Catastrophic interpretations and anxiety sensitivity as predictors of panic-spectrum psychopathology in chronic obstructive pulmonary disease ☆ Nicole Livermore a, b, ⁎, Louise Sharpe c , David McKenzie d, e a Department of Liaison Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia b School of Psychology, University of NSW, Sydney, NSW, Australia c School of Psychology, University of Sydney, Sydney, NSW, Australia d Department of Respiratory and Sleep Medicine, Prince of Wales Hospital, Sydney, NSW, Australia e Faculty of Medicine, University of NSW, Sydney, NSW, Australia abstract article info Article history: Received 23 September 2011 Received in revised form 12 January 2012 Accepted 4 February 2012 Keywords: Anxiety Panic attacks Panic disorder Chronic obstructive pulmonary disease Objective: Panic-spectrum psychopathology (denoting panic attacks and panic disorder) is highly prevalent in chronic obstructive pulmonary disease (COPD), and the cognitive model of panic has been proposed as an ex- planation of this high prevalence. In the current cross-sectional study we investigated factors predicting panic-spectrum psychopathology in COPD, and hypothesized that, consistent with the cognitive model, both the catastrophic interpretation of shortness of breath and elevated anxiety sensitivity would be signif- icant predictors when variance shared with confounding variables was controlled. Methods: Sixty-two participants with COPD were interviewed with the Anxiety Disorders Interview Schedule for DSM-IV, Panic Disorder section, and completed measures of interpretation of breathing difficulty, anxiety sensitivity, anxiety, depression, disease-specific quality of life, and stressful life events. Objective disease se- verity was measured using forced expiratory volume in the first second. Results: Direct logistic regression was performed, and worse depressive symptoms, more catastrophic inter- pretations of shortness of breath, higher anxiety sensitivity, higher magnitude of recent stressful life events, and worse disease severity were each found to be significant unique predictors of panic-spectrum psychopa- thology in COPD after shared variance was controlled. Conclusions: The results of the study provide support for the cognitive model of panic, and also suggest a diathesis-stress explanation of the development of panic-spectrum psychopathology in COPD. The findings have implications for future preventative psychological interventions. Crown Copyright © 2012 Published by Elsevier Inc. All rights reserved. 1. Introduction Chronic obstructive pulmonary disease (COPD) is a progressive, and ultimately fatal, lung disease caused primarily by cigarette smok- ing. In 2006, between 9 and 10% of all adults worldwide aged over 40 years met diagnostic criteria for the illness [1]. The Global Burden of Disease Study has estimated that by 2020 COPD will be the third leading cause of death [2]. As would be expected, the costs of COPD to individuals and to health care systems are substantial [3]. Panic at- tacks are common, and the prevalence of panic disorder in COPD is around ten times higher than the general population prevalence of 1.5–3.5%, with negative impacts including increased exacerbations, and increased frequency and duration of hospital admissions [4–7]. There is evidence that untreated panic attacks in COPD do not resolve, but may instead increase the risk of panic disorder developing [7]. For people with COPD, breathing, the most basic of all physical functions necessary for life, is objectively threatened, and this threat occurs in the context of a disabling terminal illness. Hence, the key symptom of shortness of breath on exertion lends itself to catastrophic over- interpretation (for example, as meaning that the person may die at that moment by suffocation or heart attack), consistent with the lead- ing psychological model of panic, Clark's cognitive model [8,9]. In the model, a panic attack results when ambiguous bodily sensations are interpreted as imminently catastrophic, increasing arousal, and so creating a positive feedback loop, as shown in Fig. 1. This model has been supported by a large number of clinical and experimental stud- ies of physically healthy subjects [10,11]. Psychophysiological re- search has demonstrated that the human respiratory rate is increased by physiological arousal, and in people with COPD the hy- perventilation that results from anxiety markedly worsens shortness of breath by causing bronchoconstriction and lung hyperinflation [12–14]. Hyperinflation increases the work and effort of breathing, and reduces inspiratory reserve capacity [13,14]. The panic cycle in Journal of Psychosomatic Research 72 (2012) 388–392 ☆ Department where research was conducted: Respiratory Medicine, Prince of Wales Hospital, Sydney, Australia. ⁎ Corresponding author at: Department of Liaison Psychiatry, Prince of Wales Hospi- tal, Barker St., Randwick NSW 2031 Australia. Tel.: +61 2 9382 2731; fax: +61 2 9382 2177. E-mail address: Nicole.Livermore@sesiahs.health.nsw.gov.au (N. Livermore). 0022-3999/$ – see front matter. Crown Copyright © 2012 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2012.02.001 Contents lists available at SciVerse ScienceDirect Journal of Psychosomatic Research