Relationship between panic attack symptoms and cognitions in panic disorder patients

Joumnl ofAn.+ LXsorders. Vol. 7, pp. 181-194. Printed in theUSA. All rights rc.savcd.

0%37-6185/93 $6.00 + .oO Copyright 0 1993 Pergamon Press Ltd.

1993

RESEARCH

PAPERS

Relationship Between Panic Attack Symptoms and Cognitions in Panic Disorder Patients BENGTE. WESTLING, MSC., AND LARS-GORAN &T, PH.D. Department of Psychiatry, University of Uppsala, Sweden

Abstract -The purpose of this study was to investigate the nature and relation of the distressing cognitions and symptoms experienced during panic attacks prospectively, via self-monitoring. Thirty-six patients recorded a total of 285 panic attacks over a two-week period. The results showed that nearly all (91%) of the recorded full-blown attacks (> 4 symptoms) contained catastrophic cognitions, but among limitcd-symptom attacks (2 4 symptoms) only 57% did so. Furthermore, panic attacks with catastrophical cog&ions were experienced as more severe and included more symptoms than did the non-catastrophical attacks. Finally, five panic symptoms were also meaningfully related to the bodily sensations experienced. The results largely support the cognitive theory of panic disorder. Implications of the findings for cognitive theory, for assessment of panic attacks, and for the diagnosis of panic disorder are discussed.

INTRODUCTION According

theory of panic disorder (e.g., Beck et al., 1985; in panic patients is the misinterpretation of bodily sensations as evidence of an immediately impending physical or mental catastrophe. The theory also holds that there should be a meaningful relation between the bodily symptoms and cognitions experienced during panic attacks. For example, physical symptoms like heart palpitations and chest pain should be associated with cognitions about physical catastrophes like “I’m having a heart attack/I will die,” and mental symptoms like feelings of unreality and difficulties in concentration should be associated with cognitions about mental catastrophes like “I’m losing control/I will go mad.” A Clark,

to cognitive

1986, 198S), the core disturbance

This research was supported by Grant 87/151 from the Bank of Sweden Tercentenary Foundation. Send requests for reprints to Bengt E. Westling, Department of Psychiatry, Ullertier, S-750 17 Uppsala, Sweden.

181

182

B. E. WESTLING

AND

L-G.

CjST

number of interview studies (Barlow et al., 1985; Beck et al., 1974; Hibbert, 1984; Ottaviani & Beck, 1987; Rapee, 1985; Zucker et al., 1989) and selfreport studies using symptom checklists (Pollard & Frank, 1990; Rachman et al., 1987) have shown that panic disorder patients have cognitions centered around the theme of physical and mental catastrophes, and that these cognitions appear to be meaningfully related to the bodily sensations experienced (Hibbert, 1984; Rachman et al., 1987; Pollard & Frank, 1990). However, there are findings that are inconsistent with the cognitive theory for panic disorder. Rachman et al. (1987) asked 20 DSM-III-R panic disorder patients to enter feared situations, and then afterwards at the clinic to till in check lists of cognitions and bodily symptoms that the patients had experienced during the test trial. Panic or near-panics occurred on 30 of the 69 test trials, and during eight (26.6%) of these 30 panic trials the patients did not report any catastrophic cognitions. Also, Beitman et al. (1987) reported that in 12 out of 38 cardiology patients with concomitant panic disorder, their last major panic attack was not accompanied by any fear, such as fear of dying, fear of losing control, fear of going crazy, etc. Finally, Russell et al. (1991) found that 23% of neurology patients (N = 48) with negative medical workups who were referred for psychiatric consultation met the criteria for panic disorder, but did not report anxiety or fear during panic episodes. If these findings, for which the theory has difficulty accounting, are replicated, especially with less reactive assessment methods than interviews, the conclusion will be that the theory is applicable only to a subgroup of panic patients, or a subgroup of panic attacks. Since most of the earlier studies assessed cognitions during panic attacks retrospectively, via more or less structured interviews, it is possible that the results may in part be an artifact of the assessment method. Patients trying to remember their panic attacks might be susceptible to bias caused by (a) recollection difficulties (e.g., only recalling the most severe attacks); (b) influence of the emotional state under which reporting occurs (e.g., when anxious recalling more severe attacks compared to when in a happy mood) (Dalgleish & Watts, 1990); (c) influence of the assessor; results from interviews have been shown to be influenced by such variables as age, sex, race, social class, and even religion of the interviewer (e.g., Rosenthal, 1969); (d) interviewer expectancy effects; through tone of voice, posture, facial expressions, deviations from the standard procedure in the interview, etc., the interviewer may “unwillingly” influence how the subjects answer the questions (e.g., Barber, 1976; Johnson, 1976). The purpose of the present study was to assess panic attacks in panic disorder patients prospectively (i.e., via self-monitoring of cognitions, symptoms, and panic intensity during the actual panic attacks in order to investigate if the results of previous studies hold up under more stringent assessment conditions). METHOD Subjects Thirty-six patients fullfilling the DSM-III-R criteria (American Psychiatric Association, 1987) were included

