آغاز تفاسیر پانیک در کودکان مبتلا به اختلال پانیک

Cognitive and psycho-physiological models of panic disorder stress the role of interpretation bias in the maintenance of the disorder. Several studies have reported results consistent with this hypothesis, but it is still unclear whether this bias precedes panic disorder or is a consequence of it. In the present study, we compared the interpretations of ambiguous scenarios of children of individuals with panic disorder, children of individuals with animal phobia, and children of healthy controls. Children were presented with three types of scenarios each including one of the following descriptions: panic-relevant physical sensations, animal-relevant stimuli, and panic-irrelevant physical sensations (i.e., cold symptoms). To test, if children’s interpretation bias is affected by priming, we compared their responses to the scenarios before and after watching a panic, a spider phobic, and a cold model. The results revealed that (a) children of panic disordered parents but not of parents with animal phobia and of healthy controls showed a significant increase in anxious interpretations after priming; and (b) this significant increase emerged only after priming through presentation of a panic-relevant model and not after priming through presentation of a phobia-relevant or cold-relevant model. Because the children of panic disordered parents did not have panics themselves, their increase in panic interpretations can be viewed as a vulnerability factor. Longitudinal studies should clarify the role of interpretation style in the etiology of panic disorder.

Over the past two decades many clinical researchers have been interested in elucidating the cognitive processes underlying anxiety (cf.,Williams, Watts, MacLeod, & Mathews, 1997). Indeed, influential psychological models of anxiety disorders have postulated that cognitive processes are crucial for the maintenance of these disorders (e.g., Beck, Emery, & Greenberg, 1985; Foa & Kozak, 1986) and several studies have supported this premise. In particular, three kinds of cognitive biases, which were found to differentiate anxiety disordered individuals from nonanxious controls, have been hypothesized to mediate the maintenance of anxiety disorders: attentional bias (e.g., Foa, Ilai, McCarthy, Shoyer, & Murdock, 1993; Hope, Rapee, Heimberg, & Dombeck, 1990), memory bias (e.g., Becker, Roth, Andrich, & Margraf, 1999; McNally, Litz, & Prassas, 1994), and interpretation bias (e.g., Butler & Mathews, 1983; McNally & Foa, 1987). Cognitive and psycho-physiological models of panic disorder have emphasized the role of interpretation bias in the maintenance of this disorder (Beck et al., 1985 and Clark, 1986; Ehlers & Margraf, 1989; Margraf & Ehlers, 1989). Specifically, these models postulate that individuals with panic disorder interpret body sensations associated with panic as threatening, and that this interpretation, in turn, gives rise to panic attacks, thus maintaining the disorder. Other authors conceptualized this feature as “fear of fear” (Goldstein & Chambless, 1978) or “anxiety sensitivity” (Reiss & McNally, 1985). Several studies examined the presence of an interpretation bias in panic disordered patients. McNally and Foa (1987) adopted a questionnaire originally developed by Butler and Mathews (1983), which consisted of ambiguous scenarios half of which included panic-relevant stimuli and the other half, panic-irrelevant potentially threatening stimuli. Untreated individuals with agoraphobia showed more catastrophic interpretations of panic-relevant stimuli than healthy controls and patients whose agoraphobia was successfully treated. Using McNally and Foa’s (1987) questionnaire, Harvey, Richards, Dziadosz, and Swindell (1993) compared interpretations of individuals with panic disorder to individuals with social phobia and to healthy controls. The results were consistent with those of McNally and Foa. Panic disordered individuals, with and without agoraphobia, exhibited a bias towards catastrophic interpretation of panic-relevant stimuli more than individuals with social phobia and healthy controls. However, both anxiety disordered groups also showed negative interpretation bias for panic-irrelevant scenarios compared to healthy controls. Taken together, these results suggest that anxiety disorders may be associated with a general tendency for negative interpretation, but that panic disorder is associated with a specific interpretation bias for panic-relevant stimuli. To further examine specificity of the interpretation bias in panic disordered individuals, Clark et al. (1997) modified McNally and Foa’s (1987) questionnaire by adding scenarios relevant to social anxiety and scenarios that included panic-irrelevant body symptoms. The study consisted of three groups: panic disorder, other anxiety disorders, and nonanxious controls. Results were consistent with the hypothesis that the interpretation bias in panic disorder is specific to panic-relevant stimuli. Panic disordered individuals more frequently perceived panic-relevant sensations as dangerous than did either the nonpanic anxious individuals or healthy controls. However, panic disordered individuals did not differ from individuals with other anxiety disorders in their interpretations of ambiguous social stimuli or other ambiguous stimuli. Here both groups had higher scores than healthy controls. With respect to panic-irrelevant body sensations, there were no group differences at all. Results summarized above support the supposition that panic disorder is associated with negative interpretation bias of panic-relevant body sensations. But the design of these studies does not ascertain whether this bias precedes the disorder, and thereby contributes to its etiology or whether it is a consequence of the disorder and mainly contributes to its maintenance. One way to examine this issue is to study people who are at risk for panic disorder. One study examined memory bias in individuals who exhibit panics but do not meet criteria for panic disorder, i.e., “nonclinical panickers,” who are considered to be a risk group for the disorder (e.g., Ehlers, 1995). In this study, memory for anxiety, hostility, and neutral words of nonclinical panickers was compared to memory of nonpanickers (Norton, Schaefer, Cox, Dorward, & Wozney, 1988). To prime the threat material, Norton et al. (1988) had participants read a paragraph