G. Ron Norton

Beyond pain: The role of fear and avoidance in chronicity

The purpose of the present article is to provide unification to a number of somewhat disparate themes in the chronic pain and phobia literature. First, we present a summary review of the early writings and current theoretical perspectives regarding the role of avoidance in the maintenance of chronic pain. Second, we present an integrative review of recent empirical investigations of fear and avoidance in patients with chronic musculoskeletal pain, relating the findings to existing cognitive-behavioral theoretical positions. We also discuss several new and emerging lines of investigation, specifically related to information processing and anxiety sensitivity, which appear to be closely linked to pain-related avoidance behavior. Finally, we discuss the implications of the recent empirical findings for the assessment and treatment of individuals who experience disabling chronic musculoskeletal pain and suggest possible avenues for future investigation.

Factors associated with panic attacks in nonclinical subjects

The purpose of this study was to (a) compare people who experienced recent panic attacks (panickers) with nonpanickers and (b) determine, the factors associated with panic attacks in nonclinical subjects. Two hundred and fifty-six students completed the Panic Attack Questionnaire (PAQ), the State-Trait Anxiety Inventory (STAI), the Beck Depression, Inventory (BDI), the Profile of Mood States (POMS), and two measures of fear/avoidance. Over 22% of the subjects reported one or more panic attacks in the 3 weeks, prior to testing. Comparisons of panickers and nonpanickers showed that panickers (a) scored higher on measures of anxiety, depression, etc., and (b) reported more first-order relatives who have panic attacks. The panic attacks were characterized by (a) having a sudden onset, (b) an average of eight DSM-III symptoms, and (c) occurring in a wide variety of situations (especially social situations). Subjects who experienced unpredictable panic attacks differed, on several measures from subjects with only predictable attacks. Finally, panickers reported experiencing several symptoms not included in DSM-III. Similarities, between panickers and patients with Panic Disorder and Agoraphobia and the assessment of panic-related, disorders are discussed.

Multiple Personality Disorder: An Analysis of 236 Cases:

The authors collected a series of 236 cases of multiple personality (MPD) reported to them by 203 psychiatrists, clinical psychologists and other health care professionals. MPD patients experienced extensive sexual (79.2%) and physical (74.9%) abuse as children. They had been in the health care system for an average of 6.7 years before being diagnosed with MPD and had an average of 15.7 personalities at the time of reporting. The most common alter personalities were a child personality (86.0%), a personality of a different age (84.5%), a protector personality (84.0%), and a persecutor personality (84.0%). Patients MPD are highly suicidal with 72% attempting suicide and 2.1% being successful. The patients frequently received diagnoses for other mental disorders. The most common previous diagnoses were for affective disorders (63.7%), personality disorders (57.4%), anxiety disorders (44.3%), and schizophrenia (40.8%).

Posttraumatic Stress Disorder and Work-Related Injury

The literature indicates a substantial overlap between chronic pain and posttraumatic stress disorder (PTSD) symptoms in individuals who sustain accidental injury. To date, however, there have been no studies of PTSD symptoms in individuals who experience work-related injury. Consequently, we assessed 139 consecutive injured workers using the Modified PTSD Symptom Scale (Falsetti, Resnick, & Kirkpatrick, 1993), as well as a number of general measures of psychopathology. Most participants reported chronic pain and all were receiving workers compensation. Results indicated that 34.7% and 18.2% of the sample reported symptoms consistent with PTSD and partial PTSD, respectively. When PTSD symptom frequency and severity were considered criterion variables in multiple regression analyses, depression was found to be significantly associated with the former and anxiety sensitivity, social fears, and somatic focus with the later. Finally, these measures of general psychopathology correctly classified 78.6% of individuals with PTSD and 81.3% of those with no PTSD. These results suggest that a considerable proportion of injured workers display symptoms consistent with PTSD and that these symptoms are related to general negative affect. Implications, including the suggestion of clinical intake screening of PTSD in this population, are discussed.

Anxiety sensitivity in patients with physically unexplained chronic back pain: A preliminary report

It has been proposed that high anxiety sensitivity amplifies a number of fears and anxiety reactions. The purpose of this study was to examine whether anxiety sensitivity influences pain-related anxiety and associated cognitive and affective reactions in patients with physically unexplained chronic back pain. Seventy patients with chronic back pain without demonstrable organic pathology completed a battery of questionnaires prior to admission to a multidisciplinary treatment centre. Fourteen patients (20.0%) were classified as high, 44 (62.9%) as medium and 12 (17.1%) as low anxiety sensitive. Multivariate analysis of variance indicated that the high anxiety sensitive patients were more negatively affected by their experience with pain. Specifically, high anxiety sensitivity patients exhibited greater cognitive disruption and anxiety in response to pain, greater fear of negative consequences of pain, and greater negativity of affect than the other groups. Groups did not differ in the intensity of pain that they were experiencing. The proportion of high anxiety sensitive patients reporting current use of analgesic medication was, however, significantly greater than the medium and low anxiety sensitive patients. Correlational analyses indicated significant associations between anxiety sensitivity and pain-related cognitive/affective variables that were independent of pain severity. These results suggest that chronic back pain patients with high anxiety sensitivity, despite equal levels of pain severity, are more likely to be negatively affected by their pain experiences than those with medium and low anxiety sensitivity.

