MMPI correlates of panic disorder and panic attacks

Journal o/Anriery Disorders. Vol. 3. pp. 107-I IS. 1989 Rimed in the USA. AU rights reserved.

08874185189 53.03 + .@I Copyright 0 1989 Rrgamon Press pk

MMPI Correlates of Panic Disorder and Panic Attacks

JANET WOODRUFF BORDEN, PH.D.

Western Psychiatric Institute and Clinic, Pittsburgh

GEORGE A. CLUM, PH.D., AND SUSAN E. BROYLES, M.S.

Virginia Polytechnic Institute and State University, Blacksburg

Abstract-A limited number of psychological correlates of panic have been identified. The current study employed the MMPI to examine differences on these correlates between Panic-Disordered (PD) subjects and subjects diagnosed with other anxiety disorders, as well as differences between anxiety-disordered individuals with and without panic attacks. Ninety-one subjects who received a DSM-III anxiety disorder diagnosis completed the MMPI. Two comparisons were made: PD and Agoraphobic subjects versus all other diagnosed anxiety disorders; and anxiety disorders with panic attacks versus anxiety disorders without attacks. Using t tests between groups, two systematic differences emerged on the MMPI: PD subjects presented higher scores on the L and Hypochondriasis (Hs) subscales. Further, subjects with panic as compared with those without panic also had elevated L and Hs scales. Findings are discussed in terms of somatic preoccupation and its possible role in the etiology of panic. Cross-validation of the L-scale elevation is recommended.

Although Panic Disorder (PD) has recently received a great deal of research interest, there have been few studies that have examined psychological correlates of this disorder. Such research as exists has been restricted to studies of individual variables or to comparisons of individuals with panic attacks (PAS) to normals without panic attacks (e.g., Beck & Scott, 1987; Norton, Dorward, & Cox, 1986). This research is important in that it helps to identify potential etiologic factors for PD or, alternately, may suggest how PD could lead to the development of other psychological difficulties. No studies exist that have compared PDs and anxiety-disordered individuals with panic attacks to other anxiety-disordered individuals without panic attacks. Such comparisons on an om- nibus personality measure such as the MMPI could permit even more

Address correspondence and reprint requests to Janet Woodruff Borden, Western Psychi- atric Institute and Clinic, University of Pittsburgh School of Medicine, 381 I O’Hara Street, Pittsburgh, PA 15213.

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108 J. WOODRUFF BORDEN, G. A. CLUM, AND S. E. BROYLES

specific hypotheses about etiologic factors and could help to identify possible sequalae of panic disorders and panic attacks. Accordingly, the present study utilized the MMPI in attempting to make two differentia- tions: (a) PDs from other diagnosed anxiety disorders, and (b) Anxiety- disordered individuals with PAS from anxiety-disordered individuals without PAS. Special focus was placed on three likely correlates identified in previous studies, namely, depression, passivity, and preoccupation with somatic problems.

The relationship of panic and depression received initial attention from research demonstrating the effectiveness of antidepressants in relieving the symptoms of panic attacks (Klein, 1984; Zitrin, Klein, & Woerner, 1983). This research led to speculation that antidepressants did not have a specific anti-panic effect, but rather an indirect effect through the reduc- tion of depression (Marks et al., 1983). Additional support came from data that showed that individuals diagnosed as Panic Disorder report more depression than individuals suffering from Generalized Anxiety Disorder (Hoehn-Saric, 1982; Raskin, Peake, Dickman, & Pinsker, 1982). In an examination of depression levels in panickers and nonpanickers, the panickers reported higher levels of depression (Norton et al., 1986). Although the exact mechanism of the relationship between panic and depression remains controversial (Klein, 1984; Clum & Pendry, 1987), the two appear to coexist frequently. It was thus expected that individuals who experience panic would present higher depression scores on the MMPI than anxious individuals who do not experience panic.

Another identified correlate of agoraphobia and panic is passivity. The agoraphobic individual has often been described as anxious, soft, pas- sive, shy, and dependent (e.g., Marks, 1970). Fodor (1974) suggested that the symptoms of agoraphobia are associated with extreme helplessness and dependency and as such appear related to a stereotypic feminine role. The recent revision of the Diagnostic and Statistical Manual (DSM- III-R: American Psychiatric Association, 1987) combines PD and Agora- phobia resulting in diagnoses of PD with varying degrees of avoidance. Recent research demonstrates the validity of this classification (Noyes, Clancy, Garvey, & Anderson, 1987). Noyes and colleagues indicate that Panic Disorder is a unitary diagnosis regardless of degree of avoidance. It was therefore expected that individuals diagnosed as Agoraphobic or PD would present more extreme feminine MF scores on the MMPI.

