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Clinical Psychology Review 24 (2004) 529 – 555

An integrated cognitive model of panic disorder:
The role of positive and negative cognitions
Leanne M. Casey a,b,*, Tian P.S. Oei a, Peter A. Newcombe a

School of Psychology, University of Queensland, Brisbane, Queensland 4072, Australia
Department of Psychology, The Prince Charles Hospital Health Service District, Brisbane, Queensland 4032, Australia

Received 18 November 2002; received in revised form 5 January 2004; accepted 12 January 2004

One reason for the neglect of the role of positive factors in cognitive – behavioural therapy (CBT) may relate to
a failure to develop cognitive models that integrate positive and negative cognitions. Bandura [Psychol. Rev. 84
(1977) 191; Anxiety Res. 1 (1988) 77] proposed that self-efficacy beliefs mediate a range of emotional and
behavioural outcomes. However, in panic disorder, cognitively based research to date has largely focused on
catastrophic misinterpretation of bodily sensations. Although a number of studies support each of the predictions
associated with the account of panic disorder that is based on the role of negative cognitions, a review of the
literature indicated that a cognitively based explanation of the disorder may be considerably strengthened by
inclusion of positive cognitions that emphasize control or coping. Evidence to support an Integrated Cognitive
Model (ICM) of panic disorder was examined and the theoretical implications of this model were discussed in
terms of both schema change and compensatory skills accounts of change processes in CBT.
D 2004 Elsevier Ltd. All rights reserved.
Keywords: Panic disorder; Positive cognitions; Catastrophic misinterpretation of bodily sensations; Panic self-efficacy

1. Introduction
Although a number of reasons have been advanced to explain the relative neglect of positive
cognitions in cognitive–behavioural therapy (CBT) (MacLeod & Moore, 2000), there has been little
recognition that this problem may also relate to the continuing lack of integration between existing
theoretical models within the cognitive framework. Bandura’s (1977) identification of self-efficacy
* Corresponding author. School of Psychology, University of Queensland, Brisbane, Queensland 4072, Australia. Tel.: +617-3365-6230; fax: +61-7-3365-4466.
E-mail address: l.casey@psy.uq.edu.au (L.M. Casey).
0272-7358/$ - see front matter D 2004 Elsevier Ltd. All rights reserved.


L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555

beliefs as positive cognitions that mediate a range of emotional and behavioural outcomes generated
influential support for cognitive models of human functioning (Maddux, 1995). To date, however, the
primary emphasis in cognitive therapy has been upon identification and modification of negative
cognitions. Integration of such models may provide both a more coherent account of change processes in
CBT as well as establish the basis for further development in the field.
Panic disorder provides a useful exemplar of a disorder in which development of an Integrated
Cognitive Model (ICM) may provide important momentum to continuing research efforts. Cognitive
theorists, such as Clark (1993b), have argued that changes in positive cognitions occur simply as a
corollary to changes in negative, danger-related cognitions. In contrast, other theorists, such as Bandura
(1988) and Barlow (1988), who have drawn attention to the importance of control or coping in panic
disorder, have in turn relegated negative cognitions to a subordinate role. To date, much of the research
has focused on negative cognitions (Cox, 1996) and there has been little attempt to integrate these
positions. As the following review indicates, however, there are limitations to a cognitive account of
panic disorder that focuses solely on negative cognitions, which in turn may constrain attempts to
demonstrate cognitive mediation of treatment effects. In contrast, a cognitive model that integrates both
negative and positive cognitions may not only assist treatment and research in panic disorder, but also
provide a useful template for investigation of other psychological disorders.

