Journalof Anxiety Disorders,Vol. 10,No. 5, pp. 355-364.

1996
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Frintedin the USA. All rightsnzcrved
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Panic Attack Symptomatology and

Anxiety Sensitivity in Adolescents
JASON J. LAU,M.S.

Kohler Public Schools

JOHN E. Cm, PH.D.

Finch University of Health Sciences/T%e Chicago Medical School

h'fE!GWAFtACZYNSKI,PH.D.

Universily of Wmconsin - Whitewater

Abstract - The relationship between panic attack symptoms. anxiety sensitivity, and
academic paformance was evaluated in a sample of 77 high school students. Although
it has been suggested that children and adolescents are unlikely to experience panic
attacks ad panic disorder, the results of recent studies suggest that sympoms frequently
occur in this age group. Evaluation of symptoms reported on the Panic Attack
QUM~OMZI~R revealed that 39% of our sample experienced panic attacks, and that five
subjects (6.5%) met diagnostic criteria for panic disorder at some time during their life.
Putthermote, a significant correlation between scoring on the PAQ and scores on the
Childhood Anxiety Sensitivity Index, a fear of anxiety measure, was found. Results
suggest that there is a relationship between anxiety sensitivity and panic symptomatolc+
gy in adolescents, a finding comparable with the adult litemture. The observed t-elation-
ship between anxiety sensitivity and panic symptomatology in adolescents is congruent
with theorizing that anxiety sensitivity is a cognitive risk factor for the development of
panic disorder.

Although panic disorder has previously been considered an adult malady,

evidence now exists that adolescents and children experience panic attacks and

Portions of this paper were presented at the meeting of the Anxiety Disorders Association of
America, Pittsburgh, PA, April 1995.
Requests for reprints should be sent to Dr. John E. Calamari, Department of Psychology, Finch
University of Health Sciences/The Chicago Medical School, 3333 Green Bay Road, North
Chicago, IL 60064.
3.55
 356 I. 1. LAU, J. E. CALAMARI. AND M. WARACZYNSKJ

develop panic disorder (for recent reviews see Kearney & Silverman 1992;
Moreau Jz Weissman, 1992; and Ollendick, Mattis, & King, 1994). Many
adults with panic disorder report that their condition began during adolescence
or childhood (e.g., Sheehan, Sheehan, & Minichiello, 1981; Thyer, Parrish,
Curtis, Nesse, & Cameron, 1985). Multiple case reports now document panic
disorder in adolescents (e.g., Last & Strauss, 1989), and spontaneous panic in
children as young as 8 years old (e.g., Ballenger, Carek, Steele, & Cornish-
McTighe, 1989). Moreau and Weissman (1992) concluded in their review of
child and adolescent panic disorder that there is strong evidence that panic dis-
order occurs in children and adolescents and that its clinical presentation is
similar to that found in adults. Ollendick et al. (1994) similarly concluded that
panic attacks are common during adolescence and that panic attacks and panic
disorder occur during childhood, although less frequently. Kearney and
Silverman (1992) have recommended caution, though, in the interpretation of
existing data, given many serious methodological limitations (e.g., small sam-
ple size, unreliable assessment approaches).
The substantial data now available suggesting that panic attacks and panic dis-
order occur in children and adolescents are incongruent with Nelles and Barlows
(1988) previous suggestion that true, spontaneous panic attacks develop only in
later adolescence. Nelles and Barlow suggested that younger children lack the
cognitive development necessary to drive panic disorder. As McNally (1994, pp.
167-169) has pointed out in his recent review, young children who panic appear
to experience the same fears that adults report including fears of dying (e.g.,
Moreau, Weissman, & Warner, 1989), of losing control (e.g., Ballenger et al.,
1989), and of going crazy (e.g., Black & Robins, 1990). Evidence that young
children can engage in catastrophic thinking may mean that cognitive mecha-
nisms thought important to the development of panic disorder in adults are influ-
ential in the development of panic disorder in children and adolescents.
Reiss and McNally (1985; Reiss, 1987, 1991) developed the construct anxi-
ety sensitivity, a disposition variable involving the tendency to interpret anxi-
ety symptoms as dangerous and to react fearfully to related bodily sensations
(see recent reviews by Lilienfeld, Turner, & Jacob, 1993; McNally, 1990, and
Taylor, 1995a, b). This construct has been measured in adults using the
Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1992; Reiss, Peterson,
Gursky, & McNally, 1986). Anxiety sensitivity may be a cognitive risk factor
for the development of panic disorder and the anxiety disorders in general
(e.g., McNally C Lorenz, 1987; Reiss, 1991; Reiss et al., 1986). Only recently
has a method for measuring this construct in children and adolescents been
developed (the Childhood Anxiety Sensitivity Index [CASI; Silverman,
Pleisig, Rabian, 8z Peterson, 19911). The questions on the CASI are similar to
those on the AS1 but the language describing anxiety symptoms and fearful
reactions to these symptoms has been simplified
There has been very limited evaluation of anxiety sensitivity in children and
adolescents. Silverman et al. (1991) did not find significant differences on CASI
 PANIC AND ANXIETY SENSITIVITY IN ADOLESCENTS 357