for panic disorder in the study. Their

SYMPTOMS AND COGNITIONS IN PANIC DISORDER

183

diagnoses were determined by the Anxiety Disorders Interview ScheduleRevised (DiNardo & Barlow, 1988). The ADIS-R is a structured interview schedule designed to give DSM-III-R differential diagnoses among the anxiety disorders. Twenty-eight patients were diagnosed as having panic disorder without agoraphobic avoidance and eight as having panic disorder with mild avoidance. Patients who participated in the study were consecutive individuals from a treatment study conducted at our clinic. There were 25 females and 11 males with a mean age of 32.1 years (range 23-45). Mean duration of panic disorder was 6.4 years (range l-24). Sixteen of the patients were recruited by referrals and 20 self-referred via articles in local newspapers. Procedure

After the initial diagnostic assessment the subjects were trained during a 30minute session to fill in monitoring forms about panic attacks (a so-called panic diary), yielding information about date and situation of the attacks, cognitions (thoughts, images, fantasies), DSM-III-R panic symptoms*, panic intensity (O-100), and general anxiety (o-100) during the day. The subjects were asked to carry the forms with them at all times and to record, during the course of two weeks out of a three-week pre-treatment baseline, any episode of anxiety that met the criteria for a panic attack according to the guidelines given in the interview, and in a written document attached to the monitoring forms. It was strongly emphazised that the recording, due to recollection difficulties, should be done during the actual attack or, if that was not possible, immediately following its cessation. After one week, the assessor met the subjects for other assessments (not part of this study), and on that occassion the panic diaries were reviewed and feedback was given about the way the attacks had thus far been recorded. Classification

of Data

The cognitive data were rated by an independent assessor, who was blind to any information about the panic attacks other than the cognitions, and classified into physical, mental, social, or combined catastrophes, as well as various non-catastrophical categories. Physical catastrophes most frequently contained fear of fainting, dying, being seriously ill, having a heart attack, suffocation, stroke, and being paralyzed. Among social catastrophes, most notable were fear of not being able to function in work or socially, making a fool of oneself, and failure in social situations because of the panic. Mental catastrophes most often centered around fear of losing control, going mad, and impulsive actions (e.g., hurting somebody). Finally, non-catastrophical cognitions consisted of various types of (a) generally negative/self-defeating cognitions (e.g., I will panic, I will always have these attacks); (b) positive/selfcoping cognitions (e.g., I’m going to make it, calm down - nothing will *The two cognitive symptoms (# 12 and 13 in DSM-III-R panic disorder criteria) were combined into one item “Fear of dying, going crazy or doing something uncontrolled” in the panic diary so that the cognitive emphasis should not be too strong.

