- Email: [email protected]
Panic: The links between cognitions and bodily symptoms—I
Behm. Res. 7-k. Vol. 25, No. 5, pp. 411-423, 1987 Printed in Great Britain
PANIC:
Department
GiBS-7%7/8? $3.00 + 0.00
Pcrgamon Journals Ltd
THE LINKS BETWEEN COGNITIONS AND BODILY SYMPTOMS-I
S. RACHMAN,K. LEVITT and C. LOPATKA of Psychology, The University of British Columbia, Vancouver, B.C. V6T 1Y7, Canada (Received 17 February,
1987)
S~~~o~itive theories of panic entail a causal Link between bodily sensations and fearful cog&ions. In this light, the data collected from two experimental analyses of panic were re-examined in a search for meaningful links between the fearful cog&ions and the bodily sensations reported during episodes of panic. panic episodes were accompanied by many more fearful cognitions and bodily symptoms than no-panic episodes, and several understandable iinks between the bodily symptoms and cog&ions emerged.The linksbetweencorn~~zio~~of bodily symptomsand cog&ions were even clearer than the links between single symptoms and cog&ions. For example, when claustrophobic Ss reported bodily symptoms of dizziness, choking and shortness of breath in association with the cognition of suffocation, a panic was usually recorded. Among panic-disorder patients, the combination of palpitations, dizziness and shortness of breath accompanied by the cognition of passing out, was usually associated with a panic. The links observed in a group of panic-disorder patients were different to those observed in a group of cia~trophobic Ss. Among the panic-disorder patients. the great majority of no-panic episodes were marked by an absence of fearful cog&ions; in contrast, two-thirds of the no-panic episodes reported by the claustrophobic Ss were accompanied by at least one cognition. Although the observed links were meaningful, there were fewer than might have been expected. The overall number of links fell below expectation. Among the panic-disorder patents, only eight episodes of ‘non-cognitive panics’ were recorded.
INTRODUCTION Clark’s (1986) theory of panic entails a casual link between bodily sensations and cognitionspanics occur when the person ca~strophi~lly misinterprets his/her bodily sensations. “Panic of certain bodily sensations” (Clark, attacks. . . result from the catastrophic ~sinte~re~tion 1986, p. 461). Beck’s (1987) theory differs in detail but also entails such a link. In the course of conducting a programme of research into the psychology of fear and of panic (Rachman, 1987; Rachman and Levitt, 1985; Rachman and Lopatka, 1986a, b), we collected reports of bodily sensations and of cog~tions from fearful Ss and from phobic patients, dnring episodes of panic and non-panic. This information has a bearing on Clark’s theory and we put it to a second use by re-analyzing the data in order to search for links between the bodily sensations and the cognitions experienced during panic episodes. Clark’s writings lead one to expect that there should be a meaningful, if not always rational, relationship between bodily symptoms and cognition; they should fit. The sensation of heart palpitations should be associated with the fear of cardiac illness, dizziness should be linked to the fear that one might lose control, etc. An earlier, preliminary, attempt to find evidence of such links occurring during claustrophic panics (Rachman, 1987) was partly successful. The cognitions tended to be threat-relevant and situation-s~cific. The cognition, “I am going to suffocate” was associated with the most relevant bodily sensation (shortness of breath). There were some exceptions however, and the most prominent was the frequent endorsement of the bodily sensation of palpitations, which was not linked specifically to the cognition of cardiac illness (“I am going to have a heart attack”), or to any other particular cognitions. it appears to be a bodily sensation that spans several cognitions, and not any one in particular. In the same study, on claustrophobic Ss, none of the 67 panic episodes was associated with an absence of panic cognitions, as ascertained by endorsements of the panic cognitions checklist introduced by Chambless (1985), which is conventionally used in this type of research. There were no ‘non-cognitive panics’ in the early study, but as will be described below, some have now been recorded. In order to check and expand on these preliminary results, analyses were conducted on newly collected data which include a fresh group of 20 claustrophobic Ss (who reported experiencing a 411
412
s.
bXiMAN
et al.
panic on 50 out of a total of 140 trials), and from a separate group of 20 patients with panic disorder (who reported panicking on 30 of 69 trials). The analyses were directed in the first place at the primary question of whether or not the expected links between bodily sensations and cognitions could be detected on those trials when a panic was reported. We also used this opportunity to study the nature and frequency of ‘non-cognitive panics’, that is, those panic trials during which the Ss or patient failed to endorse any of the items on the panic cognitions list. These non-cognitive panics bear a resemblance to the so-called spontaneous panics that panic-disorder patients sometimes describe. They are described as coming out of the blue, and the patient cannot connect the panic to any cognition. A brief description of the two studies is set out before reporting the results of the new analyses. PANIC
DISORDER
STUDY
In the course of attempting to replicate and extend the findings on the effects of match-mismatch on fear responding, we carried out a study of the bodily symptoms and cognitions reported during panic and non-panic episodes by 20 panic-disorder patients. The full results of this study are described elsewhere (Rachman, Lopatka and Levitt, 1987a), so for the present purpose we will concentrate on the links between the bodily symptoms and cognitions that emerged from the panic experiences of this group of patients. (Strictly speaking, the items on the DSM checklist are not ‘symptoms’, but bodily sensations. The original term will be retained here simply to avoid confusion. It is not assumed that they are symptomatic of a disease or disorder, and it is “Important to remember that many [of these] symptoms, specified for the diagnosis of panic disorder, are very common in the [general] population” wittchen, 1986, p. 261.) The Ss for this experiment were 20 patients who had received a DSM-IIIR diagnosis of panic disorder. After selection, they were asked to complete between three and five standardized behavioural tests which consisted of entering a fearful place or situation (e.g. walking alone into a store). Prior to each test trial, the patients were asked to predict how much fear and safety they expected to experience, and to predict whether or not they would panic. At the conclusion of each test trial, they reported their actual fear, safety and panic, and completed the DSM-IIIR checklist of Bodily Symptoms, and the Panic Cognition Checklist used in the Rachman and Levitt (1985) study and which was derived from the work of Chambless (1985). In addition, the patients were asked to report any cognitions or bodily sensations that were not on the standardized checklists. 50-
40-
Y 4
30-
c Y E
20-
n
tO-
Legend m no-pa& trlds I
pantc triah
Fig. 1. Fearful cognitions were endorsed far more frequently on panic trials than on no-panic trials (panic-disorder patients).
Panic: the links between cognitions and bodily symptoms-I
413
soao70-
50Y z
50-
Y h 8 6:
40-
50-
20-
10-
Fig. 2. Bodily symptoms
were endorsed more frequently on panic trials than on no-panic (panic-disorder patients).
trials
Results
Before turning to the links between bodily sensations and cognitions, a summary of the frequency of panics that occurred during these test trials is necessary. Panics or near-panics occurred on 30 of the 69 test trials (panic trials were defined as those episodes when the patient reported having panicked or come close to panicking). The occurrence of panic was evenly distributed across the sample: 70% of the patients reported either having panicked or come close to panicking on at least one occasion. As can be seen in Fig. 1, the panic trials were accompanied by many more fearful cognitions than were the non-panic trials. The panic trials were also accompanied by many more bodily symptoms than the non-panic trials (Fig. 2). Pearson correlations were computed between each of the bodily symptoms and cognitions endorsed over all panic trials (see Table 1). (Only the correlations at p = < 0.001 are reported. For the sake of clarity, Table 2 sets out the full lists of cognitions and bodily symptoms.) One of the most common cog&ions, a fear of passing out, was accompanied by feelings of faintness, choking and depersonalization. A fear of panicking was accompanied by symptoms of nausea, dizziness, shortness of breath. In general, the panic and no-panic trials were accompanied by different patterns of cognitions and bodily symptoms, as illustrated in Figs 1 and 2. The frequency of non-cognitive panics, defined as any panic episode in which the patient failed to endorse an item on the list of cognitions, was calculated. (A cognitive panic was defined as any panic episode in which at least one cognition was endorsed.) Eight (26.6%) of the panic trials fell into the non-cognitive category. These non-cognitive panics were distributed across Ss: slightly over one-third of the patients who panicked on at least one occasion experienced a non-cognitive panic, and 60% of the patients who reported a non-cognitive panic also reported a cognitive panic. The cognitive panics were accompanied by many more bodily symptoms than non-cognitive panics, with the unexplained exception of a feeling of choking (see Fig. 3). (Recall here that trials on which panic occurred were accompanied by many more bodily symptoms than those trials in which panics did not occur, Fig. 2). Panics were accompanied (caused?) by an increased percentage of bodily symptoms, and cognitive panics were accompanied by a greater percentage of bodily symptoms than the non-cognitive panics. Interestingly, on nearly all trials in which a cognition was associated with panic, many more bodily symptoms were reported than on trials that were associated with a no-panic (see Fig. 4).