scores between a group of 31 clinically referred children and a nonreferred

group, although their clinical sample was very heterogeneous and included only
three children diagnosed with anxiety disorders. Rabian, Peterson, Richtern, and
Jensen (1993) compared children diagnosed with a structumd clinical interview
as having one or more anxiety disorder (n = 18), an externalizing disorder
(n = 20; e.g., attention deficit hyperactivity disorder), or no clinical disorder
(n = 62). Scoring on the CASI reliably diffetcntiated the anxiety disorders group
from the nonclinical group, but no differences were found between the anxiety
disorders group and the externalizing disorders group. The externalizing disor-
ders group was found to score as high as the anxiety disorders group on the
Revised Childrens Manifest Anxiety Scale (Reynolds & Richmond, 1978).
though, a measure of anxiety symptomatology in children. Taylor, Koch, and
McNally (1992) evaluated anxiety sensitivity in 3 13 individuals meeting diag-
nostic criteria for anxiety disorders. Although their sample had a mean age of
35.1, the age range was 11-73 years. Unfortunately AS1 scores were not broken
out by age. To our knowledge these are the only investigators who have evaluat-
ed anxiety sensitivity in child or adolescent samples.
In the present investigation, we explored the relationship between panic
symptomatology and anxiety sensitivity in adolescents. The prevalence of
panic attack symptoms was assessed in a sample of nonreferred high school
students using the revised Panic Attack Questionnaire (PAQ; Norton, Dorward,
& Cox, 1986). This instrument contains a detailed description of panic attacks;
it questions respondents on the presence of panic attack-related symptomatolo
gy and assessesrelated life interference. Based on previous investigations, we
expected panic symptomatology to be regularly reported in our adolescent sam-
ple. Furthermore, we hypothesized that if anxiety sensitivity is a cognitive risk
factor for anxiety disorders, a positive correlation between scoring on the CASI
and the PAQ should be found. Because previous research suggests that anxiety
sensitivity is most elevated in panic disorder patients (e.g., Taylor, Koch, &
McNally, 1992), we suspected that a relationship between anxiety sensitivity
and panic symptomatology would be found in our adolescent sample. Finally,
we evaluated the relationship between panic symptomatology and academic
performance as indicated by the students grade point average (GPA). It has
been previously reported that anxiety adversely affects students performance
on school-related tasks (e.g., Chapin, 1989; Finch et al., 1988).

METHOD
Participants
Seventy-seven high school students from a semirural, middle-class, largely
Caucasian, Wisconsin community participated in the study. Parents were
approached during parent-teacher conferences for consent for their son or daugh-
ter to participate in the study. Approximately 100 parents were approached, and
65 granted permission for their son, daughter, or multiple children to participate in
 358 I. J. LALJ, I. E. CALAMARI, AND M. WARACZYNSKI

the study. Fifty-four additional students, who were 18 years old, were approached
directly. Consent for participation in the study was obtained for 125 students.
Forty-eight subjects did not complete the study for a variety of reasons. Twelve
students were absent from the high school on the day the assessmentswere com-
pleted. Twenty students declined to participate during the study hall period desig-
nated for data collection, often indicating they preferred to work on school
assignments. Sixteen additional students could not be located at the time of test-
ing. Participants ranged in age from 14 to 18 years (M = 16.74). All subjects
included in the study were Caucasians, and the sample was 44.2% male and 55.8%
female. Subjects academic performance mnged between 1.30 and 4.00 (4point
scale, M = 2.93). Student GPA was computed based on performance in all classes.
Four students who completed the assessmentwere emolled in special education.

