Attributional style and panic disorder

3. Behau. Thu. & Exp. Psychior. Vol. 21, No Printed in Great Britain.

1, pp. 9-13.

1990 0

ATTRIBUTIONAL

ooO5-7916/W 13.00+0.00 1990 Pergamon Press plc.

STYLE AND PANIC DISORDER JUSTIN KENARDY

University of Newcastle, Australia

LARRY EVANS and TIAN P. S. OEI Anxiety Disorder Clinic, University of Queensland, Australia Summary - This study investigated the relationship between the development of panic disorder and attribution style by administering the Attribution Style Questionnaire (ASQ) to 28 subjects with panic disorder with agoraphobia and 21 subjects with other anxiety disorders who had experienced a panic attack at some time. No significant differences were found between the groups suggesting that cognitive style as assessed by the ASQ may not predispose to the development of panic disorders. A factor analysis of the results indicated that the ASQ may not be appropriate for the assessment of patients with panic disorder. Alternative hypotheses for the development of panic disorder are discussed.

with state anxiety, and found a weak association between trait anxiety and attributing bad outcomes to global causes. The authors suggest that anxiety was not associated with a general attributional style and thus was not understood under the learned helplessness model. This study used a normal population and a general measure of anxiety. In a study comparing patients with dysthymic disorder, anxiety disorder, and normals on the ASQ (Heimberg, Vermilyea, Dodge, Becker, & Barlow, 1987) it was found that attribution style was similar for the dysthymic disorder group and the anxiety disorder patients only when the latter had concurrent depression. The authors concluded that the ASQ had little relevance for the assessment of anxiety. Panic attacks, however, may be a different issue. Panic attacks are experiences of extreme terror where the subject in many instances feels unable to control or understand the experience (Beck, Laude, & Bohnert, 1974). Kenardy, Oei, Ryan, and Evans (1988) showed

Recently, a number of authors have proposed that cognitive factors play a part in the etiology of panic attacks (Beck, Emery & Greenberg, 1985; Hallam, 1985; Barlow, 1986; Clark, 1986). One possible mechanism by which they may have a role in the development of panic attacks has been that of an attributional process (Hibbert, 1984; Hallam, 1985). The Attribution Style Questionnaire (ASQ; Peterson, Semmel, von Baeyer, Abramson, Metalsky, & Seligman, 1982) was designed to assess attributional style on three dimensions. This instrument was originally developed from the reformulated learned helplessness theory as it applied to depression (Abramson, Seligman & Teasdale, 1978), to assess the dimensions of causal attribution or explanatory style (internal, stable, and global for bad outcomes) that are predicted as risk factors for depression (Peterson and Seligman, 1984). Dowd, Clarborn and Milne (1985) used the instrument to assess the association of anxiety to attributional style, and found no association

Correspondence should be addressed to Justin Kenardy, Department of Psychology, University of Newcastle, Newcastle, New South Wales, 2308, Australia. 9

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JUSTIN KENARDY,

LARRY EVANS and TIAN P. S. OEI

that patients with panic disorder had difficulty attributing cause to an initial panic attack. Attributional style may be important at this stage in determining the subsequent response to panic attacks. Given the similarity of the panic experience to the learned helplessness paradigm, and following from Peterson and Seligman (1984) it is possible that the explanatory style will influence the response to the initial panic attack. Recently research has shown that the experience of panic attacks does not necessarily produce a panic disorder (Norton, Harrison, Hauch, & Rhodes, 198.5; Norton, Doward, & Cox, 1986). Barlow, Vermilyea, Blanchard, Vermilyea, DiNardo, and Cerny (1985) have also found that panic attacks are experienced across anxiety disorders. Thus some patients experience attacks but do not go on to develop panic disorder. If attribution indeed plays a role in the development of panic disorder, then there may well be differences in explanatory or attribution style between panic disordered and non-panic disordered groups who have both experienced panic attacks. The primary aim of this study was to assess the attributional style of subjects who are suffering from other anxiety disorders (who have experienced panic attacks but who have not developed panic disorder), to contrast this group with a panic disorder group to determine a relationship between general attribution style and the development of panic disorder. A secondary aim was to explore the applicability of the ASQ to beliefs concerning panic attacks.

