Anxiety Sensitivity: Cause or Consequence of Panic?

Anxiety sensitivity is a tendency to the negative misinterpretation of bodily sensations of anxiety that produces a state of fear. It is believed to be due to concerns about potential physical, social, or cognitive consequences of anxiety symptoms. Anxiety sensitivity tends to be elevated especially among people with panic disorder. In this article, we will explore whether anxiety sensitivity is a cause or rather a consequence of panic.

What is Anxiety Sensitivity?

In the 16th-century, French philosopher Montaigne (1948) once remarked in Book I of Essays: “The thing I fear most is fear.”. And centuries later, in his first inaugural address during the Great Depression, President Roosevelt once said: “The only thing we have to fear is fear itself” (Roosevelt 1965, p. 274). 

Anxiety sensitivity is the fears of anxiety-related sensations (Reiss et al., 1986). While some people are scared of snakes, flying on aeroplanes or speaking in public, others are terrorized by the sensations that accompany anxiety, fear, or panic.  

Individuals with high anxiety sensitivity are usually convinced that certain bodily sensations associated with panic, anxiety, stress or fear are dangerous or harmful. For instance, they may be convinced that heart palpitations are an imminent sign of a heart attack, or that a hyperventilation attack can signify that the person is about to lose her mind and do something insane. On the contrary, people with lower anxiety sensitivity would regard these sensations as just annoying. 

Episodes of fear are more aversive for people with high anxiety sensitive than for people with lower anxiety sensitivity. Some authors have even speculated that agoraphobia may not be viewed as the fear of public or open places but rather as a fear of fear (Goldstein & Chambless, 1978). Similarly, Clark (1986) proposed that panic attacks may be evoked by catastrophic negative misinterpretations of certain bodily sensations. For instance, an abrupt increase in blood pressure may be misinterpreted as an imminent fear of collapsing, which may likely intensify symptoms and lead to a full-blown panic attack.

Higher levels of anxiety sensitivity correlate with a greater number of objects and situations feared. This holds true even after controlling statistically for levels of trait anxiety (McNally and Lorenz 1987; Reiss et al 1986).

What is the difference between Anxiety Sensitivity and Phobias?

Anxiety sensitivity is a fundamental fear and it is distinct from derivative fears or phobias. Phobias are an overwhelming and unreasonable fear of a specific object or situation which is perceived to pose a real danger. In other words, phobia is the avoidance of the feared stimulus.

Let us consider the fear of spiders, the fear of thunders, and the fear of anxiety. There is no logical connection between spider phobia and the fear of thunders. One would never say, “I am afraid of spiders because I am afraid of thunders”. On the contrary, we may well say that anxiety sensitivity can function as a motivational basis for both spider phobia and fear of thunders. In fact, a person might admit, “I am afraid of thunders and spiders because I am terrorized by experiencing a panic attack should I be confronted with these stimuli”. It is clear from this example of how the fear of anxiety symptoms may serve as a fundamental reason or motive to avoid spiders and thunders. 

It is to note that some individuals suffering from specific phobias may manifest high levels of anxiety sensitivity, the latter is not a condition sine qua non to experience any phobia. Individuals with high anxiety sensitivity may avoid any potential stimulus (such as spiders and thunders) because of the fear that these stimuli may evoke anxiety symptoms. The basis of their anxiety is their fear of anxiety symptoms. In contrast, individuals without anxiety sensitivity may still avoid feared stimuli (such as spiders and thunders) because of their perceived danger. These individuals are having phobias without anxiety sensitivity.   

Do Anxiety Sensitivity and Trait Anxiety refer to the same construct?

Anxiety sensitivity should not be confused with trait anxiety. While trait anxiety is the tendency to respond fearfully to stressors in general, anxiety sensitivity is the specific tendency to respond fearfully to anxiety symptoms themselves (McNally, 1989). Therefore, a person might have high trait anxiety levels (i.e. a proneness to experience frequent, intense episodes of state anxiety) yet (s)he may have no additional fear of anxiety itself. 

