 |
|
Symptom Severity and Perceptions in Subjects With Panic Attacks
David A. Katerndahl, MD
Arch Fam Med. 2000;9:1028-1035.
ABSTRACT
| |
Objectives To (1) identify aspects that defined the self-perceived worst panic attack, (2) determine how subjects with panic attacks perceive symptoms compared with control subjects, and (3) determine the role of symptom perceptions in seeking care for the worst panic attack.
Design Cross-sectional survey.
Setting Community-based.
Patients or Other Participants Ninety-seven subjects with panic attacks as defined by the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (with or without panic disorder), and 97 demographically matched controls.
Intervention None.
Main Outcome Measures Subjects and controls completed the Symptom Perception Scales, and subjects with panic attacks completed the Acute Panic Inventory and a questionnaire concerning care-seeking behavior for their self-perceived worst attack.
Results Compared with controls, subjects with panic attacks perceived many symptoms as more embarrassing but differed little in their perceptions of need for treatment, threat to life, and disruption of functioning. Particular symptoms (ie, dyspnea, fear, dizziness, and faintness) tended to differ in most perceptions. However, symptom perceptions did not play a significant role in care-seeking behavior for the worst attack.
Conclusions Subjects with panic attacks perceive symptoms as more embarrassing than controls, and have different perceptions about particular symptoms. Cognitive approaches addressing negative patient perceptions may reduce anxiety, inappropriate use of health care services, and adverse outcomes.
INTRODUCTION
PANIC ATTACKS are experienced by more than 9% of community-dwelling adults,1 and are associated with substance abuse,2 agoraphobia,3 and disability.4 The prevalence of panic attacks is even higher in primary care populations,5 yet is often unrecognized.6
According to Mayou's7 model of symptom production, symptoms are the result of the patient's interpretation of physical sensations and depend on emotional arousal and illness experience. Because patients with panic disorder (PD) have high levels of anxiety sensitivity,8 their emotional arousal is also high. Because they experience panic-related disability, poor perceived health,4 and high use of health care services,9 illness experience in patients with PD is also high. Consequently, patients with PD would be expected to interpret physical sensations as more catastrophic than control subjects. This would support the cognitive model for PD.10
The distinction between sensations and symptoms is evident in the failure of subjects with palpitations to predict arrhythmias accurately11; patients with PD are no more accurate than controls.12 In fact, the positive predictive value for arrhythmia is inversely related to somatization, psychopathological symptoms, and mental health visits, suggesting that patients with PD may have palpitations more often than controls when experiencing similar changes in heart rate.13 Hyperventilation in anxiety-sensitive subjects increases their symptom severity without changing their heart rate.12 Symptom perceptions, or the meaning attached to the symptoms, in those with panic attacks predict use of specific health care sites (ie, emergency department, family physician, and psychologist),5 whereas symptom severity correlates with phobic avoidance14 and social impairment.15-16
Cognitions during panic attacks play an important role in the patient's levels of fear and anxiety. Not only do patients with PD overpredict their levels of fear on exposure17-18 but asthmatic patients with panic attacks have higher levels of fear when experiencing bodily sensations and more catastrophic thoughts when anxious.19 In experimental conditions, experiencing a panic attack results in increased catastrophic cognitions. Whereas overprediction of panic attacks results in decreased fear, underprediction causes increased predicted fear.20 Expected panic attacks and unexpected "nonpanic" result in increased levels of safety, whereas unexpected panic causes increased fear and decreased safety.21-22 Similarly, providing false feedback of an accelerated heart rate to subjects with panic attacks results in increased anxiety and arousal.22 The observation that cognitive behavioral therapy is effective further emphasizes the importance of cognitions in PD. Cognitive behavioral therapy restructures inappropriate cognitions and seeks to change catastrophic misinterpretations of physical sensations.23 Thus, symptom perceptions and cognitions are important to fear and anxiety levels in patients with PD, possibly affecting health care use patterns and outcomes.
This study was performed to improve the understanding of symptoms and symptom perceptions in people with panic attacks, and to assess whether their interactions result in seeking care.
The purposes of this study were to (1) identify aspects that defined the self-perceived worst panic attack, (2) determine how subjects with panic attacks perceive symptoms compared with controls, and (3) determine the role of symptom perceptions in seeking care for the worst panic attack.
