Alcohol use history and panic-relevant responding among adolescents: a test using a voluntary hyperventilation challenge.

Problematic alcohol use and anxiety psychopathology commonly co-occur (see Blumenthal, Leen-Feldner, Badour, & Babson, 2011; Brady & Lydiard, 1993 Kushner, Sher, & Beitman, 1990; Schuckit & Hesselbrock, 1994; Wilson, 1988 for reviews). One area receiving increasing empirical attention is the relation between alcohol use behaviors and panic-related problems (e.g., panic attacks, panic disorder; Bunaciu et al., 2010; Domalanta, Risser, Roberts, & Risser, 2003; Hayward et al., 1997; Segui et al., 2001; Zimmerman et al., 2003). Adolescence is a key developmental period in which to study the alcohol-panic linkage for at least three reasons. First, initiation and experimentation with alcohol is common during this phase (Johnston, O’Malley, Bachman, & Schulenberg, 2008; Chen, Yi, & Faden, 2011; Wittchen et al., 2008). For example, recent epidemiological work indicates that over 70% of high school students in the United States have at least experimented with alcohol, 41.8% report having consumed alcohol in the past 30 days, and 24.2% report heavy consumption (i.e., 5 or more drinks within a couple hours) in the past 30 days [Centers for Disease Control and Prevention (CDC), 2010]. Second, the rapid somatic and neurological development that characterizes the period of adolescence, particularly during puberty, sets the stage for enhanced vulnerability for somatic and neurological damage related to alcohol consumption (Brown et al., 2008; Nixon & McClain, 2010), as well as distinct acute effects when compared to adults (e.g., attenuated motor impairment, enhanced social facilitation, Nixon & McClain, 2010; Windle et al., 2008). Indeed, discrepant neurophysiologic effects (as a function of developmental stage) may lead to increased consumption as well as greater risk for alcohol use (Deas, Riggs, Langenbucher, Goldman, & Brown, 2000) and alcohol-related (including panic-relevant) problems among adolescents (Masten, Faden, Zucker, & Spear, 2010). Finally, the onset of panic-relevant responding (e.g., fearful reactivity to somatic perturbation) and panic-related problems (e.g., recurrent panic attacks) often occur during adolescence (Goodwin & Gotlib, 2004; Reed & Wittchen, 1998; Von Korff, Eaton, & Keyl, 1985). For example, a growing body of work indicates that progression through puberty, which is a “hallmark” of adolescence (Hayward & Sanborn, 2002), predicts enhanced panic-relevant vulnerability (Leen-Feldner, Reardon, & Zvloneksy, 2007) as well as the onset of panic attacks (Hayward et al., 1992). Together, these data highlight adolescence as an important developmental period in which to study the onset and progression of alcohol- and panic-related problems as they occur(cf., as retrospectively reported by adults; Cicchetti & Rogosch, 2002; Masten et al., 2010). Building on studies conducted with adults (e.g., Falk, Yi, & Hilton, 2008), an emerging body of research (albeit limited and not entirely uniform), including prospective work (Goodwin et al., 2004; Zimmerman et al., 2003), suggests a correlation between alcohol use behaviors and panic-related problems among youth. For instance, qualitative (Gardner & Kutcher, 1993) and quantitative work with incarcerated adolescents (Domalanta, Risser, Roberts, & Risser, 2003) suggests a high rate of co-occurrence between problematic alcohol use and panic attacks among treatment-seeking youth. Conversely, Clark and colleagues’ (1995) study with adolescent inpatients with a current alcohol use disorder found that rates of panic disorder were comparable to those seen in community-based samples. Similarly, after methodologically controlling for age, pubertal status, and ethnicity, Hayward and colleagues (1995) found no relation between a positive history of panic attacks and current alcohol consumption (i.e., at least 2–4 full beverages or “being drunk” over the past 30 days) within a group of 160 young adolescent girls. However, in a subsequent study involving more than 1,000 adolescent girls, Hayward and colleagues (1997) found that participants reporting a history of both cued (i.e., situationally bound) and uncued (i.e., in the absence of identifiable fear-relevant stimuli) panic attacks evidenced a threefold increase in rates of current alcohol consumption as compared to girls who had never had a panic attack (even after controlling