2. Cognitive approaches to panic disorder
2.1. Clark’s explanation of panic disorder: catastrophic misinterpretation of bodily sensations
Clark’s explanation of panic is illustrated in Fig. 1. According to Clark (1986), ‘‘panic attacks result
from the catastrophic misinterpretation of certain bodily sensations’’ (p. 462). These bodily sensations,
he suggested, were mostly those associated with normal anxiety responses, such as palpitations,
breathlessness, and dizziness, but could also be caused by routine events (e.g., exercise) or even result
from other, non-anxiety-related emotional states (e.g., excitement, anger, and happiness). Through the
process of catastrophic misinterpretation, however, the individual perceives these essentially benign
and normal sensations as evidence of imminent danger. Thus, palpitations are misinterpreted as a
signal of a heart attack, dizziness as evidence of impending loss of control, etc. Noting that a broad
range of stimuli (either external or internal) can produce panic attacks, Clark suggested that the
perception of these stimuli as threatening results in ‘‘a mild state of apprehension,’’ which is
accompanied by the bodily sensations associated with anxious arousal. Clark’s explanation of panic
disorder thus postulates a vicious circle in which misinterpretation of these bodily sensations of
anxiety results in a panic attack, although as noted, sensations associated with other causes may be
involved in the initial stages.
Initially, Clark (1988) argued that panic attacks always result from a catastrophic misinterpretation of
internal or external events, although for some individuals, this process may occur out of awareness at the
time. However, in a more recent paper, Clark (1996) has focused on the key importance of the repetitive
nature of panic attacks. Drawing a distinction between the infrequent autonomic events reported as panic
attacks in the normal population that may be caused by a number of factors, and the recurring panic
attacks that typically culminate in a diagnosis of panic disorder, he has suggested that only the latter
should be considered as linked to catastrophic misinterpretation of bodily sensations. Accordingly, a

L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555


Fig. 1. Cognitive account of panic attacks (Clark, 1986, p. 463).

central tenet of cognitively driven treatment applications is that symptom change in panic disorder
occurs through the reduction of catastrophic misinterpretation of bodily sensations (Clark et al., 1994;
Rachman, 1994).
2.2. Bandura’s theory of self-efficacy
In conceptualizing the role of self-efficacy in anxiety disorders, Bandura (1988) argued that the sense
of threat, which is the hallmark of these disorders, should not be regarded as a fixed property. Rather, it is
derived both from the individual’s appraisal of perceived coping abilities and the assessment of the
perceived dangers of the environment. However, Bandura explicitly ascribed a subordinate role to the
role of perceived danger. In panic disorder, this perceived danger is defined in Beck, Emery, and
Greenberg’s (1985) terms as thoughts of ‘‘physical or psychosocial harm, such as dying, going crazy or
humiliating oneself’’ (Williams, 1995). In other words, perceived danger closely approximates the
construct of catastrophic misinterpretation of bodily sensations. In Bandura’s model, therefore, it is
assumed that perceived danger is an effect of low self-efficacy and that changes in self-efficacy will lead
to changes in perceived danger. Thus, the self-efficacy model would predict that improvement in CBT
for panic disorder is mediated by changes in self-efficacy, rather than by changes in catastrophic
misinterpretation of bodily sensations.
2.3. Beck’s cognitive approach
Ironically, a potential resolution of these two foregoing positions was presaged in Beck’s seminal
work on cognitive therapy for anxiety disorders, but has been largely overlooked. Although Clark’s
construct has been identified as directly relating to Beck’s theory (Beck et al., 1985) concerning danger-


L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555

laden schemas in anxiety disorders (e.g., Beck et al., 1985; Salkovskis, 1998), a comparison of the
construct of catastrophic misinterpretation of bodily sensations and Beck’s original conceptualization of
anxiety disorders suggests a striking and important difference. The broader cognitive theory from which
the construct of catastrophic misinterpretation of bodily sensations is derived suggests that while anxiety
occurs because of the appraisal of events or situations as threatening, this appraisal is derived from four
constituent elements, of which the ‘‘perceived cost or awfulness of danger’’ is only one element. The
other elements are perceptions of the likelihood of danger, coping ability, and rescue factors. For Beck,
the central problem of anxiety disorders was a sense of vulnerability, defined as
a person’s perception of himself as subject to internal or external dangers over which his control is
lacking or is insufficient to afford him a sense of safety. (Beck et al., 1985, p. 67)
In Beck’s original work, then, it was the interaction between negative cognitions concerning the
presence of danger, and positive cognitions regarding control or coping that contributes to anxiety, a
topic that will be discussed in more detail in the following sections. In Clark’s explanation of panic,
however, catastrophic misinterpretation of bodily sensations provides the key focus and explanation of
clinical symptoms, and it is the role of this catastrophic misinterpretation of bodily sensations that has
dominated cognitive mediational accounts of panic disorder to date.