An additional correlate of panic involves a focus on somatic sensations. King and colleagues (King, Margraf, Ehlers, & Maddock, 1986) compared the somatization behavior of panic patients and normal control subjects. Panic sufferers presented a pattern of significantly greater somatization not related to levels of state anxiety nor to length of panic problems. Thus, this difference appears beyond that experienced from lengthy battles with panic. Goldstein and Chambless (1978) explain that agoraphobics become “conditioned” to the bodily sensations that occur during a panic attack. A number of other researchers have demonstrated that individuals who experience panic attacks have characteristic idea-

MMPI CORRELATES OF PANIC 109

tions related to these bodily sensations (e.g., Ottaviani & Beck, 1987). For example, Hibbert (1984) reported that individuals with panic focus upon personal harm, such as having a heart attack or dying. In contrast, individuals suffering from Generalized Anxiety Disorder focus upon social rejection and failure. Rapee (1986) identified greater catastrophic ideation of internal dangers or personal harm in panic as compared to GAD patients. The general themes of this harm concern bodily control loss (Beck, Laude, & Bonhert, 1974) and perceived harmful conse- quences of anxiety such as heart attacks (McNally & Lorenz, 1987). It was thus expected that PD subjects could be differentiated from other anxiety disorders based on their degree of somatic focus, as measured by the hypochondriasis scale of the MMPI. Further, it is expected that individuals with panic attacks would demonstrate greater concern with somatic sensations than individuals who do not experience panic.

There were two ways to examine MMPI correlates of panic. To take a purely diagnostic approach, subjects with diagnoses of interest can be compared on MMPI subscales. In the present study, subjects with diagnoses of Panic Disorder or Agoraphobia with panic attacks were compared to a second diagnostic group including all other anxiety conditions. Because of a limited number of subjects, this latter group consisted of a variety of other anxiety disorders, including subjects diagnosed with Generalized Anxiety Disorder, Simple and Social Phobia, Obsessive- Compulsive Disorder, and Atypical Anxiety. No subjects presented with Post-traumatic Stress Disorder. This comparison allowed an examination of differences based upon traditional diagnostic groupings.

A second way to examine correlates of panic is to compare individuals with and without panic. Panic attacks are quite prevalent and pervade diagnostic groupings. According to one group of investigators, approximately 80% of all anxiety patients experience panic attacks (Barlow et al., 1985). Therefore, a second analysis examined differences on the MMPI based on the existence or nonexistence of panic attacks regardless of diagnosis.

METHOD

Subjects

Subjects were 96 individuals who presented to the Anxiety Disorders Clinic of Virginia Polytechnic Institute and State University. Ninety-one subjects were included in this study. Three subjects were excluded because they did not meet criteria for a DSM-III anxiety disorder diagnosis. Two were excluded because they did not complete the MMPI. All partici- pating subjects received a DSM-III Anxiety Disorder diagnosis. Subjects were first grouped according to diagnosis. Group I contained subjects diagnosed with Panic Disorder and Agoraphobia (n = 50). Group 2 consisted of subjects with all other anxiety diagnoses: Generalized Anxiety

110 J. WOODRUFF BORDEN, G. A. CLUM, AND S. E. BROYLES

Disorder (n = lo), Social Phobia (n = 15), Simple Phobia (n = II), Obsessive-Compulsive Disorder (n = 2), and Atypical Anxiety (n = 3). Fifty-two of the 96 subjects received a diagnosis of Panic Disorder; 37 were female and 15 were male. Their mean age was 34.6 years. Eighty- eight percent of this group were married and the group had an average of 13 years of education. Forty-one subjects comprised the comparison group; they received other anxiety diagnoses that were not Panic Dis- order. Of this group, 26 were female and 15 were male. Their mean age was 29.9. Ninety-one percent of this group were married and the group had a mean educational level of 13 years. The only significant difference between these two groups of subjects was their age. Subjects in Group 1 (x = 34.6) were significantly older (t = 3.04, p < .05) than subjects in Group 2 (X = 29.9).

