McCall A, Waite F, Percy R, et al. Cognitive and behavioural processes in adolescent panic disorder. Behavioural and Cognitive Psychotherapy. Published online 2025:1-15. https://doi.org/10.1017/S1352465825000049
Key Takeaways
- Aims: To determine if adolescents (12–17 years) with PD show elevated levels of catastrophic cognitions, bodily sensation fear, and safety-seeking behaviours relative to adolescents with other anxiety disorders and non-anxious controls, and whether these processes predict PD symptom severity.
- Method: Three cross-sectional groups (PD, clinical control, community control; N=101) completed self-report measures of panic severity, catastrophic cognitions (frequency & belief), bodily sensation fear, and safety-seeking behaviours. Analyses controlled for age and gender.
- Findings: Adolescents with PD exhibited significantly greater catastrophic cognition frequency and safety-seeking behaviours than both control groups, and greater bodily sensation fear than community controls; all three processes predicted PD symptom severity, while belief ratings did not.
- Implications: Targeting catastrophic misinterpretations and safety-seeking behaviours may enhance the specificity and efficacy of cognitive-behavioural treatments for adolescent panic disorder.
Rationale
Panic disorder typically emerges in adolescence, peaking around age 15.5 and affecting approximately 1–3% of 11–19-year-olds (Sadler et al., 2018).
Catastrophic misinterpretation of benign bodily sensations and safety-seeking behaviours maintain panic in adults (Clark, 1986; Aslam et al., 2024), but adolescents’ evolving cognitive and neural capacities may alter these mechanisms (Holmbeck et al., 2012; Xie et al., 2021).
Limited data suggest anxiety sensitivity correlates with adolescent panic severity (Elkins et al., 2014), yet no study has directly compared key cognitive-behavioural processes in adolescents with panic versus other anxiety disorders.
Clarifying whether catastrophic cognition frequency, sensation fear, and safety behaviours are specific to adolescent panic – and whether they uniquely predict symptom severity – is essential for adapting adult cognitive models and refining targeted interventions for this developmental period.
Method
A cross-sectional, between-subjects design comparing three adolescent groups:
- Panic Disorder (PD) group
- Clinical control (other anxiety disorders)
- Community control (non-anxious)
Participants:
- Total N = 101 adolescents, aged 12–17 years
- PD group: n = 34 (88% female; M_age = 14.8)
- Clinical control: n = 33 (79% female; M_age = 14.9)
- Community control: n = 34 (79% female; M_age = 15.5)
- Predominantly White British (85%)
Procedure:
- Diagnostic confirmation: ADIS-C/P and K-SADS interviews for PD and clinical controls.
- Demographics: Age, gender, ethnicity, socioeconomic status.
- Self-report questionnaires: Completed online or in clinic before treatment.
- Community recruitment: Via local schools; identical measures.
- Compensation: Monetary voucher on completion.
Measures:
- Panic Disorder Severity Scale – Child Version (PDSS-C): 7 items assessing panic symptom severity (score range 0–28).
- Anxiety Catastrophizing Questionnaire (adapted ACQ):
- Frequency subscale: 9 catastrophic thoughts rated 1–5.
- Belief subscale: Same items rated 0–100% belief.
- Body Sensations Questionnaire (adapted BSQ): 17 bodily sensations rated 1–5 on fear.
- Panic Safety-Seeking Behaviors Questionnaire (adapted PSSBQ): 13 behaviours rated 0–3 frequency.
- Revised Child Anxiety and Depression Scale (RCADS): Screening for anxiety in community controls.
Statistical Analyses:
- Group comparisons: Multivariate regression controlling for age and gender.
- Prediction of PD severity: Separate multiple regressions with frequency and belief of catastrophizing, bodily sensation fear, and safety behaviours as predictors of PDSS-C.
- Sensitivity analysis: Excluding participants with secondary PD diagnoses.
- Robustness check: Sandwich estimator to address potential heteroscedasticity in BSQ scores.
This methodological approach allowed for direct comparisons of cognitive and behavioural processes across adolescent groups and investigation of their unique contributions to panic severity.
Results
Hypothesis 1: Adolescents with PD will report higher levels of catastrophic cognitions (frequency & belief), fear of bodily sensations, and safety-seeking behaviours than clinical and community controls.
- Catastrophic cognition frequency: PD > clinical, b = –6.51, p = .035; PD > community, b = –11.38, p < .001.
- Catastrophic cognition belief: No significant group differences, p’s > .10.
- Fear of bodily sensations (BSQ): PD > community, b = –11.02, p < .001; PD vs. clinical non-significant, p = .059.
- Safety-seeking behaviours: PD > clinical, b = –4.01, p = .043; PD > community, b = –6.96, p < .001.
Hypothesis 2: Each process (frequency & belief of catastrophic thoughts, bodily sensation fear, safety-seeking behaviours) will uniquely predict panic severity (PDSS-C).
- Catastrophic cognition frequency: B = 0.34, SE = 0.08, t = 4.22, p < .001.
