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Behaviour Research and Therapy 42 (2004) 1271–1287

Emotional processing and panic
Roger Baker a,b, Jane Holloway b, Peter W. Thomas c, Sarah Thomas a,
Matthew Owens b,

Dorset Research and Development Support Unit, Poole Hospital NHS Trust, Cornelia House, Poole,
Dorset BH15 2JB, UK
Research Department, St Ann’s Hospital, Dorset Healthcare NHS Trust, Poole, Dorset BH13 7LN, UK
Dorset Research and Development Support Unit and Institute of Health and Community Studies, Bournemouth
University, Poole Hospital NHS Trust, Cornelia House, Poole, Dorset BH15 7LN, UK
Received 3 September 2002; received in revised form 15 July 2003; accepted 16 September 2003

In this paper Rachman’s concept of emotional processing was extended and a model highlighting the
psychological operations underpinning processing was specified. Using this model, the aim was to investigate, by means of a questionnaire, whether patients with panic disorder (n ¼ 50) have more emotional
processing difficulties than two samples of healthy controls (London, n ¼ 406; Aberdeen, n ¼ 125). The
panic disorder group did have significantly more emotional processing difficulties than the control
groups, showing a marked tendency to control feelings of anger, unhappiness and anxiety. Three
emotional processing dimensions distinguished the panic from the control groups: greater control of
emotional experiences (‘smothering’ or ‘bottling up’ emotions), greater awareness of feelings and more
difficulties in labelling emotions. The authors hypothesise that emotional processing deficits act as a vulnerability factor for developing panic attacks.
# 2003 Elsevier Ltd. All rights reserved.
Keywords: Emotional processing; Emotions; Emotional control; Panic disorder

1. Introduction
The concept of emotional processing was first introduced by Rachman in 1980 who put it forward as a promising explanatory concept with particular relevance and application to the anxiety

Corresponding author. Tel.: +44-1202-492137.
E-mail address: matthew.owen@dorsethc-tr.swest.nhs.uk (M. Owens).

0005-7967/$ - see front matter # 2003 Elsevier Ltd. All rights reserved.


R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287

disorders. In 2001, Rachman restated the concept and applied it to post-traumatic stress disorder.
Rachman used the term emotional processing to refer to the way in which an individual processes stressful life events. He defined emotional processing as: ‘‘a process whereby emotional disturbances are absorbed, and decline to the extent that other experiences and behaviour can proceed
without disruption’’ (p. 51).
He noted that, for the most part, people successfully process the majority of aversive events
that occur in their lives. Indeed, if individuals were unable to absorb or ‘‘process’’ emotional
disturbances, then they would operate at a constantly high level of arousal with so much
intrusion from their feelings that it would be difficult to concentrate on the daily tasks of living.
Rachman argued that if emotional experiences were incompletely absorbed or processed then
certain direct signs of this failure would appear; for example, the return of fears, obsessions and
intrusive thoughts. Furthermore, he proposed that excessive avoidance or prolonged and rigid
inhibition of negative emotional experiences would prevent their reintegration and resolution.
This may not matter for smaller everyday hassles which are part of normal experience, but
could result in disturbances of behaviour and experience if the person experiences more serious
negative life events.
Based upon clinical and experimental observations Rachman (1980) proposed that fear
reduction in the anxiety disorders came about through successful emotional processing and that
appropriate exposure to affect-eliciting stimuli during therapy would aid processing. Foa and
Kozak (1986) further elaborated upon the mechanisms for change and asserted that successful
emotional processing resulted from the modification of information contained in the memory
structures underlying fear emotions.
In his initial formulation, Rachman described unwanted and emotionally powerful phenomena that intrude into consciousness such as intrusive thoughts, flashbacks, nightmares and the
return of phobic anxiety as being indicators of inadequate emotional processing. Given that
panic attacks also initially occur suddenly and unexpectedly, with a range of different sensations
intruding into consciousness en bloc, they would appear to provide a particularly powerful sign
of incomplete emotional processing.
In the clinical domain, researchers have recognised and attempted to highlight the importance
of emotional arousal and engagement during therapy in order to promote better emotional
processing and therapeutic change (Greenberg & Safran, 1987; Samoilov & Goldried, 2000;
Teasdale, 1999; Teasdale & Barnard, 1993). Various researchers have delineated factors that
may promote or impede emotional processing and developed theories that have important clinical implications for this (e.g. Kelley, Lumley, & Leisen, 1997; Lang, Cuthbert, & Bradley, 1998;
Shear & Weiner, 1997; Traue & Pennebaker, 1993).
However, the role of emotions has been somewhat neglected and overlooked in modern conceptualisations of panic disorder, which is surprising given that panic essentially involves powerful emotions. Current theories of panic have tended to focus primarily on cognitive factors
(Beck & Clark, 1997; Beck & Emery, 1985; Chambless & Goldstein, 1981; Clark, 1986, 1988,
1996; McNally, Riemann, Louro, Lukach, & Kim, 1992; Reiss, 1991).
Clinical observations and experimental evidence nevertheless suggest that an individual’s
characteristic emotional style may have an important role to play in the aetiology and maintenance of panic attacks.

