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Panic Disorder
in African Americans:
A Review of the
Literature and Proposal for Future Research
Jeffrey W.
Braunstein, Ph.D.
Abstract
Despite significant advances
in the assessment and treatment of panic disorder during the last fifteen years,
there still remains a void in the application of these advances with the African
American population. The influence of cultural differences regarding the
diagnosis and treatment of panic disorder requires further exploration so that
psychologists can provide more effective treatment for African Americans, a
group comprising a significant and growing part of the United States
population. The following paper compares the existing literature regarding the
etiology, diagnosis, misdiagnosis, assessment, and treatment of panic disorder
of African American and White Americans who suffer from panic disorder.
Research involving the investigation of irrational beliefs and panic disorder as
a function of ethnicity will be proposed
Diagnostic, Epidemiological,
and Assessment Issues
Researchers have
suggested that the Diagnostic Statistic Manual – IV (DSM-IV, 1994) suffers from
a lack of cultural validity and sensitivity (Mezzich, Fabrega, & Kleinman,
1992). Despite these deficits, the DSM-IV is widely used with all populations
in the United States. Innovations in diagnosis would benefit from including
normative information regarding specific cultures and ethnicity. Integrating
cultural formulations and glossaries of culture-bound syndromes into our current
diagnostic system could further our understanding of psychopathology (Hughes,
Simons, and Weintrob, 1992).
The
Diagnostic Statistic Manual – IV (DSM-IV, 1994) specifies that panic attacks
are, “a discrete period of intense fear or discomfort, in which four (or more)
of the following symptoms developed abruptly and reached a peak within 10
minutes (p. 395).” Symptoms such as palpitations, accelerated heart rate,
sweating, trembling, feeling of choking, chest pain, fear of losing control, and
a fear of dying are commonly experienced by people experiencing panic attacks.
Receiving a diagnosis of panic disorder is dependent on a person’s experience of
recurrent unexpected panic attacks, persistent concern and worry about
additional attacks, and a change of behavior due to the attacks. The DSM-IV
also specifies that “the Panic Attacks are not better accounted for by another
mental disorder (p. 402).” Physiological effects of substances and general
medical conditions are other rule out conditions that must be considered when
making a diagnosis of panic disorder. Agoraphobia frequently develops as a
result of the experience of repeated unexpected panic attacks. Anxiety about
being in situations and places associated with the experience of panic attacks
develops, leading to the avoidance of situations and places.
Various organic
conditions can produce panic and anxiety symptoms and should be screened for to
avoid a misdiagnosis (Barlow, 1988). Hypoglycemia, hyperthyroidism,
hypoparathyroidism, Cushing Syndrome, Pheochromocytoma, Temporal-Lobe Epilepsy,
caffeine intoxication, and Mitral Valve Prolapse are some examples of
physiological-based conditions that can mimic the symptoms of panic and
anxiety. The aforementioned conditions can also exacerbate panic symptomatology.
Studies conducted
throughout the world suggest that panic attacks occur frequently in the general
population. Norton, Harrison, Hauch, and Rhodes (1985) reported that 34% of the
general population experienced at least one panic attack in 1984. This study
was replicated one year later and reported a similar prevalence. Grant funded
research conducted by the NIMH has indicated that between 9 and 15 million
people suffer from panic disorder with or without agoraphobia. Self-medicating,
through the abuse of alcohol and illicit substances, has been found to occur
frequently in people who suffer from panic disorder (Quitkin, F.M., Rifkin, A.,
Kaplan, J., and Klein, D.F.,1972).
To date,
only one study funded by the NIMH has reported on the prevalence, clinical
features, comorbidity, and outcome of panic disorder among African Americans
(Eaton, & Kessler, 1985; Regier et al., 1984). Lifetime prevalence of panic
disorder among African Americans was not significantly different from whites.
African American subjects reported similar profiles regarding panic
symptomatology, with tingling sensations in the extremities presenting more
frequently in African Americans than in White Americans. African Americans also
presented with similar profiles when compared to White subjects regarding the
prevalence of suicidal and homicidal ideation, comorbid psychopathology, and
substance abuse. The primary difference between African American and White
subjects was with treatment seeking behavior. African Americans were one-fifth
as likely to pursue mental health treatment than their White counterparts,
despite controlling for socioeconomic and demographic variables. In general,
panic disorder presents as a similar illness in both African American and White
populations, but the majority of African Americans never receive appropriate
treatment.