for ethnicity). Although promising, the current literature is characterized by a number of important limitations. First, the overall body of work is relatively small, and although research generally suggests a correlation between problematic alcohol use and panic-related problems, findings are mixed. Importantly, within the limitations of the extant literature there also are plausible explanations for documented discrepancies. For example, with few exceptions (e.g., Zimmerman et al., 2003), very little work has examined the specificity of the association between alcohol and panic outcomes and none has considered theoretically-relevant “process variables,” including individual difference factors (e.g., anxiety sensitivity; Taylor, 1999), behavioral variables (e.g., nicotine use; Johnson et al., 2000), or parental factors (e.g., parental panic disorder; Nocon et al. 2008), all of which evidence substantial overlap with indices of panic among adolescents. Inclusion of these variables represents a timely and important extension to extant work seeking to evaluate the unique association between alcohol use and panic-relevant problems among youth. Further, work to date has relied exclusively on adolescent self-report of alcohol use and panic symptomatology (Blumenthal et al., 2011). Ethical constraints preclude alcohol administration to adolescents (cf., Behar et al., 1983), but there is a rich tradition of safe and effective use of biological challenge procedures to elicit physiological arousal and panic-relevant responding among adolescents (e.g., Leen-Feldner, Feldner, Bernstein, McCormick, & Zvolensky, 2005; Rabian, Embry, & MacIntyre, 1999; Unnewehr, Schneider, Margraf, Jenkins, & Florin, 1996). The value of this procedure from a theoretical perspective is that it allows us to model, or create a state analogous to that of panic (Olatunji, Leen-Feldner, Feldner, & Forsyth, 2007). Accordingly, factors related to enhanced fearful responding to such arousal can be directly examined and even subjected to causally-oriented hypothesis testing, thereby informing etiologic models of panic and co-occurring problems, such as alcohol use. Further, without eliciting bodily sensations in “real time” under controlled laboratory conditions, it is difficult to rule out affective and memory biases (Nisbett & Ross, 1980) as alternative explanations for observed relations between alcohol and panic among adolescents. For instance, it may be that youth with a history of alcohol use simply demonstrate a recall bias for bodily-oriented experiences, and not necessarily enhanced fearful reactivity to somatic perturbation. Finally, laboratory-based procedures may tap into factors not captured by standard self-report assessments such as indirect learning experiences, automatic responding, or genetic disposition (Eifert, Forsyth, Zvolensky, & Lejuez, 1999; Unnewehr et al., 1996). Utilization of experimental psychopathology techniques in which panic-relevant responding is elicited in the laboratory (e.g., voluntary hyperventilation; stair-stepping) therefore represents a key next step in this line of work (Zvolensky, Lejuez, Stuart, & Curtin, 2001). With this backdrop, the current study utilized both self-report as well as a biological challenge procedure (i.e., voluntary hyperventilation; Hornsveld, Garssen, Dop, & Van Spiegel, 1990; Leen-Feldner et al., 2005; Unnewehr et al., 1996) in an effort to better understand panic-relevant symptoms and responding as a function of alcohol use history among adolescents. It was hypothesized that adolescents who reported alcohol use, as compared to non-drinkers, would evidence higher levels of panic symptomatology as indexed via a well-established questionnaire as well as immediately following the voluntary hyperventilation challenge. Moreover, these effects were expected to remain significant even after accounting for the panic-relevant variables of age, gender (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000; Reed & Wittchen, 1998), negative affectivity (Craske, Poulton, Tsao, & Plotkin, 2001; Hayward, Wilson, Lagle, Killen, & Taylor, 2004), anxiety sensitivity (Leen-Feldner et al., 2005; Schmidt et al., 2010), child tobacco use (Isensee, Wittchen, Stein, Hofler, & Lieb, 2003; Johnson et al., 2000), parental panic disorder (Hayward, Killen, Kraemer, & Taylor, 2000; Hayward et al., 2004; Nocon et al., 2008) and parental tobacco use (Goodwin, Lewinsohn, & Seeley, 2005).