3. Empirical support for catastrophic misinterpretation of bodily sensations: Clark’s predictions
Clark (1986, 1988, 1996) suggested that there were a number of predictions that should be
investigated in order to support the construct of catastrophic misinterpretation of bodily sensations in
panic disorder. Evidence to support Clark’s predictions has steadily accumulated over the last decade or
so, and has been presented in detail in a number of extensive reviews (Clark, 1996, 1999; Khawaja &
Oei, 1998). Therefore, this body of evidence is only briefly reviewed in this section, with an emphasis on
studies that suggest there are limitations to an exclusive focus on the role of catastrophic misinterpretation of bodily sensations in cognitive accounts of panic disorder.
3.1. Cognitive specificity of catastrophic misinterpretation of bodily sensations in panic disorder
A number of studies indicate that catastrophic misinterpretation of bodily sensations appears to be
more prevalent in patients in panic disorder in comparison to both the normal population and other
clinical disorders (for review, see Khawaja & Oei, 1998). Consistent with much evidence, a comparison
between patients with panic disorder, social phobia, and nonanxious controls on response times to a
range of emotionally positive and threatening words found that patients with panic disorder had longer
response times to panic-specific threat words (Maidenberg, Chen, Craske, Bohn, & Bystritsky, 1996).
However, these patients also displayed longer response times to threat words associated with social and
general concerns, suggesting that patients with panic disorder may also be characterized by a more
generalized attentional bias to threat. Using a modified lexical decision task, Schniering and Rapee
(1997) failed to replicate differences between patients with panic disorder and nonclinical controls in the
association of somatic sensations and threat. Although they noted a number of methodological issues
that may have accounted for this discrepant finding, importantly, they suggested that other cognitive

L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555


factors may distinguish individuals with panic disorder from nonpanickers and that these factors should
be considered in addition to threat-related cognitions. Specifically, Schniering and Rapee suggested that
people with panic disorder may be more clearly distinguished by their belief that they have little capacity
to alter or influence threat-related situations, a conclusion which may be consistent with the more
generalized threat bias detected by Maidenberg et al. However, the possibility that patients with panic
disorder may be characterized by both high levels of catastrophic misinterpretation of bodily sensations
and low levels of panic self-efficacy emerges more clearly in studies investigating experimental
provocation and manipulation of panic attacks.
3.2. Cognitive mediation of panic attacks in biological challenge tests
There is considerable experimental evidence to support cognitive mediation of panic attacks induced
by biological challenge tests (Clark, 1993b; Khawaja & Oei, 1998; Rapee, 1995). However, the most
relevant question regarding the experimental evidence in the area of biological challenge tests concerns
exactly which cognitive variables are responsible for the effects demonstrated in the majority of these
experiments. Reviewing this area of research, Rapee (1995) suggested that it was both the reduction of
threat and the availability of control that are manipulated in these experiments. Furthermore, in the
broader context of laboratory-based research into panic attacks, it is worth remembering Rachman’s
(1988) caution that the experimental conditions under which these panics are induced offer, by their
nature, far greater control than is available in clinically occurring panics. According to Clark (1993a),
however, the key variable is the reduction of catastrophic misinterpretation of bodily sensations, with the
provision of control in these experiments simply further adding to the reassurance that the sensations are
not dangerous.
In a study that provides a clinical context in which to consider the relative contribution of both
types of cognition, Schmidt, Trakowski, and Staab (1997) compared CBT-treated and untreated
patients with panic disorder on pre- and posttreatment responses to five repeated vital-capacity
inhalations of 35% CO2/65% O2. Measures in this study included panic attack frequency, SUDS
ratings of subjective anxiety, psychophysiological indices of arousal, panic-related appraisals of the
likelihood, consequences and perceived self-efficacy in coping with panic, and anxiety sensitivity.
Anxiety sensitivity is a construct that refers to fears of anxiety symptoms based on the beliefs that
these symptoms may have harmful consequences (Reiss & McNally, 1985) and thus is linked to,
although separate from, the concept of catastrophic misinterpretation of bodily sensations (McNally,
Hornig, Hoffman, & Han, 1999). Although there were no pretreatment differences between groups on
any of these measures in the Schmidt et al. study, at posttreatment, patients who had participated in
CBT recorded significantly fewer panic attacks during posttreatment inhalations. CBT-treated patients
also reported significant pre- to postchanges on anxiety sensitivity and panic-related appraisals,
whereas there were no changes on any of these indices reported by untreated patients. Schmidt et al.
reported that there were relatively few posttreatment differences between treated and untreated patients
on psychophysiological measures of arousal. However, patients with high levels of anxiety sensitivity
and low levels of panic coping self-efficacy were at least at eight times greater risk for experiencing
panic during the posttreatment assessment. Patients who continued to believe that anxiety symptoms
were associated with a high probability of negative consequences, and patients who had a low level of
belief in their ability to cope with panic attacks were at greater risk of panic attacks in response to the
CO2 challenge. However, the strong negative correlation evident between levels of anxiety sensitivity