Palpitations Chesl pain Sweating Faintness Dizziness Nausea ~~r~naIi~tion Numbness Flushes/chills Trembling Fear dying Fear going crazy
Cll0kill&
Shortness of breath
Symptoms
Table 1. Jntcrcorrelations
0.56
0.86
0.64
Pass out
Act foolish
Heati attack
Suffocate 0.53
Cognilions Lose ControJ Scream
0.54 0.64
0.53
Panic Choke
Paralyzed by fear
Run oul of air
between cognitions and bodily sensations in 20 panic-disorder patients on panic trials (n = 30). Only correlations with significance levels of P < 0.001 are reported here
P
II
a
x 2
K P
vt
6
Panic: the links between cognitions and bodily symptoms-I Table 2. Bodily sensations and cognitions
(C2) (C3) 64) KS) 0) (C7)
(‘3)
0) (ClO)
I am goiqg I am going foolishly I am going attack I am going I am going of myself I am going I am going
to pass out to act
W) W)
to have a heart
63)
to suffocate to lose control
W) (S5)
to scream to panic
66) 67)
I am going to choke to death I am going to be paralyzed by fear I am going to run out of air to breathe
checklist items Bodily sensations
Cognitions
(Cl)
415
CW 69) 610) 611) 612) 613) 614)
Shortness of breath Choking or smothering sensations Palpitations or accelerated heart rate Chest pain or discomfort Sweating Faintness Dizziness, lightheadedness or unsteady feelings Nausea or abdominal distress Depersonnalization or derealization Numbness or tingling sensations Flushes (hot flashes) or chills Trembling or shaking Fear of dying Fear of going crazy or doing something . uncontrolleQ
The panic cognitions were threat-relevant; fears of passing out, losing control, panicking, were the most frequently endorsed. The cognition of losing control was correlated with shortness of breath (P = O.OOl), nauses (P = 0.05) and trembling (P = 0.05). However, the same cognition in the claustrophobic situation was accompanied by a different set of symptoms (see below). These results suggest that panic cognitions and bodily symptoms tend to be threat-relevant and situation-relevant. The sensation of shortness of breath takes on a more threatening quality in an enclosed space than in the open, and a feeling of faintness is more threatening in a crowded public place than while resting at home.
Fig. 3. Selected bodily symptoms were endorsed more frequently on cognitive panic trials than on non-cognitive panic trials (e.g. shortness of breath, faintness, nausea, palpitations). The exceptions include flushes, choking and chest pain (panic-disorder study). B.R.T
250-G
416
S. kU3IMAN et al.
20
Fig. 4. More bodily symptoms were endorsed on cognitive panic trials than on cognitive no-panic trials, with the exception of flushes (panic-disorder study).
CLAUSTROPHOBIA
STUDY
In an attempt to gain a better degree of control over the panics experienced by claustrophics, a refined version of the original experiment (Rachman and Levitt, 1985) was conducted on Ss drawn from the same student population, using the same process of selection. Twenty claustrophic Ss were assigned randomly to one of two groups. Ss in the experimental group (n = 10) were instructed to concentrate on their bodily sensations while they remained in the small, enclosed test room. They were asked to concentrate on any changes in their sensations and were given the DSM-III list of panic symptoms to read prior to each test trial. The Ss (n = 10) in the control group were asked to concentrate on a simple alphabet task while in the test room. They were asked to think of a word beginning with each letter of the alphabet for several different categories (e.g. countries, foods) supplied prior to each test trial. The Ss’ predictions of safety, fear and panic were recorded prior to each test trial. After each trial, the Ss reported their experienced levels of safety, fear, and panic, and they also provided an estimation of the percentage of time which they had spent concentrating on the assigned task (bodily sensations or alphabet) during that trial. They also completed the DSM-IIIR panic checklist and the Cognitions Checklist after each test trial (for details see Rachman and Levitt, 1985). In the earlier study we used a discrete judgment of the presence or absence of panic, but in the present study panic was reported on a dimensional scale, which ranged from 0 (“No, I did not panic”) to 100 (“Yes, I absolutely panicked”). After one ‘throw away’ practice trial, each S completed seven test trials. These were identical in format and content, but their duration was varied between 2 and 4 min, in order to reduce the predictability of the duration of each of the trials. A complete report of the results of this experiment is provided in Rachman, Levitt and Lopatka (1987b). Results The severity of panic on each of the seven trials was reported on the O-100 continuous scale. Those trials on which a score of 50 or over was reported, were classified as panic trials. Using this criterion, 75% of the Ss reported at least one panic and 55% did so on at least two test trials. Five of the twenty Ss did not report any panics. Fifty of the 140 trials were panic trials (36%). This is slightly higher than the percentage (26%) of panics or near-panics recorded in the original experiment (Rachman and Levitt, 1985). This difference might be a product of the scale used to
417
Panic: the links between cognitions and bodily symptoms-I
m
-
I
Legend trids W&
nc-panlc pmlc
Fig. 5. Fearful cognitions were endorsed far more frequently on panic trials than on no-panic trials (claustrophobia study).
measure reported panic (discrete versus continuous). The cut-off point of 50 which we used to categorize a panic may be too low. However, 85% of the panic trials defined in this way were accompanied by three or more bodily symptoms on the DSM-III checklist, compared to 49% of non-panic trials that were accompanied by three or more symptom endorsements. As can be seen in Fig. 5, a greater number of fearful cognitions was reported on panic than on no-panic trials. The cognitions were threat-relevant and situation-relevant-fear of suffocating, or of running out of air, or of passing out. It is understandable that claustrophobic Ss might have these thoughts while remaining on a small enclosed space. A greater number of bodily symptoms were reported as having occurred during panic trials in comparison to no-panic trials (Fig. 6).
Fig. 6. More bodily symptoms were endorsed on panic trials than on no-panic trials, with the exception of depersonalization (claustrophobia study).
418
s.
bCHMAt4
cl d.
Reports of choking, shortness of breath and dizziness were particularly common. There appears to be an understandable match between these reported bodily symptoms and the fearful cognitions. The correlations between the 14 bodily symptoms and ten cognitions, across all 50 panic trials, were calculated in order to reveal the presence or absence of linkages. All those with a probability of less than 0.001, are illustrated in Table 3. In most instances the relationships between the bodily symptoms and cognitions are meaningful. To take a few examples, the bodily sensation of ‘faintness’ was correlated with the cognition “I am going to pass out”. Shortness of breath and choking were both correlated with a fear of suffocating, depersonalization with “I am going to scream”, and so on. However, some relationships were not intuitively obvious. For example, palpitations were positively correlated with “I am going to lose control of myself”, but not with the cognition, “I am going to have a heart attack”: The latter cognition was not endorsed by any Ss on any of the panic trials. In addition to determining the correlations between specific symptoms and specific cognitions, we searched for links between some of the most common cognitions and patterns of bodily symptoms-in the belief that combinations of bodily symptoms are more likely to precipitate a panic cognition than any isolated bodily symptoms (see below). As described above, a proportion of the panics experienced by the panic-disorder patients were not accompanied by the endorsement of any relevant cognitions, and we therefore re-examined the data on the claustrophobia Ss in order to compare the ‘cognitive’ and ‘non-cognitive’ panics in this group. However, we quickly discovered that no non-cognitive panics had been reported in the 50 panic trials reported by the claustrophobic Ss. In contrast to the findings in the panic-disorder group of patients, at least one cognition was endorsed on every trial where a panic score of 50 or greater was reported. This absence of ‘non-cognitive panics’ is consistent with the results from the earlier experiment on claustrophobic panics (Rachman and Levitt, 1985) in which it was observed that at least one cognition was endorsed on each of the 43 panic trials reported by the 26 Ss.
