Michael J. Zvolensky

A review of psychological factors/processes affecting anxious responding during voluntary hyperventilation and inhalations of carbon dioxide-enriched air

Despite advances in our understanding of the nature of anxiety-related responding during periods of elevated bodily arousal, it is not necessarily evident by what psychological mechanisms anxiety is produced and maintained. To address this issue, researchers have increasingly employed biological challenge procedures to examine how psychological factors affect anxious responding during elevated bodily arousal. Of the challenging procedures, hyperventilation and inhalations of carbon dioxide-enriched air have been among the most frequently employed, and a relatively large body of literature using these procedures has now accumulated. Unfortunately, existing reviews do not comprehensively examine findings from hyperventilation and inhalations of carbon dioxide studies, and only rarely the methodological issues specific to these studies. To address these issues, we review the voluntary hyperventilation and carbon dioxide-enriched air literature in order to identify the primary methodological issues/limitations of this research and address the extent to which psychological variables influence anxious responding to such challenges. Overall, we conclude challenge research is a promising paradigm to examine the influence of psychological variables in anxious responding, and that such work will likely be enhanced with greater attention to psychological process issues.

The Cardiac Anxiety Questionnaire: development and preliminary validity

Heart-focused anxiety (HFA) is the fear of cardiac-related stimuli and sensations because of their perceived negative consequences. Although HFA is common to a wide variety of persons who experience chest pain and distress, it often is unrecognized and misdiagnosed, particularly in cardiology and emergency room patients without and with heart disease. To address these concerns, this article reports on the development and preliminary psychometric evaluation of the Cardiac Anxiety Questionnaire (CAQ) designed to measure HFA. In Study 1, 188 cardiology patients completed the CAQ. Item and factor analyses indicated a three-factor solution pertaining to heart-related fear, avoidance, and attention. Reliability analysis of the 18-item CAQ revealed good internal consistency of the total and subscale scores. In Study 2, 42 patients completed the CAQ and several other anxiety-related questionnaires to assess its convergent and divergent properties. Although preliminary validity results are promising, further psychometric study is necessary to cross-validate the CAQ, examine its test-retest reliability, and confirm the stability of the factor structure. Taken together, the CAQ appears to assess HFA, and may therefore be a useful instrument for identifying patients with elevated HFA without and with heart disease.

Anxiety sensitivity in the prediction of pain-related fear and anxiety in a heterogeneous chronic pain population

The present study evaluated anxiety sensitivity, along with depression and pain severity, as predictors of pain-related fear and anxiety in a heterogeneous chronic pain population (n=68). The results indicated that the global anxiety sensitivity factor, as indexed by the Anxiety Sensitivity Index (ASI: Reiss, Peterson, Gursky & McNally, 1986: Reiss, S., Peterson, R. A., Gursky, M. & McNally, R. J. (1986). Anxiety, sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8) total score, was a better predictor of fear of and anxiety about pain relative to the other relevant variables. Additionally, the physical concerns subscale of the ASI was a better predictor of pain-related fear dimensions characterized by high degrees of physiological symptoms and behavioral activation on both the Fear of Pain Questionnaire-III (FPQ-III; McNeil & Rainwater, 1998: McNeil, D. W. & Rainwater, A. J. (1998). Development of the Fear of Pain Questionnaire-III. Journal of Behavioral Medicine.) and Pain Anxiety Symptoms Scale (PASS; McCracken, Zayfert & Gross, 1992: McCracken, L. M., Zayfert, C. & Gross, R. T. (1992). The Pain Anxiety Symptoms Scale: Development and validation of a scale to measure fear of pain. Pain, 50, 67-73). In a related way, the ASI psychological concerns subscale was a better predictor of pain-related anxiety dimensions characterized by cognitive symptoms of anxiety. Overall, these findings reiterate the importance of anxiety sensitivity in understanding pain-related fear and anxiety, and suggest anxious and fearful responding can be predicted more accurately with higher levels of correspondence between a particular anxiety sensitivity domain and events that closely match that fear.

Assessment of anxiety sensitivity in young American Indians and Alaska Natives

In the present study, the Anxiety Sensitivity Index [ASI; Behav. Res. Ther. 24 (1986) 1] was administered to 282 American Indian and Alaska Native college students in a preliminary effort to: (a) evaluate the factor structure and internal consistency of the ASI in a sample of Native Americans; (b) examine whether this group would report greater levels of anxiety sensitivity and gender and age-matched college students from the majority (Caucasian) culture lesser such levels; and (c) explore whether gender differences in anxiety sensitivity dimensions varied by cultural group (Native American vs. Caucasian). Consistent with existing research, results of this investigation indicated that, among Native peoples, the ASI and its subscales had high levels of internal consistency, and a factor structure consisting of three lower-order factors (i.e. Physical, Psychological, and Social Concerns) that all loaded on a single higher-order (global Anxiety Sensitivity) factor. We also found that these Native American college students reported significantly greater overall ASI scores as well as greater levels of Psychological and Social Concerns relative to counterparts from the majority (Caucasian) culture. There were no significant differences detected for ASI physical threat concerns. In regard to gender, we found significant differences between males and females in terms of total and Physical Threat ASI scores, with females reporting greater levels, and males lesser levels, of overall anxiety sensitivity and greater fear of physical sensations; no significant differences emerged between genders for the ASI Psychological and Social Concerns dimensions. These gender differences did not vary by cultural group, indicating they were evident among Caucasian and Native Americans alike. We discuss the results of this investigation in relation to the assessment of anxiety sensitivity in American Indians and Alaska Natives, and offer directions for future research with the ASI in Native peoples.

