Introduction to

Anxiety Sensitivity
Recent Findings and New Directions
Michael J. Zvolensky
University of Vermont, Burlington
Norman B. Schmidt
Florida State University, Tallahassee
T
here has been a long-standing recognition that cognitive factors may play
a formative role in anxiety and its disorders (Barlow, 2002). Since the
1980s, there has been great progress made in understanding the nature of
cognitive risk for anxiety psychopathology. Within this context, numerous
cognitive factors have been implicated and studied as potential risk factors
for various anxiety conditions. Perhaps one of the most well-known and
promising of these has been anxiety sensitivity (AS; Reiss & McNally,
1985). AS is the fear of anxiety-related bodily sensations, which arise from
beliefs that the sensations have harmful personal consequences (McNally,
2002). To illustrate, people high in AS may be frightened of harmless heart
palpitations because they believe the sensations will lead to cardiac arrest,
whereas people low in AS do not fear these sensations because they believe
them to be harmless. High AS is theorized to enhance anxious and fearful
responding to internal cues through associative learning and/or cognitive
misinterpretation (McNally, 2002). Numerous studies have indicated that
AS is, in fact, related to increased risk of panic attacks (e.g., Hayward,
Killen, Kraemer, & Taylor, 2000; Schmidt, Lerew, & Jackson, 1997, 1999)
and anxiety disorders (Schmidt, Zvolensky, & Maner, 2006). Although the
vast majority of work on AS has been conducted in relation to panic psy-
chopathology (Zvolensky, Schmidt, Bernstein, & Keough, 2006), researchers
Behavior Modification
Volume 31 Number 2
March 2007 139-144
2007 Sage Publications
10.1177/0145445506296968
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139
Authors Note: This article was supported by National Institute on Drug Abuse research grants
(1 R01 DA018734-01A1, R03 DA16307-01, and 1 R21 DA016227-01) awarded to Dr. Zvolensky
and MH62056-01A2 awarded to Dr. Schmidt. This article was also influenced by many of the
presentations and discussions at the Jay Peak, Vermont, Anxiety Prevention Summit (February
2006). Correspondence concerning this article should be addressed to Michael J. Zvolensky,
PhD, The University of Vermont, Department of Psychology, 2 Colchester Avenue, John Dewey
Hall, Burlington, VT 05405-0134; e-mail: Michael.Zvolensky@uvm.edu.
have increasingly explored its explanatory relevance in relation to other
types of psychological problems (Taylor, 1999). This work has indicated
that AS may hold promise for other types of psychopathology and, by
extension, underscoring the relevance of this construct to the study of
abnormal behavior.
The primary purpose of the present special series is to provide a forum
for the systematic presentation of contemporary theory, empirical evidence,
and novel directions for future work as it pertains to AS. To accomplish this
aim, articles were selected to highlight a range of research on these topics.
These articles were presented at the first annual Vermont Anxiety
Prevention Summit at Jay Peak, Vermont (February 2006). By covering a
range of issues interconnected by their focus on understanding AS, it is
hoped that the series, as a whole, will (a) alert readers to the significance of
this work at a variety of different levels of analysis, (b) illustrate the type of
domains currently being explored via innovative approaches, and (c) iden-
tify fecund areas for future study. To provide a synopsis of the material cov-
ered in the articles, a brief overview of each is now presented along with a
discussion as to how they relate to the theme of this special series.