The Beck Anxiety Inventory: A psychometric analysis.

This study sought to provide information on the Beck Anxiety Inventory (BAI) with respect to psychometric properties, gender differences, and relation to depression. A sample of 291 psychiatric patients completed the BAI, and a subsample of 251 completed the Beck Depression Inventory (BDI). The results from factor analyses demonstrated that the BAI has 2 factors, corresponding to cognitive and somatic symptoms. Although men and women did not differ in terms of factor structures, they did differ on mean levels of cognitive and somatic symptom scores and on total BAI scores. Finally, the authors found that BAI items were distinguishable from BDI items, suggesting that the symptoms measured in the two scales are not entirely overlapping

Fear and avoidance in dysfunctional chronic back pain patients

Abstract Two studies that assess fear and avoidance in patients with chronic pain are presented. In the first study, 200 patients with chronic back pain were classified, using the Multidimensional Pain Inventory (Kerns et al., 1985) clustering procedure, as dysfunctional (n=53), interpersonally distressed (n=37), and adaptive copers (n=62). Groups were compared on common measures of anxiety, fear and avoidance. Multivariate analysis of variance indicated that the groups differed significantly across measures. Univariate follow‐up revealed that there were no differences between groups on agoraphobic, blood/injury, social fears, or anxiety sensitivity; however, patients classified as dysfunctional reported more pain‐specific fear and avoidance than did those classified as interpersonally distressed or adaptive copers. In the second study, pain‐specific fear and avoidance measures were used in a discriminant function analysis to predict the MPI classification of an independent sample of 55 patients with chronic pain. The measures correctly classified 76.5% of the dysfunctional group and 71.1% of a composite group of interpersonally distressed and adaptive copers. The implications of these findings are discussed.

Hierarchical Model of Generalized and Specific Vulnerabilities in Anxiety

This study evaluated a theoretical hierarchical relationship among the general anxiety vulnerability variable of neuroticism, the specific vulnerability variables of anxiety sensitivity and intolerance of uncertainty, and variables reflecting specific anxiety foci including panic symptoms, health anxiety, obsessive-compulsive symptoms and generalized anxiety/worry. Questionnaires assessing these variables were administered to a non-clinical sample of 91 first-year psychology students (64.8% women). Path analysis results were highly consistent with the hypothesized hierarchical model. Neuroticism was found to have a significant direct effect on both anxiety sensitivity and intolerance of uncertainty. Both neuroticism and anxiety sensitivity had direct significant effects on panic symptoms, neuroticism and intolerance of uncertainty both made significant direct contributions to the prediction of worry, and neuroticism made a significant direct contribution to the prediction of obsessive-compulsive symptoms. Contrary to the hypothesized model, anxiety sensitivity but not neuroticism uniquely predicted health anxiety. The results of this study provide initial empirical evidence for a hierarchical relationship among general and specific vulnerabilities, and specific anxiety manifestations.

Substance abuse and panic-related anxiety: A critical review

The relationship between substance abuse and panic-related anxiety can be divided into two broad areas: the incidence of anxiety disorders in substance abuse patients and the incidence of substance abuse in patients with panic-related anxiety disorders. Studies indicate that approx. 10-40% of alcoholics have a panic-related anxiety disorder, and about 10-20% of anxiety disorder patients abuse alcohol or other drugs. The majority of patients with both an anxiety and alcohol disorder report that anxiety problems preceded alcohol problems. In some cases substance abuse (e.g. cocaine) triggers the onset of panic attacks. Most patients believe that self-medication is efficacious despite the fact that they appear to have a more serious clinical condition (e.g. higher rates of depression). Directions for future research are outlined, including the proposal for a study to examine the effects of an anxiety intervention procedure for anxious alcoholics to reduce relapse rates.

Hierarchical Model of Vulnerabilities for Anxiety: Replication and Extension with a Clinical Sample

This study served to replicate and extend our previously obtained hierarchical model of the relationships among general anxiety vulnerabilities, specific anxiety vulnerabilities and specific anxiety manifestations including panic symptoms, health anxiety, obsessive‐compulsive symptoms and worry. Questionnaires assessing these variables, as well as positive affectivity and depressiveness, were administered to 125 outpatients seeking treatment for panic disorder, social anxiety disorder, obsessive‐compulsive disorder, generalized anxiety disorder or major depressive disorder. The results, using a clinical sample, were highly consistent with the hierarchical model obtained in the previous study using a student sample. A more elaborate model, based on published theoretical and empirical evidence, was identified and tested, and similar results were obtained. Negative affectivity had expected direct positive effects on all of the specific anxiety and depression manifestations, with the exception of health anxiety, which showed a negative relationship, and OCD symptoms, which showed no relationship. Positive affectivity was found to be a specific risk factor for depression, while intolerance of uncertainty was found to be a specific risk factor for worry and depression. Finally, anxiety sensitivity appears to be a significant risk factor for panic and health anxiety.