L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555

and panic self-efficacy in the results reported by Schmidt et al. highlights the importance of
establishing whether positive cognitions contribute to the prediction of panic severity beyond the
influence of negative cognitions.
3.3. The role of catastrophic misinterpretation of bodily sensations in maintenance of treatment outcome
Clark’s (1986) final prediction suggests that sustained improvement in panic disorder depends on
reduction of catastrophic misinterpretation of bodily sensations that has occurred during treatment. The
available evidence mostly supports this prediction (Clark, 1996, 1999). For example, Clark et al. (1997)
found that catastrophic misinterpretation of bodily sensations (as measured by the Bodily Sensations
Interpretation Questionnaire) predicted maintenance of outcome at follow-up, controlling for panic/
anxiety composite scores at the end of treatment. Similarly, in a comparison of treatment outcome
between CBT and Applied Relaxation (AR), Westling and Ost (1995) found successful treatment was
characterized by a reduction in the catastrophic interpretation of bodily sensations in panic patients
relative to the control group. They also found that compared to panickers at posttreatment, nonpanickers
had reduced their cognitive threat bias at posttreatment and at follow-up.
In contrast, Stoler and McNally (1991) found that patients judged to be recovered from panic disorder
with agoraphobia were more similar to symptomatic patients than control subjects in their cognitive bias
towards catastrophic misinterpretation of bodily sensations. Results from the sentence completion task
that Stoler and McNally used in their study provide a useful insight into the potential role of panic selfefficacy in symptom reduction. Sentence completions were classified as either biased (threat-related) or
unbiased. Biased interpretations were further classified as to whether or not subjects indicated efforts at
adaptive coping with the perceived threat. Despite persistence of cognitive biases, analysis of responses
of recovered patients revealed a pattern of adaptive coping with perceived threat. In contrast,
symptomatic patients failed to exhibit an adaptive coping style. The interesting conclusion suggested
by the Stoler and McNally study is that, even with the persistence of cognitive bias towards threat,
perceived ability to cope adaptively with threat may serve to maintain treatment gains.
In summary, although there are a number of studies that support each of the predictions that Clark has
made regarding the role of catastrophic misinterpretation of bodily sensations in panic disorder, review
of this evidence suggests that attention to the role of panic self-efficacy may serve to strengthen the case
for a cognitively based approach to panic disorder. A number of other areas relevant to cognitive
accounts of panic disorder that highlight the limitations to catastrophic misinterpretation of bodily
sensations as the sole cognitive explanation of panic disorder are reviewed in the following section.

4. Limitations to catastrophic misinterpretation of bodily sensations as an explanation of panic
disorder: the link between bodily sensations, cognitions, and affect
A central assumption of Clark’s (1986) explanation of panic disorder is that there is a logical link
between bodily sensations, affect, and cognitions that results in panic attacks. In its most straightforward
form, this link suggests that bodily sensations give rise to catastrophic misinterpretation of bodily
sensations that in turn produces panic. According to Clark, the key factor maintaining this link is the
presence of catastrophic misinterpretation of bodily sensations, and thus reduction of this negative
cognition should explain clinical change. The following section reviews evidence that suggests instead