In the lead article, Li and Zinbarg (2007 [this issue]) address the role of
AS subdimensions (lower-order factors) in predicting panic attacks across
time. Past work has indicated that AS is a risk factor for panic attacks, but
the clinical relevance of AS in panic genesis has been questioned due to the
relatively small amount of overall variance accounted for by the construct
(Barlow, 2002; Bouton, Mineka, & Barlow, 2001). Li and Zinbarg (2007
[this issue]) examined AS and panic attacks through a 1-year longitudinal
study among college-age young adults to replicate and refine understanding
of the explanatory value of the construct. Results of this investigation indi-
cated that the ASMental Incapacitation Concerns, but not other subfactors,
was a significant predictor of panic onset. The findings from this investiga-
tion also provide novel empirical evidence that AS is not only statistically
significant but also pragmatically important for the onset of panic, as the
ASMental Incapacitation Concerns factor contributed 16% of the total vari-
ance of panic onset over and beyond a tendency to experience anxiety symp-
toms. These results collectively underscore the importance of AS in panic
attack manifestation and suggest that there may indeed be utility in employ-
ing a multidimensional approach that expressly recognizes the lower-order
factors of the construct in terms of better understanding panic vulnerability.
Based on these and related findings (Bernstein, Zvolensky, Weems, Stickle,
& Leen-Feldner, 2005; Schmidt et al., 2006), future work is now poised to
address the mechanism underlying this AS-panic attack association. This
140 Behavior Modification
continued focus on AS-panic attack associations will inform not only the eti-
ology of panic disorder but ultimately set the stage for targeted prevention
programs that can be tailored to meet the unique demands of this population
(Schmidt et al., in press; Zvolensky et al., 2006).
In the second article in the series, Hayward and Wilson (2007 [this
issue]) suggest that AS may be a key reason why individuals demonstrate
clinically significant levels of agoraphobic avoidance without having expe-
rienced panic attacks. There has been an appreciable degree of controversy
surrounding whether agoraphobic avoidance can occur in the absence of a
history of panic attacks because models of panic-spectrum psychopathol-
ogy generally posit that agoraphobic avoidance may be a complication of
(severe) panic attacks (Barlow, 2002). In addition, clinicians and others fre-
quently conceptualized panic attacks as assuming a central role in the
development of agoraphobia (Hayward, Killen, & Taylor, 2003). Yet,
numerous studies, especially epidemiological surveys, found that agora-
phobia is relatively common (Andrews & Slade, 2002; Wittchen, Reed, &
Kessler, 1998). Hayward and Wilson (2007 [this issue]) suggest that there
are considerable theoretical and empirical reasons to suggest that AS may
be relevant to avoidance in general and agoraphobic avoidance in particu-
lar. In making this claim, these authors critically evaluate extant work rele-
vant to the AS-agoraphobic avoidance association and isolate specific
directions for future work to further evaluate such postulations. In total,
Hayward and Wilson (2007 [this issue]) call attention to a clinically signif-
icant issue within the larger literature on AS and panic psychopathology
and prompt further study focused on avoidance and perhaps related processes
within this context.
In the third contribution to the series, Weems, Costa, Watts, Taylor, and
Cannon (2007 [this issue]) present a study focused on AS among youth.
Although AS has frequently been discussed as a developmentally relevant
risk factor for panic and other anxiety disorders (Lau, Calamari, & Waraczynski,
1996), there is comparatively less work focused on youth. This neglect is
unfortunate and an obstacle to translating basic theory and research on this
cognitive factor to youth. Weems and colleagues focused their examination
of AS among youth on the interrelations between AS and negative cognitive
errors, anxiety control beliefs, and their unique and specific associations
with anxiety symptoms. This approach is important theoretically and clini-
cally because it contextualizes work on AS within the larger literature on
other anxiety-relevant cognitive factors. Results of the investigation indi-
cated that negative cognitive errors, AS, and anxiety control beliefs were
associated with each other and that they demonstrated unique concurrent
Zvolensky, Schmidt / Anxiety Sensitivity Introduction 141
associations with childhood anxiety disorder symptoms. Moreover, certain
cognitive biases showed specificity in their association with anxiety symp-
toms versus depressive symptoms. A subsample of the participants completed
follow-up assessments 1 year later. Results indicated that negative cognitive
errors, AS, and anxiety control beliefs all had good 1-year test-retest corre-
lations and that negative cognitive errors and anxiety sensitivity predicted
Time 2 anxiety symptoms. This work suggests that although AS is indeed
important to anxiety vulnerability (concurrently and prospectively), it may
be only one of many cognitive factors of potential relevance. Future work
is needed to further explicate the relation between AS and other cognitive
factors in a developmentally sensitive fashion.
