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Graduate Student Journal of Psychology                                                                             Copyright 2010 by the Department of Counseling & Clinical Psychology  
2010, Vol. 12                                                                                                                        Teachers College, Columbia University                          
  
Panic Disorder Subtype Gastrointestinal Response: Phenomenon and Treatment 

Recommendations 
 

Kevin Ashworth 
Pacific University 

Allison Bonifay 
Pacific University 

Johan Rosqvist  
Pacific University  

 
While research has shown strong associations between Panic Disorder and symptoms of 
gastrointestinal distress, there is a dearth of evidence on limited symptom Panic Disorder with the 
primary symptom of gastrointestinal distress.  Most published studies have been single case studies 
or small case series, and proper classification remains unclear.  Although a formal diagnosis does 
not exist for this presentation, this paper proposes the diagnosis of Panic Disorder (PD) Subtype 
Gastrointestinal (GI) Response.  This particular cluster of symptoms currently creates a diagnostic 
conundrum, which can directly affect treatment options.  This paper explores the relationship 
between Panic Disorder and gastrointestinal distress, and discusses the challenge of differential 
diagnosis among disorders with considerable symptomological overlap (e.g., Obsessive Compulsive 
Disorder, Agoraphobia, and Irritable Bowel Syndrome).  Theories such as the brain-gut loop and 
cognitive theory are discussed to explain how the interaction of cognitions and physiological 
reactivity maintain and exacerbate the proposed disorder. Finally, specific treatment 
recommendations and behavioral assessment methods are provided.   

 
 

Panic  Disorder (PD) has been conceptualized as a 
multiple symptom disorder by the American Psychiatric 
Association (DSM-IV-TR, 2000).  However, limited 
symptom PD (i.e., one symptom cluster predominates) 
confounds the categorization and treatment of PD.  
Gastrointestinal (GI) distress and PD overlap considerably, 
yet there is little research on limited symptom PD with the 
primary symptom of GI distress.  The current article 
explores the relationship between the two conditions, 
proposes the diagnosis of PD subtype Gastrointestinal 
Response as a more accurate classification of this specific 
symptom presentation, and offers appropriate treatment 
recommendations.   

The criteria for PD includes recurrent, unexpected 
panic attacks accompanied with four or more of the 13 
physiological symptoms (e.g., pounding heart, sweating, 
trembling, nausea or abdominal distress) and cognitive 
symptoms (e.g., fear of dying, and fear of losing control) 
which peak within 10 minutes (DSM-IV-TR, 2000).  An 
unexpected panic attack is defined as one that an individual 
does not immediately associate with a situational trigger 

).  
Additionally, at least one of the following must be 
experienced for one month following an attack: 1) 
persistent concern about having additional attacks; 2) worry 
about the implications of the attack or its consequences; 
and/or 3) a significant change in behavior related to the 
                                                                                                  

Correspondence concerning this article should be addressed to 
Kevin Ashworth, Pacific University, School of Professional 
Psychology, 222 SE 8th Ave, Hillsboro, OR 97123, Email 
address: ashw1543@pacificu.edu. 

attacks. In some cases, patients report experiencing only 
one or two of these symptoms during a panic attack.  
Symptom specific presentations of panic (e.g., 
cardiovascular and respiratory systems, and GI distress) that 
do not meet full criteria for PD have been referred to as a 
limited symptom panic attack (Lelliott & Bass, 1990; 
Rosqvist, 2005).   

PD accounts for approximately 10% of individuals 
referred for mental health consultation.  PD is often 
accompanied by Agoraphobia, characterized by anxiety 
about being in situations perceived as inescapable; thus 

DSM-IV-TR, 2000).  
Approximately one-third to one-half of individuals 
diagnosed with PD in community samples also suffer from 
Agoraphobia (DSM-IV-TR, 2000).  
 

Panic Disorder Subtype Gastrointestinal Response  
 

Case studies and other research document PD in terms 
of limited symptom attacks and characterize GI distress as a 
limited symptom PD (Eldridge, Walker, & Holborn, 1993; 
Hatch, 1997; Lelliott & Bass, 1990). Individuals from select 
case studies report debilitating symptoms such as 
abdominal distress, heart palpitations, hot flashes, sweating, 
and shaking (Eldridge et al., 1993; Hatch, 1997).  

ending 
excessive time contemplating the location of toilets in 
public is also reportedly common (Hatch, 1997).  
Behavioral changes range from spending an increased 
amount of time in bathrooms and modifying diets by 



ASHWORTH, BONIFAY, & ROSQVIST  
  

   46 

eliminating certain foods, to eliminating all food intake 
prior to leaving home or avoiding leaving home altogether 
(Eldridge et al., 1993; Hatch, 1997).   

