Journal of Anxiety Disorders 85 (2022) 102514

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Comparing symptom networks of daytime and nocturnal panic attacks in a

community-based sample
Nicole S. Smith *, Brian W. Bauer, Daniel W. Capron
Department of Psychology, University of Southern Mississippi, Hattiesburg, MS, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Nocturnal panic refers to waking in a state of panic without obvious triggers, experiencing the same symptoms as
Nocturnal panic panic attacks that occur while awake. Interrelationships between daytime and nocturnal panic symptoms have
Network Analysis not been examined despite theories suggesting panic symptoms perpetuate one another in a forward feedback
Panic symptoms
loop. The current study compared associations between symptoms in daytime and nocturnal panic using network
Sleep
Anxiety
analysis. Network theory conceptualizes symptoms as causing one another, rather than originating from a latent
variable (i.e., a disorder). Given that nocturnal panic originates from sleep stages without cognitive activity,
cognitive symptoms were expected to be more central in daytime panic networks than nocturnal panic networks.
Prior literature indicates similar nocturnal and daytime panic severity; thus, we expected that panic groups
would report equivalent panic symptom severity. An online community sample (N = 215) provided panic
symptom history. Panic network structures did not differ, although the daytime panic network produced stronger
and more numerous connections between physical and cognitive symptoms. The nocturnal panic group, how­
ever, reported more severe cognitive symptoms than the daytime panic group. These results challenge
biologically-focused nocturnal panic theories and suggest a more significant role of cognitive symptoms in
perpetuating nocturnal panic attacks once the individual awakens.

1. Introduction
Nocturnal panic refers to panic attacks that begin while an individual
is sleeping and result in awakening in the midst of a panic attack (Freed,
Craske, & Greher, 1999). Nocturnal panic attacks occur specifically
during the transition between light sleep (Stage II) and deep sleep (Stage
III), in the absences of external triggers such as nightmares and sudden
noises (Craske & Rowe, 1997). For this reason, nocturnal panic has often
been conceptualized as a purely biological panic attack that occurs
without precipitating cognitive factors (Craske & Rowe, 1997; Labbate,
Pollack, Otto, Langenauer, & Rosenbaum, 1994; Shapiro & Sloan, 1998).
Panic theories to date have relied heavily on cognitive influences to
explain panic attacks without accounting for nocturnal panic (see review
by Bouton, Mineka, & Barlow, 2001).
The extant literature suggests that panic attacks comprise the same
symptoms regardless of if they occur out of sleep (nocturnal panic) or
while awake (daytime panic; Freed et al., 1999; Uhde, 1994). Subtle
differences in the strength and frequency of these symptoms may help
better characterize and understand nocturnal panic. Several studies
have shown that although the same symptoms occur in both nocturnal
and daytime panic, individuals report a greater number of physical
symptoms such as increased heart rate, chest pain, and smothering
sensations during nocturnal panic compared to daytime panic attacks
(Craske & Barlow, 1989; Craske & Kreuger, 1990; Norton, Norton,
Walker, Cox, & Stein, 1999). Similarly, catastrophic cognitions such as
fear of dying or going crazy appear to be more strongly related to day­
time panic than nocturnal panic (O’Mahony & Ward, 2003). These
findings support the conceptualization of nocturnal panic as a
biologically-driven panic event, therefore challenging the assumptions
of cognitively-driven panic theories (e.g., Clark, 1988; Schmidt, Lerew,
& Trakowski, 1997).
Importantly, the literature on whether nocturnal and daytime panic
differ in severity remains inconclusive. For example, Craske and Barlow
(1989) found that daytime panic symptoms were rated as more severe
than nocturnal panic symptoms within a Panic Disorder sample. Krystal,
Woods, Hill, and Charney (1991), however, found no differences in the
number, severity, or duration of panic symptoms between nocturnal and
daytime panic groups. Finally, de Beurs et al. (1994) found that

* Correspondence to: Department of Psychology, University of Southern Mississippi, 118 College Drive #5025, Hattiesburg, MS 39406, USA.
E-mail address: nicole.s.smith@usm.edu (N.S. Smith).