R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287


Numerous studies have indicated that adverse life events or prolonged stress through problematic interpersonal relationships occur in the months preceding the emergence of initial panic
attacks (e.g. Barlow, 1988; Breier, Charney & Heninger, 1986; Chambless & Goldstein, 1981;
Faravelli & Pallanti, 1989; Goldberg, 1988; Manfro, Otto, McArdle, Worthington III,
Rosenbaum, & Pollack, 1996; Rapee, Litwin, & Barlow, 1990; Shear & Weiner, 1997). Despite
obvious antecedents, panic sufferers rarely spontaneously perceive a connection between these
events and the initial onset of panic. The failure of these individuals to link severe life events or
problematic relationships to their current difficulties may be a reflection of an inadequate style
of processing emotion.
Panic patients often fail to link physical sensations to emotional states arising from life events
and in general they have difficulties in identifying feelings and distinguishing them from bodily
sensations (Cox, Swinson, Shulman, & Bourdeau, 1995; Marchesi, Brusamonti, & Maggini,
2000). Guidano (1987) has proposed that because agoraphobic patients often believe they are
able to control their emotions they have a tendency to interpret any physical sensations not
under their direct control as a symptoms of illness, rather than being emotional in nature. Berg,
Shapiro, Chambless and Ahrens (1998) and Williams, Chambless and Ahrens (1997) have also
found that a fear of losing control of a range of emotions (anger, depression and positive emotions) appears to be linked to a greater fear of bodily sensations. Clinically, many therapists
propose that education/explanation to patients about their bodily sensations is a key part of
therapy (e.g. McFadyen, 1989; Rapee & Barlow, 1989; Weekes, 1973; Zane, 1989). In therapy,
explanations are often offered to show how physical sensations are related to anxiety or other
affects, and how the patient’s condition is psychologically based and not a physical disorder,
such as a heart attack or madness. For some patients this proves to be a startling revelation;
others are never fully convinced about the psychological nature of their symptoms.
In therapy, case studies, and autobiographies panic sufferers seem to describe or demonstrate
a range of difficulties with emotions (Baker, 1989; Baker, 2003) as has been noted by numerous
therapists (e.g. Chambless & Goldstein, 1981; Shear & Weiner, 1997; Vermilyea, 1990). Examples include:
1. A fear of any strong feelings: Mr. B., a panic sufferer RB treated, explained his fear of crying: ‘‘I allow myself to feel something in myself like sadness, crying. I go so far down. It’s bubbling in my eyes and I try to stop it and shake off what I am feeling. I don’t like starting
because I get really hysterical. The last time I did that I ended up punching in a wall.’’
2. Lack of awareness of emotions: One panic sufferer who had lost the love and inheritance of
his mother through the actions of a jealous brother described taking flowers to the family
grave, putting them on his mother’s grave but stamping on his brother’s grave and saying
‘‘get down’’. RB suggested he might be angry with his brother to which he sweetly smiled
that he had never borne anyone any ill will.
3. Suppressing feelings: Miss R. described how she suppressed feelings: ‘‘I feel butterflies in my
tummy and feel I want to cry. Then I suppress my feelings. I take a great big breath, hold it in,
tense myself or put my mind onto something else-take the dog out for a walk, do the housework.
I say ‘don’t be so b. . . stupid, pull yourself together’’’.
4. Control of emotions: Mrs. S., towards the end of therapy explained, ‘‘Before, I wanted everything to be perfect-nearly every day I was wanting to stay on this happy level all the time. I


