The role of catastrophic misinterpretation of bodily sensations and panic self-efficacy in predicting panic severity
Introduction
Two conceptually distinct cognitive factors have been hypothesized to be important in panic disorder (Hoffart, 1995a, Rapee, 1993). Catastrophic misinterpretation of bodily sensations refers to the process by which individuals misinterpret innocuous bodily sensations as being physically or psychologically dangerous, and consequently experience repeated panic attacks (Beck, Emery, & Greenberg, 1985; Clark, 1986; Salkovskis, Clark, & Hackmann, 1991). In contrast, panic self-efficacy (and the closely related construct of perceived control) concerns the individual’s perceived ability to cope with or control perceived danger in relation to panic attacks (Borden, Clum, & Salmon, 1991; Gauthier, Bouchard, Cote, Laberge, & French, 1993; Rapee, 1993; Telch, Brouillard, Telch, Agras, & Taylor, 1989; Williams & Falbo, 1996). According to Beck et al., both factors are likely to contribute to schematic processing of anxiety-related stimuli. However, research into the relative contribution of these two factors in prediction of panic severity of panic disorder has been both limited and inconclusive to date.
Although much of the research has focused on negative, danger-related cognitions (for review, see Clark, 1996; Khawaja & Oei, 1998), reduction of panic severity has been shown to be associated with both decreases in danger-related cognitions and increases in self-efficacy (Bouchard, Gauthier, Laberge, & French, 1996; Cote, Gauthier, Laberge, & Cormier, 1994; Lidren, Watkins, Gould, & Clum, 1994). However, studies that report post-treatment changes in both factors leave open the possibility that changes in one factor may be simply a co-effect of changes in the other factor (Bandura, 1988).
Several studies point to the conclusion that each of the factors is individually important in panic disorder, both in the etiology (Telch, Silverman, & Schmidt, 1996) and maintenance phases of the disorder (Michelson, Schwartz, & Marchione, 1991; Stoler & McNally, 1991). However, other studies suggest that only one or the other of these factors may be critical in determining panic severity. Borden et al. (1991) tracked cognitive changes across the treatment phase and found that changes in self-efficacy preceded changes in catastrophic thoughts in their sample of panic-disordered patients. Similarly, a number of studies reported by Williams (1995) revealed self-efficacy to be much more strongly associated with treatment outcome in patients with agoraphobia than perceived danger. In contrast, Hoffart (1995b) found that when therapy focused solely on an increase in self-efficacy, catastrophic beliefs failed to reduce. Conversely, when therapy targeted the reduction of catastrophic beliefs, an increase in self-efficacy was also observed.
One plausible explanation for some of these differing results concerns the absence or presence of agoraphobia in the samples used to examine the relationship of the two cognitive factors. A number of researchers have suggested that avoidance behavior characteristic of patients with agoraphobia is associated with low self-efficacy (Cox, Endler, Swinson, & Norton, 1992; Craske, Rapee, & Barlow, 1988; Salkovskis & Hackmann, 1997; Telch et al., 1989), raising the possibility that panic self-efficacy may be important only when agoraphobia is present. In support of this argument, the majority of studies that support the self-efficacy model in panic disorder have been conducted using samples of agoraphobic patients (Williams, 1996). Clearly, further investigation of the relative contribution of these factors needs to examine if the influence of panic self-efficacy upon panic severity remains when the presence or absence of agoraphobia is controlled.
In summary, there are a number of possible ways in which catastrophic misinterpretation of bodily sensations and panic self-efficacy may operate in patients with panic disorder. It may be that only one of these factors is critical in determining panic severity. If such a mediating relationship exists between the two factors, then the addition of the critical factor should cause the influence of the other factor to become nonsignificant in prediction of panic severity. In contrast, if the effects of catastrophic misinterpretation of bodily sensations upon panic severity are independent of panic self-efficacy, then high levels of catastrophic misinterpretation should predict high panic severity, regardless of the addition of panic self-efficacy. Similarly, if the effects of panic self-efficacy upon panic severity are independent of catastrophic misinterpretation of bodily sensations, then low levels of panic self-efficacy should predict high panic severity, regardless of the addition of catastrophic misinterpretation of bodily sensations. However, an alternative possibility is that, consistent with Beck et al.’s (1985) schema-based model of anxiety disorders, a single higher-order construct which combines both factors may provide a stronger prediction of panic severity than either factor alone. That is, the effects on panic severity may be the result of a moderating influence dependent on the levels of panic self-efficacy and catastrophic misinterpretation of bodily sensations.
An additional variable that needs to be controlled for in testing the relationship of these two factors to panic severity is the absence or presence of agoraphobia. Although evidence to date supports the influence of catastrophic misinterpretation of bodily sensations in panic disorder, regardless of the presence or absence of agoraphobia, it may be that panic self-efficacy additionally predicts panic severity only when the presence or absence of agoraphobia is uncontrolled.
These questions were investigated in the present study by examining the role of catastrophic misinterpretation of bodily sensations and panic self-efficacy in predicting panic severity in a large sample of patients awaiting therapy in a multicenter treatment trial for panic disorder (Kenardy, Dow, Johnston, Newman, & Taylor, 2002).
Section snippets
Patients
One hundred and fifty-nine patients were recruited from two clinical sites in Australia and Scotland. These patients were participants in the Panic Treatment Project (Kenardy et al., 2002) during the time when measures for this study were collected. The results of a treatment outcome comparison at post-treatment and follow-up for the Panic Treatment Project (using a composite variable that does not include the measure of symptom severity reported in the present study) are reported in Kenardy et
Site comparisons
Summary information on the variables of interest in this study, as well as a range of demographic and clinical variables for patients at each site is shown in Table 1, Table 2, Table 3. Preliminary analyses were conducted to check if there were any pre-existing differences between patients at the Australian and Scottish sites on any of these variables. Patients from the two sites were compared on each of the variables shown in Table 1, Table 2, Table 3, using one-way ANOVA for variables on a
Discussion
This study investigated the relative contribution of catastrophic misinterpretation of bodily sensations and panic self-efficacy to prediction of panic severity in panic disorder. Negative cognitions associating bodily sensations with danger and positive cognitions regarding perceived capacities to control panic attacks were found to independently predict panic severity in a sample of panic-disordered patients with and without agoraphobia. Catastrophic misinterpretation of bodily sensations
Acknowledgements
Data for this study was collected as part of the Panic Treatment Project, a multicenter study funded by a NHRMC grant awarded to Associate Professor Justin Kenardy in Australia and a Scottish Office research grant awarded to Dr. M.G.T. Dow and Professor D.W. Johnston in Scotland. We would like to thank Dr. Dow and Professor Johnston who generously provided data gathered at the Scottish site for this study. Thanks go also to the Panic Treatment Project staff for their assistance, in particular,
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