International Journal of Cognitive Therapy, 3(3), 215–227, 2010

© 2010 International Association for Cognitive Psychotherapy

BLACK ET AL.
LIFETIME HISTORY OF ANXIETY AND MOOD DISORDERS

Lifetime History of Anxiety and

Mood Disorders Predicted by
Cognitive Vulnerability to Anxiety
David Black
National Institute of Mental Health

John H. Riskind and Evan M. Kleiman

George Mason University

A retrospective behavioral high-risk design with used to test hypotheses about cog-
nitive vulnerability to anxiety with college students who were free of current anxi-
ety or mood disorders. Cognitive risk groups were selected on the basis of two cur-
rently studied factors that have conceptualized as cognitive vulnerabilities, looming
cognitive style (LCS; Riskind et al., 2000) and anxiety sensitivity (ASI; Reiss &
McNally, 1985). Consistent with cognitive vulnerability hypotheses, participants at
high cognitive risk had far higher lifetime prevalence (approximately 65%) of anxi-
ety disorders than participants at low cognitive risk (approximately 8%) and were
approximately 11 times more likely to have a prior anxiety disorder. When LCS and
ASI were looked at separately as risk group factors they had no significant effect on
anxiety disorders. Secondary analyses were also done on the whole sample using
data from the full continuum of scores. Total cognitive risk on these continuous
data no effect on anxiety disorders in general but had a small significant effect on
social anxiety disorder. When LCS and ASI were looked at separately as continu-
ous scores, the only finding to emerge was that LCS but not ASI had a significant
but small effect on past prevalence of anxiety disorders. Consistent with cognitive
specificity predictions, no effects similar to those on lifetime anxiety disorders were
found for mood disorders.

According to the cognitive theory of emotional disorders, individuals with cogni-

tive vulnerability factors are more likely than others who lack these vulnerabilities to
develop and maintain disorders. The two-site Temple-Wisconsin Cognitive Vulner-
ability to Depression Project (CVD Project; Alloy et al., 2000) is the “gold standard”
for such research. The results of these studies show that high cognitive-risk individuals
who present without current psychopathology, have higher lifetime histories of past
DSM depression and are 3.5 to 6.8 times more likely at a two year follow-up to pro-
spectively develop first or subsequent episodes of depression episodes. Thus, results
of both CVD Project retrospective and prospective studies provide strong, consistent,

Correspondence concerning this article should be addressed to John H. Riskind, Department of Psychology,
George Mason University, Mail Stop 3F5, Fairfax, VA 22030. E-mail: jriskind@gmu.edu.

215
216 BLACK ET AL.

evidence that cognitive factors play major roles in the onset and recurrence of depres-
sion
There has been a paucity of this kind of important cognitive vulnerability research
in anxiety disorders. However, research supports two putative cognitive vulnerability
factors—Looming Cognitive Style and Anxiety Sensitivity—as potential candidates
for anxiety-oriented vulnerability. Prior research has indicated that these two factors
are only moderately correlated. Looming Cognitive Style (LCS; Riskind et al., 2000)
is a tendency to emphasize perceptions of threat or danger as rapidly approaching and
intensifying. In the Anxiety Sensitivity model (AS; Reiss & McNally, 1985), vulner-
ability is conceptualized in terms of negative beliefs about the meaning and conse-
quences of anxiety symptoms themselves.
A growing body of recent work on anxiety has emerged from the Looming Vul-
nerability model. According to the model, anxious people experience anxiety and fear
in part because they generate dynamic mental scenarios in which threats are rapidly
approaching and overcoming them and even faster than they can respond (Riskind,
1997; Riskind et al., 2000). For example, people who have fears of social rejection
may tend to mentally simulate scenarios in which social rejection or humiliation is
quickly rising in risk and danger. Those who fear physical dangers may have this fear
partly because they imagine such scenarios as rapidly developing and approaching in
relation to themselves in time and space. Thus, the model asserts that dynamic percep-
tions of threats or dangers instigate worry and fear of aversive objects or events.
Many studies show that college students who have a Looming Cognitive Style
as a whole are more anxious, but not necessarily more depressed. They exhibit a sche-
matic interpretative bias (e.g., on homophones, spelling “died” instead of “dyed”) and
memory bias (e.g. pictorial images) for threat information. Moreover, several studies
using structural equation modeling found support for the idea the LCS is a common
theme across a spectrum of anxiety syndromes including social anxiety, OCD, general-
ized anxiety, and PTSD (Brown & Stopa, 2008; Reardon & Williams, 2007; Riskind
et al., 2007; Williams et al., 2005). The LCS shows remarkable stability over time and
predicts future anxiety symptom as well as worry changes over periods as short as a
week and as long as 7 months. Research has found that it predicts variance in anxiety
and worry over and above the influence of Anxiety Sensitivity, negative affectivity
(Reardon & Williams, 2007; Riskind, Williams et al., 2005), and intolerance of un-
certainty (Riskind, 2007).
Anxiety Sensitivity (AS) is a well-established cognitive style that refers to the per-
ception that anxiety symptoms may produce adverse or harmful consequences (Reiss
& McNally, 1985; Taylor, 1999). AS is elevated in a variety of anxiety disorders and
mood disorders (Cox et al., 200 Naragon-Gainey, 2010; Rector et al., 2007). AS has
been found to positively relate to increased attention to bodily sensations as threat
(Zvolensky & Forsyth, 2001). AS was experimentally found to predict panic-like re-
sponses to carbon dioxide enriched air (Zvolensky et al., 2001). Past research has indi-
cated that LCS and AS are distinct but albeit moderately correlated r = .32, p <.001
vulnerabilities to anxiety (Reardon & Williams, 2007).
Prior research has shown that LCS and AS are elevated in individuals who have
anxiety disorders. However, a major limitation of these studies is that they select sam-
ples based on whether they exhibit current diagnoses of an anxiety disorder. This
design constrains studies to examining factors that are visibly exhibited by individu-
als who already have anxiety disorders. However, these designs are not optimal tests
of cognitive vulnerabilities. By definition, cognitive vulnerabilities are risk factors in
LIFETIME HISTORY OF ANXIETY AND MOOD DISORDERS 217