https://doi.org/10.1016/j.janxdis.2021.102514
Received 5 April 2021; Received in revised form 31 October 2021; Accepted 6 December 2021
Available online 9 December 2021
0887-6185/© 2021 Elsevier Ltd. All rights reserved.
N.S. Smith et al.
nocturnal panic attacks were rated as more severe than daytime panic
attacks. A more nuanced examination of which panic symptoms are
reported as characteristic of daytime and nocturnal panic may be
necessary to fully understand the differences between these types of
panic attacks.
Panic symptoms may perpetuate one another differently depending
on whether an individual is asleep or awake when the panic attack be­
gins. The body vigilance model has been used to describe maintaining
factors for daytime panic in panic disorder and identifies attention to
physiological changes as a key element to the forward feedback loop
that triggers panic attacks (Schmidt et al., 1997). In this model, cogni­
tive factors such as scanning the body for physiological fluctuations and
fear of arousal symptoms occur prior to physical panic symptoms. For
nocturnal panic, however, researchers have argued the reverse, where
nocturnal panic physical symptoms occur first, during sleep, and are
followed by cognitive symptoms after the individual awakens (Craske &
Freed, 1995). Uhde (1994) proposed a forward feedback mechanism for
nocturnal panic where a spontaneous nocturnal panic event leads to
anticipatory anxiety in the future out of fear of additional nocturnal
panic attacks. This fear then leads to a more general fear of sleep and
sleep avoidance, resulting in chronic lack of sleep which worsens panic
and anxiety symptoms, ultimately leading to more frequent nocturnal
panic. Indeed, individuals who experience regular nocturnal panic at­
tacks report difficulty returning to sleep after a nocturnal panic attack
out of fear of additional panic attacks (Tsao & Craske, 2003) and are
more likely than individuals who only panic while awake to report
sleeping fewer than 5 hours per night (Singareddy & Uhde, 2009).
Because nocturnal panic occurs during the transition between light sleep
and deep sleep, in the absence of conscious thought, it is unlikely that
cognitive panic symptoms are responsible for triggering nocturnal panic
attacks, though they may play a role in triggering daytime panic attacks.
The relations among symptoms reported as occurring during a
typical panic attack has been an understudied topic. Network analysis is
a statistical approach that provides the unique opportunity to depict
how panic symptoms interact with one another. In the network theory of
psychopathology, symptoms have causal interactions with one another
rather than being caused by an underlying latent variable (McNally,
2016). Thus, the result of the interrelations between symptoms is the
disorder itself. This is in contrast to the medical model in which an
underlying disease causes the observed symptoms (Borsboom, 2017).
Network theory posits that mental disorders consist of clusters of
symptoms that co-occur for unknown reasons, resulting in unsuccessful
searches for a single common cause of any mental disorders (Borsboom,
2017). For example, in panic disorder the panic attacks cause worry
about future panic attacks as well as behavioral changes to avoid panic
attacks (Borsboom & Cramer, 2013). Network theory would assert that
there is no latent construct causing avoidance, worry, and panic attacks
separately (Borsboom & Cramer, 2013). Similarly, within a panic attack
symptoms are thought to have causal influences over one another (e.g.,
shortness of breath causing dizziness which in turn causes fears of losing
control).
In a network analysis, symptoms are represented as “nodes” and
connections are represented by lines called “edges.” From this
perspective, the most central nodes (i.e., symptoms) of the network exert
the most influence over the rest of the symptoms and are hypothesized to
be of most theoretical and clinical interest (Freeman, 1978). Thus, in the
case of daytime and nocturnal panic attacks, the centrality of physical
versus cognitive symptoms in each network may reveal new information
about the panic experiences in relation to one another. Some research,
however, has indicted that factors beyond centrality may be important
to consider such as the point at which the symptoms develop in the
course of the disorder, transdiagnostic factors for comorbid disorders,
and resilience factors (Fried et al., 2017).
To our knowledge, network analysis techniques have yet to be used
to characterize panic attack symptoms. Robinaugh et al. (2019) have
suggested that panic attacks may be viewed from a network perspective.
2
Journal of Anxiety Disorders 85 (2022) 102514
They proposed that learned high arousal schemas lead to panic attacks
in response to normal variations in physiological symptoms through
positive feedback loops. These positive feedback loops are believed to
consist of conditioned threat responses to interoceptive stimuli that
occur in the absence of ongoing cognitive appraisals. Robinaugh et al.
(2020) then used network analysis to illustrate changes in panic disorder
symptoms throughout treatment but did not include individual cogni­
tive and physical symptoms reported by participants as characteristic of
their panic attacks. Instead, physical symptoms were combined into one
node and cognitive symptoms were combined into another node to be
assessed in relation to avoidance behaviors, escape behaviors, and
emotional responses (Robinaugh et al., 2020). Network analysis repre­
sents an opportunity to examine the interactions between specific
physical and cognitive panic symptoms in nocturnal and daytime panic
attacks for the first time, and to compare the central nodes of those
networks to one another.
1.1. Aims and hypotheses
The current study expands on extant literature addressing nocturnal
panic attacks compared to panic attacks that occur from a wakeful state.
This study is the first to use a network analysis approach to visualize and
compare symptom clusters between nocturnal and daytime panic at­
tacks. This study will further extend the literature by using equivalence
testing to determine if nocturnal and daytime panic attacks are experi­
enced as equally severe. We predict that nocturnal and daytime panic
symptom reports will produce significantly different network structures,
with nocturnal panic attacks having more central physical symptom
nodes and daytime panic attack having more central cognitive symptom
nodes. We also predict that nocturnal and daytime panic attacks will be
rated as equally severe. We expect these patterns to hold both when
comparing individuals who panic only while awake (daytime panic
group; DP) to those who panic while awake and out of sleep (nocturnal
panic group; NP) as well as when comparing daytime and nocturnal
panic attacks within the NP group. Lastly, we predict that physical
symptoms will be rated as more severe by the NP group whereas
cognitive symptoms will be rated more severe by the DP group.
2. Methods
2.1. Participants
Participants (N = 215) were adults recruited for two online studies
examining anxiety and sleep disturbances (Smith, Martin, Bauer, Ban­
del, & Capron, 2020; Smith & Capron, 2020). Inclusion criteria for both
studies required participants to be at least 18 years of age, living in the
United States, and able to read English fluently. Participants were
divided into nocturnal panic (NP), daytime panic (DP), and without
panic (WP) groups based on self-report of panic attack history. In­
dividuals from the WP group were not included in the current study’s
analyses. Participants who endorsed having at least one past nocturnal
panic attack comprised the NP group (N = 107) regardless of whether or
not they also endorsed a history of daytime panic attacks. Ninety-five
participants endorsed both daytime and nocturnal panic attacks
(88.8% of NP) and 12 participants endorsed only nocturnal panic attacks
with no history of daytime panic attacks (11.2% of NP). Participants
who endorsed having at least one past daytime panic attack and no
history of nocturnal panic attacks comprised the DP group (N = 108).
Fifty-six NPs and 52 DPs were recruited through Amazon’s Mechanical
Turk (MTurk) system and had an approval rating of 95% or higher. The
remaining participants were recruited through a Southeastern uni­
versity’s online student participant pool.
A stringent screening process was used to account for difficulties in
differentiating panic attacks from sub-clinical anxiety in self-report data.
Participants were excluded if they endorsed having had a nocturnal or
daytime panic attack but failed the corresponding panic attack
N.S. Smith et al. Journal of Anxiety Disorders 85 (2022) 102514