R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287

didn’t want to appear out of control to anyone else-angry, unhappy. I’m not going to let this
bother me-this ‘nothing bothers me’ exterior. Now I’ve come to the regrettable conclusion that
ups and downs are normal’’.
Baker (2001) formalised these clinical observations and research findings in an emotional processing model that specifies some of the psychological operations that may impede processing.
The model adopts a systems approach whereby a negative emotional experience is regarded as
an input that needs to be consciously or unconsciously registered as a prerequisite for emotional
experience. The operations include cognitive appraisal, labelling emotions, linking them to
events, awareness of emotions and sensations, and control of the experience and expression of
emotions. This model is not incompatible with current biological or cognitive conceptualisations
of panic disorder, but rather, it complements and extends existing accounts by adding an
emotional information processing dimension. It derives primarily from a psychological therapy
perspective and is conceptually closest to psychodynamic and experiential models of emotion
such as Bucci’s Multiple Code Theory, (1997a, b) and Epstein’s Cognitive-Experiential Self
Theory (1998).
Successful emotional processing is likely to involve a range of cognitive, behavioural, physiological and emotional processes such as exposure and habituation (Hunt, 1998; Rachman,
1980), appraisal and reappraisal (Lazarus, 1999), insight (Kuiken, Cary, & Nielsen, 1987),
restructuring of cognitive and emotion schemas (Bucci, 1997a; Foa & Kozak, 1986), disclosure
and catharsis (Bohart, 1980; Traue & Pennebaker, 1993).
Using this model as a basis for emotional processing, the aims of the study were to investigate
whether patients with panic disorder have more emotional processing difficulties than a healthy
control group, and if they do, to investigate what types of difficulties are present. Rachman’s
(1980; 2001) definition of ‘emotional processing’, which was described earlier, is the working
definition of emotional processing utilised in this paper.

2. Method
2.1. Participants
2.1.1. Panic disorder cohort
Referral letters to the Clinical Psychology Department at the Royal Cornhill Hospital,
Aberdeen were scrutinised by two clinical psychologists, not involved in this study, and patients
were selected if panic attacks were the primary focus of the letter. After an assessment interview,
patients were asked to complete a battery of self-report assessments measuring various aspects of
anxiety. This information was used in conjunction with the interview to establish a more accurate diagnosis of panic disorder. The interviews were conducted by a clinical psychologist with a
research psychologist sitting in on one third of the interviews to provide independent assessment.
Those fulfilling DSM IIIR criteria for panic disorder were included in the study. Patients
with limited panic attacks or additional psychiatric diagnoses were excluded. Of the 50 panic disorder patients recruited, 48 had complete data sets and have been included in the analysis.