METHODS
SUBJECTS
The Panic Attack Care-Seeking Threshold (PACT) Study was a community-based study of randomly selected adults aged 18 years or older from randomly selected households in San Antonio, Tex. Varying numbers of subjects were identified from 18 census tracts so that the sample would be representative of the US population in age, sex, and race. Because San Antonio is predominantly Hispanic, representativeness in ethnicity was not attempted. Thus, the study sample was representative of the US population in terms of age, sex, and race but not ethnicity. Details of the sampling procedure have been described previously.1, 24 The Institutional Review Board at the University of Texas Health Science Center at San Antonio reviewed and approved this project.
DATA COLLECTION
After obtaining informed consent, subjects were screened for the presence of panic attacks using the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) (SCID).25 Those subjects with panic attacks (unexpected attacks with at least 4 symptoms) were asked to participate. Subjects did not have to meet criteria for PD and were not excluded if other Axis I disorders were present.
Subjects completed a long interview in either English or Spanish (at their preference) that included demographic information and symptom perceptions. From the subjects screened who reported no panic symptoms, a control group was selected secondarily and matched to subjects with panic attacks in a cohort fashion based on age (±3 years), sex, and race or ethnicity. Thus, for each subject with panic attacks, a control subject of the same age, sex, and race or ethnicity was randomly selected from the census tract of the subject with panic attacks. Control subjects also completed the long interview.
INSTRUMENTS
Subjects with panic attacks were asked their health care–seeking behavior for their self-perceived "worst" panic attack, whether their worst panic attack was defined by the presence of a particular symptom, and, if so, what symptom. Symptom severity during the worst panic attack was assessed with a modified version of the Acute Panic Inventory (0 indicates symptom not present; 7, severe symptom).26
The Symptom Perception Scales were developed from the work of Jones et al.27 Five scales were developed that focused on the subject's perception that particular symptoms were (1) embarrassing, (2) life threatening, (3) requiring treatment, (4) severe, and (5) disruptive to functioning, regardless of whether the subject had the symptom. Each of these 5 scales consisted of 24 Likert scales, 1 for each symptom. Twelve panic symptoms—dyspnea, chest pain, fear, dizziness, palpitations, shakiness, paresthesias, choking, faintness, hot or cold flashes, sweats, and depersonalization—were combined with 12 randomly selected nonpanic symptoms—paralysis, weight loss, skin infection, irritability, hair loss, overweight, convulsions, stuffy nose, headache, hemoptysis, high blood pressure, and intestinal gas. The 24 symptoms were ordered randomly within each scale and rated from 1 (very severe) to 7 (not severe). Internal consistencies for the 5 scales ranged from 0.89 to 0.92. Construct validity was also assessed. The Embarrassment Scale was inversely correlated (r = -0.41; P = .03) with the Interpersonal Sensitivity Scale of the Hopkins Symptom Checklist.28 Similarly, the Life-Threatening Scale was correlated (r = 0.35; P = .06) with the Thanatophobia Scale of the Illness Attitude Scales.29 The Severity Scale was inversely related (r = -0.57; P = .001) to the Acute Panic Inventory.26 Finally, subjects with panic attacks with and without work incapacity due to panic differed significantly (t = 3.22; P = .003) on the Disrupts Function Scale. The validity of the Spanish translation of the Symptom Perception Scales is suggested by comparison of performance by Hispanic subjects completing the English (n = 39) vs the Spanish (n = 15) translations. Comparing scale scores of the English and Spanish versions revealed no significant (P>.05) differences on any scales. Two differences were significant at P .20 but lost significance when adjusted for differences in education and acculturation. The measures used to establish construct validity, as presented above, produced similar results in non-Hispanic whites and in Hispanics completing the Spanish translations. Internal consistencies ranged from 0.813 to 0.888 and from 0.906 to 0.946 for the English and Spanish translations, respectively.
ANALYSIS
Symptom perceptions in subjects with panic attacks and controls were compared using paired t tests. The relationship between symptom perceptions and seeking care for the worst panic attack was analyzed by analysis of variance with 2 x 2 interaction terms. Thus, patients who had a particular symptom (eg, chest pain) were selected for each analysis of variance, differences in perceptions for the particular symptom during their worst attack (eg, chest pain) were selected for each analysis of variance, and differences in perceptions for the particular symptom (eg, chest pain is embarrassing) were sought, comparing seeking care against using that symptom to define their worst attack. P.05 was considered significant, with .05 <P.10 showing a trend toward significance. Bonferroni correction was used to correct for multiple comparisons.