184

B.E. WESTLING AND L-G. OST

happen); and (c) neutral/irrelevant cognitions (e.g., what are we going to have for dinner today). Interrater agreement assessment was carried out for the cognitive data by having a second assessor independently rate 25% of the panic attacks. This yielded 94% agreement for physical, 82% for social, 88% for mental, 72% for combined, and 87% for non-catastrophical categories, with an average of 86.4%. The other data (symptoms, number of symptoms, panic intensity, and general anxiety) were entered into the computer by another assessor, who was blind regarding information about the cognitive data. Statistical Methods Non-parametric tests (Chi-square and Fisher’s exact test) were used for nominal level data and Spearmans coefficient of rank correlation for ordinal data. One-way analysis of variance (and post hoc analysis with Scheffe’s paired comparisons) was calculated for interval level measures. Finally, independent group t-tests were used for comparing means between two samples. To assess if any training effects, etc., influenced the way attacks were recorded, an analysis was done comparing percentage of catastrophical vs. noncatastrophical cognitions during week one and two. Because this analysis yielded identical results between the two weeks, we have omitted it. All statistical tests were two-tailed and performed using the statistical package CRISP (CRunch Interactive Statistical Package), version 3.07, supplied by CRUNCH Software Corporation, 1986. RESULTS Type of Cognitions The 36 subjects recorded a total of 285 panic attacks over the two weeks, and each patient recorded an average of 7.9 panic attacks (range 2-19). The

TABLE 1 NUMBEROF ATIACKS, IN~XNS~TY (SCALE O-100), AND NUMBEROF SYM~OMS FORTHE DIFFERENTCATEGORIESOF CATASTROPHICAL GXN~TIONS Intensity %

Mean

SD

139

49

60.83

20.46

5.15

1.97

20

I

52.75

16.90

4.85

2.43

Category

n

Physical Social

# of Symptoms Mean

SD

Mental

25

9

58.00

22.81

5.04

2.23

Combined

43

15

64.77

19.02

4.98

2.17

Non-cata-

58

20

41.90

16.98

3.62

2.16

285

100 56.75

21.03

4.78

2.16

strophical Total Mean

185

SYMPTOMS AND COGNITIONS IN PANIC DISORDER

distribution of these attacks across the various types of cognition categories is presented in Table 1. Chi-square yielded significant differences in the number of attacks that each category contained [X2(4, N = 285) = 66.54, p < .OOOl)]. Global assessment of differences among the five categories regarding the intensity, number of symptoms, and general anxiety were conducted using one-way ANOVAs. There was a significant group effect for intensity (F(4, 280) = 11.88, p c .OOOl) and Scheffe’s paired comparison post hoc test showed that non-catastrophical attacks were less intense than attacks containing physical (p < .OOOl), mental (p < .05), and combined catastrophes (p < .OOOl). The number of symptoms also differed significantly between the groups (F(4, 280) = 5.73, p < .OOOS),and subsequent post hoc testing showed that non-catastrophical attacks contained less symptoms than physical (p < .0005) and combined (p < .05). The general anxiety level did not show any significant differences among the categories. Distribution

of Patients Across Cognitive Categories

Table 2 presents the number and percentage of patients having all their attacks classified into (a) the same category; (b) two different categories; or (c) three or more different categories. Overall assessment of differences in number of panic attacks among the three groups was performed using oneway ANOVA. A significant group effect (F(2, 33) = 12.29, p < .OOOl) followed by post hoc test showed that patients having their panic attacks classified into three or more of the cognitive categories had significantly more panic

TABLE 2 NUMBER AND PERCENTAGE OF PATIENB HAVING ALL THEIRPANIC ATTACKSCLASSIFIEDINTO(1) THE SAME CATEGORY;(2) INTOTwo DIFFFXENTCATEGORIES; OR (3) IN-IQTHREEOR MORE OFIHE DIFFERENTCATEGORIES. NUMLIF.R AND PEWENIAGE