For example, Eldridge et al. (1993) illustrated the 
suffering endured by one patient.  The patient avoided all 
public situations where she might feel embarrassed by the 
length of time she spent using the toilet.  She was unable to 
work, ride public transportation, or wait in a line.  She also 
reported distress while waiting for a phone call or a house 
visitor for fear of experiencing sudden diarrhea.  The 
patient refrained from eating all together on days when she 
would need to leave her house.  Her catastrophic 
misinterpretations of her GI sensations reinforced her need 
to avoid or escape certain situations.  Furthermore, her 
worries were confirmed by evidence that, when she did use 
the toilet, she experienced diarrhea.  In sum, physiological 
sensations trigger cognitive distortions (e.g., catastrophic 
thinking) and avoidance behaviors, resulting in impaired 
daily functioning due to persistent avoidance of situations 
where access to a toilet is limited (Eldridge et al., 1993; 
Hatch, 1997).  

However, research on this phenomenon is minimal, and 
likewise, data on prevalence, gender and age differences, 
and diagnostic criteria remains largely unknown.  In 
addition, the literature indicates an underreporting of PDs 
involving GI functioning, which Hatch (1997) ascribes to 
societal influences that deem speaking of bodily functions, 
even to medical and health professionals, as improper.  As a 
result of social norms, individuals suffering from irregular 
bowel functions and fear of incontinence may feel 
uncomfortable discussing personal bowel functions.  Due to 
the lack of a formalized classification and dearth of 
research, this presentation remains difficult to diagnose and 
treat.   

To better understand the mechanisms governing this 
particular cluster of symptoms and to make a case for a new 
diagnosis, we compare existing diagnoses to the proposed 
diagnosis of as PD Subtype GI Response.  Specifically, we 
discuss psychiatric and medical diagnoses that report 
manifestations of GI symptoms that may be related to Panic 
Symptoms: bowel obsessions (a variant of Obsessive-
Compulsive Disorder), Agoraphobia without a history of 
PD, and Irritable Bowel Syndrome (IBS).  We then 
consider brain-gut interaction theory, cognitive theory, and 
extant treatment strategies used for IBS, OCD, and PD to 
inform treatment recommendations for the proposed 
diagnosis of PD subtype GI response.  
 
Bowel Obsessions  

Bowel Obsession Syndrome (BOS) has a similar 
presentation to PD subtype GI response and has been 
researched and proposed as a variant of Obsessive-
Compulsive Disorder (OCD; Hatch, 1997).  BOS is 
characterized by excessive worry about fecal incontinence 
and compulsive behaviors of evacuation checking.  
Secondary symptoms may include fears of social judgment 

and inaccessibility of bathrooms when not at home.  
Individuals who experience these cognitions also engage in 
behaviors directed at controlling their bodily functions, 
such as spending considerable amounts of time in the 
bathroom as well as limiting food intake (Hatch, 1997).  

Debate exists over the diagnosis of BOS.  Some 
research proposes that bowel obsessions would be better 
conceptualized as an anxiety disorder, such as PD, due to 

pharmacological treatment (Hatch, 1997).  The following 
study highlights the lack of consensus regarding the 
diagnosis of BOS.  Hatch (1997) argued that if OCD and 
BOS shared a symptom profile, individuals suffering from 
bowel obsessions would score highly on obsessive thinking 
on the Yale-Brown Obsessive Compulsive Scale (Y-
BOCS).  However, Hatch (1997) showed in two case 
studies that both patients with bowel obsessions at pre-
treatment baseline scored lower on the (Y-BOCS) than 
classic OCD patients.  This suggests that if conceptualized 
as an OCD variant, bowel obsessions would present within 
the mild range of severity.  Due to the debilitating effects of 
bowel obsessions, it seems disproportionate to diagnose this 
syndrome as of mild severity.   

