B&X Re.7.7%~. Vol. 28. No. 4. pp. 355-357. 1990 Pnnted in Great Bntain. All rightsreserved
0005-7967~9053.00 + 0.00 Copyright E 1990 PcrgamonPressplc
Relationships between catastrophic cognitions and body sensations in anxiety disordered, mixed diagnosis, and normal subjects RICKS WARREN,’
GEORGE ZGOURIDES~
and
MARY ENGLERT’
1Oregon Graduate School of Professional Psyeho1og.v. Pacific University, Coilege Way. Forest Grace, OR 97116 and 2 The Anxieiy Disorders Clinic, Lake Grace, Ore., U.S.A. (Received 22 December
1989)
Summary-Clark’s (Behoviour Research and Therapy, 24, 461-470, 1986) cognitive model proposes that panic attacks result from the catastrophic misinterpretation of certain body sensations. The present study examined correlations between feared body sensations and catastrophic cog&ions. It was hypothesized that regardless of diagnostic status meaningful correlations between sensations and cognitions would be obtained. Three groups-anxiety disordered patients (n = 33), nonanxiety disordered patients (n = 57). and normals (n = 60)--completed the Agoraphobic Cognitions Questionnaire and the Body Sensations Questionnaire. Results generally supported the hypothesis and the cognitive model of panic and anxiety. Limitations of the correlational methodology are discussed, and treatment implications are noted.
Cognitive approaches to the theory and treatment of panic have received increased research interest and empirical support (Beck, 1988; Clark, 1986, 1988). Central to cognitive models of panic is the hypothesis that panic results from catastrophic misinterpretations of body sensations. For example, a sudden pain in the chest is interpreted as “I’m having a heart attack”. Anxiety, and often hyperventilation follow, resulting in more body sensations which are also misinterpreted as signs of impending disaster, etc. The hypothesis that the catastrophic misinterpretation of body sensations is an important cont~butor to panic has been investigated in a variety of ways. One recent approach has been to obtain correlations between individual items on measures of catastrophic cognitions and body sensations. Studies with patients receiving DSM-III diagnoses of agoraphobia with panic attacks (Chambless & Beck, 1986; Pollard, 1985) and DSM III-R diagnoses of panic disorder, claustrophobia (Rachman, Levitt & Lopatka, 1987) and panic disorder with agoraphobia (Street, Craske & Barlow, 1989) have all obtained meaningful correlations between specific catastrophic cognitions and related body sensations. Methodologies used in these studies included patients completing questionnaires pre-treatment, after panic attacks resulting from standardized behavioral tests, and during or immediately following naturally occurring panic attacks. In summary, the finding that there are meaningful correlations between catastrophic thoughts and feared body sensations appears robust. It has occurred with several anxiety disordered diagnoses and across varying methodologies. Thus far, however, similar studies have not been conducted with other anxiety disorders, other diagnostic groups, or normals. Given recent evidence that panic attacks occur throughout each ofthe above populations (Barlow % Craske, 1988). we hypothesized that significant and meaningful correlations between catastrophic cognitions and related body sensations would occur in a composite group of anxiety disordered clients, nonanxiety disordered clients, and normals. Further, cognitive theory would predict that most emotional reactions stem from cognitive processes. Therefore, regardless of diagnostic status and whether or not individuals are experiencing panic attacks, when fearful reactions to body sensations occur, danger related cognitions would be implicated (Beck & Weishaur, 1989). METHOD
Subjects Ss for the present study were a mixed group of anxiety disordered patients (n = 33) a mixed group of nonanxiety disorder clinic outpatients (n = 57). and normals (n = 60) yielding a total n of 150. Patients were seeking treatment, and normals were drawn from community college classes and a population of school teachers. Further description of the Ss and their selection are reported elsewhere (Warren, Zgourides & Jones, 1989). Measures Agoraphobic Cognitions Questionnaire (ACQ; Chumbless, Caputo, Bright & Gallagher, 1984). The ACQ is a 14-item questionnaire containing thoughts concerning possible negative consequence of experiencing anxiety. Each item is rated on a S-point scale, ranging from ‘thought never occurs’ (I) to ‘thought always occurs’ (S), indicating the frequency with which each thought occurs when the person is nervous or frightened. Sample items include *‘I will have a heart attack” and “1 am going to act foolish”. Body Sensations Questionnaire (BSQ; Chambless et al., 1984). This 174tem scale lists body sensations that may occur when a person is nervous or in a feared situation. Sample items include heart palpitations, dizziness, and feeling short of breath. Each item is rated on a 5-point scale, ranging from “not frightened or worried by this sensation” to “extremely frightened by this sensation”. Procedure