R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287


Nineteen were diagnosed with panic disorder without agoraphobia and 29 with panic disorder
with agoraphobia.
2.1.2. Aberdeen controls
One hundred and ninety-seven individuals from the Aberdeen University Psychology Department volunteer panel were sent a questionnaire pack by mail. One hundred and twenty-three
returned the pack (62% return rate).
2.1.3. London controls
Anonymised data for 406 individuals who had completed the Courtauld Emotional Control
Scale for Pettingale, Watson and Greer (1984) were provided as part of the analysis in the current study. This effectively represented a second control group, different in terms of time, place,
and investigator from the Aberdeen sample. Table 1 provides data regarding the age and gender
of these samples.
There were significant age differences between the groups (F ð2; 555Þ ¼ 72:1; p < 0:001). Bonferroni post-hoc analysis revealed that the Aberdeen controls were significantly older than the
panic group (p < 0:001) and London controls (p < 0:001) and that there were no differences
between the panic group and London controls (p ¼ 0:51).
Whilst there were fewer males (32%) to females (68%) overall, the proportion of males to
females between the three groups was not significantly different (v2 ¼ 1:4; df ¼ 2; p ¼ 0:50).
2.2. Assessments
A preliminary model describing the operations involved in emotional processing helped to
determine what was to be measured (Baker, 2001). At the time a specific instrument assessing
emotional processing was not available, thus, a validated measure of emotional control was
used as it closely related to some aspects of emotional processing (Courtauld Emotional Control
Scale, Watson & Greer, 1983). Additional items were also devised by the author to tap into
other emotional processing operations suggested by the model.
2.2.1. Courtauld Emotional Control Scale (CECS: Watson & Greer, 1983)
This 21-item self-report questionnaire asks individuals how they typically respond to three
emotions: anger, feeling unhappy and feeling anxious. It normally yields four scores: control of
anger (7–28), unhappiness (7–28), anxiety (7–28), and a total control score (21–84). For the
purposes of the current study, two other scores were devised by regrouping items in terms of
Table 1
Panic disorder cohort and control groups; age and gender











Male (%)

Female (%)

12 (25%)
38 (31%)
135 (33%)
185 (32%)

36 (75%)
84 (69%)
271 (67%)
391 (68%)






R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287

Baker’s hypothesised emotional processing operations. These were control of emotional experience (6–24), and control of emotional expression (15–60). Higher scores represented greater
degrees of control. Walker (1990) has recommended the CECS for use in anxiety research
because it seems to tap an independent dimension from other scales and is independent of social
desirability response bias.
2.2.2. Other measures of emotion
Twelve items were devised by the author to cover different aspects of emotional processing,
using a similar format to the CECS. These included two items covering the awareness and labelling of emotional feelings, four items covering the person’s constructs about having and expressing positive and negative emotional feelings and six items asking the person to rate how
frequent and intense feelings of anger, unhappiness and anxiety were. These latter six items were
included to test whether the emotional control items of the CECS were really measuring a control dimension rather than just the frequency and intensity of emotions.
2.2.3. Symptom based assessments
Several standardised self-report assessment scales were used to help clarify diagnosis and
to act as a further test of whether the CECS was measuring an independent dimension of
control, or merely reflected degree and type of symptomatology. They were: The DelusionsSymptoms-States Inventory (Bedford & Foulds, 1978), The Body Sensations Questionnaire and
the Agoraphobic Cognitions Questionnaire (Chambless, Caputo, Bright, & Gallaher, 1984), and
The Fear Questionnaire (Marks & Mathews, 1979).
2.3. Procedure
2.3.1. Panic disorder cohort
Two to three weeks after completing the diagnostic interview and the symptom-based assessments, patients were given the CECS along with the additional emotional items and asked to
return them in a stamped addressed envelope.
2.3.2. Aberdeen controls
The entire Aberdeen University Psychology Department volunteer panel (n ¼ 197) were sent
the CECS with the additional emotional items, and the symptom based assessments along with
a cover letter explaining the nature of the study and a stamped addressed envelope. One hundred and eighteen participants completed the CECS and 109 completed the additional questions
assessing emotional processing.
2.3.3. London controls
Numerical data on the London sample (n ¼ 406) were sent by post from Dr. Watson to the
author. The London sample completed the CECS only.
3. Results
Data analysis was carried out using Statistica ’99 Edition and SPSS Version 11.0. The critical
p-value was set at 0.05. Precision of estimated mean differences was summarized using 95%

