Kenneth Abrams

Anxiety mediates the association between anxiety sensitivity and coping-related drinking motives in alcoholism treatment patients

Anxiety sensitivity (AS), the tendency to interpret feelings of anxiety as dangerous, is a core dispositional trait in a well articulated and extensively studied cognitive model of proneness to anxiety disorder. In recent years, there has been an increasing body of findings that also links AS to the tendency to use alcohol in general and the tendency to use alcohol as a means of coping with negative affect in particular. We expand on this empirical base by proposing and testing a theoretical model in which anxiety symptoms mediate the association between AS and alcohol use. That is, we propose that AS promotes anxiety symptoms, which, in turn, promote alcohol use aimed at coping with anxiety and other negative affect states. Over a 1-year data collection period, we assessed 82 alcohol-dependent individuals shortly after they began an intensive alcoholism treatment program. Self-reported anxiety symptoms associated with distinct anxiety syndromes were obtained with reference to the month period preceding their entry into the treatment program. Other information, including the presence of withdrawal symptoms, was obtained via interview. We found that syndrome-related anxiety symptoms and Trait Anxiety, but not State Anxiety or withdrawal symptoms, mediated the significant association between AS and the self-reported tendency to use alcohol as a means of controlling anxiety symptoms. Demonstrating a similar pattern of findings, but much less robustly so, were tests of these mediator models using alcohol use aimed at coping with negative affect (vs. coping with anxiety per se) as an outcome. In discussing these findings, we attempt to further develop a coherent model that incorporates AS, anxiety symptoms, and drinking motives. Our findings suggest that these relationships may differ for negative affect not specifically related to anxiety. We also discuss the possible associations of AS to withdrawal symptoms implied by our findings.

Self-administration of alcohol before and after a public speaking challenge by individuals with social phobia.

: K. Abrams, M. Kushner, K. Medina, and A. Voight (2001) showed that alcohol attenuates social anxiety symptoms in socially phobic individuals. This article examines whether social anxiety symptoms can lead to increased alcohol use in this same population. Forty-four individuals with social phobia attended 2 laboratory sessions, spaced 1 week apart, in groups of approximately 10. Participants underwent a social anxiety challenge during 1 session and a control task during the other. Half of the sample self-administered alcohol immediately before, and half immediately after, these 2 activities. As predicted, participants consumed more alcohol following the anxiety challenge than following the control task; however, the opposite pattern was evidenced for drinking preceding [corrected] the 2 activities. These findings add to an understanding of why social phobia and alcohol problems tend to co-occur.

Cigarette Smoking and Panic: A Critical Review of the Literature

OBJECTIVE Cigarette smoking increases the risk of panic disorder with or without agoraphobias emerging. Although the cause of this comorbidity remains controversial, the main explanations are that (1) cigarette smoking promotes panic by inducing respiratory abnormalities/lung disease or by increasing potentially fear-producing bodily sensations, (2) nicotine produces physiologic effects characteristic of panic by releasing norepinephrine, (3) panic disorder promotes cigarette smoking as self-medication, and (4) a shared vulnerability promotes both conditions. The aim of this review was to survey the literature in order to determine the validity of these explanatory models. DATA SOURCES Studies were identified by searching English language articles published from 1960 to November 27, 2008, in MEDLINE using the key words: nicotine AND panic, tobacco AND panic, and smoking AND panic. STUDY SELECTION Twenty-four studies were reviewed and selected according to the following criteria: panic disorder with or without agoraphobia and nicotine dependence, when used, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Fourth Edition, or Fourth Edition, Text Revision; no additional comorbidity or, if present, adjustment for it in the statistical analyses; use of adult or adolescent samples; comparison with a nonclinical control group or application of a crossover design. DATA EXTRACTION Non-significant results or trends only were reported as no difference. Data on anxiety disorders or substance abuse in general were not included. DATA SYNTHESIS Panic and cigarette smoking each appear to have the capacity to serve as a causal factor/facilitator in the development of the other. Although the temporal pattern and the pathogenetic explanations of such a co-occurrence are still being discussed, cigarette smoking tends to precede the onset of panic and to promote panic itself. CONCLUSIONS Additional studies are strongly recommended.

Linkages between cigarette smoking outcome expectancies and negative emotional vulnerability

The present investigation examined whether smoking outcome expectancies, as measured by the Smoking Consequences Questionnaire (SCQ; [Brandon, T.H., & Baker, T.B., (1991). The Smoking Consequences Questionnaire: The subjective expected utility of smoking in college students. Psychological Assessment, 3, 484-491.]), were incrementally related to emotional vulnerability factors among an adult sample of 202 daily cigarette smokers (44.6% women; M(age)=23.78 years, SD=9.69 years). After controlling for cigarettes smoked/day, past 30-day marijuana use, current alcohol consumption, and coping style, negative reinforcement/negative affect reduction outcome expectancies were significantly associated with greater levels of negative affectivity, emotional dysregulation, and anxiety sensitivity. The observed effects for negative reinforcement/negative affect reduction also were independent of shared variance with other outcome expectancies. Negative personal consequences outcome expectancies were significantly and incrementally related to anxiety sensitivity, but not negative affectivity or emotional dysregulation. Findings are discussed in terms of the role of negative reinforcement/negative affect reduction smoking outcome expectancies and clinically-relevant negative emotional vulnerability for better understanding cigarette smoking-negative mood problems.

Fear reactivity to bodily sensations among heavy smokers and nonsmokers.