Subjects were next divided into those who experienced panic attacks (n = 59) and those who did not experience attacks (n = 32). Subjects who experienced panic were diagnosed as Panic Disorder (n = 50), Gen- eralized Anxiety Disorder (n = 4), Social Phobia (n = 4), and Simple Phobia (n = 1). Forty-three of these “panickers” were female and 17 were male. Their mean age was 34.9 years. Thirty-three subjects comprised the comparison group of those anxiety patients who had never experienced a panic attack. Twenty of these were female and 13 were male. Their mean age was 28.2 years. The groups did not differ on marital status; over 90% of both groups were married. They also did not differ on level of education: the mean for both groups was approximately 13 years. Again, the only significant demographic difference was age, with the panickers being older than the nonpanickers.

Measures and Procedure

Subjects presented through referrals from local physicians and from flyers advertising the clinic. Subjects were interviewed by an advanced clinical psychology graduate student or be a licensed clinical psychologist using the Anxiety Disorder Interview Schedule (ADIS: DiNardo, O’Brien, Barlow, Waddell, & Blanchard, 1983) to diagnose subjects. All interviewers were members of an Anxiety Disorders Project, who were trained in use of the ADIS through review of anxiety disorders, case dis- cussions, and role plays with the project members and leader. The ADIS is a structured interview that is designed to aid in making differential diagnoses among the DSM-III anxiety disorders categories. The authors have reported high (range K = .658 to K = .853) kappa coefficients for specific diagnostic category agreement on all but Generalized Anxiety Disorder (K = .467). Diagnoses were arrived at in the following manner: (a) based on a 1 to 2 hour interview by an advanced graduate student in clinical psychology or by a licensed clinical psychologist, a preliminary diagnosis was assigned; (b) the case was presented to the project staff and director; (c) based on this information, a final diagnosis was determined.


There were no disagreements among the staff about the appropriate diagnoses of patients in this study. We have previously assessed interrater reliability in diagnosing panic disorder versus other anxiety disorders. In an examination of interrater reliability of diagnosis, agreement on a sample of 24 patients was 94%.

At the conclusion of the diagnostic interview, the subjects were given the MMPI as part of the assessment package. The entire 566 items were administered in an individual assessment format. Subsequently, each of the answer sheets was hand-scored and the results entered onto com- puter disks from which all additional analyses were accomplished. Data analyses relied on raw scores on the MMPI. As recommended by Butcher and Tellegen (1978), no K-corrections were utilized.

RESULTS

In as much as there were systematic differences between the comparison groups on age, correlations were computed between age and each of the MMPI subscales. Age was significantly correlated (albeit to a low degree) with two of the scales: Hysteria (r = .19, p < .05) and Mania (r = - .25, p < .Ol>. Otherwise, no scales were significantly related to age, suggesting that systematic differences on other MMPI subscales is not due to these differences in age between comparison groups.

Examining differences between the two diagnostic groups utilizing t tests, subjects diagnosed with Panic Disorder and Agoraphobia with panic presented significantly higher scores on the L and Hs subscales than all other anxiety disorders combined. No other differences were found. These results are presented in Table 1. The higher L score in the PD and Agoraphobic group suggests that these subjects are concerned with “looking good.” They are presenting themselves as self-controlled and conforming. This finding is of particular interest given that the social phobics were in the other diagnostic group. The second difference, higher scores on Hypochondriasis (Hs) in the PD and Agoraphobia group, was in the expected direction. Individuals diagnosed with Panic Disorder or Agoraphobia report a greater number of somatic complaints.

Two other significant differences emerged when diagnostic groups were examined. The “other anxiety” group presented higher or more deviant scores than the PD/Agoraphobia group. Subjects in this other anxiety group show higher MF and Si scores than the PD/Agoraphobia group. Analysis using raw scores on the MF scale suggests greater passivity for both males and females in the other anxiety group. Further, this other anxiety group presents greater social introversion than the PD/ Agoraphobia group.

The second set of comparisons examined differences between anxiety- disordered subjects with and without panic attacks. These differences are presented in Table 2. As above, the two major differences are on the L

112 J. WOODRUFFB0RDEN.G. A.CLUM,ANDS. E. BROYLES

TABLE 1

MEANMMPI RAWSCORESAND STANDARDDEVIATIONSFORSUBJECTSBY

DIAGNOSTIC GROUPWG

Subscale

Panic/Agoraphobia Other Anxiety

Mean SD Mean SD I

L F K

Hs D

HY Pd MF Pa Pt SC

Ma Si

5.30 3.20 3.24 2.52 3.23” 8.14 5.29 7.49 4.06 0.63

12.36 4.87 12.68 4.12 -0.32 11.34 5.75 8.86 5.04 2.09*

21.48 10.02 24.51 7.69 - 1.54

21.58 10.07 21.65 6.96 -0.04

17.46 7.97 19.16 6.09 - 1.08

27.76 14.86 35.81 9.63 -2.16*

11.94 4.11 12.00 3.19 -0.07

16.66 8.34 19.86 7.52 - 1.85

15.58 9.15 18.30 8.43 - 1.42

14.38 5.91 16.78 6.51 - 1.80

24.72 13.90 31.59 13.65 -2.30*

*p < .05.

and HS subscales, with those subjects who have panic attacks scoring higher. No other subscales were significantly different. Again, subjects with PAS utilize more naive forms of denial while acknowledging more somatic complaints.