Patients seeking treatment at a private anxiety disorders clinic. two university psychology clinics, and a community mental health center completed the questionnaires as part of a pre-treatment assessment. Normals completed the questionnaires with the understanding that their responses would be useful in obtaining norms for the inventories. 355
j56
CASE
HISTORIES
AND
SHORTER
COMMU~ICATIONS
RESULTS
Pearson correlations were computed between each of the catastrophic cognitions and feared body sensations. Table presents the correlations which uere significant at least the 0.01 level. .As shown in Table I the majority of feared body sensations were. as predicted, meaningfully associated with catastrophic cogmtions. When catastrophic cog,nitions are broken down into their two factors (Chambless er 01.. 1984) 34 were physIca disaster and 36 uere social behavloral items.
1
DISCUSSION
Consistent with previous research. the present study provides further evidence that feared body sensations are meaningfully related to catastrophic cognitions and extends these findings to additional populations. These findings offer further support for Clark’s (1986. 1988) and Beck’s (1988) cognitive model of panic. It should be noted, ho&ever. as Pollard ( 1985) pointed out. the kind of data obtained in this and similar previous studies do not establish that body sensations rkoke catastrophic cognitions. It is alternatively possible that worry about something going wrong with one’s body could Icad to focusin; on body functioning which might lead to activation of physical symptoms. However, other studies rxJmining predlctions from the cognitive model do appear to indicate that body sensations typically are the first things noticed during a panic attack and precede cognitive interpretation (Clark. 1988; Hibbert, 1984; Ley, 1985a. b; Ottaviani & Beck, 1987). In addition, Clark, Salkovskis, Koehler & Gelder (1987) found that panic patients, compared to other anxiety patients and normal controls, were significantly more likely to interpret bodily sensations in a negative fashion. The instructions on both the BSQ and ACQ do not limit respondents to describing phenomenon occurring only during actual panic attacks. Rather, respondents are asked to indicate how often thoughts or body sensations occur when nervous, frIghtened, or in a feared situation. Thus the meaningful correlations obtained in this study may suggest a role for associations between sensations and cognitions more broadly to include any experience of anxiety (Beck & Emery, 1985). Thus. &hat may differentiate between diagnotic groups may not be the correlational phenomenon. but other factors such a~ perceived immediacy of physical or social!behavioral disaster. Street et trl. (1989) found few correlations of significance between body sensations and cognitions associated uith physical danger. though those that did appear were meaningful. Rather, more correlations were obtained between loss of control and embarrassment cognitions and sensations. These findings appear somewhat inconsistent with those of the previous studies of correlationsamong catastrophic cognitions and bodily sensations. Given the diverse sample in the present study it 1s not surprising that both physical and social;behavioral disaster cognitions were rather equally represented in correlations with feared body sensations. Though meaningful correlations were frequently obtained in the present study, most of them were not particularly large. This may have also been partly due to the diagnostically mixed sample. As Rachman (1988; Rachman er af.. 1987) noted, patients with different diagnoses, i.e. panic disorder and claustrophobia, appear to report some differing combinations of sensations and cognitions. For example. for panic patients, the combination of choking and shortness of breath was rarely ,lssociated with the cognition of suffocation. while this combination was frequently noted in claustrophobics. Thus, the small to moderate size correlations obtained with our mixed diagnoses sample is not surprising. Also. as Barlow (1987. 1988) has explained, individuals tend to react fearfully to specific interoceptive cues rather than to more global stress or anxiety symptoms. This idiosyncratic nature of fear learning may also account for the variability in what cognitions become associated with what sensations. which may result in low to moderate correlations. Ottaviani and Beck (1987). in discussing the results of an interview study with panic disorder patients, also noted individual variations in patients’ interpretations of similar body sensations. As Rachman er al. (1987) found with panic disorder and claustrophobic patients, the obtained correlations between sensations and coenitions were not always intuitively obvious. For example, one might predict that the sensation ‘blurred or distorted vision. might be most correlated with the cognition of “I am going blind”. On the other hand. when mixed
Table
I. Intercorrelations
between
items
on
the .Agoraphobic
scnutlon
Heart
pdlp>t.ttlons
Heart
attack
Pass out Prew~rc
in chest
>umbneis
Cognitlons
Questionnaire
and
Catastrophic
Bad\
in arms
or
legs
(0.61)P.