COGNITIONS
ASSOCIATED
WITH
COMBINATIONS
OF
SYMPTOMS
The search for links between bodily sensations (‘symptoms’) and panic cognitions should not be confined to examining the connections between single symptoms and single cognitions; the putative catastrophic cognitions are more likely to be triggered by a combination of symptoms (e.g. dizziness and sweating) than by a single symptom. In pursuit of this idea we selected combinations of 2 or 3 of the most common symptoms (drawn from the larger list) that might provoke claustrophobic and panic-disorder cognitions, and tried to match these combinations with each of the ten cognitions, separately for each of the two samples of Ss. Panic-disorder
Some remarkable patterns emerged from the data generated by the panic-disorder patients. In all of the 12 combinations of two or three symptoms that we examined (consisting of various combinations of faintness, dizziness, sweating, depersonalization, shortness of breath, choking, nausea, flushes and palpitations), no panics were reported unless there was an associated cognition. When they were associated with a panic cognition, however, these same combinations of symptoms ended in a panic in most instances. So, for example, the combination of breathlessness and dizziness plus a cognition (pass out, lose control, panic) ended in panic on 11 out of 13 occasions; but in all of the no-panic trials with this combination of symptoms, there was no associated panic cognition. The most common patterns associated with a panic were: (a) dizziness-shortness of breath, and a cognition of pass out, lose control, or panic; (b) palpitations-shortness of breath-dizziness, plus a cognition of pass out, lose control, panic.
or
The prominence of shortness of breath is consistent with the emphasis placed on the role of hyperventilation in the onset of panics (e.g. Clark, 1986; Ley, 1985). The combination of choking plus shortness of breath was associated with the cognition of ‘suffocation’ only twice-in marked contrast to the reports given by the claustrophobic Ss (see below). The cognition of suffocation that was so frequently reported by the claustrophobics was unusual in the panic-disorder patients
ShortncsJ of breath Choking Palpitations Cheat pain Sweating Fainlntss Ditimxs Nausea Depersonalization Numbness FIushea~chills Trembling Fear dying Fear going crazy
SYWtOIt%S
out
0.44
0.49
Pass
OS8
Act foolish
Hear( attack
0.42
0.54 0.57
SuiTocaIe
0.52
0.56
0.64
0.54
Cognitions Lose control Scream
0.54
0.46
Panic
0.49
0.48
0.85
Choke
Paralyzed by fear
are
0.51
0.52
Run 0111of air
Table 3. ~n~e~o~elali~ns between c~gnitions aad bodily sensations in 20 Cla~sIrophobic Ss on panic lrials (n = SO). Only correlations with significance levels of P -c 0.001 reported here
420
S.
kU3tMAN et al.
90
60
Fig. 7. The fearful cognitions endorsed on panic trials by the panic-disorder endorsed by the claustrophobic Ss.
patients differed from those
(see Fig. 7). The bodily symptoms reported by the two groups are included for general interest (Fig. 8). The common patterns of non-cognitive panics were:
(a) faintness-dizziness-short of breath, but no cognition; (b) depersonalization-flushes-dizziness, but no cognition. An unexpected aspect of the frequency of cognitions should be mentioned. As can be seen in Fig. 7, panic-related cognitions were more frequently reported by the claustrophobic Ss than by the panic-disorder patients. Two factors may account for this difference. By virtue of their DSM 100
a
Fig. 8. The pattern of bodily symptoms endorsed on panic trials by the panic-disorder slightly from those endorsed by the claustrophobic Ss.
patients differed
Panic: the links between cognitions and bodily symptoms--I
421
diagnoses, the panic-disorder patients must have experienced many panics before entering this study, and it is possible that they had become jaded, and failed to experience or notice the all too familiar cognitions. This may also explain the occurrence of non-cognitive panics in this group and their absence in the claustrophobic group. A second factor may be the novelty and hence provoking quality of the enclosed room for the claustrophobics. They may have found the test situation more stimulating because more novel. Before moving from the cognitions of the panic patients to those of the claustrophobics, it is essential to bear in mind the distinctions between panic trials, no-panic trials and non-cognitive panics. The three patterns, and their frequencies, observed in the panic-disorder patients were as follows: Trials (69) 1. Panics-symptoms plus cognition (22/69) 2. Non-cognitive panics-symptoms minus cognition (8/69) 3. No-panics-symptoms minus cognition (39/69) We can illustrate the difference between plain panics and non-cognitive panics with this example. The symptom combination of faintness-dizziness-shortness of breath ended in a panic on those seven trials when there was an associated cognition (pass out or panic). On the other seven trials containing this combination, panic was also recorded despite the absence of a cognition-i.e. there were seven non-cognitive panics. Claustrophobics No non-cognitive panics occurred in the total of 140 test trials, and this is a major difference from the findings on the panic-disorder group. Additionally, the clarity of the division between panics and no-panics that emerged from the panic-disorder patients was not as evident in the claustrophobics. Among the claustrophobics, 64/90 no-panics were associated with at least one cognition. However, no-panics among the patient sample were seldom accompanied by a fearful cognition. Very many more cognitions were reported on panic than on no-panic trials (see Fig. S), and some interesting combinations with symptoms emerged. The commonest physical symptoms were combinations that included two or all three of the following: shortness of breath-chokingdizziness. These combinations of symptoms when associated with the cognition of suffocation, frequently occurred in panic trials. To illustrate: the combination of choking-shortness of breath, plus the cognition of suffocation, went with panic on 25 occasions, and with a no-panic on only 6 occasions. The combination of choking-shortness of breath-dizziness, plus suffocation, went with a panic on 20 occasions and a non-panic on 5 occasions. These links frequently went with panic, and the links are understandable. Claustrophobics in an enclosed room who begin to feel short of breath and to choke, and interpret these sensations as signs of possible suffocation, are understandably panicky. These links, and the absence of non-cognitive panics, are consistent with Clark’s (1986) theory of panic. It is less easy to accommodate the 64 test trials (out of 140) on which symptoms plus cognitions failed to be associated with a panic. The results of the search for links between cognitions and combinations of symptoms can be summarized. Among the panic-disorder patients, even in the presence of common combinations of bodily symptoms, no-panics were usually reported unless there was an associated cognition. When the same combinations of symptoms were associated with a cognition, they usually went with a panic. Common patterns of this type included understandable associations between dizziness-shortness of breath-palpitations and the cognition of passing out. Eight of the panics were associated with symptoms but not accompanied by cog&ions, and are classed as noncognitive panics. No non-cognitive panics were reported by the claustrophobic Ss. Very many more cognitions were reported on the 50 panic trials, but as many as 64 no-panic trials were associated with at least one cognition. The commonest combinations of symptoms included at least two of these three: choking-shortness of breath-dizziness. When these symptom combinations were associated with the cognition of suffocation, panic was frequently reported.
422
S. R.xHhuN
et al.