Treatment implemented by Hatch (1997) included 
cognitive-behavioral interventions, such as cognitive 
restructuring and in-vivo exposures, which resulted in 
significant symptom reduction of bowel obsessions.  Given 
the positive response to cognitive-behavioral treatment 
strategies among BOS patients, and the overlapping 
symptomotology of BOS and the proposed PD subtype GI 
response, we suggest that individuals suffering from PD 
subtype GI response would benefit from a similar treatment 
protocol as those with BOS.  
 
Agoraphobia Without a H istory of Panic Disorder  

The DSM-IV-TR (2000) describes Agoraphobia 
without a History of PD as the presence of Agoraphobia 
related to fear of developing panic-like symptoms (e.g., 
dizziness or diarrhea) and that criterion have never been 
met for PD.  The fear of fecal incontinence while in public 
and the fear that access to a bathroom may be limited, 
overlap with the aforementioned symptoms of BOS and 
PD, and may contribute to certain agoraphobic conditions.  
While Agoraphobia without a History of PD has been 
questioned as a legitimate diagnosis separate from PD, two 
models have been proposed.  The first model describes the 
development of Agoraphobia as a sequelae of PD and the 
second model suggests that Agoraphobia is a conditioned 
avoidance response from the pairing of situations (e.g., 
driving, traffic, shopping) to noxious experiences of panic 
or fear of vomiting, panicking, or bowel incontinence 
(DSM-IV-TR, 2000; Goisman et al., 1995).  Goisman et al. 
(1995) found that individuals who met criteria for 
Agoraphobia without a History of PD had experienced 
limited symptom attacks that narrowly missed the criteria 
for PD with Agoraphobia, suggesting that both can be seen 



GASTROINTESTINAL PANIC DISORDER 
 

   47 

on the same continuum.  Goisman et al. (1995) also found 
that a high number of individuals with Agoraphobia 
reported catastrophic cognitions associated with their 
disorder, the most common of which were 1) fear of doing 
something embarrassing (n = 11, 25%), 2) fear of fainting 
(n = 8, 18%), 3) fear of losing control (n = 7, 16%), and 4) 
fear of becoming ill (n = 7, 16%; Goismann et al., 1995).  
 

I r r itable Bowel Syndrome  
Drossman, Li, Andruzzi, Temple, and Talley (1993) 

reported that functional GI disorders effects 69% of the 
United States population with 40% complaining of bowel 
distress.  Of these sufferers, 8% - 17% experience 
debilitating effects of the disorder.  Moreover, research 
indicates that many individuals who seek treatment for IBS 
have a psychiatric history (Lydiard & Falsetti, 1999).  

Taylor (2000) speculated that PD presents as one 
psychiatric disorder often comorbid with IBS because IBS 
symptoms conceivably include undesirable body sensations 
that can easily lead to misappraisals.  Because those with 
IBS are often hypervigilant of bowel symptoms, any bowel 
sensation (even those that are benign) could be interpreted 
as an indication of possible loss of bowel control.  This 

trigger a panic attack. 
To determine the link between PD and GI symptoms, 

Lydiard et al. (1994) conducted a study among a 
community-based sample consisting of 13,537 participants.  
Four groups were created from this random probability 
sample: (a) individuals diagnosed with PD at any time in 
their lives, (b) participants diagnosed with any other anxiety 
disorder, (c) individuals diagnosed with any other major 
psychiatric disorder, and (d) those who did not meet 
qualifications for any DSM-III classified disorder.  The 
results of this study showed that participants with PD 
reported experiencing GI symptoms at a higher frequency 
than the other groups.  Symptoms of diarrhea were reported 
by 12.9% of individuals with PD as compared to 2.9% of 
those without a psychiatric diagnosis.   

Additionally, Lydiard and colleagues (1994) found 
evidence to suggest that, contrary to previous research on 
treatment-seeking populations, PD and IBS symptoms do in 
fact co-exist.  This diagnostic overlap generalizes the co-
occurrence beyond treatment-seeking populations and 
speaks to the challenge of differential diagnosis.  
 

