) and anxious arousal symptoms, but not depressive symptoms. Individuals who had higher smoking rates and lower perceived health reported higher levels of anxiety sensitivity and anxious arousal, but not depressive symptoms. The primary implication of these findings is that there may be segments of the cigarette smoking population who are at relatively greater risk for anxiety symptoms and fear of bodily sensations by virtue of individual differences in perceived health. The identification of such moderating effects is clinically important, because it helps to refine our understanding of complex associations between drug behavior and panic vulnerability.

Perceived Health: A Test of Incremental Validity in Relation to Smoking Outcome Expectancies, Motivation to Smoke and Desire to Quit Smoking

This study examined the role of perceived health in predicting theoretically-relevant aspects of smoking behavior among 161 young adult regular smokers (67 females; mean age = 21.9 years (SD = 7.2), cigarettes per day (M) = 12.2 (SD = 5.7)) recruited from the general community. Consistent with prediction, results indicated that relative to anxiety sensitivity, gender, number of cigarettes smoked per day and nicotine dependence, perceived physical health uniquely and significantly predicted expectancies for negative affect reduction and expectancies that smoking would lead to negative personal consequences. Additionally, perceived health incrementally predicted motivation to smoke to reduce negative affect. In contrast to expectation, perceived health was unrelated to motivation to quit smoking. Results are discussed in relation to the role of perceived health as a cognitive vulnerability factor for specific types of smoking patterns.

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.