Lose
control
the
Body
Sensations
Questionnaire
cognitions
(0.4O)SB.
Stroke
(0.38)P.
Choke
ID
death
(0.33)P.
(0.33)P
Heart
attack
Lose
control
(0.46)P.
Choke
(0.32)SB.
to death
Go
crazy
(0.46)P.
(0.3O)SB.
Stroke Hurt
(0.36)P.
someone
Pass out (0.35)P.
(0.29)SB.
Go crazy
Paralyzed
b!
fear
(0.35)SB (0.27)SB.
Scream (026)SB Tingling
Heart
m tingcrt~ps
Numbness
m another
Dart
attack
Hurt
of body
(0.25)P.
someone
Babble
(0.30)SB.
or talk
Choke
funny
to
(0.27)SB.
death
(0.27)P.
Lose
control
Scream
(0.25)SB
(0.27)SB,
Lose
control
(0.25)SB.
Go crazv (O.?J)SB Fszlmy
short
of
Heart
breath
at&k
(0.35)P. Heart
D~zzlness Blurred
or distorted
ButterRIes
Lose
in stomach
\Vobbl)
or
rubber
Lose Dr>
Feehng
disoriented
Feehng
disconnecred
bodk
only
Correlations space.
partI>
and
confused
to death
(0.34)SB
Lose
control
Lose
(0.29)P.
Pass out
Go
attack
(0.38)SB.
(0.27)SB. crazy
(0.49)P.
Choke
Heart Hurt
(0.44)P.
Lose control
control
Go
by fear
(0.36)SB.
Choke
to death
(0.34)SB.
Pass out
(0.44)P
(0.28)P
by fear
(0.27)SB
control
(0.32)SB
(0.4S)SB.
(0.35)P,
Stroke
Lose
control
(0.33)P.
(O.MJSB
Choke
to death
(0.44)SB.
(0.39)SB
(0.42)P.
someone
Lose
crazy
to death
attack
Pass out
Paralyzed
(0.43)SB.
(0.49)P.
Paralyzed
(0.4l)SB.
to death
(0.35)P.
attack
crazy
(0.47)SB.
(0.4l)SB.
fear
Choks
from
by fear
(0.37)SB.
(0.33)SB
up (0.3O)P Go
Heart
Go crazy
by fear
to death
Heart
Throw
(0.54)P,
control
Choke
throat
Choke
(0.27)SB. by fear
Paralyzed
Susrtting
Paralyzed
(0.37)P.
(0.31)P.
Pass out
legs
(0.43)P.
control
Paralyzed
in stomach
Pass out (0.38)P.
(0.34)P.
Io death
Pass out
Y;LUBSd Knot
attack
Choke
vismn
(0.5J)P.
Stroke
Brain
(0.36)SB.
(0.43)P.
tumor
Go
Heart
crazy
attack
(0.37)P.
Pass out (0.35)P.