B rain-gut Interaction and Cognitive Theory 
 

The enteric nervous system (ENS), which regulates 
behaviors, such as bowel performance, has been compared 
to the brain in its organizational and functional structure.  
Similar to the brain, which processes external stimuli 
transmitted to the central nervous system (CNS) through the 
dorsal root and cranial nerve ganglion cells to control 
behaviors, the ENS responds to stimuli signaled through 
intrinsic primary afferent neurons (IPANS).  Although both 

systems can work independently of one another, they 
generally work in tandem.  The CNS and ENS both rely on 
receiving information from the bowel to make informed 
decisions (Gershon, 2005).  Lydiard and Falsetti (1999) 
postulate that by understanding the relationship between the 
CNS and ENS, explanations for GI distress may be 
established.  They propose a brain-gut loop model to 
explain the positive feedback cycle that occurs in IBS 
patients.  This model suggests that when aversive stimuli 
are detected by the gut, the locus ceruleus (LC), a CNS 
noradrenergic nucleus that mediates fear and arousal states 
is activated.  Activation of the LC leads to activation of the 
CNS, sending messages to CNS fear and arousal-mediating 
components, such as the amygdala and medial 
hypothalamus (Coplan & Lydiard, 1998).  Given the 
interaction between the CNS and ENS, individuals with 
increased arousal (or hypervigilance) could experience GI 
distress due to the increased CNS sympathetic outflow and 
responsive input to the LC creating a positive feedback loop 
(Lydiard & Falsetti, 1999).  This brain-gut loop explains 
how hypervigilance and increased sensitivity to aversive 
stimuli is reinforced by neurochemical feedback sent to the 
brain by way of the CNS and ENS, thus validating 
irrational or negative cognitions associated with sensations 
experienced during high arousal states.  

Cognitive theory, as described by Chambless et al. 
(2000), conceptualizes panic using a similar feedback loop.  
When a person grossly misinterprets somatic sensations, 
anxiety levels are increased.  This, in turn, heightens 
sensitivity to subsequent bodily sensations creating an 
experience of panic.  The negative cognitions and feared 
bodily sensations interplay with one another to create this 
positive feedback loop of heightened anxiety followed by 
heightened sensitivity.  Understanding the brain-gut 
interaction and cognitive processes is crucial to informing 
appropriate treatment interventions focusing on GI-related 
cognitive distortions and obsessive thinking.   

Many individuals who experience GI distress seek 
relief through pharmacological interventions.  For example, 
Sandler (1990) reported that over two million prescriptions 
for IBS are written per year in the United States. Masand 
and colleagues (2002) studied treatment effects of 
paroxetine, a commonly prescribed selective serotonin 
reuptake inhibitor (SSRI), in two groups of IBS patients: (a) 
10 patients with coexisting anxiety disorders (Specific 
Phobia, PD, and Social Phobia as indicated by the 
Structured Clinical Interview [SCID]), and (b) 10 patients 
with no anxiety disorder diagnosis.  Both groups of patients 
received 12 weeks of paroxetine at a mean dose of 31 
mg/day.  Results showed that seven patients with anxiety 
disorders reported a 70% or greater improvement in 
abdominal pain, versus 20% of the non-anxiety disorder 
group.  Diarrhea frequency and severity decreased in 71% 
of anxiety patients versus 43% of the non-anxiety patients.  
These results may be due to the effects of psychotropic 
medication on the interplay between the CNS and ENS, 



ASHWORTH, BONIFAY, & ROSQVIST  
  

   48 

particularly for those with co-existing anxiety disorders 
(Masand et al., 2002).  

T reatment Recommendations 
 

While cognitive-behavioral treatment of PD has been 
studied extensively, specific examination of GI symptoms 
is less widespread (Barlow, Gorman, Shear & Woods, 
2000; Landon & Barlow, 2004).  A relevant study by 
Lelliot and Bass (1990) compared the subjective and 
physiological responses to imaginal exposure and voluntary 
hyperventilation of two groups of patients with PD.  One 
group was classified as experiencing cardiovascular and 
respiratory (CR) symptoms of panic (e.g., shortness of 
breath, smothering sensations, and chest pain), while the 
second group primarily reported GI symptoms (e.g., 
abdominal discomfort, diarrhea, and fear of fecal 
incontinence).  The findings indicated that the GI group 
experienced significantly less distress than the CR group.  
The authors concluded that because the hyperventilation 
exposure induced sensations similar to those experienced 
during a panic attack for the CR patients, they were more 
likely to produce distress in the CR group.  This finding 
suggests that PD is heterogeneous in presentation and 
effective treatment is dependent upon on accurate targeting 
of the specific symptoms experienced. 