African Americans are often
misdiagnosed when seeking treatment at mental health centers. Friedman, Lazar,
Grubea, & Kesselman, (1992) reported that anxiety disorders are often
underdiagnosed in African Americans. African Americans suffering from anxiety
disorders are often misdiagnosed with affective and psychotic disorders.
Research has suggested that isolated sleep paralysis, which is not classified by
the DSM IV as a symptom of panic disorder, is frequently experienced by African
Americans (Bell, Hildreth, Jenkins, & Carter, 1988) with clinicians frequently
missing concurrent panic symptomatology. Friedman (1994) emphasizes that
further investigation is needed to assess symptoms that are specific to African
Americans but which are not currently classified in the DSM-IV.
Structured interviews, questionnaires,
self-monitoring measures, assessing cognition, and the assessment of safety
signals and their relationship to agoraphobic avoidance are the primary methods
of assessing the existence and severity of panic disorder (Barlow, 1988). The
Anxiety Disorder Interview Schedule Fourth Edition (ADIS – IV) is a
comprehensive interview for diagnosing all DSM IV anxiety disorders and is
highly regarded in this area (DiNardo & Barlow, 1988). Friedman (1994) suggests
that the ADIS – IV is the most accurate instrument for diagnosing panic disorder
in African Americans. Self-report measures such as the Fear Questionnaire
(Marks & Mathews, 1979), Agoraphobic Cognitions Questionnaire (Chambless,
Caputo, Bright, & Gallegher, 1984), Body Sensations Questionnaire (Chambless, et
al., 1984), and Mobility Inventory for Agoraphobia (Chambless, Caputo, Jasin,
Gracely, and Williams, 1985) are commonly used to assess panic disorder and can
be completed rapidly. Cognitive therapy techniques and the in vivo exposure of
feared situations and places routinely illicit catastrophic ideation and
irrational beliefs found in people with panic disorder (Barlow, 1988).
Unfortunately, empirical investigations regarding the prevalence and
characteristics of irrational beliefs found in people with panic disorder have
not been conducted. The monitoring of behavioral and emotional events
associated with panic attacks usually uncover panic symptomatology and the
extent of agoraphobic avoidance (Barlow, 1988). Safety signals such as safe
places, a safe person, or inanimate objects such as unused or empty pill bottles
should be delineated before the commencement of treatment.
The Etiology of Panic Disorder
Currently, there
has not yet been a discovery of a clear biological marker for panic (Barlow,
1988). Research investigating differential neurobiological processes have
failed rigorous empirical tests. Environmental influences rather than genetic
disposition account for more of the variance in the development of panic
disorder. It is also hypothesized that a genetic vulnerability such as an
overly responsive autonomic nervous system might predispose a person to
developing an anxiety disorder under specific environmental and psychological
condition.
Approximately 80%
- 90% of panic disorder patients usually experience a negative life event
closely associated with their first panic attack (Barlow, 1988). Physiological
changes such as giving birth, menopause, and gynecological surgery have also
been identified as precipitating a first panic attack.
Research suggests
that panic attacks are generated by misappraisals of normal bodily sensations
that are typically experienced during stressful situations (Barlow, 1988).
These misappraisals lead to an excessive amount of fear that result in the
experience of panic. People who experience unexpected panic attacks do not
associate stressful situations with the cause of their symptoms but instead
learn to become fearful of normal physiological changes. These fears become
strongly associated with objects and situations, resulting in the experience of
anxiety in the presence of these objects and situations. Anxiety also occurs
when patients worry about having another unpredictable panic attack.
Cognitive-Behavioral
Interventions
Within the last 15 years,
cognitive-behavioral interventions have provided a significantly improved
prognosis for patients suffering from panic disorder. A protocol treatment for
panic disorder (Barlow, 1988) has received the greatest amount of study
regarding efficacy and consists of four components: psychoeducation, breathing
and relaxation training, and exposure/desensitization interventions.