DISCUSSION Trials on which panics were reported were accompanied by many more fearful cognitions, and many more bodily symptoms, than no-panic trials. Among the panic-disorder patients, the trials on which no panic was reported were notable for the very low frequency of fearful cognitions. On 31 of the 39 no-panic trials, there was a complete absence of fearful cognitions. By contrast, 64 of the 90 of the no-panic trials reported by the claustrophobics were accompanied by at least one cognition. In both samples, the claustrophobics and the patients with panic-disorder, meaningful links between the fearful cognitions and the bodily symptoms were observed. Moreover, the links between fearful cognitions and combinations of bodily symptoms were even clearer. It is noteworthy too that the links which were observed among the panic-disorder patients differed from the links that emerged in the claustrophobic Ss. This implies that the links between cognitions and bodily symptoms are likely to be threat-relevant and also situation-relevant. Non-cognitive panics were recorded among the sample of panic-disorder patients, but were absent among the claustrophobics. It is also of interest that the non-cognitive panics were accompanied by fewer bodily symptoms than were the cognitive panics, possibly suggesting that there is some relationship between the range/intensity of bodily symptoms and the probability of a fearful cognition being recognized. It is worth pointing out that broadly speaking, fewer fearful cognitions were reported by the panic-disorder patients than might have been expected; the claustrophobic Ss reported a high frequency of fearful cognitions. The fact that panics were far more frequent (roughly four times more likely) when the bodily symptoms were accompanied by a cognition, indicates that the cognitions were contributory. In the case of claustrophobic panics, they may even be a necessary condition for the occurrence of a panic Among panic-disorder patients, the contributory quality of the cognitions was evident from the facts that panics were accompanied by a greater number of cognitions than were no panics, and that in the absence of fearful cognitions, these patients tended to report no panics. The detection of meaningful links between symptoms and cognitions in two different types of Ss, and the replication from one sample of clautrophobic Ss to another (see Rachman, 1987), provides useful support for Clark’s (1986) general argument. His posits that panics are caused by a catastrophic misinterpretation of bodily symptoms, and the present results show that links between bodily sensations and cognitions can indeed be demonstrated. They are mostly meaningful, and can be detected in the panics reported by differing samples of fearful Ss. The links detected on panic trials were seldom evident on no-panic trials. However, it is important to notice that some expected links were not detected on panic trials. There were fewer links than expected, and if confirmed, thus will constitute a problem for cognitive theories. As far as the links between the symptoms and cognitions go, almost all of them appear to be readily understandable, but they are perhaps insufIicient. Confirmation of our earlier report on the absence of ‘non-cognitive’ panics in the claustrophobic groups is welcome, but the recording of eight episodes of panic that were not accompanied by cognitions in the patients with panic-disorder, presents a second and possibly serious problem for cognitive theory. For if they are interpreted at face value, it means that we now have to contend with experimental examples of non-cognitive panics. (The possible relation of these non-cognitive panics to the nocturnal panics described by Adler, Craske and Barlow, 1987, needs to be considered.) In these instances, there was no link between the bodily sensation and a catastrophic misinterpretation. These non-cognitive panics can be regarded as unexplained exceptions to the theory, or as a signal that the theory is insticient. It is of course possible that panics that occur in experimental conditions do not resemble uncontrived panics, and in particular they do not resemble the spontaneous panics which a significant number of patients with panic-disorder report. However, as has been argued elsewhere (Rachman, 1987) it is not unreasonable to regard the experimental and uncontrived panics as having a good deal of similarity. Furthermore, the dismissal of the data on non-cognitive panics on these grounds would inevitably debase the many positive and interesting findings that have been the product of this experimental approach. Instead, the occurrence of these non-cognitive panics can be dealt with in one of two ways. It can be objected that the patients’ failure to endorse any of the cognitions on the standard list does
Panic: the links between
cognitionsand bodily symptoms-I
423
not exhaust the possibilities and that they might have had other catastrophic cognitions that did not appear on the list. This is an empirical question that can be tested by introducing an expanded list of cognitions and by making further attempts to elicit cognitions by interviewing the Ss/patients directly after each panic has occurred. (It should be pointed out, however, that after each trial, the patients were asked, in a non-systematic manner, for further information, but almost always re-asserted that they had not experienced a fearful cognition.) An empirical resolution of this problem, following the procedures outlined, would be a simple conclusion. If, however, this extension of information fails to resolve the problem the next alternative is complicated. It is possible that these non-cognitive panics are misleading and simply a product of the S’s/patient’s inability to detect the cognition and/or his inability to recall or describe it. The occurrence and importance of ‘automatic thoughts’ is a central feature of Beck’s (1987) approach to the subject of panic (and depression) and much therapeutic effort is devoted precisely to training the patients in the detection and report of these automatic thoughts. By extension, it can be argued that when patients or Ss report non-cognitive panics, they should be given specific training in detecting and reporting automatic thoughts, or those cognitions which are too fleeting for them to notice during the state of panic. This is a reasonable approach, and one that is buttressed by clinical information regarding the occurrence of automatic thoughts and their recognition and subsequent modification. It will not pass unnoticed, however, that we are approaching a slippery path, for the testability of this defense of the theory is questionable. If non-cognitive panics are to be explained by the occurrence of unnoticed, automatic thoughts, is the explanation open to disconfirmation? Can it be falsified? The reasons for the occurrence of some non-cognitive panics among panic-disorder patients and their absence in the panics of claustrophobic Ss are not known. The difference may be accounted for by the unambiguous threat in the claustrophobic setting-the cognitions were specific and restricted to a greater degree than in the settings in which the panic-disorder patients were tested. Another possibility is that the panic patients were more habituated to their bodily symptoms because they had experienced them so very often; hence, the awareness of these bodily sensations was not always intepreted as a sign of impending catastrophe. Margraf, Ankers and Blank (1986) report that patients show decreasing panic frequencies with the repetition of lactate infusions, and this may help to account for our non-cognitive panics. Non-cognitive panics present less of a problem for a conditioning theory of panic because cognitions do not feature in the theory. Panics are triggered by a CS. The patient need not be aware of the CS or its presence, and the theory does not require the operation of cognitive mediation. However, the conditioning theory is then left to contend with the non-regularity of the panics reported in this group of patients. Presumably the answer would be that the CSs vary in prominence, intensity and salience, from trial to trial. Hence, the panics vary in probability of occurrence. To conclude. most of our findings are consistent with Clark’s cognitive theory of panic, which entails a close link between bodily symptoms and cognitions. The links can be detected in many instances, and they are understandable. The problem of ‘non-cognitive panics’ remains to be resolved. Acknowledgemenrs-This
research was supported by a grant from the B.C. Health Care Foundation.
REFERENCES Adler C., Craske M. and Barlow D. (1987) Relaxation-induced panic. J. Integruriue Psych&. In press. Beck A. (1987) Cognitive approaches to panic disorder. In Punk: Psychological Perspecriues (Edited by Rachman S. and Maser J.). Erlbaum, New Jersey. Chambless D. (1985) The mobility inventory for agoraphobia. Behau. Res. Ther. U, 354% Clark D. (1986) A cognitive approach to panic. Behau. Res. Ther. 24, 461470. Ley R. (1985) Agoraphobia, the panic attack and the hyperventilation syndrome. Behuv. Res. Ther. 23, 79-81. Rachman S. (1987) Panics and their consequences: Review and prospect. In Panic: Psychological Perspectives (Edited by Rachman S. and Maser J.). Erlbaum, New Jersey. Rachman S. and Levitt K. (1985) Panics and their consequences. Behuu. Res. Ther. 23, 585-600. Rachman S. and Lopatka 6. (1$86a) Match and mismatch in the prediction of fear. Behnv. Res. Ther. 24, 387-393. Rachman S. and Lopatka C. (1986b) Match and mismatch of fear in Gray’s theory. Be&u. Res. Ther. 24, 395401. Rachman S., Lopatka C. and Levitt K. (1987a) II. Experimental analyses of panic: Panic patients. B&au. Res. Ther. Fbchman S., Levitt K. and Lopatka C. (1987b) III. Experimental analyses of panic: Claustrophobic subjects. Behuu. Res. Ther.