Thus, designing an effective treatment for PD subtype 
GI response would require use of interoceptive exposures 
that induce symptoms of GI distress.  Chambless et al. 
(2000) endorsed this methodology asserting that Cognitive-
Behavior Therapy (CBT) approaches for inducing panic-
like experiences should be targeted to induce the symptoms 
experienced by each patient. As Andrews et al. (2003) 
suggest, in order to improve treatment outcome, exposures 
should closely resemble the actual feared situations, as well 
as aim to modify maladaptive cognitions.  

Exposure therapy prompts change by challenging the 
inappropriate anxiety response that has been conditioned to 
produce or elicit fear.  A reduction in anxiety occurs by re-
experiencing the feared stimuli (e.g., limited access to 
bathroom, travel, and traffic) and associated catastrophic 

bowel incontinence; Rosqvist, 2005).  In order for new non-
threatening conditioning to occur, an individual must first 
habituate to the perceived threatening stimulus.  
Habituation occurs when a person does not flee or avoid 
anxiety-provoking situations, but remains present.  
Remaining present despite a perceived threat provides the 
body with a new experience (i.e., new physiological 
evidence) that actual threat or danger is not occurring and 
anxiety responses begin to diminish (Foa & McNally, 
1996).   

Based on the literature reviewed herein, we 
recommend a specialized CBT treatment strategy for PD 
subtype GI response that includes graded exposures to GI-
related somatic sensations in addition to psycho-education 
about anxiety, somatic skills training (e.g., utilizing 

diaphragmatic breathing), and cognitive restructuring (e.g., 
distorted versus objective thinking).  Additionally, we 
suggest integrating bowel control training (e.g., 
distinguishing normal abdominal sensations from bowel 
distention), as well as utilizing in-vivo exposures to 
challenge agoraphobic avoidance and escape behaviors 
(e.g., eating in public, going places where restroom access 
is limited).  

Despite the diagnostic challenges the proposed 
symptom presentations create, recommended intervention 
strategies would reflect those most commonly used to treat 
PD, OCD, and IBS.  Treatment for IBS, for example, 
mimics similar components used to treat other anxiety 
disorders (e.g., muscle relaxation, diaphragmatic breathing, 
activity scheduling) and would, likewise, be presumed 
effective for PD subtype GI response.  In addition, 
interoceptive and in-vivo exposure, both established 
treatments for PD and OCD (Barlow, 2008), would also 
likely be effective with GI-related symptoms.   
 

Assessment Strategies 
 

To effectively administer and monitor the proposed 
treatment, psychometrically sound assessment tools are 
required.  Cognitive, physiological, and motor information 
can be gained through self-report, in addition to diagnostic 
clinical interviews.  We recommend the Anxiety Sensitivity 
Profile (ASP) for cognitive aspects of the treatment and the 
Body Vigilance Scale (BVS) for the physiological 
symptoms (Schmidt, Lerew, & Trarkowski, 1997; Taylor & 
Cox, 1998).  In addition to these formal self-report 
measures, behaviors can be monitored through self-report 

or agoraphobic exposure experiments.  
The ASP measures cognitions of the perceived danger 

associated with the anxiety symptoms.  The questionnaire 
consists of 60 questions that list specific bodily sensations 
and asks the respondent to answer how likely it is that each 
sensation would lead to something bad happening (e.g., 

dying).  It is divided into six subscales that 
assess the amount of fear associated with a particular group 
of experiences: cardiovascular, respiratory, gastrointestinal, 
observable, neurological, and cognitive dyscontrol.  The 
ASP takes approximately 10 minutes to complete.  While 
normative data is not yet available, the reliability found 
within a group of university students was good with an 
internal consistency for GI symptoms of 0.88 (Taylor & 
Cox, 1998).  

The BVS consists of a four item self-report inventory.  
Each item uses an 11 point Likert scale. The first three 
questions measure the degree of focus given to internal 
physiological stimuli.  The fourth item lists 15 bodily 
sensations, as listed in the DSM-IV for panic attacks, and 
assesses how much attention is given to each sensation.  
The BVS takes 3 to 5 minutes to complete.  The BVS has 



GASTROINTESTINAL PANIC DISORDER 
 

   49 

Schmidt et al., 1997).  Validity of this measure has been 
studied and found to be supported; patients with PD have 
been found to have higher scores on the BVS pre-treatment 
than patients of social phobia or nonclinical trials, and 
scores on the BVS tend to decrease following cognitive-
behavioral treatment (Schmidt et al., 1997). 