OF PANICATACKS FORWE

THREEDIFFEREW GROUPSOF PATIENTSARE ALSO SHOWN Patients n

Panic Attacks %

n

%

1. Physical

6

17

30

10

2. Social

0

0

0

0

3. Mental

1

3

5

2

4. Combined

1

3

2

1

5. Non-catastrophical

0

0

0

0

8

23

37

13

2 categories

15

41

92

32

2 3 categories

13

36

156

55

Total

36

100

285

100

Total (1 category)

186

B.E. WESTLING AND L-G. OST TABLE 3 THEMEAN INTENSITY (SCALEO-100). NUMBER OF SYMFTUMS,ANDCOGNITIVECONENTFORFULL-BLOWN (2FOUR SYMPTOMS) AND LIME SYM~OMATTACKS (< FOURSYhWl’OMS) Ty~x of Attacks Full-blown SD

Mean

SD

1.81 19.31 22.46

2.58 43.28 45.00

0.60 17.87 19.62

MtXUl # of symptoms Intensity General anxiety

5.58 63.28 51.97

Limited

attacks than patients having their attacks (p < .OOl> or two categories (p < .OOl). Full-blown

classified

into one category

vs. Limited Attacks

Table 3 presents the mean intensity, percentage of symptoms, and cognitive content for full-blown (2 four symptoms) and limited (< four symptoms) attacks, respectively. An independent t-test showed that the full-blown attacks were significantly more intense (t(283) = -8.40), p < .OOOl) than the limited symptom attacks. Chi-square showed significant differences (see Table 4) among the five cognition categories (X*(4, N = 285) = 47.66, p < .OOOl), and attacks classified as containing catastrophical cognitions were significantly more common in fullblown than in limited attacks (X*( 1, N = 285) = 41.68, p < .OOOl). TABLE 4 FULL-BLOWN AND LIMITEZD SYMFCOMAITACKSFORTHE DI~RENT CATEGORIESOFCOGN~ONS Limited

Full-blown Cognitive Category

n

%

n

%

Physical Social Mental Combined

110 12 21 31

58 6 11 16

29 8 4 12

31 9 4 13

All catastrophical Non-catastrophical

174 18

53 40

57 43

Total

192

91 9 _ 100 _

93

100

187

SYMP'TOMSANDCOGNITIONSINPANICDISORDER TABLE 5 PFXCENTAGEOFFULL-BLOWNANDLIM~~ED A?TACKSCONTAININGTHE DIFI=IXENTDSM-III-R SYMIWMSUSING (I)?HET~TALSAMFJLEOFFULLBLOWN@= ~~~)ANDLIM~~EDPANICAT~ACKS(N= 93); OR (~)ONLYONE AVERAGESYMFT~MPATIXRNFOREACHPATIENT'SFULL-BLOWN(N= ~~)AND LIMITED(N=26) PANICA~ACKSIN?HEANALYSIS Percentage of Different Symptoms Total Sample Symptom Dyspnea Dizziness Palpitations Trembling Sweating Choking Nausea Derealization Numbness Flushes Chest pain Fear of dying