definition check. The definition checks for both nocturnal and daytime
panic required that the participants choose the correct description from
four alternatives containing distractor options that are commonly
confused with panic (e.g., feelings of nervousness, waking from a
nightmare). Participants were also excluded if they endorsed having had
a nocturnal or daytime panic attack but denied ever experiencing four or
more panic symptoms during a single panic attack, as required by DSM-5
criteria (APA, 2013). No demographic differences were found when
comparing those included and excluded from analyses.
Participants ranged in age from 18 to 67 (M=28.4, SD=10.5) and
were mostly female (N = 152; 70.7%). The majority of participants
identified their race as White (70.2%) with the rest of the sample
identifying as Black/African American (13.0%), Latinx (7.0%), Bi-racial
(7.0%), Asian (2.3%), or American Indian (0.5%). Demographic char­
acteristics of panic groups are reported in Table 1. Participants in the NP
group were more likely to identify as Bi-racial (11.3%), to have served in
the military (14%), to have a disability (17.8%), and to identify as
transgender (10.3%). Participants in the DP group were more likely to
identify as Black/African American (17.6%).
2.2. Procedure
2.3. Measures
2.3.1. Nocturnal Panic Screen
The Nocturnal Panic Screen (Craske & Tsao, 2005) is an 18-item
measure used to assess an individual’s history of nocturnal panic at­
tacks regarding frequency, symptom severity, and timeline (e.g., When
was your most recent panic attack from a sleeping state?). The online
version of the screener provides a detailed description of a nocturnal
panic attack displayed at the top of the screen so that participants may
easily differentiate nocturnal panic from other nighttime awakenings (e.
g., nightmares, sudden noises). Participants provide severity ratings for
the fourteen panic symptoms listed in the DSM-5 on a 5-point Likert
scale (ordinal variables) ranging from 0 (Not at all) to 4 (Extreme) based
on their typical experience of recent panic attacks. Participants rated the
severity of ten physical symptoms (e.g., shortness of breath, dizziness)
and four cognitive symptoms (e.g., detached or unreal feelings, fears of
going crazy). The final item on the online version of the Nocturnal Panic
Screen is a definition check used to ensure that participants could
correctly identify a nocturnal panic attack from a set of distractors
commonly confused with nocturnal panic. In this sample, the symptom
severity ratings of the nocturnal panic screener had good reliability (ω =
0.87, 95% CI:.84–0.91).

Participants who met the eligibility criteria completed self-report 2.3.2. Daytime Panic Screen
questionnaires online. Please refer to the original studies (Smith et al., The Daytime Panic Screen mirrors the structure and wording of the
2020; Smith & Capron, 2020) for specific procedures. All procedures for Nocturnal Panic Screen (described above). It is a 19-item measure that
both studies received approval from the university’s Institutional Re­ assesses the frequency, symptom severity, and timeline of daytime panic
view Board. All participants provided informed consent prior to data attacks (e.g., Have you ever experienced a panic attack while awake?). In
collection. addition to the items included in the Nocturnal Panic Screen, the Day­
time Panic Screen also contains an item concerning unexpected daytime
Table 1 panic attacks (e.g., Have you ever experienced a panic attack while awake
Demographic characteristics by group. that occurred for no apparent reason or “out of the blue”?) The online
Nocturnal Panic Daytime Panic version of this screener provides a detailed description of a daytime
Percentage Percentage χ2 panic attack displayed at the top of the screen so that participants may
Biological Sex easily differentiate daytime panic from other forms of anxiety. Partici­
Female 68.2% 73.1% 52 pants report severity ratings for the fourteen panic symptoms listed
Race 04 * above on a 5-point Likert scale (ordinal variables) ranging from 0 (Not at
White 72.0% 68.5%
all) to 4 (Extreme). The final item on the online version of the Daytime
Black/African American 8.4% 17.6%
Latinx 6.5% 7.4%
Panic Screen is a definition check used to ensure that participants could
Asian 9% 3.7% correctly identify a daytime panic attack from a set of distractors
American Indian 9% 0% commonly confused with panic. In this sample, the symptom severity
Bi-racial 11.3% 2.7% ratings of the daytime panic screener had good reliability (ω = 0.89,
Marital Status 10
95% CI:.86–0.91).
Never married 65.4% 77.8%
Married 26.2% 13.9%
Divorced 8.4% 7.4% 2.4. Data Analytic Plan
Widowed 0% .9%
Education 31
We performed the network analyses in four main steps: 1) Network
High school diploma 15.0% 21.3%
Some college, no degree 41.1% 32.4% estimation; 2) Network inference; 3) Network stability; and 4) Network
College Degree 43.9% 45.4% comparison. All data analyses were performed using R version 4.0.3 (R
Employment status 44 Core Team, 2020) and we used the R package qgraph (Epskamp, Cramer,
Unemployed 28.0% 36.1% Waldorp, Schmittmann, & Borsboom, 2012) to visualize networks. A full
Employed part-time 25.2% 25.0%
Employed full-time 45.8% 38.9%
list of packages can be found in the Supplemental Material. Study var­
Military Status 02 * iables were normally distributed. Missing data were handled using the
Not a veteran 86.0% 97.2% MICE package v. 3.8 in R (Van Buuren & Oudshoorn, 2020).
Veteran 6.5% .9%
Active duty 6.5% .9%
2.4.1. Network estimation
Reserve 9% .9%
Disability 17.8% 5.6% 01 * To examine the network structure of panic symptoms between DP
Sexual Orientation 68 and NP, we estimated two independent Gaussian Graphical Models (i.e.,
Heterosexual 73.8% 82.4% regularized partial correlation network) using the qgraph package
Homosexual 2.8% 1.9% (Epskamp et al., 2012). The Gaussian Graphic Models (GGM) is a reg­
Bisexual 20.6% 13.9%
Asexual 9% .9%
ularization technique that retrieves a sparse network where spurious
Pansexual 9% .9% edges are removed (Epskamp & Fried, 2018), and is encouraged when
Transgender 10.3% .9% 01 * assessing psychological networks with smaller sample sizes (Epskamp,
Age Kruis, & Marsman, 2017). In GGM, if two symptoms are connected, they
Mean (SD) 28.6 (10.9) 28.1 (10.2) p = .68
form an edge indicating that symptoms may be conditionally dependent
Note. Nocturnal Panic N = 107. Daytime Panic N = 108. * p < .05. upon one another after controlling for all other symptoms. We used the