individuals who have not already developed a current anxiety disorder. To demon-
strate that putative factors play a cognitive vulnerability role, it is necessary to assess
putative cognitive vulnerabilities in individuals who are not concurrently disordered
at the time of the assessment. This entails the use of behavioral high risk designs that
exclude individuals with concurrent disorders. In other words, those selected are free
of psychopathology.
In the field of vulnerability to depression, Alloy and Abramson identified two dis-
tinct variants of behavioral high risk designs for studying cognitive vulnerability (Alloy
& Abramson, 1999; Alloy et al., 2000), retrospective and prospective. Retrospective
high risk designs are used to test whether purported vulnerability factors increase the
likelihood of disorders in a person’s past lifetime (i.e., “looking back”) prior to the pres-
ent. On the other hand, prospective variants of high risk—the preferred approach—are
employed to test whether the vulnerability factors increase the likelihood of disorders
in the future (“looking forward”). The research by Alloy and Abramson on cognitive
vulnerability to depression has used both prospective and retrospective designs and
found similar results in both. The prospective behavioral high risk design is considered
the more rigorous but also more intensive of resources.
By contrast, there has been hardly any research using behavioral high risk designs
to study cognitive vulnerability to anxiety. To our best knowledge, there have been
no retrospective (“or look back”) high risk designs of either LCS or AS and anxiety
vulnerability. There is just one published study, to our knowledge, that has used the
more rigorous prospective behavioral high risk design to test AS as a cognitive vulner-
ability (Schmidt, Zvolensky, & Maner, 2006). Schmidt et al. followed a sample of 404
individuals for two years who had no diagnosed disorders or other Axis I pathology
at baseline but differed in ASI. Results showed that participants who had higher ASI
scores exhibited more anxiety and Axis 1 disorders at follow-up. These findings sug-
gest that AS functions as a cognitive vulnerability for onset of anxiety disorders, but
for other Axis I disorders as well.

PURPOSE OF THE PRESENT STUDY

The present study extends the use of retrospective behavioral high risk designs to the
field of anxiety-oriented cognitive vulnerability. We adopted the approach customar-
ily taken by the Temple-Wisconsin behavioral high risk studies (Alloy & Abramson,
1999; Alloy et al., 2000). That is, we used a composite scores for two vulnerability
constructs, looming cognitive style and anxiety sensitivity, to identify extreme (high
versus low) cognitive risk groups for anxiety. We selected participants who were free of
current anxiety or mood disorders at baseline in order to examine whether individuals
at high cognitive risk exhibited greater lifetime prevalence of anxiety disorders than
individuals at low cognitive risk. In exploratory analyses, we examined cognitive risk
for LMS and ASI separately to assess their relative effects. We also conducted second-
ary analyses using scores for the whole continuum of cognitive risk (Lewinsohn et
al., 2001), as well as for LMSQ and ASI separately, to compare this to the high risk
approach used by the Temple-Wisconsin studies. We hypothesized that LMS and ASI,
and the cognitive risk composite, would only apply to anxiety disorders and not mood
disorders.
218 BLACK ET AL.