Manualized behavior therapy: Merits and challenges

Treatment manuals have been hailed as an important breakthrough in the development, evaluation, and dissemination of empirically validated therapies. Yet manualized behavior therapy has also been criticized because (a) practice involves the application of validated principles of behavior rather than the application of fixed strategies, and (b) successful behavioral interventions must supposedly be based on an idiographic functional problem analysis and tailored to each individual patient. This article evaluates the relative merits, potential limitations, and misconceptions about the use of manuals. We conclude that individualizing treatment and manual use are not mutually exclusive and propose that manuals be used in a flexible theory-driven fashion guided by empirically tested clinical decision rules.

The relation between anxiety and skill in performance-based anxiety disorders: A behavioral formulation of social phobia

Anxiety-related responding and skill deficits have historically been associated with performance-based anxiety disorders such as social phobia. Prominent cognitive-behavioral models of social phobia have typically deemphasized skill deficits and focused more on the effects of negative cognition on social performance. Considering that empirical accounts of the relation between social skill and social performance are generally modest, the impact of skill deficits on the development and maintenance of performance inadequacies may be relatively neglected in theoretical paradigms in this area. A second problem that has plagued social skill research is the misuse of the term skill deficit as a synonym for performance deficit. In response to these issues, we utilize the multilevel framework of psychological behaviorism to offer a more parsimonious account of the relation between anxiety and skill in social phobia. We argue that this integrated model assimilates contemporary accounts of social phobia and uniquely expands upon them by delineating the unique and cumulative effects of skill and anxiety on social performance. We further suggest that this model resolves existing theoretical incompatibilities, facilitates improved patient-treatment matching, and shows promise as a guiding framework for empirical research.

The role of offset control in anxious responding: An experimental test using repeated administrations of 20% carbon dioxide-enriched air.

The present investigation attempted to clarify whether a lack of control affects self-reported anxiety and physiological reactivity during eight administrations of 20% carbon dioxide (CO 2 )-enriched air. Thirty individuals who reported high levels of suffocation fear were randomly assigned to a condition that either permitted or did not permit control over the offset of CO 2 gas inhalation. In contrast to participants with control, participants without control reported significantly more self-reported anxiety and intense panic experiences. Although 20% CO 2 -enriched air reliably evoked physiological arousal for both groups, no significant between-group differences for peripheral indices of somatic reactivity were observed. We discuss the implications of these findings for understanding how control over aversive environmental stimuli mediates anxious responding in panic disorder.

Offset control during recurrent 20% carbon dioxide-enriched air induction: relation to individual difference variables.

Although control over aversive events maintains a central role in contemporary models of anxiety pathology, particularly panic disorder, there is little understanding about the emotional consequences of specific types of control processes. In the present study, offset control over 8 20% carbon dioxide-enriched air administrations was experimentally manipulated in a large nonclinical population (n = 96) varying in anxiety sensitivity (high or low) and gender. Dependent measures included self-reported anxiety, affective reports of valence, arousal, emotional control, and physiological indices of heart rate and skin conductance. High anxiety-sensitive participants who lacked offset control reported significantly greater elevations in self-reported anxiety, emotional displeasure, arousal, and dyscontrol relative to their yoked counterparts with offset control. In contrast, low anxiety-sensitive individuals responded with similar levels of cognitive and affective distress regardless of the offset control manipulation. Although the provocation procedure reliably produced bodily arousal relative to baseline, at a physiological level of analysis, no significant differences emerged across conditions. These findings are discussed in relation to offset control during recurrent interoceptive arousal, with implications for better understanding anxiety about abrupt bodily sensations.

The effects of offset control over 20% carbon-dioxide-enriched air on anxious responding.

Control over the offset of repeated administrations of 20% carbon-dioxide-enriched air was assessed in nonclinical participants (n = 30) reporting elevated levels of anxiety sensitivity--a population at an increased risk for experiencing panic attacks and possibly developing panic disorder. In Phase I, participants were randomly assigned to 1 of 2 conditions: one that permitted offset control over gas inhalation and one that did not. These conditions were reversed in Phase II. Across phases, a lack of offset control resulted in greater self-reported anxiety compared with having control, although no significant differences were observed for heart rate. Whereas all participants demonstrated a Stroop interference effect for general (e.g., coffin) compared with specific (e.g., dizzy) physical threat word types prior to the first experimental phase, this effect persisted only for participants who had offset control in Phase I. We discuss these results in relation to the differential effects of offset control, with implications for better understanding anxious responding during elevated bodily arousal.

Fear of pain in orofacial pain patients

&NA; In the present study, we examined whether fear of pain, dental fear, general indices of psychological distress, and self‐reported stress levels differed between 40 orofacial pain patients and 40 gender and age matched control general dental patients. We also explored how fear of pain, as measured by the Fear of Pain Questionnaire‐III (J Behav Med 21 (1998) 389), relates to established measures of psychological problems in our sample of patients. Finally, we examined whether fear of pain uniquely and significantly predicts dental fear and psychological distress relative to other theoretically‐relevant psychological factors. Our results indicate that fear of severe pain and anxiety‐related distress, broadly defined, are particularly elevated in orofacial pain patients relative to matched controls. Additionally, fear of pain shares a significant relation with dental fear but not other general psychological symptomology, and uniquely and significantly predicts dental fear relative to other theoretically‐relevant variables. Taken together, these data, in conjunction with other recent studies, suggest greater attention be placed on understanding the fear of pain in orofacial pain patients and its relation to dental fear and anxiety.