3
N.S. Smith et al.
Graphical Least Absolute Shrinkage and Selection Operator (gLASSO;
Friedman, Hastie, & Tibshirani, 2014) with Extended Information Cri­
terion model selection (EBIC; Luo & Chen, 2014; γ = 0.5) to estimate two
individual networks (i.e., DP, NP).
The Fused Graphical Lasso (FGL) was used to estimate a joint
network (Danaher, Wang, & Witten, 2014). The FGL extends gLASSO by
applying an additional penalty to differences among corresponding edge
weights in networks using differing samples. Overall, FGL improves
network estimates by neither suppressing differences or increasing
similarities across groups. Optimal values and parameters were selected
by using a k-fold cross-validation using the EstimageGroupNetwork
package (Costantini & Epskamp, 2017). Networks were plotted using the
Fruchterman-Reingold’s algorithm (Fruchterman & Reingold, 1991),
where more strongly related nodes hold central positions. The strength
of the associations is reflected visually by the thickness of the edges
whereas the valence (i.e., positive, negative) connections between nodes
is depicted by edge color. The maximum absolute edge weight was set at
“1.0′′ and graph layouts were fixed allow comparison between the two
network graphs.
2.4.2. Network inference
To identify nodes that were most influential in the 14-item panic
symptom network, we estimated expected influence (Robinaugh, Mill­
ner, & McNally, 2016) rather than strength. Expected influence is the
sum of all edges of a node and takes into account both positive and
negative edges. This is in contrast to using the absolute sum of all edges
(i.e., node strength), which may distort interpretation. Further, recent
work has indicated that betweenness and closeness are often not reliably
estimated (Epskamp, Borsboom, & Fried, 2018); this also occurred in
our analyses (see Supplemental Material). Thus, we focus on expected
influence in this manuscript to interpret centrality. Higher expected
influence values suggest that nodes are more central within the network.
We estimated the variance of each node explained by its neighbors (i.e.,
node predictability; Haslbeck & Fried, 2017) using the mgm package
(Haslbeck & Waldorp, 2015). The predictability of a node is visualized
as a pie chart in the circles surrounding the nodes, with the colored area
in the outer ring representing the percentage of variance of the node that
is explained by neighboring nodes. Lastly, the network approach is ideal
for locating symptoms that serve as bridges between symptoms (Cramer,
Waldorp, Van Der Maas, & Borsboom, 2010). Thus, we also calculated
the bridge expected influence values (Jones, Ma, & McNally, 2019) to
detect the sum of all edges between physical panic symptoms and
cognitive panic symptoms.
2.4.3. Network stability
To test the accuracy and stability of the networks we adhered to the
guidelines provided by Epskamp et al. (2018) using the bootnet package
(Epskamp, 2015). Stability estimates have only recently been introduced
(Epskamp et al., 2018) and at present have not been available for jointly
estimated networks; thus, we examined stability for the two individual
networks. First, we used 1000 non-parametric bootstrapping iterations
to estimate the accuracy (95% confidence intervals [CI]) of the edge
weights to investigate the accuracy of edges within each network (rec­
ommended for ordinal data; see Epskamp et al., 2018) and plotted sig­
nificant differences between edge weights. Because regularization is
used to estimate the networks, edge-estimates are biased towards zero
and sampling distributions are not CIs that are centered on the true
parameter value. Importantly, although quantiles overlapping with zero
could indicate that the corresponding CI does not overlap with zero, if
there is no overlap, then it is known that the corresponding CI does not
overlap with zero. As such, bootstrapped results should not be used for
testing if edges are significantly differently from zero (Epskamp et al.,
2018; Fried et al., 2020). Therefore, edge-weight boostrapped CIs should
only be used to show the accuracy of edge-weight estimates and
compare edges to one another, with wider boostrapped CIs indicating
that edge strength may be more difficult to interpret (Epskamp et al.,
4
Journal of Anxiety Disorders 85 (2022) 102514
2018). Lastly, as other authors have noted (e.g., (Vervaet, Puttevils,
Hoekstra, Fried, & Vanderhasselt, 2021)), cutoffs for interpreting
edge-weight accuracy through bootstrapped confidence intervals is
currently missing in the literature.
We assessed the stability of the order of the centrality indices by
using a case-dropping subset bootstrap, where nodes that remain
centralized in an estimated network after random subsets of participants
are removed, it suggests stability of the order of centrality estimates. For
this, we report the correlation stability coefficient that represents the
proportion of participants that can be removed to retain a correlation of
≥ 0.7 between the centrality order of the bootstrapped datasets and the
full dataset or the bootstrap edge weights and the original edge weights
(with 95% probability). According to Epskamp and colleagues (2018),
the centrality stability coefficient should be > 0.25 and preferably ≥
0.50.
2.4.4. Network difference estimation
To evaluate potential difference in network structure between panic
groups, we performed two analyses. First, we investigated the similarity
of the two networks by correlating their adjacency matrices, the pre­
dictability nodes, and the centrality indices. Correlation coefficient
strength from + /− 0.1 to.3 were considered weak, + /− 0.3 to + /− 0.6
moderate, and + /.7 or above was conserved strong (Dancey & Reidy,
2007). Second, we used permutation tests for connectivity invariance
and network structure invariance to determine potential differences
between the networks using the NetworkComparisonTest package (van
Borkulo, Epskamp, Jones, Haslbeck, & Millner, 2016). Connectivity
invariance tests if the sum of all absolute edges (i.e., global strength)
between the two networks differ whereas the network structure
invariance investigates if the two graphs differ statistically.
2.4.5. Power analysis
We used a post-hoc sensitivity analysis to determine if the NP sample
was adequate for assessing similarities and differences between both
networks. To do this, we simulated datasets with different sample sizes
(i.e., 100, 200, 300, 450, 750, 1000) based on the parameters of the DP
data set. We used three indices to determine an adequate sample size: 1)
the correlation between the estimated network and the true network; 2)
sensitivity – the ability for the estimated network to discover edges; and
3) specificity – the extent to which the estimated network can discover
absent edges. Lastly, we investigated how well expected influence is
obtained. The simulation study (see Supplemental Material) indicated
that 100 participants was an adequate sample size with correlation
values of.85 (N = 200 resulted estimated at.9), a sensitivity value of.78
(N = 200 resulted estimated at.85), and expected influence of.88 (N =
200 resulted estimated at.94). As expected, the specificity (0.65) did not
differ after increasing the sample size due to regularization techniques
sacrificing specificity for sensitivity (Epskamp & Fried, 2018).
2.4.6. Symptom severity comparisons
Independent sample two-tailed t-tests were used to examine the
differences in symptom severity ratings between the NP and DP groups.
Symptom severity ratings were averaged across all 14 symptoms
(overall), 10 physical symptoms, and 4 cognitive symptoms. Compari­
sons for overall symptom severity, physical symptom severity, and
cognitive symptom severity were examined. Paired sample two-tailed t-
tests were used to examine differences in overall, physical, and cognitive
symptom severity for daytime and nocturnal panic attacks reported by
individuals from the NP group who reported a history of both types of
panic attacks (N = 95). We used the false discovery rate control method
described by Glickman, Rao, and Schultz (2014) for these four com­
parisons to minimize type I error. We included follow-up testing pro­
cedures for non-significant results.
We used the two one-sided t-test (TOST) approach for equivalence
testing (Lakens, 2017; Rogers, Howard, & Vessey, 1993; Schuirmann,
1987) using selected upper and lower limit bounds (90% confidence
N.S. Smith et al. Journal of Anxiety Disorders 85 (2022) 102514