PANIC:
Department
GiBS-7%7/8? $3.00 + 0.00
Pcrgamon Journals Ltd
THE LINKS BETWEEN COGNITIONS AND BODILY SYMPTOMS-I
S. RACHMAN,K. LEVITT and C. LOPATKA of Psychology, The University of British Columbia, Vancouver, B.C. V6T 1Y7, Canada (Received 17 February,
1987)
S~~~o~itive theories of panic entail a causal Link between bodily sensations and fearful cog&ions. In this light, the data collected from two experimental analyses of panic were re-examined in a search for meaningful links between the fearful cog&ions and the bodily sensations reported during episodes of panic. panic episodes were accompanied by many more fearful cognitions and bodily symptoms than no-panic episodes, and several understandable iinks between the bodily symptoms and cog&ions emerged.The linksbetweencorn~~zio~~of bodily symptomsand cog&ions were even clearer than the links between single symptoms and cog&ions. For example, when claustrophobic Ss reported bodily symptoms of dizziness, choking and shortness of breath in association with the cognition of suffocation, a panic was usually recorded. Among panic-disorder patients, the combination of palpitations, dizziness and shortness of breath accompanied by the cognition of passing out, was usually associated with a panic. The links observed in a group of panic-disorder patients were different to those observed in a group of cia~trophobic Ss. Among the panic-disorder patients. the great majority of no-panic episodes were marked by an absence of fearful cog&ions; in contrast, two-thirds of the no-panic episodes reported by the claustrophobic Ss were accompanied by at least one cognition. Although the observed links were meaningful, there were fewer than might have been expected. The overall number of links fell below expectation. Among the panic-disorder patents, only eight episodes of ‘non-cognitive panics’ were recorded.
INTRODUCTION Clark’s (1986) theory of panic entails a casual link between bodily sensations and cognitionspanics occur when the person ca~strophi~lly misinterprets his/her bodily sensations. “Panic of certain bodily sensations” (Clark, attacks. . . result from the catastrophic ~sinte~re~tion 1986, p. 461). Beck’s (1987) theory differs in detail but also entails such a link. In the course of conducting a programme of research into the psychology of fear and of panic (Rachman, 1987; Rachman and Levitt, 1985; Rachman and Lopatka, 1986a, b), we collected reports of bodily sensations and of cog~tions from fearful Ss and from phobic patients, dnring episodes of panic and non-panic. This information has a bearing on Clark’s theory and we put it to a second use by re-analyzing the data in order to search for links between the bodily sensations and the cognitions experienced during panic episodes. Clark’s writings lead one to expect that there should be a meaningful, if not always rational, relationship between bodily symptoms and cognition; they should fit. The sensation of heart palpitations should be associated with the fear of cardiac illness, dizziness should be linked to the fear that one might lose control, etc. An earlier, preliminary, attempt to find evidence of such links occurring during claustrophic panics (Rachman, 1987) was partly successful. The cognitions tended to be threat-relevant and situation-s~cific. The cognition, “I am going to suffocate” was associated with the most relevant bodily sensation (shortness of breath). There were some exceptions however, and the most prominent was the frequent endorsement of the bodily sensation of palpitations, which was not linked specifically to the cognition of cardiac illness (“I am going to have a heart attack”), or to any other particular cognitions. it appears to be a bodily sensation that spans several cognitions, and not any one in particular. In the same study, on claustrophobic Ss, none of the 67 panic episodes was associated with an absence of panic cognitions, as ascertained by endorsements of the panic cognitions checklist introduced by Chambless (1985), which is conventionally used in this type of research. There were no ‘non-cognitive panics’ in the early study, but as will be described below, some have now been recorded. In order to check and expand on these preliminary results, analyses were conducted on newly collected data which include a fresh group of 20 claustrophobic Ss (who reported experiencing a 411
412
s.
bXiMAN
et al.
panic on 50 out of a total of 140 trials), and from a separate group of 20 patients with panic disorder (who reported panicking on 30 of 69 trials). The analyses were directed in the first place at the primary question of whether or not the expected links between bodily sensations and cognitions could be detected on those trials when a panic was reported. We also used this opportunity to study the nature and frequency of ‘non-cognitive panics’, that is, those panic trials during which the Ss or patient failed to endorse any of the items on the panic cognitions list. These non-cognitive panics bear a resemblance to the so-called spontaneous panics that panic-disorder patients sometimes describe. They are described as coming out of the blue, and the patient cannot connect the panic to any cognition. A brief description of the two studies is set out before reporting the results of the new analyses. PANIC
DISORDER
STUDY
In the course of attempting to replicate and extend the findings on the effects of match-mismatch on fear responding, we carried out a study of the bodily symptoms and cognitions reported during panic and non-panic episodes by 20 panic-disorder patients. The full results of this study are described elsewhere (Rachman, Lopatka and Levitt, 1987a), so for the present purpose we will concentrate on the links between the bodily symptoms and cognitions that emerged from the panic experiences of this group of patients. (Strictly speaking, the items on the DSM checklist are not ‘symptoms’, but bodily sensations. The original term will be retained here simply to avoid confusion. It is not assumed that they are symptomatic of a disease or disorder, and it is “Important to remember that many [of these] symptoms, specified for the diagnosis of panic disorder, are very common in the [general] population” wittchen, 1986, p. 261.) The Ss for this experiment were 20 patients who had received a DSM-IIIR diagnosis of panic disorder. After selection, they were asked to complete between three and five standardized behavioural tests which consisted of entering a fearful place or situation (e.g. walking alone into a store). Prior to each test trial, the patients were asked to predict how much fear and safety they expected to experience, and to predict whether or not they would panic. At the conclusion of each test trial, they reported their actual fear, safety and panic, and completed the DSM-IIIR checklist of Bodily Symptoms, and the Panic Cognition Checklist used in the Rachman and Levitt (1985) study and which was derived from the work of Chambless (1985). In addition, the patients were asked to report any cognitions or bodily sensations that were not on the standardized checklists. 50-
40-
Y 4
30-
c Y E
20-
n
tO-
Legend m no-pa& trlds I
pantc triah
Fig. 1. Fearful cognitions were endorsed far more frequently on panic trials than on no-panic trials (panic-disorder patients).
Panic: the links between cognitions and bodily symptoms-I
413
soao70-
50Y z
50-
Y h 8 6:
40-
50-
20-
10-
Fig. 2. Bodily symptoms
were endorsed more frequently on panic trials than on no-panic (panic-disorder patients).
trials
Results
Before turning to the links between bodily sensations and cognitions, a summary of the frequency of panics that occurred during these test trials is necessary. Panics or near-panics occurred on 30 of the 69 test trials (panic trials were defined as those episodes when the patient reported having panicked or come close to panicking). The occurrence of panic was evenly distributed across the sample: 70% of the patients reported either having panicked or come close to panicking on at least one occasion. As can be seen in Fig. 1, the panic trials were accompanied by many more fearful cognitions than were the non-panic trials. The panic trials were also accompanied by many more bodily symptoms than the non-panic trials (Fig. 2). Pearson correlations were computed between each of the bodily symptoms and cognitions endorsed over all panic trials (see Table 1). (Only the correlations at p = < 0.001 are reported. For the sake of clarity, Table 2 sets out the full lists of cognitions and bodily symptoms.) One of the most common cog&ions, a fear of passing out, was accompanied by feelings of faintness, choking and depersonalization. A fear of panicking was accompanied by symptoms of nausea, dizziness, shortness of breath. In general, the panic and no-panic trials were accompanied by different patterns of cognitions and bodily symptoms, as illustrated in Figs 1 and 2. The frequency of non-cognitive panics, defined as any panic episode in which the patient failed to endorse an item on the list of cognitions, was calculated. (A cognitive panic was defined as any panic episode in which at least one cognition was endorsed.) Eight (26.6%) of the panic trials fell into the non-cognitive category. These non-cognitive panics were distributed across Ss: slightly over one-third of the patients who panicked on at least one occasion experienced a non-cognitive panic, and 60% of the patients who reported a non-cognitive panic also reported a cognitive panic. The cognitive panics were accompanied by many more bodily symptoms than non-cognitive panics, with the unexplained exception of a feeling of choking (see Fig. 3). (Recall here that trials on which panic occurred were accompanied by many more bodily symptoms than those trials in which panics did not occur, Fig. 2). Panics were accompanied (caused?) by an increased percentage of bodily symptoms, and cognitive panics were accompanied by a greater percentage of bodily symptoms than the non-cognitive panics. Interestingly, on nearly all trials in which a cognition was associated with panic, many more bodily symptoms were reported than on trials that were associated with a no-panic (see Fig. 4).
