300 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Hypothesis 3. Catastrophic Misinterpretation
Panic attacks are characterized by a misinterpretation of bodily or mental sensations
as signifying an imminent physical, mental, or social catastrophe. Production of the
catastrophic misinterpretation will increase panic symptoms in individuals with panic
disorder, whereas correction of the misinterpretation will prevent panic attacks (see D. M.
Clark, 1996).
Over the years various reviews of the relevant literature have concluded that there is
strong support that individuals with panic disorder are significantly more likely to mis-
interpret bodily sensations in terms of a serious impending threat or danger than non-
panic comparison groups (for reviews, see Austin & Richards, 2001; Casey et al., 2004;
Khawaja & Oei, 1998). Moreover, there is considerable empirical evidence that panic
disorder is characterized by elevated scores on the ASI Fear of Somatic Sensations sub-
scale, a finding entirely predicted by the catastrophic misinterpretation hypothesis (e.g.,
Deacon & Abramowitz, 2006a; Rector et al., 2007; Taylor, Zvolensky, et al., 2007; see
also discussion of anxiety sensitivity in Chapter 4). And yet, dissenting views have been
expressed stating that a number of key aspects of the catastrophic misinterpretation
hypothesis remain in doubt (McNally, 1994; Roth et al., 2005). Three types of research
provide a critical test of the catastrophic misinterpretation hypothesis: self- report mea-
sures of catastrophic cognitions, clinical studies of the relation between misinterpreta-
tions of bodily sensations and subsequent panic symptomatology, and evidence of cogni-
tive mediation in biological challenge experiments.
Various clinical studies indicate that most individuals with panic disorder report
thoughts or images of physical or mental catastrophe in response to internal stimuli
during panic episodes (e.g., Argyle, 1988; Beck et al., 1974; Ottaviani & Beck, 1987).
The Agoraphobic Cognitions Questionnaire (ACQ) assesses the frequency of maladap-
tive thoughts about catastrophic consequences (e.g., fainting, choking, heart attack,
loss of self- control) when feeling anxious (Chambless, Caputo, Bright, & Gallagher,
1984). Individuals with panic disorder score significantly higher than depressed and
other anxiety disorder groups on the ACQ Physical Concerns but not the Social/Behav-
ioral Consequences factor (Chambless & Gracely, 1989).
D. M. Clark et al. (1997) developed the Body Sensations Interpretation Question-
naire (BBSIQ) to assess endorsement rates and belief in threatening, positive, or neutral
explanations for ambiguous panic body sensations and external events (control items).
Analysis revealed that panic disorder patients ranked negative interpretations of panic
body sensations as significantly more probable and believed the negative explanation
more than GAD, social phobia, or nonclinical comparison groups. Furthermore, the
BBSIQ correlated .49 with the ACQ Physical Concerns subscale (for similar findings, see
Austin, Richards, & Klein, 2006; Teachman et al., 2007). However, Austin et al. (2006)
found that panic patients rarely made a subsequent harm- related interpretation (e.g.,
“I’m having a heart attack”) to their initial anxiety- related interpretation (e.g., “I’m
having a panic attack”). Studies that examined interpretations to ambiguous scenarios
also found evidence of a threat interpretation bias for physical sensations in panic disor-
der compared to nonclinical controls (Kamieniecki et al., 1997; McNally & Foa, 1987;
see also Uren et al., 2004), although it appears the panic disorder individuals generated
more anxiety interpretations for both internal and external threats. Generally the self-