describing a panic attack, anger, or hunger. Immediately thereafter, participants were presented with words related to the three categories followed by a free recall test. Nonclinical panickers, who were primed by the panic attack paragraph, displayed a recall bias towards anxiety words. The authors suggested that the panic paragraph primed a danger schema in nonclinical panickers, thus enhancing retrieval of anxiety-relevant information. Interestingly, studies with panic disorder individuals reported memory bias without priming (Becker, Rinck, & Margraf, 1994; Cloitre, Cancienne, Heimberg, Holt, & Liebowietz, 1995; McNally, Foa, & Donnell, 1989). Possibly, priming may be necessary for nonclinical, but not for clinical, panickers because the former are constantly primed for danger stimuli. The concept of priming assumes that there are already existing structures within the memory that represent familiar items such as words. After presentation of relevant material these information structures become more readily accessible for retrieval (Baddeley, 1990). Several family studies have established that panic disorder runs in families (Maier, Buller, & Hallmayer, 1988; Noyes et al., 1986 and Weissman et al., 1993); thus, offspring of panic disordered patients are another group at risk of developing the disorder. While existence of panic disorder is well established in adults, controversy exists as to whether this phenomenon occurs in children and adolescents. With respect to adolescents, there are several community studies showing that panic attacks and panic disorder are common in this age group (Hayward, Killen, & Taylor, 1989; King, Gullone, Tonge, & Ollendick, 1993; Reed & Wittchen, 1998). In children prior to adolescence this phenomenon is quite seldom, but nevertheless exists (Last & Strauss, 1989; Ollendick, Mattis, & King, 1994). Citing the cognitive model of panic (Clark, 1986), Nelles and Barlow (1988) hypothesized that children are not capable of “catastrophic misinterpretation” of panic-relevant somatic symptoms up until adolescence and that their cognitive reactions are dominated by notions of external causation. However, a study by Mattis and Ollendick (1997) found that, while the tendency to make internal, catastrophic attributions in response to panic imagery may not be a common childhood phenomenon, certain individual factors (i.e., internal attributional style in response to negative outcomes and anxiety sensitivity) may predispose children to experience internal, catastrophic attributions in response to panic-relevant symptoms, thus facilitating the likelihood of having a panic attack. There are only a few studies examining cognitive biases in children; however, recent studies demonstrated that children with anxiety disorders and highly anxious children appear to show the same attentional bias (e.g., Martin, Horder, & Jones, 1992; Vasey, Daleiden, Williams, & Brown, 1996; Vasey, El-Hag, & Daleiden, 1996) and interpretation bias (Barrett, Rappee, Dadds, & Ryan, 1996; Chorpita, Albano, & Barlow, 1996) as their adult counterparts. Furthermore, it seems that interpretation bias may be sensitive to influence from parents as demonstrated by Barrett et al. (1996) and Chorpita et al. (1996). Barrett et al. (1996) asked children with anxiety disorders, children with oppositional defiant disorder, children without mental disorder, and the parents of these children to complete a questionnaire similar to the ambiguous-situations task outlined by Butler and Mathews (1983). The questionnaire consisted of 12 ambiguous situations referring half to physical and half to social threat. The situations described were relevant for children with anxiety disorders. The children were asked to interpret and how to handle the described situations. The parents were asked to answer what their child might think and do in these situations. Children with anxiety disorders and their parents showed higher threat interpretation scores than normal controls. However, children with oppositional defiant disorder showed the highest threat interpretation score. Furthermore, children with anxiety disorders and their parents reported more often avoidance solutions for the ambiguous scenarios than both other groups. After a family discussion concerning a mutual solution, only children with anxiety disorders showed an increase in avoidance solutions. Chorpita et al. (1996) showed with a similar methodology as used in the Barrett et al. (1996) study, that higher trait-anxious children have a heightened tendency to interpret ambiguous material as threatening, to express avoidance plans when faced with ambiguity, and to assign higher probability to the occurrence of threatening events. In the proposed study, we examined presence of panic interpretations in children of parents with panic disorders who do not themselves exhibit the disorder. Because children of panic patients are often exposed to panic attacks of their panic parent, it seems reasonable that these children do have panic-relevant schema, but these are not readily accessible. The children may show increased threat activation on interpretive task, when previously primed by anxious ideas from their anxious parent. To investigate possible panic interpretations for panic-relevant stimuli in children of panic disordered individuals, we developed an “Anxiety Interpretation Questionnaire for Children (AIQ-C)” modeled on those of McNally and Foa (1987) and Clark et al. (1997). We hypothesized that like nonclinical panickers, these children would show such panic interpretations but only when presented with priming information. To test for specificity in interpretation we compared three classes of scenarios: panic-relevant, spider phobic-relevant, and cold-relevant symptoms (panic-irrelevant symptoms). We primed children using three video models describing: (a) a severe panic attack, (b) a frightening encounter with a spider, or (c) a cold. We predicted that: (a) children of individuals with panic disorder would show a significant increase in panic interpretations of panic-relevant stimuli after watching the panic model, but not after watching the other two models; (b) after watching the panic model, children of panic disordered individuals would show a significant increase in panic interpretations of panic-relevant stimuli whereas children of individuals with animal phobias and children of healthy controls would not show a significant increase.