Utilization of the aforementioned narrow-band 
measures allows for proper assessment of physiological and 
cognitive symptoms indicative of PD subtype GI response.  
Such detailed assessment is necessary for accurate 
conceptualization and treatment planning, while also 
providing an opportunity for objective symptom tracking 
throughout the treatment process.  
 

Conclusion 
 

PD with GI response represents a rare but significant 
form of the disorder, where in the person does not 
experience the full range of conventional symptoms 
associated with a panic attack.  Instead, the single symptom 
of GI reactivity predominates.  While many panic attack 
sufferers typically experience automatic thoughts (e.g., 

often dispelled by an emergency room visit, the GI distress 
symptom can present with an actual reality of fecal 
incontinence.  For those who experience PD subtype GI 
response, this misappraisal fundamentally changes from a 
perceived threat to something that has additional social 
implications.  

When considering a PD subtype GI response diagnosis, 
it is necessary to consider and rule out that the particular GI 
focus is not better explained by another psychological 
disorder, such as Agoraphobia or IBS.  Therefore, careful 
diagnostic interviewing is critical.  To this end, relying on 
such diagnostic tools as The Anxiety Disorders Interview 
Schedule  Fourth Revision (ADIS-IV, 2007), medical 
records, previous treatment records, and collateral 
information may aide in accurately diagnosing this type of 
PD vis-à-vis other conditions that GI problems could 
represent.  

Due to its unique presentation, PD subtype GI response 
needs a tailored treatment strategy.  While potentially 
capitalizing on medications (e.g., Paroxetine) to reduce 
sheer gut reactivity, the multi-pronged treatment 
recommendations include many conventional panic control 
treatment strategies (e.g., psycho-education, cognitive 
restructuring), while including an emphasis on bowel 
control training and in-vivo exposure to feared situations 
that are related to anticipated bowel problems (e.g., eating 
in public, taking longer trips while snacking).  This 
strategic approach takes advantage of learning theory and 
conditioning paradigms to ensure that treatment gains 
generalize to various natural environments.   

In conclusion, it remains largely true that the brain-gut 
relationship is not yet well understood, especially in regards 
to PD subtype GI response.  More research is needed to 
better grasp how to specifically tailor treatment to 

accommodate the pragmatic addition of this particular 
symptom to any panic presentation.  Additionally, it 
remains to be determined whether PD subtype GI response 
constitutes PD per se, or if this unique presentation warrants 
its own diagnostic category.  Future research is needed to 
further understand the nature and consequences of this 
distressing problem.  

 
References 

 
American Psychiatric Association. (2000). Diagnostic and 

statistical manual of mental disorders (4th ed., text 
revision). Washington, DC: Author.  

Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L., 
& Page, A. (2003). The treatment of anxiety disorders: 
Clinician guides and patient manuals (2nd ed.). New 
York, NY: Cambridge University Press.  

Barlow,   D.   H.   (2004).   Cognitive-­behavioral   treatment   for  
panic   disorder:   Current   status.   Journal   of   Psychiatric  
Practice,  10,  211-­226.    

Barlow,  D.  H.  (2008).  Clinical  Handbook  of  Psychological  
Disorders.  New  York,  NY:  Guilford  Press.  

Barlow,  D.  H.,  Gorman,  J.  M.,  Shear,  M.  K.,  &  Woods,  S.  
W.  (2000).  Cognitive-­behavioral   therapy,  imipramine,  or  
their   combination   for   panic   disorder:   A   randomized  
controlled   trial.   Journal   of   American   Medical  
Association,  283,  2529-­2536.    

Brown,   T.,   DiNardo   P.   A.,   Barlow   D.   H.   (2007):   Anxiety  
Disorders   Interview   Schedule   Adult   Version   (ADIS-­IV).  
New  York,  NY:  Oxford  University  Press. 

Chambless, D. L., Beck, A. T., Gracely, E. J., Grisham, J. 
R. (2000). Relationship of cognitions to fear of somatic 
symptoms: A test of the cognitive theory of panic. 
Depression and Anxiety, 11, 1-9.  

Coplan, J. D. & Lydiard, R. B. (1998). Brain circuits in 
Panic Disorder. Society of Biological Psychiatry, 44, 
1264-1276.  