Psychoeducational components involve readings and explanations of anxiety and
panic. Cognitive restructuring techniques involve the monitoring of cognitions,
the analysis of faulty logic, and correcting misappraisals of bodily
sensations. Diaphragmatic breathing and progressive muscle relaxation training
provide the patient with coping skills to cope with panic symptomatology.
Interoceptive exposure interventions weaken the associations between specific
bodily cues and panic reactions. Examples of interoceptive exposures are:
spinning in a chair, hyperventilation, rapid breathing, exposure to bright light
and cardiovascular exercise. Situational exposure techniques are in vivo in
nature, and involve a repeated confrontation with objects and situations that
are avoided.
Studies
throughout the United States using a protocol treatment for panic disorder have
demonstrated that approximately 80% of patients who received empirically tested
cognitive-behavioral protocol treatments no longer met DSM-IV criteria for panic
disorder (Barlow, 1988). Several meta-analyses have demonstrated that
cognitive-behavioral protocol interventions provide greater treatment gains when
compared psychopharmacological treatment (Gould, Otto, and Pollack, 1993; Clum,
Clum, and Surls, 1993). Long-term outcome studies have demonstrated that
cognitive-behavioral treatments provide less relapses than psychopharmacological
treatments (Brown and Barlow, 1995).
Although the
effectiveness of these treatments is well documented, most of the patients in
these studies have been predominately white. There are few studies examining
the efficacy of these interventions with African Americans. A recent study has
provided some information regarding the efficacy of exposure-based interventions
with African Americans (Chambless, et. al, 1994). This study suggested that
exposure-based interventions significantly reduced panic symptomatology in
African Americans. Despite these results, African Americans experienced
significantly less benefit than white subjects.
Irrational Beliefs and Anxiety
To date,
research investigating the relationship between irrational and panic disorder
has not been conducted. Studies regarding irrational beliefs and their
prevalence in African Americans have not been conducted. Despite the paucity of
information regarding irrational beliefs and panic disorder, significant
research has been conducted on the relationship between irrational beliefs and
general measures of anxiety. Warren and Zgourides (1989, 1988) have suggested
that a positive correlation exists between irrational beliefs and anxiety and
depression. Irrational beliefs correlate more highly with each other than with
accepted measures of depression, hopelessness, and anxiety, suggesting that
instruments used to detect irrational beliefs do not just measure general
distress or emotionality. Ellis (1994) believes that demandingess, the
superordinate irrational belief, (musts and shoulds) is the cause of and is
present in all psychopathology. Ellis has proposed three subordinate
derivatives of demandingness: awfulization, low frustration tolerance, and
worthlessness.
Proposal and Hypotheses
A review of the
literature has demonstrated that research concerning the prevalence and nature
of irrational beliefs with African Americans suffering from panic disorder has
not been conducted. The purpose of the proposed study is to investigate the
relationship of irrational beliefs and panic disorder as a function of
ethnicity. This proposed study will investigate the prevalence, severity, and
nature of irrational beliefs with African American and White American persons
who are diagnosed with panic disorder as defined by the DSM-IV.
It is hypothesized that
both African American and White American participants who are diagnosed with
panic disorder will exhibit similar levels of irrational beliefs. Previous
research, demonstrating the similarities in symptom profiles and prevalence of
panic disorder in both white and African Americans, support this hypothesis. It
is also hypothesized that both African American and White American participants
will exhibit similar irrational belief profiles, with the irrational belief of
demandingess as most prevalent. A revision in the REBT model of
psychopathology, (Ellis, 1994) which claims that demandingness is the
superordinate irrational belief, supports this hypothesis.
METHOD
Participants
The population for this study will be limited to White and African American
adult males who have received a DSM-IV diagnosis of panic disorder. It is
expected that approximately 100 White Americans and 100 African Americans who
have received a diagnosis of panic disorder could be recruited for this study.
The participants could range in age from 18 to 65 years. The principal
investigator will include data from the first 100 participants collected for
each group and will eliminate all other data from the study.