R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287


Confidence Intervals (CI). In order to ensure that the panic patients and panic patients with
agoraphobia were a cohesive group they were compared on each outcome measure. There were
no significant differences between them.
3.1. Courtauld Emotional Control Scale
Analyses of variance (ANOVAs) were carried out with Group (panic, London and Aberdeen
controls) as the independent factor and the CECS subscales and total score as the dependent
variables. Analyses of covariance (ANCOVAs) were subsequently carried out to take account of
age and gender differences. Post-hoc analyses using Bonferroni’s correction were conducted for
significant overall group differences to identify their source.
Box and whisker plots indicating the range of Total Emotional Control scores for each of the
three groups are shown in Fig. 1. There were highly significant differences between the groups
(F ð2; 556Þ ¼ 31:3; p < 0:001). The panic group had significantly higher Emotional Control
scores than the Aberdeen (p < 0:001) and London controls (p < 0:001). The Aberdeen control
group also controlled their emotions significantly more than the London control group
(p ¼ 0:01). When age and gender differences were taken into account these differences remained
significant. In terms of mean scores (controlling for age and gender) the mean difference
between the panic group and Aberdeen controls was 10.2 points (95% CI 6.0, 14.3) and between
the panic group and London controls 13.4 points (95% CI 9.9, 16.8). Between the Aberdeen and
London controls the difference was 3.2 points (95% CI 0.6, 5.9).
Table 2 shows the mean scores for each subscale of the CECS unadjusted and adjusted for
age and gender. There were significant group differences for Control of Anger
(F ð2; 557Þ ¼ 18:5; p < 0:001), Control of Unhappiness (Fð2; 557Þ ¼ 23:14; p < 0:001), and
Control of Anxiety (F ð2; 559Þ ¼ 22:51; p < 0:001). In each case the panic group controlled their
anger, unhappiness and anxiety significantly more than the London (all p < 0:001) and
Aberdeen controls (all p < 0:05) and the Aberdeen controls controlled their anger (p < 0:001),
unhappiness (p ¼ 0:02) and anxiety (p ¼ 0:02) significantly more than the London controls.
When age and gender differences were taken into account the mean difference between the panic

Fig. 1. Box plot of total emotional control scores (CECS).


R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287

Table 2
Mean scores for each subscale of the CECS (higher scores, more control), unadjusted (line 1) and adjusted for age
and gender (line 2)
CECS scales
Control of anger
Mean (SD) and CI
Mean (SD) (age and gender)
Control of unhappiness
Mean (SD) and CI
Mean (SD) (age and gender)
Control of anxiety
Mean (SD) and CI
Mean (SD) (age and gender)
Total control
Mean (SD) and CI
Mean (SD) (age and gender)