- Catastrophic cognition belief: B = 0.02, SE = 0.01, t = 1.35, p = .18 (ns).
- Fear of bodily sensations: B = 0.30, SE = 0.06, t = 4.88, p < .001.
- Safety-seeking behaviours: B = 0.50, SE = 0.10, t = 4.98, p < .001.
- Model fit: R² = .62, F(4, 48) = 19.85, p < .001.
Sensitivity Analyses:
- Excluding participants with secondary PD diagnoses did not alter pattern of results.
- Robust sandwich estimator for BSQ showed identical significance levels.
Insight
Adolescents with PD experience frequent panic-related thoughts and engage in safety behaviours significantly more than peers, supporting Clark’s model in youth.
Fear of bodily sensations appears as an anxiety-broader mechanism rather than PD-specific.
Unlike adults, adolescents’ belief in catastrophic thoughts does not drive symptom severity, suggesting frequency of misinterpretations is the critical target.
These findings extend adult PD research to adolescence and highlight developmental nuances, pointing to refining measures (e.g., catastrophic misinterpretation tasks) and exploring age-related changes in cognitive-behavioural processes across adolescence.
Clinical Implications
- Targeted Cognitive Restructuring: Clinicians should prioritize interventions that reduce the frequency of catastrophic misinterpretations of bodily sensations (e.g., through thought‐monitoring and reality testing exercises), rather than focusing solely on strength of belief, to more effectively alleviate panic symptoms in adolescents.
- Behavioural Experiments to Reduce Safety Behaviours: Incorporate graded exposure tasks and behavioural experiments aimed at disconfirming feared outcomes (e.g., deliberately inducing mild physiological arousal without retreating to safety) to weaken the association between bodily sensations and panic.
- Developmentally Tailored Psychoeducation: Provide age‐appropriate education on normative adolescent physiological changes (e.g., heart rate variability, hormonal shifts) to normalize sensations and reduce misinterpretations, leveraging multimedia and peer discussion to enhance engagement.
- Integrating Family and School Systems: Work collaboratively with parents, teachers, and school counselors to identify and modify environmental reinforcements of safety behaviours (e.g., allowing school avoidance), and to establish consistent, supportive responses to panic symptoms across contexts.
- Training for Practitioners: Offer specialized workshops on adolescent panic disorder that emphasize assessment of catastrophic cognition frequency and safety behaviours, the use of adolescent‐validated measurement tools, and adaptation of adult cognitive‐behavioural protocols to younger clients.
- Policy Recommendations: Advocate for mental health curricula in secondary schools to include modules on anxiety sensitivity and panic, equipping educators to recognize early signs and refer students for evidence‐based interventions.
- Implementation Considerations: Anticipate challenges such as stigma around panic symptoms and limited access to trained CBT therapists; mitigate these by developing brief, manualized group programs and digital tools (e.g., apps with guided exposure tasks) to broaden reach.
References
McCall A, Waite F, Percy R, et al. Cognitive and behavioural processes in adolescent panic disorder. Behavioural and Cognitive Psychotherapy. Published online 2025:1-15. https://doi.org/10.1017/S1352465825000049
Aslam, S. Y., Zortea, T., & Salkovskis, P. M. (2024). The cognitive theory of panic disorder: A systematic narrative review. Clinical Psychology Review, 113, 102483. https://doi.org/10.1016/j.cpr.2024.102483
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470. https://doi.org/10.1016/0005-7967(86)90011-2
Elkins, R. M., Pincus, D. B., & Comer, J. S. (2014). A psychometric evaluation of the Panic Disorder Severity Scale for children and adolescents. Psychological Assessment, 26(2), 609–618. https://doi.org/10.1037/a0035283
Holmbeck, G. N., Colder, C., Shapera, W., Westhoven, V., Kenealy, L., & Updengrove, A. (2012). Working with adolescents: Guides from developmental psychology. In P. C. Kendall (Ed.), Child and Adolescent Therapy: Cognitive-Behavioral Procedures (4th ed., pp. 334–383). Guilford Press.
Sadler, K., Vizard, T., Ford, T., Goodman, A., Goodman, R., & McManus, S. (2018). Mental health of children and young people in England, 2017: Trends and characteristics. NHS Digital. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017
Xie, S., Zhang, X., Cheng, W., & Yang, Z. (2021). Adolescent anxiety disorders and the developing brain: Comparing neuroimaging findings in adolescents and adults. General Psychiatry, 34, e100411. https://doi.org/10.1136/gpsych-2020-100411
Socratic Questions
- How might developmental changes in abstract reasoning during adolescence influence catastrophic misinterpretations?
- Could frequency versus belief in catastrophic thoughts differentially affect treatment engagement and outcome?
- In what ways might peer and family attitudes toward panic symptoms moderate the relationship between bodily sensation fear and safety-seeking behaviours?
- How could longitudinal designs clarify the causal role of these cognitive-behavioural processes in the onset of adolescent PD?
- What adaptations would improve the validity of adult-derived measures for diverse adolescent populations?
