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
This study examined whether adolescents with panic disorder (PD) experience the core processes from Clark’s (1986) adult model – catastrophic thoughts about bodily sensations, fear of those sensations, and safety-seeking behaviors.
McCall et al. (2025) further investigated whether these processes are unique to PD (compared to other anxiety disorders or non-anxious peers) and whether they predict symptom severity.
Because adolescence brings distinct biological and cognitive changes and research to date has focused almost entirely on adults, confirming these mechanisms in young people could lead to more precise early identification and tailored treatments for PD during this pivotal developmental stage
Method
The study enrolled 101 adolescents (12–17 years) across three groups—panic disorder (n = 34), other anxiety disorders (n = 33), and non-anxious community controls (n = 34).
Clinical groups received standardized diagnostic interviews (ADIS-C/P, K-SADS), then all participants completed:
- PDSS-C: panic severity
- Adapted ACQ: catastrophic thought frequency & belief
- Adapted BSQ: fear of bodily sensations
- Adapted PSSBQ: safety-seeking behaviors
- RCADS: anxiety screening (controls only)
Demographics (age, gender, ethnicity, SES) were recorded.
Missing data were mean-imputed if ≥ 80% of items were answered.
Group differences on cognitive-behavioral processes were tested via multivariate regressions controlling for age and gender, and separate multiple regressions examined whether catastrophic cognition frequency & belief, bodily sensation fear, and safety behaviors uniquely predicted 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?