Palpitations Chesl pain Sweating Faintness Dizziness Nausea ~~r~naIi~tion Numbness Flushes/chills Trembling Fear dying Fear going crazy
Cll0kill&
Shortness of breath
Symptoms
Table 1. Jntcrcorrelations
0.56
0.86
0.64
Pass out
Act foolish
Heati attack
Suffocate 0.53
Cognilions Lose ControJ Scream
0.54 0.64
0.53
Panic Choke
Paralyzed by fear
Run oul of air
between cognitions and bodily sensations in 20 panic-disorder patients on panic trials (n = 30). Only correlations with significance levels of P < 0.001 are reported here
P
II
a
x 2
K P
vt
6
Panic: the links between cognitions and bodily symptoms-I Table 2. Bodily sensations and cognitions
(C2) (C3) 64) KS) 0) (C7)
(‘3)
0) (ClO)
I am goiqg I am going foolishly I am going attack I am going I am going of myself I am going I am going
to pass out to act
W) W)
to have a heart
63)
to suffocate to lose control
W) (S5)
to scream to panic
66) 67)
I am going to choke to death I am going to be paralyzed by fear I am going to run out of air to breathe
checklist items Bodily sensations
Cognitions
(Cl)
415
CW 69) 610) 611) 612) 613) 614)
Shortness of breath Choking or smothering sensations Palpitations or accelerated heart rate Chest pain or discomfort Sweating Faintness Dizziness, lightheadedness or unsteady feelings Nausea or abdominal distress Depersonnalization or derealization Numbness or tingling sensations Flushes (hot flashes) or chills Trembling or shaking Fear of dying Fear of going crazy or doing something . uncontrolleQ
The panic cognitions were threat-relevant; fears of passing out, losing control, panicking, were the most frequently endorsed. The cognition of losing control was correlated with shortness of breath (P = O.OOl), nauses (P = 0.05) and trembling (P = 0.05). However, the same cognition in the claustrophobic situation was accompanied by a different set of symptoms (see below). These results suggest that panic cognitions and bodily symptoms tend to be threat-relevant and situation-relevant. The sensation of shortness of breath takes on a more threatening quality in an enclosed space than in the open, and a feeling of faintness is more threatening in a crowded public place than while resting at home.
Fig. 3. Selected bodily symptoms were endorsed more frequently on cognitive panic trials than on non-cognitive panic trials (e.g. shortness of breath, faintness, nausea, palpitations). The exceptions include flushes, choking and chest pain (panic-disorder study). B.R.T
250-G
416
S. kU3IMAN et al.
20
Fig. 4. More bodily symptoms were endorsed on cognitive panic trials than on cognitive no-panic trials, with the exception of flushes (panic-disorder study).
CLAUSTROPHOBIA
STUDY
In an attempt to gain a better degree of control over the panics experienced by claustrophics, a refined version of the original experiment (Rachman and Levitt, 1985) was conducted on Ss drawn from the same student population, using the same process of selection. Twenty claustrophic Ss were assigned randomly to one of two groups. Ss in the experimental group (n = 10) were instructed to concentrate on their bodily sensations while they remained in the small, enclosed test room. They were asked to concentrate on any changes in their sensations and were given the DSM-III list of panic symptoms to read prior to each test trial. The Ss (n = 10) in the control group were asked to concentrate on a simple alphabet task while in the test room. They were asked to think of a word beginning with each letter of the alphabet for several different categories (e.g. countries, foods) supplied prior to each test trial. The Ss’ predictions of safety, fear and panic were recorded prior to each test trial. After each trial, the Ss reported their experienced levels of safety, fear, and panic, and they also provided an estimation of the percentage of time which they had spent concentrating on the assigned task (bodily sensations or alphabet) during that trial. They also completed the DSM-IIIR panic checklist and the Cognitions Checklist after each test trial (for details see Rachman and Levitt, 1985). In the earlier study we used a discrete judgment of the presence or absence of panic, but in the present study panic was reported on a dimensional scale, which ranged from 0 (“No, I did not panic”) to 100 (“Yes, I absolutely panicked”). After one ‘throw away’ practice trial, each S completed seven test trials. These were identical in format and content, but their duration was varied between 2 and 4 min, in order to reduce the predictability of the duration of each of the trials. A complete report of the results of this experiment is provided in Rachman, Levitt and Lopatka (1987b). Results The severity of panic on each of the seven trials was reported on the O-100 continuous scale. Those trials on which a score of 50 or over was reported, were classified as panic trials. Using this criterion, 75% of the Ss reported at least one panic and 55% did so on at least two test trials. Five of the twenty Ss did not report any panics. Fifty of the 140 trials were panic trials (36%). This is slightly higher than the percentage (26%) of panics or near-panics recorded in the original experiment (Rachman and Levitt, 1985). This difference might be a product of the scale used to
417
Panic: the links between cognitions and bodily symptoms-I
m
-
I
Legend trids W&
nc-panlc pmlc
Fig. 5. Fearful cognitions were endorsed far more frequently on panic trials than on no-panic trials (claustrophobia study).
measure reported panic (discrete versus continuous). The cut-off point of 50 which we used to categorize a panic may be too low. However, 85% of the panic trials defined in this way were accompanied by three or more bodily symptoms on the DSM-III checklist, compared to 49% of non-panic trials that were accompanied by three or more symptom endorsements. As can be seen in Fig. 5, a greater number of fearful cognitions was reported on panic than on no-panic trials. The cognitions were threat-relevant and situation-relevant-fear of suffocating, or of running out of air, or of passing out. It is understandable that claustrophobic Ss might have these thoughts while remaining on a small enclosed space. A greater number of bodily symptoms were reported as having occurred during panic trials in comparison to no-panic trials (Fig. 6).
Fig. 6. More bodily symptoms were endorsed on panic trials than on no-panic trials, with the exception of depersonalization (claustrophobia study).
418
s.
bCHMAt4
cl d.
Reports of choking, shortness of breath and dizziness were particularly common. There appears to be an understandable match between these reported bodily symptoms and the fearful cognitions. The correlations between the 14 bodily symptoms and ten cognitions, across all 50 panic trials, were calculated in order to reveal the presence or absence of linkages. All those with a probability of less than 0.001, are illustrated in Table 3. In most instances the relationships between the bodily symptoms and cognitions are meaningful. To take a few examples, the bodily sensation of ‘faintness’ was correlated with the cognition “I am going to pass out”. Shortness of breath and choking were both correlated with a fear of suffocating, depersonalization with “I am going to scream”, and so on. However, some relationships were not intuitively obvious. For example, palpitations were positively correlated with “I am going to lose control of myself”, but not with the cognition, “I am going to have a heart attack”: The latter cognition was not endorsed by any Ss on any of the panic trials. In addition to determining the correlations between specific symptoms and specific cognitions, we searched for links between some of the most common cognitions and patterns of bodily symptoms-in the belief that combinations of bodily symptoms are more likely to precipitate a panic cognition than any isolated bodily symptoms (see below). As described above, a proportion of the panics experienced by the panic-disorder patients were not accompanied by the endorsement of any relevant cognitions, and we therefore re-examined the data on the claustrophobia Ss in order to compare the ‘cognitive’ and ‘non-cognitive’ panics in this group. However, we quickly discovered that no non-cognitive panics had been reported in the 50 panic trials reported by the claustrophobic Ss. In contrast to the findings in the panic-disorder group of patients, at least one cognition was endorsed on every trial where a panic score of 50 or greater was reported. This absence of ‘non-cognitive panics’ is consistent with the results from the earlier experiment on claustrophobic panics (Rachman and Levitt, 1985) in which it was observed that at least one cognition was endorsed on each of the 43 panic trials reported by the 26 Ss.