Measures and Procedure

All subjects completed the revised PAQ (Norton et al., 1986) This instru-
ment surveys panic attack symptomatology including the specific diagnostic cri-
teria relating to the Diagnostic and Statistical Manual of Mental Disorders, 3rd
ed., revised (DSM-III-R, American Psychiatric Association, 1987). Because
there is not a standardized methodology for generating a PAQ total score, a pro-
cedure was developed for this study. Gn the PAQ subjects are asked to answer all
questions that apply. Therefore, a nonresponse to a particular symptomatology
question on the PAQ was scored 0. The PAQ total score was generated by adding
the ratings of the following items: the number of panic attacks experienced dur-
ing the past year (O-l l), the number of panic attacks experienced during the past
4 weeks (O-lo), the greatest number of panic attacks experienced during any
Cweek period (O-lo), the rating of how disturbing or distressing experienced
panic attacks were (O-4), and the rating of the degree to which panic attacks
have restricted or changed lifestyle (O-4). Additionally, the severity of 20 panic-
related autonomic arousal and cognitive symptoms experienced during the most
recent panic attack was quantified by summing the ratings of symptoms experi-
enced as moderately severe or greater (o-80). Lastly, the ratings of concern
about future attacks (O-5), and the degree of perceived seriousness (physical or
psychological) of experienced panic attacks (O-4) was added to the score. Thus,
scoring on the PAQ could range between 0 (a report of no experienced panic
attacks nor related symptomatology) to a possible score of 128.2
Students also completed the CASI (Silverman et al., 1991). The CASI mea-
sures anxiety sensitivity, a dispositional factor involving fear of anxiety symp-

tThe Panic Attack Questionnaire was obtained from G. R. Norton, Department of Psychology,
University of Winnipeg, Canada.
2The specific methods for scoring each item on the Panic Attack Questionnaire (PAQ) to deter-
mine classification as a panickers or as having met criteria for panic disorder (lifetime) arc avail-
able from the corresponding author. Additionally, an item-by-item break down of the PAQ in terms
of derivation of the total PAQ score is also available upon request to the corresponding author.
 PANIC AND ANXIETY SENSiTIVlTY IN ADOLEWENTS 359

toms and beliefs that these symptoms have harmful consequences (Reiss &
McNally, 1985). The CASI has acceptable psychometric properties (Silverman
et al., 1991), although there has been limited evaluation of the CASI to date.
The CASI has been found to have adequate test-retest reliability in clinical
(r = .79) and nonclinical (r = .76) samples and good internal consistency, sug-
gesting that it measures a single trait (Silverman et al., 1991). Furthermore,
scores on the CASI have been shown to account for variance not directly related
to levels of anxiety symptomatology or trait anxiety (Silverman et al., 1991).
High school grade point average (GPA) obtained from school records was the
measure of academic achievement.
Students were asked to complete questionnaims during a standard study hall
period and assured that all information provided was contidential. It took approxi-
mately 20 min to complete the two questionnaires, the PAQ and the CASI.

RESULTS
Review of PAQ data showed that 39% of the sample were panickers (i.e.,
reported having one or more panic attacks during the past year, experienced
four or more panic attack-related symptoms during the attack, experienced a
rapid onset of symptoms, and indicated that there was not an identified medi-
cal reason for their panic symptoms). Five students endorsed symptoms meet-
ing diagnostic criteria (lifetime) for panic disorder including indication of
uncued attacks, attacks involving four or more panic symptoms, a period of
four or more attacks in a 4-week period, and continuing wony about future
attacks. Scoring on the PAQ ranged between 0 and 83 (M = 14.32; SD = 21.29)
with 38 of the nonpanickers scoring 0.
The correlation between scoring on the PAQ and the CASI was significant
[r(76) = .42, p < BOOS], but the correlation between scoring on the PAQ and
GPA was not significant [r(76) = -.06, p = .621]. The correlation between
CASI scores and GPA was also not significant [r(76) = .05, p = -6781.We next
evaluated the relationship between subjects responses to specific questions on
the PAQ and CASI total score by computing Spearman rank correlations. The
results are shown in Table 1. A significant correlation between CASI score and
the number of attacks experienced during the past year and the last 4 weeks
was found. Additionally, CASI score, the level of distress caused by panic
symptoms, and the judged psychological or medical seriousness of panic
attacks were significantly correlated. The number of autonomic symptoms and
degree of negative cognitive appraisal associated with panic symptoms (listed
as Symptoms on Table 1) were also correlated with CASI score. Only subjects
ratings of the degree of life interference caused by their panic symptoms failed
to correlate with the CASI total score.
Evaluating these data from a slightly different perspective, we next grouped
subjects by panic status (panickers and nonpanickers). These results are shown
in Table 2. Scoring on the CASI was significantly different for panickers and
 360 I. J. LAU, J. E. CALAMARI, AND M. WARACZYNSKI