Whereas the first three articles in the special issue focus on AS and its
association with anxiety vulnerability processes, the last two articles in the
series bridge work on this construct to substance use disorders. Here,
Schmidt, Buckner, and Keough (2007 [this issue]) directed a study on AS
and alcohol use disorders among young adults. There has been increasing
attention devoted to AS and its possible relation to substance use disorders
in general (Forsyth, Parker, & Finlay, 2003) and alcohol in particular
(Stewart, Zvolensky, & Eifert, 2001). Yet, there has been an overarching
lack of attention focused on the nature of AS-alcohol relations using
prospective measurement and with attention to gender differences. In the
Schmidt, Eggleston, and colleagues (2007 [this issue]) report, a large, non-
clinical sample of young adults was prospectively followed for approxi-
mately 2 years. Findings indicated that AS was uniquely associated with the
later development of alcohol use disorder diagnoses. Data also indicated
that gender and AS did not act synergistically to predict alcohol use disor-
ders. These data provide novel evidence for the unique effects of AS as a
prospective risk factor in the development of alcohol-related disorders.
Future work will need to continue to refine AS-alcohol use disorder rela-
tions by exploring the mechanisms linking these variables.
The final contribution of the series further extends work on AS and sub-
stance use disorder by exploring the potential feasibility of a targeted inter-
vention focused on this cognitive factor in regard to changing addictive
behavior and improving emotionally functioning. Following earlier work
that has found an association between AS and heroin users (Lejuez,
Paulson, Daughters, Bornovalova, & Zvolensky, 2006), Tull, Schulzinger,
Schmidt, Zvolensky, and Lejuez (2007 [this issue]) developed an AS reduc-
tion program for heroin addiction. The logic underlying this approach is
that by reducing AS there can be greater opportunity for emotional distress,
withdrawal symptoms, and coping-driven use of heroin during the course
142 Behavior Modification
of treatment. Specifically, the article describes the development of a brief
(six session) behavioral treatment for heightened AS among heroin users.
The treatment consists of the following components: (a) psychoeducation
about anxiety, (b) interoceptive exposure exercises, and (c) skills training
focused on heightening emotional acceptance, tolerance, and nonevaluative
awareness (to facilitate willingness). Preliminary data on this treatment are
provided in the form of a case study with a 46-year-old African American
man in an inner-city residential substance use treatment facility. Results
indicate reductions in AS (especially physical concerns) as well as corre-
sponding decreases in heroin cravings and improvements in emotion regu-
lation. Future work is needed to evaluate the potential merits of this
program in a controlled design format.
Overall, the present series of articles highlights the importance of
addressing AS in panic as well as other anxiety and drug-related problems
and the strong public health need to cultivate systematic work in this
domain. As the series illustrates, such work will likely have the greatest
impact when it is conducted with explicit attention to theoretical processes,
mechanisms of action, and proceeds in a manner that includes both a basic
and applied (integrative) conceptual focus. The present series of articles
indicate that the time is indeed ripe to proceed with work in this domain.
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Michael J. Zvolensky, PhD, is an associate professor in the Department of Psychology at The
University of Vermont and director of the Anxiety and Health Research Laboratory and Clinic.
Dr. Zvolenskys research program cuts across basic and applied work in the area of anxiety disorders.
Norman B. Schmidt, PhD, is a professor of psychology at Florida State University and direc-
tor of the Anxiety and Behavioral Health Clinic. He has published more than 125 articles,
chapters, and books, mainly on the nature, prevention, and treatment of anxiety.
144 Behavior Modification