Paralyzed
by
(O.JJ)SB (0.42)P
present
of 0.25 to 0.31 = P < 0.01. 0.32 or greater P = PhysIcal
Disaster
factor
item
of the
=
0005-7967~9053.00 + 0.00 Copyright E 1990 PcrgamonPressplc
Relationships between catastrophic cognitions and body sensations in anxiety disordered, mixed diagnosis, and normal subjects RICKS WARREN,’
GEORGE ZGOURIDES~
and
MARY ENGLERT’
1Oregon Graduate School of Professional Psyeho1og.v. Pacific University, Coilege Way. Forest Grace, OR 97116 and 2 The Anxieiy Disorders Clinic, Lake Grace, Ore., U.S.A. (Received 22 December
1989)
Summary-Clark’s (Behoviour Research and Therapy, 24, 461-470, 1986) cognitive model proposes that panic attacks result from the catastrophic misinterpretation of certain body sensations. The present study examined correlations between feared body sensations and catastrophic cog&ions. It was hypothesized that regardless of diagnostic status meaningful correlations between sensations and cognitions would be obtained. Three groups-anxiety disordered patients (n = 33), nonanxiety disordered patients (n = 57). and normals (n = 60)--completed the Agoraphobic Cognitions Questionnaire and the Body Sensations Questionnaire. Results generally supported the hypothesis and the cognitive model of panic and anxiety. Limitations of the correlational methodology are discussed, and treatment implications are noted.
Cognitive approaches to the theory and treatment of panic have received increased research interest and empirical support (Beck, 1988; Clark, 1986, 1988). Central to cognitive models of panic is the hypothesis that panic results from catastrophic misinterpretations of body sensations. For example, a sudden pain in the chest is interpreted as “I’m having a heart attack”. Anxiety, and often hyperventilation follow, resulting in more body sensations which are also misinterpreted as signs of impending disaster, etc. The hypothesis that the catastrophic misinterpretation of body sensations is an important cont~butor to panic has been investigated in a variety of ways. One recent approach has been to obtain correlations between individual items on measures of catastrophic cognitions and body sensations. Studies with patients receiving DSM-III diagnoses of agoraphobia with panic attacks (Chambless & Beck, 1986; Pollard, 1985) and DSM III-R diagnoses of panic disorder, claustrophobia (Rachman, Levitt & Lopatka, 1987) and panic disorder with agoraphobia (Street, Craske & Barlow, 1989) have all obtained meaningful correlations between specific catastrophic cognitions and related body sensations. Methodologies used in these studies included patients completing questionnaires pre-treatment, after panic attacks resulting from standardized behavioral tests, and during or immediately following naturally occurring panic attacks. In summary, the finding that there are meaningful correlations between catastrophic thoughts and feared body sensations appears robust. It has occurred with several anxiety disordered diagnoses and across varying methodologies. Thus far, however, similar studies have not been conducted with other anxiety disorders, other diagnostic groups, or normals. Given recent evidence that panic attacks occur throughout each ofthe above populations (Barlow % Craske, 1988). we hypothesized that significant and meaningful correlations between catastrophic cognitions and related body sensations would occur in a composite group of anxiety disordered clients, nonanxiety disordered clients, and normals. Further, cognitive theory would predict that most emotional reactions stem from cognitive processes. Therefore, regardless of diagnostic status and whether or not individuals are experiencing panic attacks, when fearful reactions to body sensations occur, danger related cognitions would be implicated (Beck & Weishaur, 1989). METHOD
Subjects Ss for the present study were a mixed group of anxiety disordered patients (n = 33) a mixed group of nonanxiety disorder clinic outpatients (n = 57). and normals (n = 60) yielding a total n of 150. Patients were seeking treatment, and normals were drawn from community college classes and a population of school teachers. Further description of the Ss and their selection are reported elsewhere (Warren, Zgourides & Jones, 1989). Measures Agoraphobic Cognitions Questionnaire (ACQ; Chumbless, Caputo, Bright & Gallagher, 1984). The ACQ is a 14-item questionnaire containing thoughts concerning possible negative consequence of experiencing anxiety. Each item is rated on a S-point scale, ranging from ‘thought never occurs’ (I) to ‘thought always occurs’ (S), indicating the frequency with which each thought occurs when the person is nervous or frightened. Sample items include *‘I will have a heart attack” and “1 am going to act foolish”. Body Sensations Questionnaire (BSQ; Chambless et al., 1984). This 174tem scale lists body sensations that may occur when a person is nervous or in a feared situation. Sample items include heart palpitations, dizziness, and feeling short of breath. Each item is rated on a 5-point scale, ranging from “not frightened or worried by this sensation” to “extremely frightened by this sensation”. Procedure