TABLE 1
INT@RCORRPLATONS Bm-ww CASI TOTU. Saw AND Specmc PAQ QUESTIONS

Measures 1 2 3 4 5 6 I

1. CASI 1.00
2. Attacks past year .43* 1.00
3. Attacks last month .34* .59* 1.00
4. Distress 49* .81* .51* 1.00
5. Interference .14 .52* .36* .62* 1.00
6. Symptoms .41 .71* .41* .70* .47* 1.00
7. Judged seriousness .52* .69* .37* .71* .32* .69* 1.00

*p<.OO1.

nonpanickers, t(76) = 3.51, p < .005. Examination of CASI scoring for our
small (n = 5) panic disordered group revealed the following: M = 33.00;
SD = 6.7 1; Range, 22-40.
The GPA of panickers and nonpanickers did not differ, t(76) = 0.06, p = ns.
There was not a significant difference in the proportion of panickers who were
female or male (38.64 % vs. 39.39% [X2(1, N = 77) = .00&p = .946]).

DISCUSSION
Gur fmding that 39% of a nonclinical sample of adolescents experienced at
least one 4-symptom panic attack is congruent with suggestions from other
reports that panic symptomatology occurs frequently in this age group.
Zgourides and Warren (1988) reported that 31% of their adolescent high
school sample had experienced at least one panic attack meeting diagnostic
criteria (Diagnostic and Statistical Manual of Mental Disorders, 3rd ed.
[DSM-III; American Psychiatric Association, 19801). Hayward, Killen, and
Taylor (1989) found that 11.6% of their high school sample experienced at

TABLE 2
kOlUNG ON THIS CHILD i%NXBTY f%WllVllY
- @XSI) AND GRADS Porn Ammz. (GPA)
RIR Pm- AND Nowmrcm~s

Panickers Nonpanickers

CASI M = 32.20 M = 27.66

SD = 4.77 SD = 4.36
N=30 N=47

GPA M = 2.88 M = 2.87

SD = 0.68 SD = 0.70
N=30 N=47
 PANIC AND ANXIETY SENSlTMTY IN ADowm 361

least one Csymptom panic attack while King, Gullone, Tonge, and Ollendick
(1993) reported that 49% of their sample panicked. Macaulay and Kleinknecht
(1989), using a D&U-ZZZ version of the PAQ, reported that 63.3% of their high
school sample panicked. The substantial variability observed in these and other
investigations of panic iu children and adolescents likely results from differ-
ences in the age and size of the samples and inconsistencies iu the assessment
instruments employed and in the definition of panic. Furthermore, the present
study and most prior investigations are significantly limited by their exclusive
dependence on self-report questionnaire measures. Recent studies (e.g., Brown
Jr Deagle, 1992; Wilson et al. 1992) have found that there is not an exact cor-
respondence between panic symptomatology reported on questionnaires such
as the PAQ and clinical panic disorder diagnosed with structured clinical inter-
views. Questionnaire measures may inflate estimations of panic prevalence
(Brown & Deagle, 1992). Future investigations could be improved by verify-
ing questionnaire symptomatology with a structured clinical interview and by
using the structured clinical interview to differentiate cued and uncued panic.
The present investigation is further limited by small sample size and sample
selection problems. Although consent for participation in the study was
obtained for 125 students, only 77 were available or willing to participate on
the day data were collected. There is no way of determining whether the stu-
dents who were absent or who declined participation may have experienced
more or less anxiety symptoms than the students evaluated.
This study is the first investigation of anxiety sensitivity in adolescents with
panic symptoms. Our finding of a significant relationship between anxiety sen-
sitivity and panic symptomatology in adolescents is congruent with previous
research with adult samples showing elevated AS1 scores in panic patients
(e.g., McNally & Lorenz, 1987) and in nonclinical samples experiencing panic
attack symptoms (e.g., Donnell & McNally, 1990). As previously discussed,
Silverman et als (1991) failure to fmd differences on CASI scores between
clinically referred and nonreferred children may have been a result of the het-
erogeneity of the clinical sample and the inclusion of only three children diag-
nosed with anxiety disorders. Rabian et als (1993) faihue to find that CASI
scores differentiated children with anxiety disorders from a sample with diag-
nosed externalizing disorders may have resulted from the high levels of anxi-
ety symptomatology present in the externalizing group.
Our findings suggest that the anxiety sensitivity construct may have utility
in understanding the development and maintenance of anxiety disorders in ado
lescents. It should be noted, though, that the CASI score diEerences in our pan-
icker and nonpanicker groups were small (4.54 points on average). This may
suggest that the CASI needs further psychometric refinement to measure anxi-
ety sensitivity in children more accurately. Taylor, Koch, and Crockett (1991)
have made such suggestions for the ASI, pointing out that some questions fail
to load on the first principal component of the scale and may need to be elimi-
nated. An alternative explanation for the small group differences on the CASI
 362 I. I. LAU, I. E. CALAMARI, AND M. WARACZYNSKI