COGNITIONS
ASSOCIATED
WITH
COMBINATIONS
OF
SYMPTOMS
The search for links between bodily sensations (‘symptoms’) and panic cognitions should not be confined to examining the connections between single symptoms and single cognitions; the putative catastrophic cognitions are more likely to be triggered by a combination of symptoms (e.g. dizziness and sweating) than by a single symptom. In pursuit of this idea we selected combinations of 2 or 3 of the most common symptoms (drawn from the larger list) that might provoke claustrophobic and panic-disorder cognitions, and tried to match these combinations with each of the ten cognitions, separately for each of the two samples of Ss. Panic-disorder
Some remarkable patterns emerged from the data generated by the panic-disorder patients. In all of the 12 combinations of two or three symptoms that we examined (consisting of various combinations of faintness, dizziness, sweating, depersonalization, shortness of breath, choking, nausea, flushes and palpitations), no panics were reported unless there was an associated cognition. When they were associated with a panic cognition, however, these same combinations of symptoms ended in a panic in most instances. So, for example, the combination of breathlessness and dizziness plus a cognition (pass out, lose control, panic) ended in panic on 11 out of 13 occasions; but in all of the no-panic trials with this combination of symptoms, there was no associated panic cognition. The most common patterns associated with a panic were: (a) dizziness-shortness of breath, and a cognition of pass out, lose control, or panic; (b) palpitations-shortness of breath-dizziness, plus a cognition of pass out, lose control, panic.
or
The prominence of shortness of breath is consistent with the emphasis placed on the role of hyperventilation in the onset of panics (e.g. Clark, 1986; Ley, 1985). The combination of choking plus shortness of breath was associated with the cognition of ‘suffocation’ only twice-in marked contrast to the reports given by the claustrophobic Ss (see below). The cognition of suffocation that was so frequently reported by the claustrophobics was unusual in the panic-disorder patients
ShortncsJ of breath Choking Palpitations Cheat pain Sweating Fainlntss Ditimxs Nausea Depersonalization Numbness FIushea~chills Trembling Fear dying Fear going crazy
SYWtOIt%S
out
0.44
0.49
Pass
OS8
Act foolish
Hear( attack
0.42
0.54 0.57
SuiTocaIe
0.52
0.56
0.64
0.54
Cognitions Lose control Scream
0.54
0.46
Panic
0.49
0.48
0.85
Choke
Paralyzed by fear
are
0.51
0.52
Run 0111of air
Table 3. ~n~e~o~elali~ns between c~gnitions aad bodily sensations in 20 Cla~sIrophobic Ss on panic lrials (n = SO). Only correlations with significance levels of P -c 0.001 reported here
420
S.
kU3tMAN et al.
90
60
Fig. 7. The fearful cognitions endorsed on panic trials by the panic-disorder endorsed by the claustrophobic Ss.
patients differed from those
(see Fig. 7). The bodily symptoms reported by the two groups are included for general interest (Fig. 8). The common patterns of non-cognitive panics were:
(a) faintness-dizziness-short of breath, but no cognition; (b) depersonalization-flushes-dizziness, but no cognition. An unexpected aspect of the frequency of cognitions should be mentioned. As can be seen in Fig. 7, panic-related cognitions were more frequently reported by the claustrophobic Ss than by the panic-disorder patients. Two factors may account for this difference. By virtue of their DSM 100
a
Fig. 8. The pattern of bodily symptoms endorsed on panic trials by the panic-disorder slightly from those endorsed by the claustrophobic Ss.
patients differed
Panic: the links between cognitions and bodily symptoms--I
421
diagnoses, the panic-disorder patients must have experienced many panics before entering this study, and it is possible that they had become jaded, and failed to experience or notice the all too familiar cognitions. This may also explain the occurrence of non-cognitive panics in this group and their absence in the claustrophobic group. A second factor may be the novelty and hence provoking quality of the enclosed room for the claustrophobics. They may have found the test situation more stimulating because more novel. Before moving from the cognitions of the panic patients to those of the claustrophobics, it is essential to bear in mind the distinctions between panic trials, no-panic trials and non-cognitive panics. The three patterns, and their frequencies, observed in the panic-disorder patients were as follows: Trials (69) 1. Panics-symptoms plus cognition (22/69) 2. Non-cognitive panics-symptoms minus cognition (8/69) 3. No-panics-symptoms minus cognition (39/69) We can illustrate the difference between plain panics and non-cognitive panics with this example. The symptom combination of faintness-dizziness-shortness of breath ended in a panic on those seven trials when there was an associated cognition (pass out or panic). On the other seven trials containing this combination, panic was also recorded despite the absence of a cognition-i.e. there were seven non-cognitive panics. Claustrophobics No non-cognitive panics occurred in the total of 140 test trials, and this is a major difference from the findings on the panic-disorder group. Additionally, the clarity of the division between panics and no-panics that emerged from the panic-disorder patients was not as evident in the claustrophobics. Among the claustrophobics, 64/90 no-panics were associated with at least one cognition. However, no-panics among the patient sample were seldom accompanied by a fearful cognition. Very many more cognitions were reported on panic than on no-panic trials (see Fig. S), and some interesting combinations with symptoms emerged. The commonest physical symptoms were combinations that included two or all three of the following: shortness of breath-chokingdizziness. These combinations of symptoms when associated with the cognition of suffocation, frequently occurred in panic trials. To illustrate: the combination of choking-shortness of breath, plus the cognition of suffocation, went with panic on 25 occasions, and with a no-panic on only 6 occasions. The combination of choking-shortness of breath-dizziness, plus suffocation, went with a panic on 20 occasions and a non-panic on 5 occasions. These links frequently went with panic, and the links are understandable. Claustrophobics in an enclosed room who begin to feel short of breath and to choke, and interpret these sensations as signs of possible suffocation, are understandably panicky. These links, and the absence of non-cognitive panics, are consistent with Clark’s (1986) theory of panic. It is less easy to accommodate the 64 test trials (out of 140) on which symptoms plus cognitions failed to be associated with a panic. The results of the search for links between cognitions and combinations of symptoms can be summarized. Among the panic-disorder patients, even in the presence of common combinations of bodily symptoms, no-panics were usually reported unless there was an associated cognition. When the same combinations of symptoms were associated with a cognition, they usually went with a panic. Common patterns of this type included understandable associations between dizziness-shortness of breath-palpitations and the cognition of passing out. Eight of the panics were associated with symptoms but not accompanied by cog&ions, and are classed as noncognitive panics. No non-cognitive panics were reported by the claustrophobic Ss. Very many more cognitions were reported on the 50 panic trials, but as many as 64 no-panic trials were associated with at least one cognition. The commonest combinations of symptoms included at least two of these three: choking-shortness of breath-dizziness. When these symptom combinations were associated with the cognition of suffocation, panic was frequently reported.
422
S. R.xHhuN
et al.