L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555


that the link between bodily sensations, cognitions, and affect that results in panic may also be
maintained by low levels of positive cognitions concerning coping or control.
4.1. The link between cognition and affect
According to Clark (1986, 1996, 1999), the reason that people experience panic is that they interpret
bodily sensations as a signal for imminent physical or psychological catastrophe. The ‘‘normalizing
rationale’’ of the cognitive approach therefore is to suggest that anyone who makes such an appraisal of
imminent danger would be extremely anxious and likely to respond in a manner designed to minimize
the risk. As Salkovskis and Hackmann (1997) have commented: ‘‘the awfulness of many of the feared
catastrophes appears to be self-evident’’ (p. 46). Thus, the presence of cognitions regarding imminent
danger should be reliably associated with panic or anxiety and avoidance.
However, as Rachman (1990) has documented, there is instead a considerable diversity of reactions
manifested when people face situations that are literally life-threatening. People can parachute from
planes, deactivate bombs, and face combat conditions without panicking. In these situations, people may
experience fear, yet enter or remain in the situation despite this fear, or even more intriguingly, simply
experience relatively little fear in these obviously dangerous situations. Importantly, fear appears to
decrease even when the perceived danger of the situation remains the same. Salkovskis and Hackmann
(1997) have noted that the anxiety reactions experienced in life-threatening situations are not likely to be
regarded as abnormal. In this sense, the absence of panic in these situations may in part reflect the
operation of an alternative explanation for anxiety symptoms. Despite this explanation, however, it
seems clear that the actual danger of these situations remains, thus challenging the inevitability of
overwhelming anxiety associated with danger-related cognitions that is posited by the construct of
catastrophic misinterpretation of bodily sensations.
According to Rachman (1990), what appears to distinguish people operating in such situations is a
high level of self-confidence, a concept similar to self-efficacy. Thus, even in situations of actual and
acute danger, the presence of positive cognitions concerning coping or control may enable people to
tolerate cognitions concerning imminent danger and perform adequately. This observation can be
translated in two ways that are relevant to the experience of panic. Firstly, an initial appraisal of threat or
danger may not inevitably escalate into incapacitating anxiety, even in the absence of a plausible
reinterpretation of the threat stimuli itself. Instead, it appears that the presence of positive cognitions
concerning coping or control may somehow prevent this escalation, potentially either through simply
broadening attentional focus (Fredrickson, 2001), or by allowing an individual to encapsulate and
thereby contain threat-related cognitions within a broader, implicational level of self-referent meaning
associated with control and coping (e.g., Power & Dalgleish, 1997; Teasdale, 1993). Secondly, in clinical
terms, the presence of panic self-efficacy may enable a reinterpretation of threatening stimuli to take
place, with a concomitant reduction of catastrophic misinterpretation of bodily sensations. Treatment
strategies associated with CBT often involve asking patients to enter and remain in situations that are
likely to trigger negative cognitions regarding imminent danger. Presence of panic self-efficacy that
allows them to tolerate this experience seems, at a minimum, likely to be of considerable assistance in
assisting patients to disconfirm the feared catastrophe. The threat stimuli that are most clearly involved in
panic disorder are bodily sensations. It is therefore of importance to consider ways in which positive
cognitions concerning coping or control may be involved in interpretation and response to these


L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555

4.2. The link between bodily sensations and cognitions
According to Clark (1986, 1996), physiological arousal acts as a trigger for catastrophic misinterpretation of bodily sensations in people with panic disorder, and thus should precede or accompany
catastrophic misinterpretation. There is relatively little evidence to suggest that people with panic
disorder either experience more fluctuations in physiological functions, or are generally more
physiologically reactive (and thus more prone to experience bodily sensations) than other people
(Ehlers, 1993). On the contrary, it seems that when exposed to similar bodily sensations, people with
panic disorder are more likely to experience anxiety and catastrophic cognitions (e.g., Pauli et al., 1991).
Even when comparison subjects from a normal population are experiencing chest pain of demonstrated
medical concern, they appear significantly less likely to experience catastrophic cognitions than patients
with panic disorder (Fraenkel, Kindler, & Melmed, 1997).
Such findings are, of course, consistent with the role of catastrophic misinterpretation of bodily
sensations in mediating the experience of panic. However, it is of interest to consider why such
comparison subjects from the normal population do not experience the same level of catastrophic
cognitions as people with panic disorder. One possibility is the existence of positive illusions, such as
exaggerated perceptions of control or mastery, which have been suggested as being not only normative,
but also as having considerable protective value with regards to both mental and physical health (Taylor
& Brown, 1988; Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000). Arguably, comparison subjects
may have been less likely to experience catastrophic cognitions regarding bodily sensations because of
the presence of positive cognitions concerning coping or control (see also, Folkman & Moskowitz,
2000). An alternative view, however, is that these comparison subjects simply had no prior underlying
association of bodily sensations with danger. Thus, when experiencing chest pain, these subjects were
simply not primed to interpret these sensations in a negative way.
Certainly, Clark (1988) has postulated that the tendency to catastrophically misinterpret bodily
sensations is a ‘‘relatively enduring cognitive trait . . . amplified when a individual enters an anxious
state’’ (p. 77). As a consequence, most people at risk for panic attacks presumably should exhibit these
interpretive biases prior to the development of clinical symptoms. However, results from a recent study
fail to support this hypothesis.
Anxiety sensitivity has been established as a cognitive risk factor for the development of panic attacks
(Schmidt, Lerew, & Jackson, 1997) and thus, is of particular value in experiments that are concerned
with the responses of people who are at risk of, but have not yet developed, panic disorder. McNally et
al. (1999) used a nonpanicking sample to investigate the relationship between scores on the Anxiety
Sensitivity Index and a range of interpretative, memory and attentional tasks similar to those that have
been used to measure threat-related cognitive biases in patients with panic disorder. If these threat-related
cognitive biases predate the development of the disorder, then people who are identified as being at risk
of developing the disorder presumably should show greater evidence of these threat-related cognitive
biases than people who are considered to be a low risk of developing the disorder. In contrast, McNally
et al. found little evidence to support the association between risk of developing panic disorder and
cognitive biases for threat, concluding instead that these threat-related cognitive biases may be the result,
rather than the precursor, of panic disorder.
Two aspects of the McNally et al. (1999) study are of particular importance in the current context.
Firstly, their results do suggest that more marked interpretive biases for internal cues are evident at
higher levels of anxiety. Secondly, McNally et al. speculated that either absence of these cognitive