intervals) based on effect size. With this approach, the null hypothesis is Node predictability (the amount of explained variance of each symptom
that the symptom severity ratings are significantly different at the upper by all other symptoms) is represented by the shaded area surrounding
and lower bounds, and the alternative hypothesis is that both the upper the node. In the DP network panic symptoms explained a mean variance
and lower bounds of the confidence interval are within the bound of of 44.2% and in NP explained a mean variance of 43.8%.
equivalence, thereby rendering the severity ratings between groups The DP and NP networks were strongly correlated with one another
statistically equivalent and clinically unimportant. A sensitivity analysis (r = 0.81). In the DP network, however, the cognitive symptoms were
was conducted using G*Power (v. 3.1) to determine the equivalence more strongly associated with the physical symptoms than in the NP
margin (δ) given the assumption that the true effect is zero, with alpha network, with differences in partial correlation coefficients ranging
level = 0.05, power = 0.80, and sample size of 215, resulting in a from.01 [feeling unreal with fear of going crazy] to.12 [feeling unreal
minimum effect size of d= 0.34. TOST was performed using R (version with fear of losing control], though these differences were not statisti­
4.0.3; R Core Team, 2020) using the “TOSTER” package (Lakens, 2017). cally significant. The strengths of these relationships are depicted in the
When interpreting equivalence testing, if the Null Hypothesis Signifi­ boldness of the lines connecting symptoms in Fig. 1. Inspecting the
cance Test (NHST) is non-significant and the TOST is significant, then graphs, fear of losing control was associated with trembling in the DP
the effect is considered to be statistically equivalent to zero (Lakens, network – as indicated by edge thickness – but appeared less associated
2017). in the NP network. Additionally, detached or unreal feelings was asso­
ciated with hot flashes or cold chills in the DP network, but no such
3. Results association was observed in the NP network.
Interrelationships between physical symptoms were stronger in the
Each group’s data set had less than 1% data missing. Missing data DP network than the NP network as well. For example, racing heart was
were handled by multiple imputation in R using the “MICE” package (v. strongly associated with shortness of breath, moderately associated with
3.8; (Van Buuren and Groothuis-Oudshoorn, 2010)). The MICE package trembling, and very weakly associated with sweating in the NP network.
uses a Fully Conditional Specification algorithm (Buuren & In the DP network, however, racing heart was also moderately associ­
Groothuis-Oudshoorn, 2010), where each continuous variable has its ated with tight or painful chest and weakly associated with hot flashes or
own imputation model using predictive mean matching. Because of the cold chills, nausea, and dizziness. Associations between trembling and
low proportion of missing data (total missing data = 1.1%), a total of choking sensations as well as between hot flashes or cold chills and
five imputations were performed (Enders, 2010; Graham, Olchowski, & numbness were present only in the DP network. Generally, the DP
Gilreath, 2007), resulting in complete data for the network analyses.” network consisted of stronger and more numerous associations between
symptoms compared to the NP network.
Finally, fear of losing control and fear of going crazy were strongly
3.1. Network estimation associated with one another in both networks. The strong association
between these symptoms is unsurprising, given that they are classified as
Descriptive statistics of symptom severity ratings can be found in one symptom in the DSM-5 (APA, 2013). Fear of losing control was
Table 2. Correlations between study variables can be found in Table 3. separated from fear of going crazy in the original Nocturnal Panic Screen
The FGL for DP and NP is presented in Fig. 1 and depicts two clusters of (Craske & Tsao, 2005) because fear of loss of control was thought to
nodes: (1) Physical symptoms of panic disorder; (2) Cognitive symptoms refer specifically to acting in an uncontrolled way whereas fear of going
of panic disorder. The physical symptom cluster contained shortness of crazy was thought to refer to a lack of control over one’s thoughts. Early
breath (“Breath”), pounding heart (“Heart”), chest pain/discomfort nocturnal panic literature sought to differentiate fear of losing control
(“Chest”), feeling dizzy (“Dizzy”), trembling/shaking (“Tremb”), from fear of loss of vigilance, the latter of which was hypothesized to be
sweating (“Sweat”), feelings of choking (“Choke”), chills/heat sensa­ uniquely related to nocturnal panic (Tsao & Craske, 2003).
tions (“HotCold”), nausea/abdominal distress (“Nausea”), and pares­
thesias (“Numb”). The cognitive symptom cluster consisted of 3.2. Network inference
derealization/depersonalization (“Unreal”), fear of losing control
(“Control”), fear of going crazy (“Crazy”), and fear of dying (“Dying”). Next we examined the expected influence and bridge expectance
values between the two networks. The five nodes that exhibited the
Table 2 greatest node expected influence (see Fig. 2) in the DP network were (in
Means and standard deviations for panic symptom severity ratings by group. order) fear of losing control, trembling/shaking, fear of going crazy,
Nocturnal Panic Mean (SD) Daytime Panic Mean (SD) pounding heart, and depersonalization/derealization. Whereas in the
NP network the nodes displaying the greatest expected influence were
1. Breath 2.33 (1.18) 2.39 (1.15)
2. Heart 2.89 (0.89) 2.93 (0.89)
(in order) fear of going crazy, chest pain/discomfort, shortness of
3. Chest 2.15 (1.27) 2.10 (1.35) breath, paresthesias, and feelings of choking.
4. Dizzy 1.74 (1.25) 2.10 (1.35) The highest bridge expected influence values (see Fig. 3) for the DP
5. Tremb 2.37 (1.15) 2.24 (1.24) network were depersonalization/derealization, fear of losing control,
6. Sweat 2.58 (1.22) 1.94 (1.35)
hot/cold sensations, trembling/shaking, and fear of going crazy. For the
7. Choke 1.26 (1.42) .87 (1.21)
8. HotCold 1.96 (1.29) 1.46 (1.26) NP network, the five nodes displaying the largest bridge expected in­
9. Nausea 1.43 (1.35) 1.49 (1.30) fluence were paresthesias, fear of going crazy, fear of losing control,
10. Numb 1.44 (1.28) 1.26 (1.34) depersonalization/derealization, and fear of dying.
11. Unreal 2.43 (1.24) 2.00 (1.38)
12. Crazy 1.91 (1.34) 1.55 (1.44)
13. Control 1.96 (1.35) 2.04 (1.49)
3.3. Network stability
14. Dying 2.04 (1.46) 1.15 (1.41)
Results from the stability analyses suggested that the networks were
Note. Nocturnal Panic N = 107. Daytime Panic N = 108. Symptoms: shortness of
fairly accurately estimated as evidenced by the bootstrapped confidence
breath or smothering sensations (Breath), pounding or racing heart (Heart),
tight or painful chest (Chest), dizziness unsteadiness or faintness (Dizzy), intervals surrounding the edge weights (see Supplemental Material) and
trembling or shaking (Tremb), sweating (Sweat), choking sensations (Choke), adequate edge correlation-stability coefficients (0.28–0.36). The
hot flashes or cold chills (HotCold), nausea or abdominal distress (Nausea), correlation-stability coefficient for expected influence was.29 for DP
numbness or tingling (Numb), detached or unreal feelings (Unreal), fears or and.28 for NP, indicating adequate stability. The correlation-stability
going crazy (Crazy), fears of losing control (Control), fears of dying (Dying). coefficient for bridge expected influence for DP was.29, but.21 for NP.

