Relationship between panic attacks and health locus of control

Journal of Family Practice, April, 1991 by David A. Katerndahl

Background. Health locus of control has significant implications for treatment response, compliance, patient education, and health maintenance. Because of the association between locus of control and anxiety, this study was conducted to determine the health locus of control (HLOC) in patients with panic attacks, changes in HLOC through treatment of panic attacks, and the relationship between HLOC and phobic avoidance.

Methods. The HLOC and panic screening questionnaires were administered to 50 patients complaining of a panic-related symptom or condition known to be associated with panic, and to 119 randomly selected patients. Nineteen patients with panic attacks were later reevaluated to determine if there had been a change in locus of control.

Results. Stepwise multiple regression demonstrated that panic attacks, educational level, and being divorced significantly predicted HLOC (F = 5.66, P. [is less than or equal to] .0001). An analysis of covariance (ANCOVA) showed that resolution of panic attacks was associated with a greater decrease in the HLOC score (F = 4.68, P [is less than or equal to] .05). Phobic avoidance was also associated with greater levels of externality (r = .48, P [is less than or equal to] .05) and correlated with HLOC in response to treatment.

Conclusions. This study suggests there is a significant relationship between HLOC and panic attacks, and between HLOC and phobic avoidance. Panic resolution is associated with a decrease in externality. Measurement of HLOC may be helpful in assessing the treatment response of patients who have panic attacks.

Key words. Internal-external control, phobic disorders, and anxiety disorders. J Fam Pract 1991; 32:391-396.

The concept of cognitive style means that each individual has a characteristic way of conceptually organizing the environment. [1] Locus of control (LOC) relates specifically to the location from which an individual perceives that control of his or her life is derived. Individuals with an internal LOC perceive control of events to rest within themselves, while individuals with an external LOC perceive control to rest with others. [2] The Health Locus of Control scale measures LOC beliefs as they relate specifically to health issues. [3]

Previous studies have found that, in general, the more severe the psychiatric pathology, the greater is the externality of LOC. [4-7] Higher levels of anxiety, in particular, are associated with externality. [8-13] This increased anxiety may be related to the expectancy of unsuccessfully controlling stress, which typifies the individual with an external LOC. In general, internality is associated with a greater sense of psychological and physical well-being, [14,15] although extremes in either internality or externality may be detrimental to coping. [16]

Prompted by the extreme levels of anxiety and the spontaneous nature of panic attacks, this study was conducted to determine the relationship between panic attacks and the health locus of control (HLOC). It was hypothesized that (1) patients with panic attacks would have a more external HLOC than those without attacks, (2) improvement in the panic attacks would be associated with a commensurate reduction in externality, and (3) the presence of phobic avoidance would be associated with greater levels of externality.

Methods

Patients presenting to the Family Practice Medical Group at the University of Texas Health Science Center with any unexplained panic-related symptom or condition known to be associated with panic attacks (spontaneous attacks of anxiety associated with at least four autonomic symptoms [17]) were asked to participate in the study. Fifty patients completed the Panic Screening Questionnaire (PSQ), the Health Locus of Control scale, and a demographic data sheet. In a previous study of 200 randomly selected patients in the Family Health Center at the Brady Green Community Health Center, the self-administrated PSQ was compared with the Diagnostic Interview Schedule (DIS). The DIS diagnosed 45 patients with panic attacks, while the PSQ diagnosed 50 patients with panic attacks. With a false-positive rate of 6% and a false-negative rate of 3.5%, the PSQ has a sensitivity of 84.4% and a specificity of 92.3%. The HLOC scale is an 11-item questionnaire producing scores ranging from 11 (most internal LOC) to 66 (most external LOC). Those meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) [17] criteria for panic attacks additionally completed instruments describing their phobic avoidance behaviors (fear or avoidance of situations associated with panic or in which help is not readily available) and the characteristics of their panic attacks. Severity of panic and avoidance were assessed according to the DSM-III-R, and improvement with respect to panic attacks was determined by a review of pretreatment and posttreatment panic descriptions. Panic attacks were said to be "improved" if there had been a reduction in frequency or severity. All coding was done by the investigator, who was blinded to HLOC scores. Each patient was thus classified into one of five groups: panic attacks, simple phobia, limited-symptom attacks, exercise-induced attacks, and normal.