Average Symptom Pattern

Full-blown

Limited

Full-blown

Limited

41.7 71.9 71.4 50.5 51.6 34.4 42.7 58.9 34.9 22.9 34.4 68.8

15.1 32.3 45.2 12.9 26.9 16.1 23.7 25.8 10.8 3.2 19.4 26.9

50.0 67.7 73.5 47.1 44.1 29.4 35.3 55.9 29.4 26.5 29.4 73.5

15.4 38.5 57.7 23.1 19.2 19.2 7.7 23.1 7.7 0.0 26.9 30.8

Symptom Patterns

The percentage of full-blown and limited attacks containing the different DSM-III-R symptoms are shown in Table 5. In order to use as much information as possible, all the analyses in the study were performed using the total sample of panic attacks (n = 285), although patients are represented in the data with different numbers of panic attacks. In order to assess to what extent the unequal number of panic attacks between patients influenced the results, we also did an additional analysis where only one “average symptom pattern” for each patient was taken into account. The average symptom pattern was computed for each patient by calculating the mean number of symptoms for that patient’s panic attacks, and assigning the patient’s average symptom pattern his or her most common symptoms, up to the mean number of symptoms. The symptoms that showed the largest differences between the total sample and the average symptom pattern was dyspnea for full-blown attacks, with an 8.3 percentage points difference, and nausea for limited symptom attacks with a 16.0 percentage points difference. The smallest differences can, for the fullblown attacks, be seen for the symptom derealization (2.6 percentage points), and for the limited attacks for dyspnea (0.3 percentage points). Spearmans coefficient of rank correlation between the total sample and the average symptom pattern was 0.92 (p < .OOl) for the full-blown attacks, and 0.78 (p < .Ol) for the limited attacks.

188

B.E.

WESTLING

ANDL.-G. t%.T

Non-catastrophfcal

attacks

PANICATACKS.

Links Between Cognitions and Symptoms The percentages of attacks having each of the DSM-III-R panic symptoms are shown in Fig. 1 for the different categories of catastrophical cognitions. To assess whether the symptoms were differentially associated with the cognition categories, chi-square (and Fischer) tests were performed, and yielded significant differences among the categories for five of the symptoms (Fig. 2). Dyspnea was more often reported in the category of physical catastrophes compared to social (X2 = 5.97, p < .05), combined (X2 = 11.01, p < .OOl), and non-catastrophical categories (X2 = 8.63, p < .Ol). Dizziness figured more often in the social (X2 = 4.85, p < .05) and combined (X2 = 4.94, p < .05) categories than in the non-catastrophical category. Feelings of unreality/derealization were more prevalent in mental catastrophes than in all other categories

ra-

0

0

N

IO

10 -

C

20

20-

S

30

50

30-

Y

ttt

r

40

t

60

70

60

80

loo

40 -

P

1

Dyspnea

P S

Y

Chiiess

C N

o-

10 -

20-

30 -

40 -

50 -

60 -

70 -

P

1

;t

1

-

60 -

90 -

100

S

t-7

C

N

I ttt

ttt

=SOCIAL,M=

Y

Derealization

M

C

N

P

S

ttt --

U

Fear of d@g_

C

P-C

N

tti

.05,**=PC .Ol,***= PC .OOl).

MENTAL,C=COMBINED,N=NON-CATASTROPHICAL)1NWHlCHTHESYMP-

0 S

40 0b

20

30

40

50

10

P

t

60

70

60

so

100

10

20

30

50

60

70

60

90

100

TOMWASPREVALENT.CA~GORIESCONNECIEDW~~ALINEANDONEORMORESTARSDI~SIGNIL~CANILYFROMEACHOTHER(*=

Frc.2. ~OWRTIONSOF~ED~ENTCATEGORIESOFPANICATTACKS(P=PHYSICAL,S

a

b

:~.-*

C

I

10 -

60

90

100

190

B. E. WESTLING AN0L-G. OST

(Physical: X2 = 6.80, p < .Ol; Social: X2 = 4.59, p < .05; non-catastrophical: X2 = 12.53, p < .OOl), except for combined. Furthermore, feelings of unreality were more prevalent in combined compared to the physical (X2 = 5.57, p < .05> and non-catastrophical (X2 = 11.37, p < .OOl) categories. Nausea figured more often in combined catastrophes than in physical (X2 = 3.86, p < .05). Finally, fear of dying, going crazy, or doing something uncontrolled during an attack figured more often in (a) combined compared to social (X2 = 11.79, p c .OOl) and non-catastrophical categories (X2 = 19.88, p < .OOl); (b) mental compared to social (X2 = 8.03, p < .Ol) and non-catastrophical categories (X2 = 12.47, p c .Ol); and (c) physical compared to non-catastrophical (X2 = 17.92, p < .OOl) and social (X2 = 8.26, p < .Ol) categories.