TABLE 2

MEAN MMPI RAW SCORES AND STANDARD DEVIATIONS FOR SUBJECTS WITH AND WITHOUT PANIC

Subscale

Panic Subjects

Mean SD

Nonpanic Subjects

Mean SD t

L F K

Hs D

HY Pd MF Pa Pt SC Ma Si

4.98 3.09 3.50 2.84 2.24*

8.25 5.19 7.53 4.12 0.68

12.29 4.39 12.84 4.38 -0.58

11.98 5.77 8.06 4.37 3.35**

23.12 10.42 23.31 7.98 -0.09

22.39 9.80 21.03 7.55 0.68

18.39 7.96 18.34 5.97 0.03

29.81 14.52 32.28 10.85 -0.84

12.29 4.49 11.69 3.09 0.67

18.19 9.04 18.44 7.64 -0.13

17.41 10.01 16.91 9.05 0.24

14.71 5.90 16.81 6.57 - 1.56

26.95 14.84 29.84 13.71 -0.91

l p < .05 l p < .Ol


DISCUSSION

Since the only demographic variable to differ systematically between the comparison groups was age, it was important to determine whether age was related to MMPI subscale scores. Only two of the correlations were significant. Since neither of these correlations was with subscales that differentiated the groups of interest, it may be assumed that demonstrated differences between the two groups on the MMPI subscales were not attributable to age.

The only hypothesized difference that consistently emerged involved the Hs scale. These results indicate that PD individuals or anxiety-disordered individuals with PAS are more likely to be somatically preoccupied. This finding is consistent with the somatic Autonomic Nervous System (ANS) symptoms that characterize PAS and further suggests a link between these attacks and somatic preoccupation. The question arises as to what this relationship indicates. One possibility is that this preoccupation antedates PAS and is involved etiologically in their development. Because of this somatic preoccupation, ANS symptoms may be interpreted cata- strophically (see Beck et al., 1974; Hibbert, 1984; Ottaviani & Beck, 1987). Such a catastrophic interpretation by the subject in turn sets up the possibility of a vicious circle as it leads to increased vigilance and somatic preoccupation followed by more PAS, etc. An alternative explana- tion is that the PA, when first experienced, is followed by catastrophic cognitions that then yield to the somatic vigilance reflected on the Hs scale. The present investigation underscores the importance of this preoccupation in PAS and PD.

The tendency for the L scale to be elevated in individuals with PD or PAS is more difficult to explain. Because this scale reflects social con- formity and a tendency toward denial and showing oneself in the best possible light, it may be that this naive perfectionism is an important in- gredient in the development of PD and PAS. It appears less likely to be a sequalae of PAS. This group is characterized by a tendency to expect the worst from their PAS and not to engage in denial. Inasmuch as this relationship has not previously been reported, it will require cross-validation before it can be considered a reliable finding.

Our two other predicted relationships, namely, higher depression and feminine interest patterns, in the PA and PD groups were not supported. In the latter instance, feminine interest scores were higher for the other anxiety group, though not in the comparison of PAS and non-PAS. What accounts for these latter findings is difficult to determine, especially since passivity has been found to be one of the distinctive features of agoraphobia (e.g., Fodor, 1974). Clearly, however, it is dangerous to generalize from data in one area of investigation (agoraphobia) to data in another (panic attacks).

The failure to support the relationship between depression and panic is consistent with other data (Clum & Pendry, 1987) which indicates that depression can sometimes precede or succeed panic, but that it is not

114 I. WOODRUFF BORDEN, G. A. CLUM, AND S. E. BROYLES

necessarily co-extensive with it. Further, the relationship between depression and anxiety disorders in general is well established.

The current investigation provides normative data concerning the MMPI profiles of subjects who suffer from panic. Regardless of how panic patients are grouped, they present the same 2-point profile of L-l. This is consistent regardless of whether grouping is by diagnosis or by the presence of panic attacks. The differences on the L scale have not been previously observed and as such suggest the need for cross-validation research.

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MMPI correlates of panic disorder and panic attacks