RESULTS
Of 1683 individuals contacted, 1266 (75%) agreed to be screened. Of the 119 subjects meeting criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition,30 for panic attacks, 97 (82%) completed the long interview. Of the 97 subjects with panic attacks, 42 (43%) met criteria for PD. Demographic data on the 97 subjects with panic attacks and the matched controls are presented in Table 1.
|
|
|
|
Table 1. Sample Demographics
|
|
|
Table 2 lists the symptoms present during the self-perceived worst attack and each symptom's severity rating. Concerning the characteristics about the panic attack that caused subjects to define it as worst, 90 (93%) stated that the worst panic attack had the most severe symptoms, 92 (95%) that a particular symptom defined the worst attack, and 81 (84%) that the worst attack lasted the longest. Table 3 lists the panic-related symptoms that defined the worst panic attack and that caused subjects to first seek care. Although few differences in percentages were found, subjects were more likely to include sweating as defining their worst attack but were more likely to first seek care for paresthesias, even though paresthesias did not define their worst attack.
|
|
|
|
Table 2. Symptom Characteristics of Self-perceived Worst Panic Attack for 97 Subjects
|
|
|
|
|
|
|
Table 3. Panic Attacks With Particular Symptoms*
|
|
|
Comparisons of symptom perceptions for subjects with panic attacks vs controls are presented in Table 4. Subjects with panic attacks consistently perceived symptoms—panic or nonpanic—as more embarrassing than did controls. Although there was a tendency for subjects with panic attacks to perceive panic symptoms as more severe and requiring treatment, these were only tendencies and did not apply to all symptoms. Few symptoms were perceived as more disruptive to functioning by subjects with panic attacks, and only fear was perceived as significantly more life threatening. From a symptom standpoint, trends toward significance were found in all 5 perceptions assessed for both dyspnea and dizziness, whereas 4 of 5 perceptions differed notably for fear and faintness. Comparing perceptions of panic symptoms within subjects with panic attacks, whether the subject had the symptom during their worst attack made no difference in perception of embarrassment, need for treatment, or disruption of functioning. However, subjects with panic attacks with those particular symptoms tended to perceive their symptoms as more life threatening (mean difference, 0.05; paired t = l.78; P = .08).
|
|
|
|
Table 4. Panic-Control Comparisons for Symptom Perceptions*
|
|
|
Of the 97 subjects with panic attacks, 50 (52%) sought health care for their worst panic attack. To assess the impact of a particular symptom and its perception on seeking care, analysis of variance was used for interaction terms. As seen in Table 5, few differences in perceptions were significant. Perceptions of dyspnea requiring treatment, severity, or disrupting functioning tended toward significance. Similarly, perceptions of hot or cold flashes in severity or as life threatening tended toward significance.
|
|
|
|
Table 5. Interaction Between Seeking Care and Attack Defined by Symptom in Terms of Symptom Perceptions
|
|
|
COMMENT
Subjects with panic attacks defined their worst panic attack on the basis of the symptoms being considered most severe or the presence of a particular symptom—dyspnea and palpitations most commonly, but sweats disproportionately. Phenomenologically, the worst panic attack included all of the panic symptoms—dyspnea, palpitations, and trembling most often—with symptom severity highest for palpitations, fear, and trembling. Compared with controls, subjects with panic attacks reported more embarrassment from symptoms and, to a lesser extent, more need for treatment and more severity. These findings generally agree with the previous literature.26, 32 Symptoms cited as important to first seeking care were dyspnea, palpitations, and, disproportionately, paresthesias. Severe symptom perceptions were important in defining the worst panic attack by a particular symptom, but few were independently significant to seeking care for the worst attack. However, symptom perceptions for dyspnea and hot or cold flashes were important to seeking care when defining the worst attack by dyspnea or hot or cold flashes (Table 5). This lack of a perceived severity–care-seeking relationship contradicts Mechanic's theory on the importance of symptom severity in seeking care.33
Although all of the symptoms were common during the worst attack, the high severity ratings for palpitations and trembling may be attributed to their high prevalences. However, although dyspnea was prevalent, its severity rating was lower, suggesting that, when present, dyspnea was not that severe. Conversely, fear during the worst attack was given a high severity rating, even though fear was not that prevalent. The severity of fear during panic attacks was noted previously.34 Subjects defined their worst attack by its severity and the presence of particular symptoms. These definitions are important because subjects with panic attacks first seek care for their worst attack (74%) and for an attack with particular symptoms (43%).24 Cognitions during the worst attack include physical problems (eg, heart attack or dying) and mental illness (eg, stress or going crazy).24 These cognitions may explain patients' defining the worst attack by the presence of dyspnea and palpitations (physical problems) or sweats (mental illness).