DISCUSSION The results of this self-monitoring study are in line with the findings of previous interview studies (e.g., Beck et al., 1974; Hibbert 1984; Rapee, 1985; Barlow et al., 1985, Ottaviani & Beck, 1987; Zucker et al., 1989), and selfreport studies using symptom checklist (e.g., Rachman et al., 1987; Pollard & Frank, 1990), and they mostly support the cognitive theory of panic (Clark, 1986, 1988). It is again demonstrated, but with a different assessment method, that cognitions experienced during panic attacks have a characteristic cognitive element. Moreover, the significant associations between symptoms and cognitions are mostly meaningful, and suggest that the cognitions appear to be catastrophic misinterpretations of bodily sensations. For example, it is understandable that patients experiencing dyspnea during a panic attack more often have cognitions about physical catastrophes (e.g., I will suffocate) than about social catastrophes like “I will make a fool of myself.” Some expected associations between symptoms and cognitions that were not found (e.g., between palpitations and physical catastrophes like “I’m having a heart attack”) can be explained by the fact that certain symptoms (e.g., palpitations and dizziness) were fairly common across all panic attacks. It is therefore hard to find any differential associations between those nearly “obligatory” symptoms and cognitions. For other symptoms, those not so common and where an association with a cognition should have been expected (e.g., chest pain-physical catastrophes), there was a trend in the results towards a meaningful association. The finding that attacks containing catastrophical cognitions generally were significantly more intense and included more symptoms than attacks containing non-catastrophical cognitions, are in line with the results of Rachman et al. (1987), and further indicates the contributory role of catastrophical cognitions in panic attacks. However, the obtained relationship between cognitions and bodily sensations/anxiety level does not tell us anything about the sequence of events in panic attacks. It is impossible from this body of data to decide whether the cognitions led to more symptoms and higher anxiety level, or whether the symptoms and the higher anxiety level led to catastrophical cognitions. To answer this questions the sequence of events in panic attacks must be studied in more detail (e.g., by letting the patient wear a portable tape recorder (Walkman), and directly describe the symptoms and cognitions experienced during a panic attack).

SYMPTOMS AND COGNITIONS IN PANIC DISORDER

191

However, there are also findings in the study that are inconsistent with the cognitive theory. The theory says that panic attacks will occur if, and only if, the sensations are perceived and misinterpreted. In the present study all patients (100%) reported at least one panic attack that was associated with catastrophic cognitions, but not all panic attacks were accompanied by catastrophic misinterpretations of bodily sensations. In 58 (20%) of the 285 panic attacks the patients did not report any catastrophic cognitions. This percentage of non-catastrophical panic attacks is rather similar to the findings in other studies investigating this phenomenon and described in the introduction (Rachman et al., 1987; Beitman et al., 1987; Russell et al., 1991). The relatively high percentage of non-catastrophic attacks in different studies has several possible explanations which are not mutually exclusive. 1. Patients might have a lot of reasons for not reporting (or omitting) certain misinterpretations from the panic diary. For example, shame, fear, pride, believed secondary gains of denying “psychological symptoms” (cognitions), etc., might bias the reporting. 2. Cognitive theory has mainly focussed on conscious cognitive events. However, according to certain theorists it is possible that cognitive processes are in a way “nonconscious” (Lang, 1988). For example, it is suggested (Clark, 1989) that the catastrophic misinterpretations might on ocassion be so habitual, plausible, brief, and fast that patients fail to recognize or remember them. In other instances, the thought content might be so bizzare and frightening that the patients, through various forms of covert or overt avoidance (e.g., distraction, leaving the situation), fail to recognize the anxiety-provoking cognitions. However, if the existense of non-catastrophic panic attacks are to be explained by “nonconscious events” one wonders whether the theory can be falsified. For example, self monitoring as in this study is insufficient as a measure of cognitive events during panic episodes if misinterpretations can be either conscious or unconscious. If misinterpretations are not found with selfreports, it can simply be argued that the patient catastrophized unconsciously. To allow testability of the catastrophic misinterpretation hypothesis, it is therefore necessary to develop measures of catastrophic misinterpretations that do not rely exclusively on self reports. 3. A final explanation is that misinterpretations are not always necessary to produce panic attacks in panic disorder patients. If so, the conclusion will be that the theory is unable to serve as a comprehensive theory for panic disorder, although it will explain a majority of panic attacks. Perhaps a wider scope, a theory incorporating both conditioning and cognitive processes, is neccesary to understand the complexity of panic disorder. Non-catastrophical attacks, for example, are less problematic for conditioning theory. According to the principles of classical (Pavlovian) conditioning, the mere perception of the bodily sensations (conditioned stimulus) is enough to produce the panic attack (conditioned response). In order to rule out this possibility, cognitive researchers will have to show that panic attacks occur only when the sensations are perceived and misinterpreted. However, regardless of whether cognitive theory can explain all panic attacks, the finding in the present study that among full-blown attacks nearly all (91%) contained catastrophic misinterpretations, and among limited-symp-