Method

sample consisted of 37 females and 12 males (age range 19-60) and had the following DSM-III diagnoses, panic disorder (2), agoraphobia with panic attacks (26), generalized anxiety disorder (3), social phobia (1.5). and simple phobia (3). These patients were collapsed into 2 groups, the first comprising of patients with a diagnosis of panic disorder or agoraphobia with panic attacks (28), And the second comprising the other anxiety disorders (21). Instruments

The Attributional Style Questionnaire (ASQ; Peterson et al., 1982) consists of 12 situations for which the respondent is asked to imagine a cause. Half the situations have a good outcome, and half have a bad outcome. The respondent rates using a seven point scale the extent to which the cause is due to themself (internality), present in the future (stability), and influences all other situations (globality), and the importance of the situation to the respondent (importance). Two further items were added to the questionnaire to assess the attributions concerning panic. These were ‘You have a sudden rush of intense fear or anxiety’ (bad outcome) and ‘You become quite anxious but the anxiety lessens before you become overwhelmed’ (good outcome). These were also rated on the scales for internality, stability, globality, and importance. The Hamilton Clinical Rating Scale for Depression (Ham-D; Hamilton, 1960) was used as a measure of severity of depression in the anxiety disorder group. The scale consists of 17 items which are rated by a trained clinician which assess various aspects of depression.

Subjects Procedure

In all 49 subjects participated in this study. These were all patients presenting for assessment by the Anxiety Disorder Clinic, Brisbane. These subjects had all experienced a panic attack according to DSM-III criteria (American Psychiatric Association, 1980). The

Following referral from a medical practitioner, hospital casualty department, or medical specialist all patients were asked to attend an assessment interview. Subjects underwent an interview involving both structured and

Attributional Table 1

ASQ scores, STAI Subscales and Hamilton Depression Ratings for panic and non-panic anxiety disorders and normal controls

Anxiety Disorders

ASQ Good outcome Internal Stable Global Bad outcome Internal Stable Global Ham-D

Panic (n = 28) Mean (SD)

Non-panic (n = 21) Mean (SD)

LlO(O.96) 5.62(0.72) 4.93(1.06)

4.80(1.13) 5.17(0.87) 4.33(1.23)

4.54(1.23) 4.60(0.98) 4.20( 1.06) 11.64(5.09)

4.84(0.99) 4.53(1.03) 4.09(1.18) 14.05(8X0)

11

Style and Panic Disorder

non-structured formats. The interview was undertaken by a staff clinician, either a psychiatrist or clinical psychologist skilled in assessment and diagnosis of anxiety disorders (Oei, Cavallo, & Evans, 1988, Kenardy et al., 1988). The interview lasted about one and a half hours. A life history was taken and selfreport forms were reviewed with the patient. During this time the Ham-D was administered. The case history was then presented to a meeting of all clinical staff where a diagnosis using DSM-III criteria was formulated. Once the diagnosis was reached patients who had an anxiety disorder and had experienced panic attacks were asked to complete the ASQ with the additional items.

a principle axis factor analysis was performed on the composite scores for each item, including the additional panic outcome items, for the anxiety disorders. Using the ‘scree’ test and simple structure of solution as guidelines (Tabachnick & Fidell, 1983) three factors were derived accounting for 45.7% of the variance. An oblique rotation was chosen since there was substantial correlation between factors 1 and 3 (r = .333, P-C.05). The factor loadings are presented in Table 2. As can be seen factors 1 and 2 load for the ASQ bad and good outcome items respectively. The panic items load only on the third factor. There is also a loading for item 3. This items asks for attributions about becoming rich. The majority of subjects (37/ 49,69.4%) reported that luck was the cause of the event.