Compared with controls, subjects with panic attacks perceived all of the panic symptoms—and nonpanic symptoms—as more embarrassing. This may reflect the high degree of interpersonal sensitivity noted by those with PD.35 This is supported by their sense of shame when discussing anxiety36 and their fear of acting foolish.37 Embarrassment about the first panic attack predicts the development of agoraphobia.38 Subjects with panic attacks were also more likely to perceive panic symptoms as severe and requiring treatment. Few differences were found, however, in perceptions of symptoms as disrupting functioning or as being life threatening. One notable exception was that subjects with panic attacks rated fear as more life threatening. Excluding perceptions of embarrassment, differences between subjects with panic attacks and controls were seen in most perceptions for dyspnea, dizziness, faintness, and fear, but not for chest pain or paresthesias. Previous work also found more anxiety,39 fear,32, 40 bodily sensations,11, 40 and catastrophic ideation26, 32, 39-41 in subjects with PD. Catastrophic cognitions in which patients believe panic attacks signal life-threatening events were worse in unexplained panic.42 Cognitive behavioral therapy appears to be effective by restructuring these catastrophic misinterpretations of physical sensations.23
Looking at the relationship of symptom perceptions to defining the worst attack by particular symptoms and seeking care for the worst attack, few perceptions independently predicted seeking care, and those did not differ from controls. A variety of symptom perceptions independently predicted defining the worst attack on the basis of particular symptoms, especially with perceived embarrassment. This may reflect the association of interpersonal sensitivity with symptom-related disability and lack of social adjustment.15 Although previous studies found associations between the presence of particular panic symptoms and particular cognitions,37, 43 none have focused on how perceptions and symptoms interact to determine care-seeking behavior. Our study found that, although the particular perceptions varied, only 2 panic symptoms—dyspnea and hot or cold flashes—were significant. The emphasis on perceptions about dyspnea agrees with the report by Ley.44 Hence, our study suggests that defining the worst attack as one having dyspnea or hot or cold flashes, and perceiving those symptoms as severe symptoms in general, predicts seeking care in subjects with panic attacks.
IMPLICATIONS
Because the presence or severity of panic-related symptoms appears to be less important than symptom perceptions to outcomes, physicians need to attend to these perceptions. In many cases, these perceptions are held more in subjects with panic attacks than in controls. In addition, those with panic attacks perceive symptoms—any symptoms—as more embarrassing. This supports the work of others who found that patients with PD processed information differently, perceiving specific threats as being related to their symptoms.45-46 However, our study found that patients with PD do not indiscriminately endorse somatic symptoms.47 For all symptoms, only in perceptions of embarrassment did subjects with panic attacks differ significantly from controls.
Although this study cannot dictate therapeutic approaches, it could guide future research. Physicians could attempt to bolster coping mechanisms within subjects with panic attacks. The use of coping strategies distinguishes between recovered and symptomatic patients,46 and between those with and without phobic avoidance.48 By using principles of cognitive behavioral therapy to restructure cognitions in patients, physicians may enable patients to reinterpret their physical sensations so as not to become symptomatic and to minimize health care use and the development of adverse outcomes. The observation that the quality, not quantity, of cognitive behavioral therapy sessions is predictive of outcome emphasizes the potential for change in patients with panic attacks who receive counseling.49
LIMITATIONS
There are several limitations to this study. In addition to the limited set of variables by which controls were matched and the multiple comparisons made, the instrument used to assess symptom perceptions has not been studied thoroughly. In the original study, factor analysis found that perceptions of embarrassment clustered separately from all other perceptions.27 On the basis of comparisons between subjects with panic attacks and controls, our study also found a unique pattern for the embarrassment subscale. However, this raises questions about the uniqueness of each of the other perceptions used.