Creed, F., Guthrie, E., Ratcliffe, J., Fernandes, L., Rigby, 
C., Tomenson, B., et al. (2005). Does psychological 
treatment help only those patients with severe Irritable 
Bowel Syndrome who also have a concurrent psychiatric 
disorder? Australian and New Zealand Journal of 
Psychiatry, 39, 807-815.  

Drossman, D. A., Li, Z., Andruzzi, E., Temple, R. D., & 
Tally, N. J. (1993). U.S. householder survey of functional 
gastrointestinal disorders. Prevalance, sociodemography, 
and health impact. Digestive Diseases and Sciences, 38, 
1569-80. 

Eldridge, G., Walker, J., & Holborn, S. (1993). Cognitive-
behavioral treatment for Panic Disorder with 
gastrointestinal symptoms: A case study. Journal of 
Behavior Therapy and Experimental Psychiatry, 24, 367-
371.  

Foa, E. B., & McNally, R. J. (1996). Mechanisms of change 
in exposure therapy. In Rapee R. M. (Ed.), Current 
controversies in the anxiety disorders (pp. 329-343). New 
York, NY: Guilford Press. 



ASHWORTH, BONIFAY, & ROSQVIST  
  

   50 

Gershon, M. D. (2005). Nerves, reflexes, and the enteric 
nervous system: Pathogenesis of The Irritable Bowel 
Syndrome. Journal of Clinical Gastroenterology, 39, 
S184-S193. 

Goisman, R. M, Warshaw, M. G, Steketee, G. S, Fierman, 
E. J, & et al. (1995). DSM-IV and the disappearance of 
Agoraphobia without a history of Panic Disorder: New 
data on a controversial diagnosis. The American Journal 
of Psychiatry, 152, 1438-1443.  

Greene, B., & Blanchard, E. B. (1994). Cognitive therapy 
for Irritable Bowel Syndrome. Journal of Consulting and 
Clinical Psychology, 62. 576-582.   

Hatch, M. L. (1997). Conceptualization and treatment of 
bowel obsessions: Two case reports. Behavioral 
Research Therapy, 35, 253-257.  

Lelliott, P. & Bass, C. (1990). Symptom specificity in 
patients with panic. British Journal of Psychiatry, 157, 
593-597.  

Lydiard, R. B. (1997). Anxiety and the Irritable Bowel 
Syndrome: Psychiatric, medical, or both Journal of 
Clinical Psychiatry, 58, 51-58.  

Lydiard, R. B., & Falsetti, S. A. (1999). Experience with 
anxiety and depression treatment studies: Implications for 
designing irritable bowel syndrome clinical trials.  
American Journal of Medicine, 107, 65S-73S.  

Lydiard, R. B., Greenwald, M. A., Weissman, M., Johnson, 
J., Drossman, D., & Ballenger, J. (1994). Panic Disorder 
and gastrointestinal symptoms: Findings from the NIMH 
epidemiological catchment area project. American 
Journal of Psychiatry, 151, 64-70.  

Masand, P. S., Gupta, S., Schwartz, T. L., Kaplan, D., Virk, 
S., Hameed, A., et al. (2002). Does a preexisting anxiety 
disorder predict response to paroxetine in Irritable Bowel 
Syndrome? Psychosomatics, 43, 451-455.  

Rosqvist, J. (2005). Exposure treatments for anxiety 
disorder: A practioner's guide to concepts, methods, and 
evidence-based practice. New York, NY: Routledge.  

Sandler, R. S. (1990). Epidemiology of irritable bowel 
syndrome in the United States. Gastroenterology, 99, 
409-415. 

Schmidt, N. B., Lerew, D. R., & Trakowski, J. H. (1997). 
Body vigilance in panic disorder: Evaluating attention to 
bodily perturbations. Journal of Consulting and Clinical 
Psychology, 65, 214-220.  

Taylor, S. (2000). Understanding and treating Panic 
Disorder. Chichester UK: John Wiley & Sons.  

Taylor, S., & Cox, B. J. (1998). Anxiety Sensitivity: 
Multiple dimensions and hierarchic structure.  Behaviour 
Research and Therapy, 36, 37-51.  

Toner, B. B., Segal, Z. V., Emmott, S. D., & Myran, D. 
(2000). Cognitive-behavioral treatment of Irritable Bowel 
Syndrome: The brain-gut connection. New York, NY: 
Guilford Press.  

 
 
 
  