Individuals who smoke are more likely to experience panic attacks and develop panic disorder than those in the general population. One possible explanation is that smokers may experience a heightened fear response to somatic disturbances. To date, few laboratory studies have tested this hypothesis directly. The present study examined 24 adult heavy smokers (10 females) in 12-hr nicotine withdrawal and 24 adult nonsmokers (12 females) on subjective and physiological reactivity to a 4-min carbon dioxide rebreathing challenge. Results indicate that, despite an attenuated acceleration in respiration during the challenge, smokers experienced a significantly greater increase in self-reported panic symptoms than nonsmokers. In addition, smokers reported significantly greater trait levels of suffocation fear prior to the challenge. Findings are discussed with respect to the role of smoking in panic vulnerability.

Effect of nicotine on 35% CO2-induced anxiety: A study in healthy volunteers.

Panic disorder and cigarette smoking co-occur at a rate that exceeds what would be expected by chance. Theoretically, cigarette smoking may (a) attenuate panicky symptoms via cognitive factors or pharmacological action, (b) contribute to the development of panic disorder, or (c) share an etiological vulnerability with panic. The present study was aimed at testing whether nicotine has a direct influence on laboratory-elicited panic. In a placebo-controlled, double-blind, randomized, cross-over study, 33 healthy nonsmokers underwent a 35% CO2 challenge after transdermal administration of a nicotine patch on one test day and a placebo patch on another test day. Physiological measures (blood pressure, heart rate) and rating scale scores (Panic Symptom List [PSL], Visual Analog Scale of Anxiety, State-Trait Anxiety Inventory) were assessed. Compared with the placebo condition, nicotine increased diastolic blood pressure (p < .1), heart rate (p < .001), and PSL scores (p < .005) prior to the CO2 challenge but did not affect responding to the CO2 challenge itself. Results are consistent with the notion that nicotine promotes autonomic activation. However, the present study did not provide direct evidence that nicotine elicits panic in healthy volunteers. Replication in a clinical sample is warranted.

Biological challenge procedures used to study co-occurring nicotine dependence and panic disorder

A wide array of biological challenge procedures - including carbon dioxide inhalation, hyperventilation, and breath holding - have been used to model panic in laboratory settings. Originally used to study developmental processes in panic disorder (PD), these procedures, along with nicotine patch administration and self-administered smoking, have recently been applied to help understand the etiology of co-occurring nicotine dependence and PD. The goals of the present paper are to review studies that have employed biological challenges to study the comorbid condition, identify the advantages and limitations of the various procedures, describe desirable outcome measures for use in biological challenges, and present recommendations for future challenge studies in this field. We argue that biological challenges, though in need of standardization, are useful for studying the development, maintenance, prevention, and treatment of comorbid nicotine dependence and PD.

Effects of alcohol on anxiety-relevant cognitions in individuals with social phobia

There is substantial evidence that alcohol can attenuate anxiety responding under some circumstances; however, the mechanisms supporting this effect remain a matter of speculation. One possibility involves the effect of alcohol on the salience of cognitions that either promote or inhibit anxiety in response to anxiety-related cues. We tested this view from a phenomenological perspective by asking individuals with social phobia to record up to 6 thoughts they experienced during 2 public speaking challenges, 1 before and 1 after consuming either an alcoholic, placebo or control beverage. After assigning the thoughts listed by participants to rationally based categories, we found that the pharmacological and expectancy effects of alcohol, in combination, were associated with an increase in positive thoughts and a decrease in negative thoughts experienced while speaking. Subsequent analyses showed that the impact of alcohol on subjective anxiety was substantially mediated by these changes in cognitions. These findings shed light on why social phobia and alcoholism frequently co-occur.

Nicotine Withdrawal Exacerbates Fear Reactivity to CO2-Induced Bodily Sensations Among Smokers

INTRODUCTION Independent lines of research suggest that smoking increases the prospective risk of panic disorder. Studies that have examined the hypothesized link between nicotine withdrawal and panic have typically employed light smokers or lacked optimal control groups. Our laboratory team previously found, for example, that smokers who abstained from cigarettes for 12 hr demonstrated greater fear reactivity to a CO(2) rebreathing challenge than nonsmokers. However, the absence of a smoking-as-usual group limited our ability to draw conclusions about the potential role of nicotine withdrawal. METHODS We exposed 27 heavy smokers who abstained from smoking for 12 hr and 27 heavy smokers who smoked as usual to a 5-min CO(2) rebreathing challenge. RESULTS More intense prechallenge nicotine withdrawal symptoms (regardless of group status) were associated with more severe panicky symptoms and a stronger urge to escape during the challenge, even after we controlled for prechallenge anxiety and daily cigarette use. Unexpectedly, group status did not predict challenge reactivity. CONCLUSION Smokers who regularly experience intense withdrawal symptoms, regardless of length of smoking abstinence, may be at heightened risk for experiencing panic attacks.

Panic-Relevant Cognitive Processes Among Smokers

To further understand the frequent co-occurrence of smoking and panic disorder (PD), we examined panic-relevant cognitive processes among heavy smokers, half of whom were in 12-hour withdrawal, and nonsmokers. All participants (N = 85) underwent a 5-minute carbon dioxide rebreathing challenge. Prior to the challenge, participants completed questionnaires on reasons for smoking, anxiety sensitivity, and suffocation fear. Results are consistent with a model in which smokers with predisposing risk factors (high anxiety sensitivity and high suffocation fear) misappraise bodily sensations and experience panicky symptoms. No evidence was found that being in acute withdrawal heightened this risk. Overall, findings highlight (a) cognitive vulnerabilities that may place smokers at elevated risk for developing PD and hence (b) potential targets for intervention.