Another concern is the meaningfulness of the magnitude of the differences between subjects with panic attacks and controls. In general, differences in perceptions of about 0.5 units were sufficient to reach the .10 level of significance. Redelmeier et al50 found that when patients used a scale of 1 to 7 to rate symptoms, a difference of 0.5 units represented the minimal important difference. This suggests that the 0.5-point differences found when using such scales may be meaningful differences.
Finally, subjects with panic attacks did not have to meet criteria for PD to be included in this study. Although this may improve the generalizability of the results, differences between subjects with panic attacks and those with PD may play a role in interpretation. Analysis revealed that, although no differences were found in most definitions of the worst attack or symptom perceptions of severity or need for treatment, subjects with PD rated their symptom perceptions for panic symptoms as more embarrassing, more life threatening, and more disruptive to functioning (data not shown). Consequently, the implications concerning these perceptions may be more applicable to people with PD than to those with subsyndromal panic.
CONCLUSIONS
The self-perceived worst panic attack was defined by either the severity of its symptoms or the presence of particular symptoms, ie, dyspnea, palpitations, or sweats. The identification of the particular symptom may depend on the symptom perceptions—particularly embarrassment—of that symptom. Although subjects with panic attacks perceive all symptoms—panic and nonpanic—as more embarrassing than do controls, they also tend to perceive panic symptoms as more severe and as requiring more treatment. Certain symptoms—dyspnea, dizziness, faintness, and fear—are associated with stronger perceptions in general in subjects with panic attacks. Although perceptions did little to predict seeking care for the worst panic attack, defining the worst attack with a particular symptom—dyspnea and hot or cold flashes—and how that symptom is perceived did predict seeking care. These results may be helpful in understanding the behavior and outcomes in patients with panic attacks as well as for providers to develop therapies to assist patients in using adaptive coping mechanisms. Future research on panic symptomatology should include symptom perceptions as well as symptom presence and severity.
AUTHOR INFORMATION
Accepted for publication September 12, 2000.
This study was supported by a grant from the Upjohn Company, Kalamazoo, Mich.
Corresponding author: David A. Katerndahl, MD, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MSC-7795, San Antonio, TX 78229-3900 (e-mail: katerndahl{at}uthscsa.edu).
From the Department of Family Practice, University of Texas Health Science Center at San Antonio.
REFERENCES
| |
1. Katerndahl DA, Realini JP. Lifetime prevalence of panic states. Am J Psychiatry. 1993;150:246-249.
FREE FULL TEXT
2. Katerndahl DA, Realini JP. Relationship between substance abuse and panic attacks. Addict Behav. 1999;24:731-736.
FULL TEXT
|
ISI
| PUBMED
3. Weissman MM, Bland RC, Canino GJ, et al. The cross-national epidemiology of panic disorder. Arch Gen Psychiatry. 1997;54:305-309.
FREE FULL TEXT
4. Rubin HC, Rapaport MH, Levine B, et al. Quality of well-being in panic disorder: the assessment of psychiatric and general disability. J Affect Disord. 2000;57:217-221.
FULL TEXT
|
ISI
| PUBMED
5. Katerndahl DA, Realini JP. Where do panic attack sufferers seek care? J Fam Pract. 1995;40:237-243.
ISI
| PUBMED
6. Katerndahl DA, Trammell C. Prevalence and recognition of panic states in STARNET patients presenting with chest pain. J Fam Pract. 1997;45:54-63.
ISI
| PUBMED
7. Mayou RA. Patients' fears of illness. In: Creed F, Mayou R, Hopkins A, eds. Patients With Medically Unexplained Physical Symptoms. London, England: Royal College of Physicians and Royal College of Psychiatrists; 1991:534-535.
8. Cox BJ, Endler NS, Norton GR, Swinson RP. Anxiety sensitivity and nonclinical panic attacks. Behav Res Ther. 1991;29:367-369.