5
N.S. Smith et al. Journal of Anxiety Disorders 85 (2022) 102514

Table 3
Intercorrelations for panic symptom severity ratings.
Mean SD 1 2 3 4 5 6 7 8 9 10 11 12 13

1. Breath 2.36 1.16 –

2. Heart 2.91 .89 .57** –
3. Chest 2.13 1.31 .55** .43** –
4. Dizzy 1.92 1.31 .35** .30** .42** –
5. Tremb 2.31 1.91 .43** .48** .36** .38** –
6. Sweat 2.26 1.32 27** 29** .29** .21** .47** –
7. Choke 1.07 1.33 .33** .12 .42** .43** .29** .23** –
8. HotCold 1.71 1.30 .26** .24** .29** .33** .33** .44** .34** –
9. Nausea 1.46 1.32 .21** .18** .27** .32** .31** .26** .38** .39** –
10. Numb 1.35 1.31 .30** .22** .38** .45** .34** .21** .41** .34** .36** –
11. Unreal 2.21 1.33 .30** .24** .30** .34** .33** .13 .35** .35** .14* .40** –
12. Crazy 1.73 1.40 .38** .23** .38** .34** .36** .24** .33** .40** .30** .42** .54** –
13. Control 2.00 1.42 .39** .27** .40** .40** .40** .20** .33** .25** .23** .28** .50** .74** –
14. Dying 1.59 1.50 .26** .16* .28** .27** .26** .19** .27** .30** .14* .35** .45** .56** .48**

Note. **p < .01. *p < .05. Symptoms: shortness of breath or smothering sensations (Breath), pounding or racing heart (Heart), tight or painful chest (Chest), dizziness
unsteadiness or faintness (Dizzy), trembling or shaking (Tremb), sweating (Sweat), choking sensations (Choke), hot flashes or cold chills (HotCold), nausea or
abdominal distress (Nausea), numbness or tingling (Numb), detached or unreal feelings (Unreal), fears or going crazy (Crazy), fears of losing control (Control), fears of
dying (Dying).

the global strength test (S=0.03, p = .98) or centrality test (C=− 0.15,
p = .25). These results indicate that the two networks are not statisti­
cally different.

3.5. Symptom severity comparisons

3.5.1. Overall symptom severity between groups

An independent sample two-tailed t-test between the DP and NP
group overall symptom severity mean rating revealed a statistically
significant difference, t(213) = − 2.025, p = .04. After accounting for
false discovery rates, however, this result no longer reached the signif­
icance threshold. To test if this lack of a significant difference was
clinically unimportant, we conducted an equivalence test (TOST). The
equivalence test was not significant, t(213) = 0.758, p = .23, indicating
that the difference in overall symptom severity ratings between the NP
and DP groups was not statistically equivalent. The NP group rated
symptom severity at 2.04 on average whereas the DP group rated
symptom severity at 1.82 on average. This non-significant difference
indicates that the NP group experienced panic symptoms as somewhat
more intense than the DP group, but the difference may be unreliable.