Patients seeking treatment at a private anxiety disorders clinic. two university psychology clinics, and a community mental health center completed the questionnaires as part of a pre-treatment assessment. Normals completed the questionnaires with the understanding that their responses would be useful in obtaining norms for the inventories. 355
j56
CASE
HISTORIES
AND
SHORTER
COMMU~ICATIONS
RESULTS
Pearson correlations were computed between each of the catastrophic cognitions and feared body sensations. Table presents the correlations which uere significant at least the 0.01 level. .As shown in Table I the majority of feared body sensations were. as predicted, meaningfully associated with catastrophic cogmtions. When catastrophic cog,nitions are broken down into their two factors (Chambless er 01.. 1984) 34 were physIca disaster and 36 uere social behavloral items.
1
DISCUSSION
Consistent with previous research. the present study provides further evidence that feared body sensations are meaningfully related to catastrophic cognitions and extends these findings to additional populations. These findings offer further support for Clark’s (1986. 1988) and Beck’s (1988) cognitive model of panic. It should be noted, ho&ever. as Pollard ( 1985) pointed out. the kind of data obtained in this and similar previous studies do not establish that body sensations rkoke catastrophic cognitions. It is alternatively possible that worry about something going wrong with one’s body could Icad to focusin; on body functioning which might lead to activation of physical symptoms. However, other studies rxJmining predlctions from the cognitive model do appear to indicate that body sensations typically are the first things noticed during a panic attack and precede cognitive interpretation (Clark. 1988; Hibbert, 1984; Ley, 1985a. b; Ottaviani & Beck, 1987). In addition, Clark, Salkovskis, Koehler & Gelder (1987) found that panic patients, compared to other anxiety patients and normal controls, were significantly more likely to interpret bodily sensations in a negative fashion. The instructions on both the BSQ and ACQ do not limit respondents to describing phenomenon occurring only during actual panic attacks. Rather, respondents are asked to indicate how often thoughts or body sensations occur when nervous, frIghtened, or in a feared situation. Thus the meaningful correlations obtained in this study may suggest a role for associations between sensations and cognitions more broadly to include any experience of anxiety (Beck & Emery, 1985). Thus. &hat may differentiate between diagnotic groups may not be the correlational phenomenon. but other factors such a~ perceived immediacy of physical or social!behavioral disaster. Street et trl. (1989) found few correlations of significance between body sensations and cognitions associated uith physical danger. though those that did appear were meaningful. Rather, more correlations were obtained between loss of control and embarrassment cognitions and sensations. These findings appear somewhat inconsistent with those of the previous studies of correlationsamong catastrophic cognitions and bodily sensations. Given the diverse sample in the present study it 1s not surprising that both physical and social;behavioral disaster cognitions were rather equally represented in correlations with feared body sensations. Though meaningful correlations were frequently obtained in the present study, most of them were not particularly large. This may have also been partly due to the diagnostically mixed sample. As Rachman (1988; Rachman er af.. 1987) noted, patients with different diagnoses, i.e. panic disorder and claustrophobia, appear to report some differing combinations of sensations and cognitions. For example. for panic patients, the combination of choking and shortness of breath was rarely ,lssociated with the cognition of suffocation. while this combination was frequently noted in claustrophobics. Thus, the small to moderate size correlations obtained with our mixed diagnoses sample is not surprising. Also. as Barlow (1987. 1988) has explained, individuals tend to react fearfully to specific interoceptive cues rather than to more global stress or anxiety symptoms. This idiosyncratic nature of fear learning may also account for the variability in what cognitions become associated with what sensations. which may result in low to moderate correlations. Ottaviani and Beck (1987). in discussing the results of an interview study with panic disorder patients, also noted individual variations in patients’ interpretations of similar body sensations. As Rachman er al. (1987) found with panic disorder and claustrophobic patients, the obtained correlations between sensations and coenitions were not always intuitively obvious. For example, one might predict that the sensation ‘blurred or distorted vision. might be most correlated with the cognition of “I am going blind”. On the other hand. when mixed
Table
I. Intercorrelations
between
items
on
the .Agoraphobic
scnutlon
Heart
pdlp>t.ttlons
Heart
attack
Pass out Prew~rc
in chest
>umbneis
Cognitlons
Questionnaire
and
Catastrophic
Bad\
in arms
or
legs
(0.61)P.