192

B. E. WESTLING AND L.-G. OST

tom attacks only 57%, indicates that misinterpretation is a necessary condition for more intense panic attacks (full-blown), and can be seen as a secondary “cognitive reaction” to limited symptom attacks, which might have various causes, of which conditioning and cognitive mechanism are two. This view is also in line with our clinical experience after working with cognitive-behavioral treatments for panic disorder patients. As therapy progresses and patients are more skilled in detecting and reporting cognitions, and when a good trusting therapeutic relationship has been established, it is very unusual that the patients report non-catastrophical full-blown panic attacks. In other words, it is possible that the 9% of full-blown non-catastrophical panic attacks in the present study reflects the patients’ inability or “unwillingness” to detect/report certain misinterpretations. One methodological problem with this study is the variance in the number of attacks (range 2-19) that the patients recorded during the two weeks of registration. An alternative method would have been to collect the data during a longer time period and, for example, only analyze the 10 first recorded panic attacks for each patient. However, such a procedure, with a much longer time period before offering therapy, presents obvious ethical dilemmas. To go on with the recording during treatment is not an alternative either, because the therapy will obviously influence the way the attacks are perceived and recorded. However, the analyses done in this study, to assess how much the results may be influenced by the different number of panic attacks the patients presented with (Table 2), generally showed identical results between the mean percentage of different symptoms for all the registered attacks and a so-called “average attack” for each patient. Spearmans coefficient of rank correlation between the two symptom pictures was also high. Furthermore, the analysis showed (Table 2) that patients having their panic attacks classified into three or more of the cognitive categories had significantly more panic attacks than patients having their attacks classified into one or two categories. In other words, the panic attacks for each patient were generally not accompanied with the same cognitions over all attacks. Taken together, these two analyses show that, despite the variance in number of panic attacks that the patients presented with, it is not likely that any single patient influenced the results unduely by having a lot of panic attacks with the same symptom or cognition picture. Other studies that also have used self-monitoring for studying features of panic attacks (e.g., Margraf et al., 1987; Rapee et al., 1990) have accepted that patients contributed unequal numbers of panic attacks. The conclusion that can be drawn is that the cognitions of panic disorder patients during panic attacks mainly center around immediately impending physical and mental catastrophes, and to a lesser extent social catastrophes. These cognitions also appear to be meaningfully related to the bodily sensations experienced during the attacks. One important implication that these findings should lead to is to include the typical cognitive elements of panic disorder (fear of immediately impending physical or mental catastrophes) in future diagnostic criteria. Such a change would place the criteria for panic disorder more in line with the criteria for other anxiety disorders where the specific fear (thought content) is part of the diagnoses. For example, in social phobia “... fears that he or she may do something or act in a way that will be

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humiliating” (APA, 1987, p. 241), or in generalized anxiety disorder “worry ... about two or more life circumstances” (APA, 1987, p. 251). At present, DSMIII-R technically even allows the diagnosis of panic disorder to individuals without fear, as long as they have at least four out of 13 symptoms (11 somatic and 2 psychological symptoms).

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