Different people are characterized by different levels of both trait anxiety and anxiety sensitivity. In fact, individuals vary in their tendency to experience anxiety symptoms and to respond fearfully to them.

What is the difference between Anxiety Sensitivity and Anticipatory Anxiety?

Anxiety sensitivity and anticipatory anxiety reflect two different constructs. Individuals experience anticipatory anxiety manifest an increase in distress when they face a situation that they perceive as dangerous. For instance, anticipatory anxiety can be experienced before speaking in public, before having sex with someone, and so on. People usually fear they will not be able to perform as expected (e.g. they will stutter or blush in front of the audience, or they will not have an erection during the intercourse). 

Anticipatory anxiety often provokes a worsening of the performance. This happens because when anxiety levels are too high, people cannot focus properly on the task. For example, when giving a speech, they become anxious because they anticipate negative reactions from the audience and that results in poor speech delivery. Other times, their performance is compromised when they become so focused on what is going on in their bodies or they expect to control every subtle physiological variation (e.g. they are afraid of sweating or blushing in front of the audience).

Is Anxiety Sensitivity a Cause or a Consequence of Panic?

Both, I would say. Anxiety sensitivity is a risk factor for panic attacks and panic disorder. In this sense, anxiety sensitivity can be a cause of panic. In fact, high levels of anxiety sensitivity can predict panic symptoms in response to biological challenges that provoke feared bodily sensations (such as carbon dioxide inhalation). Prospective longitudinal studies (e.g. Schmidt et al., 1999) have suggested that high levels of anxiety sensitivity may predict subsequent spontaneous attacks. These studies indicated that elevated anxiety sensitivity is a risk factor for panic and perhaps panic disorder.

In other cases, anxiety sensitivity may be a consequence of panic. After experiencing a panic attack, some people may develop a fear of the symptoms of panic and become prone (i.e. sensible) to recognize every subtle variation in their bodies. They would tend to closely monitor their heartbeat, breathing, blood pressure, and so on, and in time, they tend to become extremely capable in this task. In this sense, anxiety sensitivity may follow, and hence be a consequence, of even a single episode of panic. Of course, if these individuals tend not only to recognize but also to misinterpret the bodily variations as a dangerous symptom, it is likely their fear may lead to further full-blown panic attacks and in some cases to develop panic disorder. This hypothesis has been corroborated by Schmidt and colleagues (1999), who have found that not only did high anxiety sensitivity predicted panic attacks, but that the occurrence of panic, in turn, increased levels of anxiety sensitivity.

Where does Anxiety Sensitivity come from?

Many researchers have investigated where anxiety sensitivity comes from. It seems that anxiety sensitivity is a dispositional construct, that is some individuals are born with higher levels of anxiety sensitivity. 

Despite being a “trait-like” construct, this does not imply that anxiety can increase or diminish over time. 

It is still not clear whether anxiety sensitivity precedes adverse childhood experiences with symptoms or vice versa. What is more certain is that if parents are concerned about anxiety symptoms, their children can manifest higher levels of anxiety sensitivity and later panic. In fact, parental concerns regarding arousal-reactive symptoms (e.g., nausea, dizziness) can directly influence both anxiety sensitivity and panic frequency (Stewart et al., 2001).

However, it seems that shared genes, rather than parental modelling, may explain the link between parental concern about symptoms and later panic attacks (Stein et al., 1999).

Is it possible to lower anxiety sensitivity?

Yes. As mentioned earlier, despite anxiety sensitivity being a trait-like construct, levels can fluctuate over time. For example, psychotherapy reduces anxiety sensitivity in individuals suffering from agoraphobia. Psychotherapy may even protect against relapse (McNally and Lorenz, 1987). Imipramine likewise can lower anxiety sensitivity (Mavissakalian et al., 1998).

So, this is good news. Psychotherapy can reduce anxiety sensitivity. Lower levels of anxiety sensitivity may, in turn, be a protective factor for the suffering of panic disorder and other anxiety disorders, such as specific phobias, agoraphobia, claustrophobia, and social phobia. Psychotherapy is an evidence-based approach to rid anxiety and panic,  giving you back the freedom you have lost from the limitations these disorders imply.