Lose
control
the
Body
Sensations
Questionnaire
cognitions
(0.4O)SB.
Stroke
(0.38)P.
Choke
ID
death
(0.33)P.
(0.33)P
Heart
attack
Lose
control
(0.46)P.
Choke
(0.32)SB.
to death
Go
crazy
(0.46)P.
(0.3O)SB.
Stroke Hurt
(0.36)P.
someone
Pass out (0.35)P.
(0.29)SB.
Go crazy
Paralyzed
b!
fear
(0.35)SB (0.27)SB.
Scream (026)SB Tingling
Heart
m tingcrt~ps
Numbness
m another
Dart
attack
Hurt
of body
(0.25)P.
someone
Babble
(0.30)SB.
or talk
Choke
funny
to
(0.27)SB.
death
(0.27)P.
Lose
control
Scream
(0.25)SB
(0.27)SB,
Lose
control
(0.25)SB.
Go crazv (O.?J)SB Fszlmy
short
of
Heart
breath
at&k
(0.35)P. Heart
D~zzlness Blurred
or distorted
ButterRIes
Lose
in stomach
\Vobbl)
or
rubber
Lose Dr>
Feehng
disoriented
Feehng
disconnecred
bodk
only
Correlations space.
partI>
and
confused
to death
(0.34)SB
Lose
control
Lose
(0.29)P.
Pass out
Go
attack
(0.38)SB.
(0.27)SB. crazy
(0.49)P.
Choke
Heart Hurt
(0.44)P.
Lose control
control
Go
by fear
(0.36)SB.
Choke
to death
(0.34)SB.
Pass out
(0.44)P
(0.28)P
by fear
(0.27)SB
control
(0.32)SB
(0.4S)SB.
(0.35)P,
Stroke
Lose
control
(0.33)P.
(O.MJSB
Choke
to death
(0.44)SB.
(0.39)SB
(0.42)P.
someone
Lose
crazy
to death
attack
Pass out
Paralyzed
(0.43)SB.
(0.49)P.
Paralyzed
(0.4l)SB.
to death
(0.35)P.
attack
crazy
(0.47)SB.
(0.4l)SB.
fear
Choks
from
by fear
(0.37)SB.
(0.33)SB
up (0.3O)P Go
Heart
Go crazy
by fear
to death
Heart
Throw
(0.54)P,
control
Choke
throat
Choke
(0.27)SB. by fear
Paralyzed
Susrtting
Paralyzed
(0.37)P.
(0.31)P.
Pass out
legs
(0.43)P.
control
Paralyzed
in stomach
Pass out (0.38)P.
(0.34)P.
Io death
Pass out
Y;LUBSd Knot
attack
Choke
vismn
(0.5J)P.
Stroke
Brain
(0.36)SB.
(0.43)P.
tumor
Go
Heart
crazy
attack
(0.37)P.
Pass out (0.35)P.
Paralyzed
by
(O.JJ)SB (0.42)P
present
of 0.25 to 0.31 = P < 0.01. 0.32 or greater P = PhysIcal
Disaster
factor
item
of the
=