is that these differences are an accurate depiction of the nature of anxiety sensi-
tivity in children and adolescents. That is, anxiety sensitivity may be a develop
ing predisposition during childhood and adolescence such that differences are
initially small. Even small anxiety sensitivity differences, though, may signifi-
cantly influence the development of anxiety symptoms in some children and
adolescents.3 If it is the case that anxiety sensitivity is a developing predisposi-
tion in earlier childhood that increases over time, Silverman et als (1991) and
Rabian et al.s (1993) failure to find differences between groups on CASI
scores may be in part attributable to the younger age of their samples.
Given the very limited information on risk factors for anxiety disorders in
children and adolescents, further evaluation of the anxiety sensitivity construct
is warranted. A preferable approach would entail the longitudinal study of
young children high or low on anxiety sensitivity. These children would be
monitored for the development of anxiety states and other psychopathology.
Such a study could further illuminate the relationship between this fear-of-fear
construct and the development of anxiety disorders. To date, there are two lon-
gitudinal investigations of AS1 with adults. Maller and Reiss (1992) found that
subjects scoring high on the ASI initially were five times more likely than a
low-scoring comparison group to have anxiety disorders 3 years later. Ehlers
(1995) found that anxiety sensitivity at initial assessment predicted at follow-
up evaluation one year later the continuation of panic disorder in patients,
continuing infrequent panics in initial infrequent panickers, and the first
occurrence of panic attacks in control subjects. Ehlers (1995) findings with
adults showed that both infrequent panic and anxiety sensitivity are related to
the development of panic disorder. This relationship may also hold true in
children and adolescents, suggesting the need for further study of both panic
symptomatology and anxiety sensitivity in these age groups.
Our failure to find a relationship between panic symptomatology and aca-
demic performance may have resulted from our dependence on the GPA index.
This measure may not be sufficiently sensitive. Alternatively, it may be that
only the most severe levels of anxiety symptomatology will adversely affect
academic performance. The relationship between anxiety sensitivity and aca-
demic performance may be nonlinear with low or moderate anxiety sensitivity
functioning to increase performance. This possibility should be evaluated in
future investigations with larger samples.
Recently, Hayward et al. (1995) reported an association between panic
attacks, school refusal, and depressive symptoms in a sample of sixth and sev-
enth grade girls. Although academic performance was not evaluated in this
investigation, it is likely that academic performance would be adversely affected
by school refusal. It is possible that if a relationship between anxiety symptoma-
tology and academic performance is seen, the relationship might be mediated by
avoidance behavior of some type. Substantially elevated anxiety sensitivity may

3We would like to thank an anonymous reviewer for pointing out this possibility.
 PAMCANDANxlFXv SENSllIVtlY IN ADOLESCENTS 363

result in school avoidance. Further evaluation of the impact of anxiety symp

toms and anxiety risk factors on academic performance also is warranted.

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