and CI

19.1 (4.7) 17.8, 20.5
18.9 (5.8) 17.1, 20.6

17.1 (4.5) 16.2, 17.9
16.4 (8.7) 14.7, 18.1

15.4 (4.5) 14.9, 15.8
14.9 (11.0) 13.7, 16.0

and CI

21.2 (4.1) 20.0, 22.4
19.6 (5.5) 18.0, 21.2

18.1 (4.3) 17.3, 18.9
15.7 (8.3) 14.1, 17.3

16.8 (4.4) 16.4, 17.3
15.0 (10.3) 14.0, 16.1

and CI

21.6 (4.8) 20.2, 23.0
21.0 (5.8) 19.3, 22.7

18.5 (4.5) 17.6, 19.4
17.3 (8.7) 15.6, 19.1

17.1 (4.5) 16.7, 17.6
16.3 (11.0) 15.1, 17.4

and CI

62.0 (11.4) 58.7, 65.3
59.7 (14.0) 55.6, 63.8

53.5 (11.4) 51.3, 55.7
49.5 (20.9) 45.3, 53.6

49.3 (10.9) 48.2, 50.4
46.3 (26.3) 43.6, 49.0

group and London controls for their Control of Anger was 4.0 points (95% CI 2.6, 5.4)
p < 0:001; for Control of Unhappiness 4.6 points (95% CI 3.2, 5.9) p < 0:001, and for Control
of Anxiety 4.7 points (95% CI 3.3, 6.1) p < 0:001. The mean difference between the panic group
and Aberdeen controls for their Control of Anger was 2.5 points (CI 0.8, 4.1) p ¼ 0:003; for
Control of Unhappiness 3.9 points (CI 2.4, 5.5) p < 0:001 and for Control of Anxiety 3.6 points
(CI 2.0, 5.3) p < 0:001. Finally, between the Aberdeen and London controls the difference
between the groups on the Control of Anger subscale was still significant when age and gender
differences were taken into account p ¼ 0:006, mean difference of 1.5 points (CI 0.4, 2.7), but no
longer significant for their Control of Unhappiness, mean difference of 0.6 (CI 0.1, 1.2) p ¼ 0:7
ns, and Control of Anxiety, mean difference of 1.1 (CI 0.02, 2.2) p ¼ 0:15 ns.
3.2. Other measures of emotional processing (panic cohort and Aberdeen controls only)
Independent samples t-tests were used to compare the panic group and Aberdeen controls on
the additional emotional processing items and items relating to the control of emotional experience and expression from the CECS. Data for these items had not been collected for the
London controls. When the assumptions of these tests appeared to be violated the p-values were
compared with those from the Mann–Whitney U-test to check whether they were similar.
ANCOVAs were subsequently carried out to take account of age and gender differences.
Means, standard deviations and critical p-values for the additional emotional processing items
are shown in Table 3, along with age and gender adjusted mean difference scores between the
The panic group showed significantly greater awareness of feelings (p < 0:001), significantly
poorer ability to label emotions (p < 0:001), and significantly greater control of emotional
experience (p < 0:001) and expression (p < 0:001). Their constructs about having and expressing
emotions did not differ from the control group, although when age and gender differences were
accounted for, the panic group did regard it as more appropriate to have negative feelings




1.4 (0.6)
1.8 (0.7)
1.6 (0.6)
2.2 (0.7)
13.7 (4.3)
40.0 (7.7)
1.9 (0.6)
1.7 (0.6)
1.8 (0.7)
2.5 (0.7)
2.1 (0.8)
2.1 (0.8)

3.1 (0.7)
1.6 (0.8)

Aberdeen mean

0.5 (0.2, 0.8) <0.001
0.4 (0.1, 0.7) <0.001
0.1 (0.2, 0.3) 0.50
0.3 (0.1, 0.6) 0.02
0.1 ( 0.4, 0.1) 0.36
0.1 ( 0.2, 0.4) 0.44
4.6 (2.8, 6.3) <0.001
6.2 (3.1, 9.3) <0.001
0.2 (-0.04 , 0.4) 0.09
0.9 (0.7, 1.2) <0.001
1.2 (0.9, 1.5) <0.001
0.3 ( 0.03, 0.5) 0.07
0.8 (0.5, 1.2) <0.001
1.2 (0.9, 1.5) <0.001


Mean diff (CI) and P-value
(age and gender adjusted)



Confirmed with non-parametric Mann–Whitney U-test. In all other cases parametric assumptions were met.


3.6 (0.6)
2.2 (0.9)


Awareness of feelings
Labelling emotions
Constructs. It is right to. . .
Have positive feelings
Have negative feelings
Express positive feelings
Express negative feelings
Control of emotional experience (CECS)
Control of emotional expression (CECS)
Frequency of anger
Frequency of unhappiness
Frequency of anxiety
Intensity of anger
Intensity of unhappiness
Intensity of anxiety

Panic mean


Emotional processing dimensions

Table 3
Emotional processing dimensions

R. Baker et al. / Behaviour Research and Therapy 42 (2004) 1271–1287

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