L.M. Casey et al. / Clinical Psychology Review 24 (2004) 529–555


biases, or more interestingly, presence of what they described as ‘‘positivity’’ biases, may protect
people with high anxiety sensitivity from developing panic disorder. Thus, schematic processing,
which in Beck et al.’s (1985) terms reflects an interaction between negative and positive cognitions,
that results in higher levels of anxiety is likely to be more strongly associated with interpretative
threat biases, such as catastrophic misinterpretation of bodily sensations. But as a consequence,
presence of positive cognitions concerning coping or control may determine the impact of these
biases, either by inhibiting the development of the initial triggering anxiety, or by offsetting their
situational influence, even in people who have a marked underlying interpretative bias associating
bodily sensations with danger. Positive cognitive factors, such as panic self-efficacy, may thus be
helpful in explaining, and ultimately decreasing, the frequency with which people with panic disorder
experience catastrophic misinterpretation of bodily sensations when experiencing physiological
Paradoxically, the evidence to support the proposition that panic attacks are necessarily associated
with marked physiological arousal is at best mixed. Many studies looking at the role of bodily sensations
in panic disorder have focused on the role of cardiovascular states. Although a number of earlier studies
suggested that panic attacks were associated with elevated heartbeat (e.g., Taylor et al., 1986; Taylor,
Telch, & Havvik, 1983), more recent studies have failed to clearly support this association (Kenardy,
Oei, Weir, & Evans, 1993; Khawaja & Oei, 1999).
Attempting to account for these discrepant results, it has been argued that panic disorder patients
are simply more accurate in heartbeat detection (HBP; Clark, 1999) and thus presumably may be
more sensitive to minor variations in HBP. However, a recent reanalysis of this literature (Van der
Does, Antony, Ehlers, & Barsky, 2000), which combined the results of seven HBP studies, does not
support this contention. Instead, Van der Does et al. concluded that although accurate HBP is more
likely to be found in people who have continuous or frequent episodes of clinical anxiety, it does not
appear to be specific to panic disorder. Of course, not all individuals with panic disorder report
cardiac-related concerns, and for those who do not, evidence pertaining to HPB may be less relevant
(Ehlers, 1993). Similarly, methodological limitations in studies testing interoceptive accuracy in HPB
may account for some of these findings (Zoellner & Craske, 1999). A more broadly based test of the
specificity of interoceptive acuity to panic disorder, however, was reported by Rapee (1994). He
found that panic-disordered patients were no better than normal controls at detecting increases in CO2
concentrations in inhaled air, despite the fact that such increases should impact across a range of
bodily sensations.
Accuracy does not, of course, necessarily equate to awareness or even more importantly, to
interpretation. It has been frequently assumed in the literature that the ability of individuals to accurately
detect bodily sensations is associated with increased attention (Schmidt, Lerew, & Trakowski, 1997), and
thus, a greater probability of making a catastrophic misinterpretation of bodily sensations. However,
failure to support such a relationship does not by itself reflect on the role of catastrophic misinterpretation of bodily sensations in mediating panic (McNally, 1999). Van der Does et al. (2000) argued, for
example, that their findings regarding HBP in panic disorder should be understood in terms of schemabased processing, suggesting that
once a patient with Panic Disorder perceives a situation as threatening, an ‘anxiety’ schema is
activated, and that perception of symptoms is more guided by the schema (that is, past information)
than based upon present physiological status. (p. 61)

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