Instruments
Demographic Questionnaire
All participants will
complete a two page demographic questionnaire. This brief self-report
instrument identifies the participant’s age, ethnicity, education level, income
level, and current medication status for both mental and physical illnesses. The
instrument also identifies the participant’s history of mental health treatment
and current relationship status.
Anxiety Disorder Interview
Schedule – IV (ADIS-IV)
The ADIS-IV is a
structured interview based on DSM-IV diagnostic criteria and assesses the full
spectrum of anxiety and affective disorders (DiNardo & Barlow, 1994). This
instrument also screens psychotic disorders, somatoform disorders, psychotic
disorders, and drug conditions. The ADIS-IV provides symptom ratings, the
assessment of safety signals, assisting greatly with the functional analysis of
anxiety disorders.
Attitudes and Belief Scale II
(ASBII)
The Attitudes and Belief
Scale II is a measure of Ellis’ (1994) Irrational/Rational Beliefs (DiGiuseppe,
Leaf, Exner & Robin, 1988). It consists of 72 items consisting of three
factors. The first factor for Cognitive Process has four levels representing
the irrational beliefs processes of Demandingness, Self-Worth, Low Frustration
Tolerance, and Awfulizing. The second factor, Content/Context has three levels:
beliefs about Affiliation, Achievement, and Comfort. The third factor has two
levels: irrationally worded items and rationally worded items. Items were
selected for use in the scale only if there was unanimous agreement among 13
judges who were therapists at the Institute for Rational-Emotive Therapy
(IRET). The ASBII only measures attitudes and beliefs and does not include
references to emotional distress or behavioral consequences, which may
artificially increase correlational relationships. Past measures of irrational
beliefs have received significant criticism due to the aforementioned confound.
The ASBII has
demonstrated excellent internal consistency and validity (DiGiuseppe, Leaf,
Exner, and Robin, 1988) with alpha coefficients ranging from .71 to .89 in a
sample of 431 college students. The ASBII has also demonstrated excellent
internal consistency and validity in a sample of clinical and college student
groups (N=1135) with alpha coefficients for the four belief processes and the
three content subscales ranging from .92 to .86. The total score for the entire
72 items yielded an alpha coefficient of .96.
The ASBII
can adequately discriminate between non-disturbed and disturbed groups, with the
endorsement of rational items providing the best power to classify (DiGiuseppe
et al. 1988). The best predictor of emotional states among college students is
the total irrational subscale (DiGiuseppe et al. 1988). The ASBII significantly
correlated with ten of the thirteen Personality Disorder Scales; and seven of
the nine Clinical Syndrome Scales of the MCMI II in 230 patients, providing
further support for the ASBII as a valid measure of psychological/emotional
disturbance.
Procedure
The principal
investigator visited or called medical centers, hospitals, and physicians to
obtain permission to approach their clients or advertise for participants both
for the control and criterion groups. All participants will receive written
instructions for participating in the study. The instruments will be
administered in the proceeding order: a statement explaining basic information
about the study, a consent form, demographic questionnaire, the ADIS-IV, and the
ABS-II. All participants will be guaranteed anonymity and will be instructed to
sign consent before beginning other procedures. Participants will be instructed
to not write their name on any of the materials with the exception of the
consent form. They will be informed that consent forms will be separated from
all other materials. The written instructions inform the participants that they
will not receive individual results of their testing but can receive results of
the study upon request in eight months. The participants will be instructed
that they will receive five dollars upon completing the instruments.
Reimbursement will be sent to the address that they provide on the consent
form. A list of emergency and community resources will be included in the
materials in the event of an emergency. Participants who fail to complete all
research instruments will be excluded from the study. Confusion, low energy,
cognitive impairment, and poor effort are expected to contribute to a small
percentage of incomplete data.
Statistical Analyses
Descriptive statistics,
frequencies, means, and standard deviations for all demographic variables and
instruments will be reported according to cultural group. A Full Model Multiple
Regression will be conducted to predict panic disorder using the variables:
total irrational beliefs and demandingness. A Full Model Factorial 2x2 ANOVA
will be conducted to analyze irrational beliefs, and demandingness as a function
of cultural status. Orthogonal contrasts will be conducted post-hoc to analyze
the ANOVA.
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