FULL TEXT
|
ISI
| PUBMED
9. Boyd JH. Use of mental health services for the treatment of panic disorder. Am J Psychiatry. 1986;143:1569-1574.
FREE FULL TEXT
10. Clark DM. A cognitive approach to panic. Behav Res Ther. 1986;24:461-470.
FULL TEXT
|
ISI
| PUBMED
11. Barsky AJ, Cleary PD, Barnett MC, Christiansen CL, Ruskin JN. Accuracy of symptom reporting by patients complaining of palpitations. Am J Med. 1994;97:214-221.
FULL TEXT
|
ISI
| PUBMED
12. Asmundson GJG, Norton GR, Wilson KG, Sandler LS. Subjective symptoms and cardiac reactivity to brief hyperventilation in individuals with high anxiety sensitivity. Behav Res Ther. 1994;32:237-241.
FULL TEXT
|
ISI
| PUBMED
13. Ehlers A, Margraf J, Roth WT, Taylor CB, Birbaumer N. Anxiety induced by false heart rate feedback in patients with panic disorder. Behav Res Ther. 1988;26:1-11.
FULL TEXT
|
ISI
| PUBMED
14. Katerndahl DA. Factors in the panic-agoraphobia transition. J Am Board Fam Pract. 1989;2:10-16.
15. Noyes R Jr, Clancy J, Woodman C, et al. Environmental factors related to the outcome of panic disorder. J Nerv Ment Dis. 1993;181:529-538.
FULL TEXT
|
ISI
| PUBMED
16. Starcevic V, Kellner R, Uhlenhuth EH, Pathak D. Panic disorder and hypochondriacal fears and beliefs. J Affect Disord. 1992;24:73-85.
FULL TEXT
|
ISI
| PUBMED
17. Schmidt NB, Jacquin K, Telch MJ. Overprediction of fear and panic in panic disorder. Behav Res Ther. 1994;32:701-707.
FULL TEXT
|
ISI
| PUBMED
18. Van Hout WJ, Emmelkamp PM. Overprediction of fear in panic disorder patients with agoraphobia. Behav Res Ther. 1994;32:723-734.
FULL TEXT
|
ISI
| PUBMED
19. Carr RE, Lehrer PM, Rausch LL, Hochron SM. Anxiety sensitivity and panic attacks in an asthmatic population. Behav Res Ther. 1994;32:411-418.
FULL TEXT
|
ISI
| PUBMED
20. Rachman S, Levitt K, Lopatka C. Experimental analyses of panic. Behav Res Ther. 1988;26:33-40.
FULL TEXT
|
ISI
| PUBMED
21. Rachman S, Levitt K. Panics and their consequences. Behav Res Ther. 1985;23:585-600.
FULL TEXT
|
ISI
| PUBMED
22. Street LL, Craske MG, Barlow DH. Sensations, cognitions, and the perception of cues associated with expected and unexpected panic attacks. Behav Res Ther. 1989;27:189-198.
FULL TEXT
|
ISI
| PUBMED
23. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA. 2000;283:2529-2536.
FREE FULL TEXT
24. Realini JP, Katerndahl DK. Factors affecting the threshold for seeking care: the Panic Attack Care-Seeking Threshold (PACT) Study. J Am Board Fam Pract. 1993;6:215-223.
25. Spitzer RL, Williams JB. Structured Clinical Interview for DSM-III-R, Upjohn Version, Revised. New York: New York State Psychiatric Institute; 1989.
26. Carr DB, Sheehan DV, Surman OS, et al. Neuroendocrine correlates of lactate-induced anxiety and their response to chronic alprazolam therapy. Am J Psychiatry. 1986;143:483-494.
FREE FULL TEXT
27. Jones RA, Wiese HJ, Moore RW, Haley JV. On the perceived meaning of symptoms. Med Care. 1981;19:710-717.
FULL TEXT
|
ISI
| PUBMED
28. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19:1-15.
ISI
| PUBMED
29. Kellner R. Illness Attitude Scales. Albuquerque: University of New Mexico; 1983.
30. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Washington, DC: American Psychiatric Association; 1987.
31. Hollingshead AB. Two-Factor Index of Social Position. New Haven, Conn: Yale University; 1957.
32. Ahmad T, Wandle J, Hayward P. Physical symptoms and illness attributions in agoraphobia and panic. Behav Res Ther. 1992;30:493-500.
