Abnormal Psychology

Anxiety Disorders 271

over and above the physical ones, were more challenging to people with preexisting

anxiety sensitivity (Schmidt, Lerew, & Jackson, 1997). (Note, however, that this

study examined spontaneous panic attacks, not panic disorder.)

Cognitive explanations can also explain nocturnal panic attacks. Nocturnal

panic attacks occur in the fi rst few hours of sleep during the transition into the

stage of slow-wave (deep) sleep (Bouton, Mineka, & Barlow, 2001); they do not

occur during REM sleep—the stage of sleep when rapid eye movements occur and

during which most dreaming occurs. Thus, nocturnal panic attacks are not asso-

ciated with dreams (or nightmares). What might cause these nighttime panic at-

tacks? A cognitive explanation focuses on the individual’s hypervigilance for bodily

changes—such as alterations in breathing patterns—during sleep, as might occur

during the transition to slow-wave sleep (Barlow, 2002b; Craske & Rowe, 1997).

Support for this explanation comes from the fi nding that patients who experience

nocturnal panic attacks report more breathing-related symptoms than do patients

whose panic attacks occur solely while they are awake (Sarísoy et al., 2008).

Social Factors: Stressors, “Safe” People, and a Sign of the Times

Evidence suggests that social stressors contribute to panic disorder: People with panic

disorder tend to have had a higher than average number of such stressful events dur-

ing childhood and adolescence (Horesh et al., 1997). Moreover, 80% of people with

panic disorder reported that the disorder developed after a stressful life event.

Social factors are often related to the ways patients cope with agoraphobia. The

presence of a close relative or friend —a “safe person”— can help decrease catastrophic

thinking and panicking when a person with agoraphobia feels anxious. The safe person

can also decrease the sufferer’s arousal (Carter et al., 1995). Although a safe person can

make it possible for the patient with agoraphobia to go into situations that he or she

wouldn’t enter alone, reliance on a safe person can end up perpetuating the disorder:

By venturing into anxiety-inducing situations only when a safe person is around, the

patient never habituates to his or her anxiety symptoms. Campbell describes his feelings

about being alone versus having another person with him: “I’m still afraid to be alone

for long stretches of time: my fear is that I’ll have an attack, no one will be there to help

me, and I’ll die. But because I used to enjoy spending time alone, I push that envelope

hard” (Campbell & Ruane, 1999, p. 197).

Cultural factors can infl uence whether people develop panic disorder, perhaps

through culture’s infl uence on personality traits. Consider that over the last fi ve

decades, increasing numbers of Americans have developed the personality trait of

anxiety-proneness (Spielberger & Rickman, 1990). The average child today scores

higher on measures of this trait than did children who received psychiatric diag-

noses in the 1950s (Twenge, 2000)! Specifi cally, the average anxiety score for chil-

dren with psychological problems in 1957 was somewhat lower than the average

anxiety score for children without psychological problem in the 1980s. The higher

baseline level of anxiety in the United States may be a result of greater dangers in

the environment—such as higher crime rates, new threats of terrorism, and new

concerns about food safety.

FEEDBACK LOOPS IN ACTION: Understanding Panic Disorder

Cognitive explanations of panic disorder can help show how a few panic attacks can

progress to panic disorder, but not everyone who has panic attacks develops panic

disorder. It is only when neurological and psychological factors interact with bodily

states that panic disorder develops (Bouton, Mineka, & Barlow, 2001). Cognitive

processes such as catastrophic thinking and anxiety sensitivity (psychological fac-

tors) are triggered, in part, by environmental and social stressors (social factors).

Indeed, such stressors may lead an individual to be aroused (neurological factor),

but he or she then misinterprets the cause of this arousal (psychological factor). This

misinterpretation may increase the arousal (Wilkinson et al., 1998), making it more

likely that symptoms of panic—rapid heartbeat or shallow breathing—will follow.

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