ارزیابی آینده نگر از علائم موقعیت هراس و افسردگی پس از حملات هراس در یک جامعه نمونه از نوجوانان

In a community sample of high schoolers who experienced their first panic attack, we examined the prospective relationships among pre-panic vulnerabilities, panic attack severity, and post-panic agoraphobia and depression symptoms. Students were evaluated yearly over 4 years to test the following four hypotheses: (1) pre-panic anxiety sensitivity, negative affect, and childhood behavioral inhibition will serve as vulnerabilities that predict agoraphobia and depression symptoms following a panic attack; (2) these vulnerabilities will lead to more severe panic attacks; (3) severe and spontaneous panic attacks will predict subsequent agoraphobia and depressive symptoms; and (4) the interaction between panic severity and vulnerabilities will be associated with worse outcomes following a panic attack. Results supported the first three hypotheses, but no evidence emerged for an interactive effect. Findings are discussed in light of recent modernized classical conditioning models that address factors contributing to development of more severe panic related psychopathology after panic attacks.

Although some studies have examined predictors of panic attacks (e.g., Hayward, Killen, Kraemer, & Taylor, 2000), there are no prospective investigations that explain why panic attacks are followed by psychopathology in some and by a benign course in others. As an important starting point, two longitudinal studies indicate considerable risk for developing an internalizing disorder after experiencing a panic attack. In a sample of 46 participants with infrequent panic attacks, Ehlers (1995) reported that seven (15%) had developed panic disorder by the 1-year follow-up assessment. Although these data are useful, this study is limited by its use of a questionnaire to assess panic. In addition, Pine, Cohen, and Gurly (1998) reported that fearful spells, defined as episodes of brief, spontaneous crescendo anxiety, reported during adolescence were associated with an increased risk for panic disorder (), generalized anxiety disorder (), social phobia (), and major depressive disorder () 7 years later in young adulthood. Neither of these studies addresses the important question as to why some of those with panic or fearful spells develop internalizing disorders and some do not. Only a subset of those who experience a panic attack go on to develop psychopathology (e.g., Reed & Wittchen, 1998 and Wittchen, 1986), and more research is needed to identify those at risk. For some, panic attacks can be followed by any number of psychiatric disorders including, but not limited to, panic disorder and agoraphobia. For example, both the National Comorbidity Survey and the Epidemiologic Catchment Area (ECA) Study have documented an increased chance for developing major depression following panic attacks (Andrade, Eaton, & Chilcoat, 1996; Kessler et al., 1998 and Roy-Byrne et al., 2000). According to the ECA data, those with DSM-IV panic attacks experienced a 6.9 times greater relative hazard for developing major depression than those without a history of panic attacks. In the Early Developmental Stages of Psychopathology study, only 8.5% of participants met criteria for no DSM-IV diagnosis after experiencing a spontaneous DSM-IV panic attack (Reed & Wittchen, 1998). Data further indicated that the conditional probability of developing panic disorder was 37% and agoraphobia was 27% for both genders, and the conditional probability of developing any other mental disorder following the attack was 63% in males and 40% in females. Although the potential for psychopathology following panic attack is substantial, who are at greatest risk for developing these problems? Cross-sectional studies have contributed some useful data for this puzzle, and have suggested that both panic attack characteristics as well as predisposing factors may be important in determining various trajectories to psychopathology. For example, the number of symptoms experienced in a panic attack has been linked to both the severity of panic disorder (Korff, Eaton, & Keyl, 1985) and agoraphobic avoidance (Cox, Endler, & Swinson, 1995), although this finding has not been consistent (Aronson & Logue, 1987 and Craske & Barlow, 1988). Cognitions also seem to play an important role as exemplified by experimental manipulations of thoughts that have increased risk for panic following induction techniques (e.g., Coryell, Noyes, Clancy, Crowe, & Chaudry, 1985; Salkovskis & Clark, 1990 and Van den Hout & Griez, 1982) and numerous other investigations that show heightened catastrophic thinking in clinical samples (see Khawaja & Oei, 1998, for a review). For example, at least one study found that cognitive symptoms during an attack, such as fear of dying or going crazy, are associated with four times the risk for developing agoraphobia (Langs et al., 2000). Spontaneity may also play a role, and Norton, Dorwood, and Cox (1986) found that this element (along with catastrophic cognitions) clearly differentiated between clinical versus non-clinical panic attacks. Predisposing vulnerabilities established prior to the panic attack may also increase risk for subsequent psychopathology, and support exists for three constructs in particular: anxiety sensitivity, negative affect, and behavioral inhibition. Anxiety sensitivity has predicted panic in both cross-sectional (Cox, Enns, Walker, Kjernisted, & Pidlubny, 2001; Donnell & McNally, 1990; Reiss, Peterson, Gursky, & McNally, 1986) and longitudinal studies (Hayward et al., 2000 and Maller & Reiss, 1992; Schmidt et al., 1997 and Schmidt et al., 1999), and is also elevated in patients with major depression (Otto et al., 1995 and Otto et al., 1998). Negative affect, defined as temperamental tendencies toward negative emotion and cognition, has been shown to prospectively predict panic attacks (Hayward et al., 2000), panic disorder (Craske, Poulton, Tsao, & Plotkin, 2001), and depression (see Clark, Watson, & Mineka, 1994, for a review). Behavioral inhibition, or fearful response to novelty, has been associated with panic disorder and agoraphobia (Biederman, Rosenbaum, Chaloff, & Kagan, 1995) and depression (Kasch, Rottenberg, Arnow, & Gotlib, 2002; Muris, Merckelbach, Schmidt, Gadet, & Bogie, 2001). Although these traits have all been linked to internalizing disorders, their interaction with panic attacks on later psychopathology has yet to be explored. The current study attempts to add to extant literature by examining differential trajectories following the experience of new onset panic attacks. The aim is to evaluate whether vulnerabilities serve a priming role that exacerbates somatic response during a panic attack. We further propose to test whether these vulnerabilities have both a direct effect on subsequent internalizing psychopathology, and an indirect effect by creating an affect-laden context for the attack that moderates, and specifically heightens, the impact of the attack on risk for subsequent negative outcomes. The following four hypotheses were tested: (1) anxiety sensitivity, negative affect, and childhood behavioral inhibition will serve as vulnerabilities that increase agoraphobia and depression symptoms following a panic attack; (2) these vulnerabilities will lead to more severe panic attacks, defined as those with heightened physical symptoms and catastrophic cognitions; (3) severe panic attacks will predict subsequent agoraphobia and depressive symptoms; and (4) the interaction between panic severity and vulnerabilities will be associated with worse outcomes following a panic attack.