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Panic disorder (PD) is a, common psychiatric disorder, the primary feature of which is recurrent and unexpected panic attacks. A panic attack is defined as "a discrete period of intense fear or discomfort that has an abrupt onset, reaches a peak within 10 minutes, and is accompanied by at least 4 of 13 somatic or cognitive symptoms" (American Psychiatric Association PA], 1994, p. 394). Somatic symptoms include shortness of breath, accelerated heart rate, chest pain, choking sensations, dizziness, tingling or numbing sensations, hot/cold flashes, sweating, trembling, and nausea. Cognitive symptoms include fear of dying, going crazy, and losing control. Based on the distinction between somatic and cognitive symptoms, Clark (1986) has put forth a cognitive model of panic in which panic attacks are said to result from "catastrophic misinterpretation" of the bodily (i.e., somatic) sensations. Such catastrophic misinterpretation involves perception of the somatic symptoms as far more dangerous than they actually are. For example, heart palpitations may be interpreted as a sign of an impending heart attack, shortness of breath as evidence of cessation of breathing and imminent death, and shakiness or trembling as signaling loss of control and perhaps "going crazy" (Clark, 1986, p. 462). Clark proposed that such catastrophic misinterpretations play a, critical role in the vicious cycle that culminates in a panic attack and, subsequently, PD. Although some researchers have questioned the support for Clark’s cognitive model, and competing theories exist (e.g.; McNally, 1990), the cognitive approach to understanding panic ‘attacks and PD has been embraced by many researchers and theorists studying the genesis, course, and correlates ‘of panic (cf. Barlow, 1988; Ollendick, 1995; Rapee, Mat-tick, & Murrell, 1986).
Although the existence of panic attacks and PD is well established in the adult literature, and empirically supported psychosocial and pharmacological treatments have been developed for adults (cf. Barlow & Cerny, 1988; Beck & Emery, 1985; Clark, Salkovskis, Chalkley, 1985; Clum, 1989; Marks, 1987; Ost, Westling, & Hellstrom,. 1993), little is known about these disorders or their treatment in children and adolescents (Kearney, Albano, Eisen, Allan, & Barlow, 1997; Ollendick, Maths, & King, 1994). Indeed, considerable controversy exists whether these phenomena even exist in children and adolescents (Nelles & Barlow, 1988).
Panic In Adolescents
Among community samples, for example, 35.9% to 63.3% of adolescents report experiencing panic attacks in their lifetimes (Hayward, Killen, & Taylor, 1989; King, Gullone, Tonge, & Ollendick, 1993; King, Ollendick, Mattis, Yang, & Tonge, 1997; Lau, Calamari, & Waraczynski, 1996; Macaulay, & Kleinknecht, 1989), and 0.6% to 4.7% report past or present symptoms sufficient to meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for PD (Warren & Zgourides, 1988; Whitaker et al., 1990). Moreover, Last and Strauss (1989) reported that approximately 10% of adolescents referred to an outpatient anxiety disorders clinic, met diagnostic criteria for PD, whereas Alessi, Robbins, and Dilsaver (1987) reported that 15% of hospitalized adolescents in an adolescent inpatient unit warranted such a. diagnosis. Biederman et at. (1997) reported similar rates of PD. in adolescents referred to a pediatric psychopharmacology clinic.
Although such findings support the conclusion that panic attacks and PD occurring adolescence, Kearney and Silverman (1992). have cautioned against blanket acceptance of these findings. In doing. so, they have cited several methodological problems. that . characterize these studies, including small sample sizes and the use of questionable assessment and diagnostic strategies.
Although these limitations are acknowledged there is little doubt that panic attacks and PD as defined in the DSM.(4th ed. .(DSM—IV); APA,, 1994), exist in adolescence. Two recent studies conducted by our research group illustrate the available support. In the first study, conducted with 649 unselected Australian youth between 12 and 17 years of age. (King et at., 1997), we demonstrated that 16% of the youth’ reported at least one full-blown panic attack (characterized by presence of 4 or more of the 13 somatic and cognitive symptoms) in their lifetime. More girls (21.3%) reported full-blown panic attacks than boys (10.8%). Te most frequently endorsed symptoms were similar, with few exceptions, for boys and girls trembling dizziness (faintness pounding heart, and sweating. However girls reported more dizziness/faintness and more nausea than boys. Cognitive symptoms were reported less frequently than somatic ones: fear of dying in. 38.7% of the sample, and fear of going crazy or losing control in 56.7% of the sample, with a significant differences between boys and girls.
In this study, ‘the youth were also provided a list of events or situations found to be associated with panic attacks in earlier research and clinical studies and asked to indicate those events/situations in which their panic attacks typically occurred. The most frequently endorsed situations were being separated from someone important and walking alone at night (42.3% and 39.4%, respectively). Approximately 21% indicated that their panic attacks typically occurred unexpectedly, or "out of the blue." Two situations were endorsed more frequently by. girls, than boys.: walking alone at night and meeting strangers.
To assess relations between panic and psychosocial ‘stressors and, support, youth in this study were also asked, "How much stress have you experienced in the past six months as a result of family pressure? school pressure?" To assess social, support, they were asked, "When you are upset or under stress, how much support do you receive from: family? close friends?’ Both of these sets of questions had four response options: none, ‘a little, some, and a great deal. Significant differences were observed: between the panic group. and nonpanic group in the degree of, social support reportedly received from family. members and the. degree of family stress experienced, in recent months. The panic group of youth reported significantly less social support from family ‘and more ‘stress and pressure from the family than the nonpanic group. No differences in support from peers or school stressors were observed between the groups, however. . interactions with sex were not evident in our analyses.
Youth in this study were also administered self-report measures of anxiety (Reynolds & Richmond, 1978), depression (Kovacs & Beck, 1977),, and fear (Olleudick, 1983) to determine relations between such measures, and panic. attack status. The’, panic attack group reported higher levels of anxiety, depression, and fear than the nonpanic group. Although girls ‘reported higher levels of these negative mood states than boys.
Finally, we conducted a path analysis to determine the relative importance of a number .of influences on panic attack status. In our ‘exploratory model we included’ relevant background (sex, age): and life history support family, stress at home) influences that we thought needed’ to be controlled in order for the path analysis to provide meaningful results. These four variables were placed first in the model. Next, based On earlier findings. (cf. King Ct at., 1993), we included measures of. anxiety, depression, and, fear. Following path-analytic procedures, a series of regression analyses were conducted in which each variable was regressed on the preceding variables in. the model. First, panic attack group status was regressed on the three measures of negative mood and the background and life history variables in the model to determine direct effects. Next, anxiety, depression, and fear were’ regressed on the background and life history variables of interest. Anxiety, depression, and fear were directly and positively related to panic attack group status, as was perceived level of stress in ‘the home.’ Level of support from the family in times of stress was directly related to anxiety and depression but not to fear. Finally, sex was related to all three measures of negative mood, whereas age was related to anxiety and fear but not depression.
Reflection Exercise Explanation
Reflection Exercise #1