Discussion This study provides no support for an association between attribution style and the development of panic disorder, with or without agoraphobia subsequent to panic attacks. The results of the study do not support the generalisation of an attributional style similar to that Table 2 Factor loadings for ASQ events and panic events

Item

Results Table 1 presents the mean scores for the ASQ subscales and the Ham-D, for the two groups. One-way MANCOVA’s were performed on the ASQ subscales for good and bad outcomes using the Ham-D as a covariate. No significant differences were found between the anxiety disorder groups on the bad outcome (FCl, df=3,44) or the good outcome substales (F= 1.486, df= 3,44). To determine if the situations used in the ASQ were applicable to 1panic attack outcomes _.

Qutcome

Factor loadings

1. Compliment 2. Unsuccessful 3. Rich 4. Friend’s problem 5. Negative talk 6. Praise 7. Hostility 8. Can’t finish 9. Loving 10. Position 11. Bad date 12. Raise Panic 1. Panic attack 2. Anxiety subsides

Good Bad Good Bad Bad Good Bad Bad Good Good Bad Good

Factor 1 Factor 2 Factor 3 l ,628 .525 .361 .355 ,819 ,729 .640 .629 .489 .353 .872 .689 ,419

* Factor loadings less

than .30 are not reported

ASQ

Bad Good

.504 .923

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JUSTIN KENARDY,

LARRY EVANS and TIAN P. S. OEI

found for learned helplessness to the development of panic disorder. Furthermore, the attribution of ASQ events does not appear to involve the same processes as attribution of panic events. Support for this also comes from the factoring of panic events distinctly from other life events. Not surprisingly panic attacks seem to be seen as unique experiences which bring with them unique responses. The factoring of the items associated with panic suggests that panic attacks are not appropriately assessed by the ASQ. The study is consistent with previous studies (Dowd et al., 1985; Heimberg et al., 1987) finding that the ASQ is not an appropriate instrument for assessing beliefs underlying anxiety. While attribution style and learned helplessness is not indicated as important in the development of panic disorder, this study fails to negate the proposal that cognitive processes may be involved in the development of panic disorder. For example Wolpe and Rowan (1989) suggest that fearful thoughts can, through classical conditioning to the initial panic attack, become a conditioned antecedent to subsequent panic attacks. This does not explain why panic disorder develops in one group of subjects who have experienced a panic attack but not the other. The key to understanding this puzzle may be in a careful analysis of the circumstances and experience of the initial panic attack for the two groups. Some clues to what may be found comes from Breier, Charney, and Heninger (1986) who investigated the development and course of agoraphobia. They found that when their patients had an understanding of their initial panic attack as non-threatening there was a significantly greater latency to the development of agoraphobia and repeated panic attacks compared to patients who misattributed the cause of their panic attack to a physical cause. Thus one possibility is the presence of a psychological predisposition to develop panic disorder. This may take the form of a sensitivity to anxiety-like states where such states are

particularly aversive, even experienced as lifethreatening (Reiss, Peterson, Gursky, & McNally, 1986), thus facilitating the conditioning process. As Wolpe and Rowan (1988) reported, post-initial panic attacks are preceded by fear of the panic state and this may be a consequence of the anxiety-threat related beliefs. Another possibility is that particular situational factors influence the impact of the initial panic attack. Breier et al. (1986) found that the presence of a precipitant significantly increased the latency from the initial panic to agoraphobia. Yet another possibility is that panic disorder develops in those who have a physiological predisposition that leads to a tendency to experience repeated abrupt uncontrolled (and possibly bizarre symptomatology. Such a predisposition may be a result of chronic hyperventilation (Ley, 1987) or some inherent autonomic lability (e.g. Kagan, Reznick & Snidman, 1988). Any of these factors may be important in the development of panic disorder. It is likely though that these factors will combine in a complex fashion to determine the growth of panic disorder. Very careful analysis of these factors may be necessary in order to understand development. Acknowledgements-The authors wish to express their thanks to the staff and patients of the Anxiety Disorder Clinic, Brisbane. This research was supported by a University Research Scholarship,

of Queensland Postgraduate and the NHMRC.

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