FULL TEXT
|
ISI
| PUBMED
33. Mechanic D. The epidemiology of illness behavior and its relationship to physical and psychological distress. In: Mechanic D, ed. Symptoms, Illness Behavior, and Help-Seeking. New York, NY: Prodist; 1982:1-24.
34. Cox BJ, Swinson RP, Ender NS, Norton GR. Symptom structure of panic attacks. Compr Psychiatry. 1994;35:349-353.
FULL TEXT
|
ISI
| PUBMED
35. Katerndahl DA, Realini JP. Comorbid psychiatric disorders in subjects with panic attacks. J Nerv Ment Dis. 1997;185:669-674.
FULL TEXT
|
ISI
| PUBMED
36. Zucker D, Taylor CB, Rouillard M, et al. Cognitive aspects of panic attacks. Br J Psychiatry. 1989;155:86-91.
FREE FULL TEXT
37. Rachman S, Levitt K, Lopatka C. Panic: the links between cognitions and bodily symptoms. Behav Res Ther. 1987;25:411-423.
FULL TEXT
|
ISI
| PUBMED
38. Amering M, Katschnig H, Berger P, Windhaber J, Baischar W, Dantendorfer K. Embarrassment about the first panic attack predicts agoraphobia in panic disorder patients. Behav Res Ther. 1997;35:517-521.
FULL TEXT
|
ISI
| PUBMED
39. Pauli P, Marquardt C, Hartl L, Nutzinger DO, Holzl R, Strian F. Anxiety induced by cardiac perceptions in patients with panic attacks. Behav Res Ther. 1991;29:137-145.
FULL TEXT
|
ISI
| PUBMED
40. McNally RJ, Riemann BC, Kim E. Selective processing of threat cues in panic disorder. Behav Res Ther. 1990;28:407-412.
FULL TEXT
|
ISI
| PUBMED
41. Whittel ML, Goetsch VL, Suchday S. Infrequent panic. Behav Res Ther. 1994;32:453-457.
FULL TEXT
|
ISI
| PUBMED
42. Rapee R, Mattick R, Murrell E. Cognitive mediation in the affective component of spontaneous panic attacks. J Behav Ther Exp Psychiatry. 1986;17:245-253.
FULL TEXT
|
ISI
| PUBMED
43. Warren R, Zgourides G, Englert M. Relationships between catastrophic cognitions and body sensations in anxiety disordered, mixed diagnosis and normal subjects. Behav Res Ther. 1990;28:355-357.
FULL TEXT
|
ISI
| PUBMED
44. Ley R. Dyspneic-fear and catastrophic cognitions in hyperventilatory panic attacks. Behav Res Ther. 1989;27:549-554.
FULL TEXT
|
ISI
| PUBMED
45. Carter CS, Maddock RJ, Magliozzi J. Patterns of abnormal processing of emotional information in panic disorder and major depression. Psychopathology. 1992;25:65-70.
ISI
| PUBMED
46. Stoler LS, McNally RJ. Cognitive bias in symptomatic and recovered agoraphobics. Behav Res Ther. 1991;29:539-545.
FULL TEXT
|
ISI
| PUBMED
47. Goetz RR, Gorman JM, Dillon DJ, et al. Do panic disorder patients indiscriminately endorse somatic complaints? Psychiatry Res. 1989;29:207-213.
FULL TEXT
|
ISI
| PUBMED
48. Telch MJ, Brouilland M, Telch CF, Agras WS, Taylor CB. Role of cognitive appraisal in panic-related avoidance. Behav Res Ther. 1989;27:373-383.
FULL TEXT
|
ISI
| PUBMED
49. Schmidt NB, Woolaway-Bickel K. The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: quality versus quantity. J Consult Clin Psychol. 2000;68:13-18.
FULL TEXT
|
ISI
| PUBMED
50. Redelmeier DA, Guyatt GH, Goldstein RS. Assessing the minimal important difference in symptoms. J Clin Epidemiol. 1996;49:1215-1219.
FULL TEXT
|
ISI
| PUBMED
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Panic & Plaques: Panic Disorder & Coronary Artery Disease in Patients with Chest Pain
Katerndahl
J Am Board Fam Med 2004;17:114-126.
ABSTRACT
| FULL TEXT
|