DISCUSSION Trials on which panics were reported were accompanied by many more fearful cognitions, and many more bodily symptoms, than no-panic trials. Among the panic-disorder patients, the trials on which no panic was reported were notable for the very low frequency of fearful cognitions. On 31 of the 39 no-panic trials, there was a complete absence of fearful cognitions. By contrast, 64 of the 90 of the no-panic trials reported by the claustrophobics were accompanied by at least one cognition. In both samples, the claustrophobics and the patients with panic-disorder, meaningful links between the fearful cognitions and the bodily symptoms were observed. Moreover, the links between fearful cognitions and combinations of bodily symptoms were even clearer. It is noteworthy too that the links which were observed among the panic-disorder patients differed from the links that emerged in the claustrophobic Ss. This implies that the links between cognitions and bodily symptoms are likely to be threat-relevant and also situation-relevant. Non-cognitive panics were recorded among the sample of panic-disorder patients, but were absent among the claustrophobics. It is also of interest that the non-cognitive panics were accompanied by fewer bodily symptoms than were the cognitive panics, possibly suggesting that there is some relationship between the range/intensity of bodily symptoms and the probability of a fearful cognition being recognized. It is worth pointing out that broadly speaking, fewer fearful cognitions were reported by the panic-disorder patients than might have been expected; the claustrophobic Ss reported a high frequency of fearful cognitions. The fact that panics were far more frequent (roughly four times more likely) when the bodily symptoms were accompanied by a cognition, indicates that the cognitions were contributory. In the case of claustrophobic panics, they may even be a necessary condition for the occurrence of a panic Among panic-disorder patients, the contributory quality of the cognitions was evident from the facts that panics were accompanied by a greater number of cognitions than were no panics, and that in the absence of fearful cognitions, these patients tended to report no panics. The detection of meaningful links between symptoms and cognitions in two different types of Ss, and the replication from one sample of clautrophobic Ss to another (see Rachman, 1987), provides useful support for Clark’s (1986) general argument. His posits that panics are caused by a catastrophic misinterpretation of bodily symptoms, and the present results show that links between bodily sensations and cognitions can indeed be demonstrated. They are mostly meaningful, and can be detected in the panics reported by differing samples of fearful Ss. The links detected on panic trials were seldom evident on no-panic trials. However, it is important to notice that some expected links were not detected on panic trials. There were fewer links than expected, and if confirmed, thus will constitute a problem for cognitive theories. As far as the links between the symptoms and cognitions go, almost all of them appear to be readily understandable, but they are perhaps insufIicient. Confirmation of our earlier report on the absence of ‘non-cognitive’ panics in the claustrophobic groups is welcome, but the recording of eight episodes of panic that were not accompanied by cognitions in the patients with panic-disorder, presents a second and possibly serious problem for cognitive theory. For if they are interpreted at face value, it means that we now have to contend with experimental examples of non-cognitive panics. (The possible relation of these non-cognitive panics to the nocturnal panics described by Adler, Craske and Barlow, 1987, needs to be considered.) In these instances, there was no link between the bodily sensation and a catastrophic misinterpretation. These non-cognitive panics can be regarded as unexplained exceptions to the theory, or as a signal that the theory is insticient. It is of course possible that panics that occur in experimental conditions do not resemble uncontrived panics, and in particular they do not resemble the spontaneous panics which a significant number of patients with panic-disorder report. However, as has been argued elsewhere (Rachman, 1987) it is not unreasonable to regard the experimental and uncontrived panics as having a good deal of similarity. Furthermore, the dismissal of the data on non-cognitive panics on these grounds would inevitably debase the many positive and interesting findings that have been the product of this experimental approach. Instead, the occurrence of these non-cognitive panics can be dealt with in one of two ways. It can be objected that the patients’ failure to endorse any of the cognitions on the standard list does
Panic: the links between
cognitionsand bodily symptoms-I
423
not exhaust the possibilities and that they might have had other catastrophic cognitions that did not appear on the list. This is an empirical question that can be tested by introducing an expanded list of cognitions and by making further attempts to elicit cognitions by interviewing the Ss/patients directly after each panic has occurred. (It should be pointed out, however, that after each trial, the patients were asked, in a non-systematic manner, for further information, but almost always re-asserted that they had not experienced a fearful cognition.) An empirical resolution of this problem, following the procedures outlined, would be a simple conclusion. If, however, this extension of information fails to resolve the problem the next alternative is complicated. It is possible that these non-cognitive panics are misleading and simply a product of the S’s/patient’s inability to detect the cognition and/or his inability to recall or describe it. The occurrence and importance of ‘automatic thoughts’ is a central feature of Beck’s (1987) approach to the subject of panic (and depression) and much therapeutic effort is devoted precisely to training the patients in the detection and report of these automatic thoughts. By extension, it can be argued that when patients or Ss report non-cognitive panics, they should be given specific training in detecting and reporting automatic thoughts, or those cognitions which are too fleeting for them to notice during the state of panic. This is a reasonable approach, and one that is buttressed by clinical information regarding the occurrence of automatic thoughts and their recognition and subsequent modification. It will not pass unnoticed, however, that we are approaching a slippery path, for the testability of this defense of the theory is questionable. If non-cognitive panics are to be explained by the occurrence of unnoticed, automatic thoughts, is the explanation open to disconfirmation? Can it be falsified? The reasons for the occurrence of some non-cognitive panics among panic-disorder patients and their absence in the panics of claustrophobic Ss are not known. The difference may be accounted for by the unambiguous threat in the claustrophobic setting-the cognitions were specific and restricted to a greater degree than in the settings in which the panic-disorder patients were tested. Another possibility is that the panic patients were more habituated to their bodily symptoms because they had experienced them so very often; hence, the awareness of these bodily sensations was not always intepreted as a sign of impending catastrophe. Margraf, Ankers and Blank (1986) report that patients show decreasing panic frequencies with the repetition of lactate infusions, and this may help to account for our non-cognitive panics. Non-cognitive panics present less of a problem for a conditioning theory of panic because cognitions do not feature in the theory. Panics are triggered by a CS. The patient need not be aware of the CS or its presence, and the theory does not require the operation of cognitive mediation. However, the conditioning theory is then left to contend with the non-regularity of the panics reported in this group of patients. Presumably the answer would be that the CSs vary in prominence, intensity and salience, from trial to trial. Hence, the panics vary in probability of occurrence. To conclude. most of our findings are consistent with Clark’s cognitive theory of panic, which entails a close link between bodily symptoms and cognitions. The links can be detected in many instances, and they are understandable. The problem of ‘non-cognitive panics’ remains to be resolved. Acknowledgemenrs-This
research was supported by a grant from the B.C. Health Care Foundation.
REFERENCES Adler C., Craske M. and Barlow D. (1987) Relaxation-induced panic. J. Integruriue Psych&. In press. Beck A. (1987) Cognitive approaches to panic disorder. In Punk: Psychological Perspecriues (Edited by Rachman S. and Maser J.). Erlbaum, New Jersey. Chambless D. (1985) The mobility inventory for agoraphobia. Behau. Res. Ther. U, 354% Clark D. (1986) A cognitive approach to panic. Behau. Res. Ther. 24, 461470. Ley R. (1985) Agoraphobia, the panic attack and the hyperventilation syndrome. Behuv. Res. Ther. 23, 79-81. Rachman S. (1987) Panics and their consequences: Review and prospect. In Panic: Psychological Perspectives (Edited by Rachman S. and Maser J.). Erlbaum, New Jersey. Rachman S. and Levitt K. (1985) Panics and their consequences. Behuu. Res. Ther. 23, 585-600. Rachman S. and Lopatka 6. (1$86a) Match and mismatch in the prediction of fear. Behnv. Res. Ther. 24, 387-393. Rachman S. and Lopatka C. (1986b) Match and mismatch of fear in Gray’s theory. Be&u. Res. Ther. 24, 395401. Rachman S., Lopatka C. and Levitt K. (1987a) II. Experimental analyses of panic: Panic patients. B&au. Res. Ther. Fbchman S., Levitt K. and Lopatka C. (1987b) III. Experimental analyses of panic: Claustrophobic subjects. Behuu. Res. Ther.