3.5.2. Overall symptom severity within nocturnal panic group

Fig. 1. Visualization of Fused Graphical Lasso (FGL) estimated networks of
daytime panic (left) and nocturnal panic (right). Each node represents a
symptom. Each edge represents the regularized partial correlation between
symptoms. Edge thickness illustrates the degree of positive association. The
shaded gray rings around the nodes represent the predictability (i.e., variance
of a node explained by all its neighbors). “Chs” = chest pain/discomfort; “Brt”
= shortness of breath; “Hrt” = pounding heart; “Trm” = trembling/shaking;
“Swt” = sweating; “HtC” = chills/heat sensations; “Nas” = nausea/abdominal
distress; “Chk” = feelings of choking; “Dzz” = feeling dizzy; “Nmb”
= paresthesias; “Cnt” = fear of losing control; “Crz” = fear of going crazy;
“Unr” = derealization/depersonalization; and “Dyn” = fear of dying.
This indicates that bridge expected influence values may be unreliable in
the current sample. Overall, these stability estimates are on the low end
of acceptability (>0.25; Epskamp et al., 2018) and should be interpreted
with caution.
3.4. Network comparison
Correlations between the adjacency matrices (r = 0.64), predict­
ability nodes (r = 0.33), and centrality indices (r = 0.31) for the two
networks suggested weakly to moderately similarity across groups. The
network invariance test was not significant (M=0.23, p = .86), nor was
A paired sample two-tailed t-test between the daytime and nocturnal
panic attack overall symptom severity ratings for individuals who re­
ported a history of both types of panic attacks (N = 95) revealed a sta­
tistically significant difference, t(94) = 3.012, p = .003. This result
remained significant after accounting for false discovery rates. This
subsection of the NP group rated nocturnal panic symptom severity at
2.09 on average and daytime panic symptom severity at 2.24 on
average. Thus, the NP group rated panic attacks out of a wakeful state as
more severe than panic attacks out of a sleeping state.
3.5.3. Physical symptom severity between groups
An independent sample two-tailed t-test between the DP and NP
group physical symptom severity mean ratings revealed no statistically
significant difference, t(213) = − 1.616, p = .11. To test if this lack of a
significant difference was clinically unimportant, we conducted an
equivalence test (TOST). The equivalence test was not significant, t
(213) = − 0.005, p = .50, indicating that the difference between phys­
ical symptom severity ratings is not statistically equivalent. These results
indicate that the differences found in physical symptom severity ratings
between DP and NP groups can neither be considered statistically
different nor equivalent.

6
N.S. Smith et al.
3.5.4. Cognitive symptom severity between groups
An independent sample two-tailed t-test between the DP and NP
group cognitive symptom severity mean ratings revealed a statistically
significant difference, t(213) = − 2.394, p = .02. This result remained
significant after accounting for false discovery rates. The NP group rated
cognitive symptom severity at 1.97 on average whereas the DP group
rated cognitive symptom severity at 1.57 on average. This small but
significant difference indicates that despite the fact that nocturnal panic
occurs out of a sleeping state with no cognitive triggers, the NP group
still experienced cognitive symptoms as somewhat more intense than
the DP group.
4. Discussion
The present study directly compared the associations between
nocturnal and daytime panic attack symptoms using a network analysis
approach. This is the first study, to our knowledge, to use network
analysis to examine the interrelationships between reported panic attack
symptoms. Panic symptoms have long been theorized to perpetuate one
another in a forward feedback loop (Schmidt et al., 1997; Uhde, 1994);
however, no study has used network analysis to identify specific
7
Journal of Anxiety Disorders 85 (2022) 102514
Fig. 2. Expected influence values for each node
in the Daytime (blue) and Nocturnal panic (red)
networks. Nodes with greater influence are
more central to the network. “1-Brth”
= shortness of breath; “2-Hrt” = pounding
heart; “3-Chst” = chest pain/discomfort; “4-
Dzzy” = feeling dizzy; “5-Trmb” = trembling/
shaking; “6-Swt” = sweating; “7-Chke”
= feeling of choking; “8-HtC” = chills/heat
sensations; “9-Nsea” = nausea/abdominal
distress; “10-Numb” = paresthesias; “11-Unrl”
= depersonalization/derealization; “12-Crzy”
= fear of going crazy; “13-Cont” = fear of
losing control; “14-Dyng” = fear of dying.
associative patterns between symptoms or identify if patterns differ
based on the state the individual is in when the panic occurs (i.e.,
sleeping, awake). Our hypotheses were largely unsupported. Overall,
the network structures of NP and DP groups were largely similar,
although the number and strengths of associations between symptoms
differed between networks. Panic severity ratings were also not statis­
tically equivalent between panic groups, types of panic attacks, or types
of panic symptoms. Interestingly, individuals in the NP group rated
panic attacks that they experienced while awake as more severe than
those experienced out of a sleeping state. The NP group also rated
cognitive symptoms as more severe than the DP group, despite nocturnal
panic being described by Craske and Rowe (1997) as “purely biological”.
Prior research has suggested that because nocturnal panic onset occurs
in the absence of cognitive processes or triggering behavioral events, it
cannot be caused by catastrophic cognitions (Craske & Rowe, 1997;
Labbate et al., 1994). Thus, catastrophic cognitions occurring during
nocturnal panic, presumably after the individual wakes due to the
physical symptoms, have been largely ignored. The results of the present
study suggest that although cognitive symptoms may not cause
nocturnal panic attack onset, they do contribute to distress and likely
play a role in perpetuating physical symptoms after the individual
N.S. Smith et al.
awakens. The maintaining role of cognitive symptoms in nocturnal
panic may help to account for the efficacy of Cognitive Behavioral
Therapy (CBT) approaches to treatment (Craske, Lang, Aikins, & Myst­
kowsk, 2005).
Daytime and nocturnal panic network structures were not statisti­
cally different, indicating that the interrelationships between panic
symptoms are largely similar regardless of whether the panic begins
while the individual is awake or asleep. Several more subtle differences
in symptom associations were noted, however, which provide directions
for future research. First, although cognitive symptoms were not more
central to the DP network, they did produce more relationships with
physical symptoms compared to the NP network. Those cognitive-
physical symptom relationships were also stronger in the DP versus
NP networks. It is possible that cognitive symptoms are more inter­
connected in the DP network because they are present throughout the
panic experience when panic originates from a wakeful state.
Conversely, in nocturnal panic, panic symptoms begin during non-REM
sleep, when there is no opportunity for cognitive activity (Craske &
Rowe, 1997). Thus, cognitive panic symptoms can only occur after the
individual wakes up, already experiencing a constellation of physical
panic symptoms. Importantly, cross-sectional analyses cannot provide
8
Journal of Anxiety Disorders 85 (2022) 102514
Fig. 3. Bridge expected influence values for
each node in the Daytime (blue) and Nocturnal
panic (red) networks. Nodes with greater bridge
expected influence may be most influential for
functioning as a bridge between physical and
cognitive panic symptoms. “1-Brth” = shortness
of breath; “2-Hrt” = pounding heart; “3-Chst”
= chest pain/discomfort; “4-Dzzy” = feeling
dizzy; “5-Trmb” = trembling/shaking; “6-Swt”
= sweating; “7-Chke” = feeling of choking; “8-
HtC” = chills/heat sensations; “9-Nsea”
= nausea/abdominal distress; “10-Numb”
= paresthesias; “11-Unrl” = depersonalization/
derealization; “12-Crzy” = fear of going crazy;
“13-Cont” = fear of losing control; “14-Dyng”
= fear of dying.
information about the order in which symptoms occur; thus, future
longitudinal studies are required to determine when cognitive symp­
toms begin in daytime compared to nocturnal panic attacks.
Individuals in the NP group rated panic symptoms as somewhat more
severe than the DP group despite prior literature demonstrating that
nocturnal panic does not constitute a more severe form of panic disorder
(Craske et al., 2002). Craske and colleagues (2002), however, found a
lack of difference between symptoms characteristic of the disorder (e.g.,
agoraphobic avoidance, interpersonal functioning impairment) rather
than differences in the experience of the panic attacks themselves. In
contrast to the Craske et al. (2002) study, the current study was not
limited to individuals who met criteria for panic disorder, but included
participants who had experienced panic attacks regardless of psycho­
logical diagnoses. Therefore, it is possible that individuals who panic out
of sleep do experience more severe panic attacks without also experi­
encing more fear of future panic attacks, avoidance behaviors, and
functional impairment. Differences in reported severity related to ex­
pected versus unexpected daytime panic may also be relevant. The
current study did not separate daytime panic symptom ratings based on
whether or not the individual was aware of external factors leading to
the panic attack. Previous literature has indicated that expected panic
N.S. Smith et al.
attacks are rated as less severe than unexpected daytime panic attacks
(Brown et al., 2016). Thus, future studies should separate daytime panic
severity ratings based on whether they were expected or unexpected to
clarify this point. It is possible that nocturnal panic attacks are rated
equally severe compared to unexpected daytime panic, but more severe
than expected daytime panic. Accounting for the nature of daytime
panic severity may also help to clarify the severity ratings of physical
symptoms, which were neither statistically different nor equivalent in
the current study.
Cognitive symptoms were rated as significantly more severe in
nocturnal compared to daytime panic attacks. This finding did not
support our hypothesis and challenges the conceptualization of
nocturnal panic as a purely biological event (Labbate et al., 1994; Sha­
piro & Sloan, 1998). Given that nocturnal panic begins during the
transition between Stage II and Stage III sleep, during which there are no
dreams or nightmares (Craske & Rowe, 1997), it is possible that
cognitive symptoms play no role in initiating the panic episode but occur
when the individual is awakened. This may also help to explain the lack
of associations between cognitive and physical symptoms in the
nocturnal panic symptom network. Physical symptoms may develop
first, while the individual is still sleeping, then intensify to the point of
distrupting sleep, at which point cognitive symptoms are added, inter­
acting with and perpetuating physical symptoms. The cognitive symp­
toms may also be at least partly related to waking abruptly from sleep,
resulting in weaker connections to physical panic symptoms when
compared to daytime panic attacks. Though, longitudinal studies are
needed to determine the temporal order of panic symptoms or the source
of any particular symptom.
The results of this study must be interpreted in light of the limita­
tions. Panic symptom information was based on cross-sectional retro­
spective reporting. Although the measures produced good reliability
estimates and the networks were adequately stable, some error is ex­
pected when asking about symptom severity of panic attacks occurring
throughout participants’ lifetimes. A promising line of future research
may be to employ an ecological momentary assessment design to cap­
ture symptom severity ratings immediately following panic events
across a period of time. Wearable technology, such as actigraphs and
smart watches, may also be employed to track certain physical symp­
toms in real time. This approach may help to address questions
regarding temporal relations of symptoms that cannot be answered with
cross-sectional data.
The current study also had a number of notable strengths. Network
analysis provides a unique opportunity to conceptualize panic symp­
toms as having causal influence over one another instead of being
caused by a latent variable (McNally, 2016). Further, this study did not
rely on a panic disorder diagnosis for inclusion, as previous nocturnal
panic studies have (e.g., Craske & Barlow, 1989; Freed et al., 1999).
Panic attacks occur outside the context of panic disorder regardless of
whether they occur during sleeping or wakeful states (Craske & Rowe,
1997). Thus, a complete understanding of panic attacks, and nocturnal
panic more specifically, cannot be based only on data from individuals
diagnosed with panic disorder. Finally, participants were required to
pass a thorough screening process in order to be included in the study to
ensure reliable panic group assignment, whereas prior research has
relied on single items to assess for panic history (e.g., Smith, Albanese,
Schmidt, & Capron, 2019; Tsao & Craske, 2003) or one-on-one clinical
interviews (e.g., Craske, Lang, Tsao, Mystkowski, & Rowe, 2001; 2005).
4.1. Conclusions
This study contributes to existing nocturnal panic literature by
providing novel information regarding symptom networks in both
daytime and nocturnal panic attacks. Results indicate broad similarities
between the two types of panic attacks (i.e., daytime, nocturnal) as well
as subtle differences in the number and strengths of connections be­
tween physical and cognitive panic symptoms. Differences in severity
9
Journal of Anxiety Disorders 85 (2022) 102514
ratings, particularly the more severe cognitive symptom ratings reported
by the nocturnal panic group provide new insights and challenge pre­
vious conceptualizations of nocturnal panic as a purely biological form
of panic. Future research is needed to clarify the role of cognitive
symptoms in nocturnal panic.
Acknowledgments
None.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declarations of interest
none.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.janxdis.2021.102514.
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