Method

Participants

A sample of 241 participants (62% female; mean age = 21.2, SD = 5.33) were re-
cruited from the undergraduate student population of a major public university. Par-
ticipants were given research participation credit in exchange for the time they contrib-
uted to complete this study. Participants were included in the primary analyses (N =
224) if they did not meet criteria for an anxiety or mood disorder during the 4 weeks
prior to and including this assessment.
Materials
Cognitive Vulnerability to Anxiety. To measure the LCS, the Looming Maladap-
tive Style Questionnaire (LMSQ; Riskind et al., 2000) was used. The LMSQ is an
18-item measure of an individual’s tendency to appraise threat as rapidly rising in risk,
progressively worsening, or actively accelerating or speeding up; that is exhibiting the
looming cognitive style. Participants respond to six vignettes describing a range of
potentially stressful situations including: physical illness, financial problems, public
speaking, social rejection and embarrassment, and being trapped or hurt. Participants
answer three questions about each vignette on a 5-point Likert-type scale. Individual
item scores are aggregated such that higher scores indicate higher levels of looming
vulnerability. Good internal consistency (Chronbach’s alpha = .91), retest reliability
(1 week retest reliability = .88, p <.01) and construct validity for this measure has
been demonstrated (Riskind et al., 2000).
The Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986)
was used to assess AS. This is a 16-item self-report inventory of anxiety sensitivity or
the belief that anxiety has negative implications. Participants are asked to indicate how
descriptive each statement is of them using a 1 (very little) to 5 (very much) point
Likert-type scale. Higher scores indicate higher levels of anxiety sensitivity. The ASI
has sound psychometric properties including retest-reliability, internal consistency, and
criterion validity (Reiss et al., 1986). It is also independent of other measures of anxi-
ety including cognitive and somatic measures (Peterson & Heilbronner, 1987). The
original ASI used in this study was not designed to be multidimensional. The new edi-
tion of the ASI (Taylor, Zvolensky, Cox, Deacon et al., 2007), which reliably assesses
three subfactors, was not available at the time of data collection in this study.
Current Psychopathology. Several instruments were used to assess current psychi-
atric symptomatology. The Patient Health Questionnaire (PHQ; Spitzer, Kroenke,
Williams, & The PHQ Primary Study Group, 1999) was used to identify participants
with probable current diagnoses of anxiety or mood disorders. The PHQ is a self-
report questionnaire that assesses several current DSM-IV disorders including anxiety
and mood disorders. Each item is answered using a 3- or 4-point scale that allows
participants to indicate the extent to which they have been bothered or distressed by
each of the symptoms listed. Algorithms are applied to the participants’ responses to
arrive at a probable diagnosis. The PHQ has been widely used as a self-report diagnos-
tic instrument and has been demonstrated to be reliable and valid in a sample of 3,000
individuals recruited from the offices of primary care physicians (Spitzer et al., 1999).
When compared to diagnoses obtained via clinical interview by a mental health profes-
sional, the PHQ was 85% accurate with a specificity of 75% and sensitivity of 90%.
LIFETIME HISTORY OF ANXIETY AND MOOD DISORDERS 219

To measure current symptoms of anxiety and depression, the Beck Anxiety In-
ventory (BAI; Beck, Epstein, Brown, & Steer, 1988) and Beck Depression Inventory
(BDI; Beck, Steer, & Brown, 1996) were administered. Both measures are self-report
inventories of anxiety and depression symptoms, respectively, that have demonstrated
excellent reliability and validity (BAI; Fydrich, Dowdall, & Chambless, 1992; Steer,
Ranieri, Beck, & Clark, 1993; BDI; Dozois, Dobson, & Ahnberg, 1998; Steer, Clark,
Beck, & Ranieri, 1994). Participants rate how much they have been bothered by
symptoms of using a 4-point Likert-type scale. Both the BAI and BDI yield aggre-
gated scores such that higher scores indicate more severe symptoms.
Past History of Psychopathology. The anxiety and depression modules of the com-
puter administered Composite International Diagnostic Interview (CIDI; World
Health Organization, 1997) were used to measure the lifetime prevalence of anxiety
and depression diagnoses, the primary dependent variables in this study. The CIDI is
a structured computer assisted clinical interview that assesses lifetime prevalence of
DSM-IV Axis I disorders, indicating whether full or partial diagnostic criteria have
been met. Both the computer and clinician administered versions of the CIDI have
been used extensively in previous research. Peters, Clark, and Carrol (1998) found
that the computer-administer versions of the anxiety and depression modules demon-
strate good reliability with clinician-administered versions of the CIDI. All individual
anxiety diagnoses had 80% or higher agreement between clinician and computer ad-
ministered versions.

Procedure

Participants completed each of the measures described above including the LCS
(LMSQ), ASI, BAI, BDI, PHQ, and the CIDI. Participants who, at the time of the
study, did not meet criteria for any Axis-I disorder as measured by the PHQ were re-
tained in the primary analyses.

RESULTS

Sample Characteristics

A total of 17 (7.1%) participants were excluded from participation because they met
diagnostic criteria for a current major depressive disorder, panic disorder, or had sig-
nificant anxiety symptoms as measured by the PHQ. Ten (4.3%) participants had
a major depressive disorder, eight (3.4%) met criteria for panic disorder, and seven
(3.0%) had significant anxiety symptoms suggestive of an anxiety disorder. Because
some participants met criteria for more than one disorder, the total number of partici-
pants excluded is less than the sum of all groups. Mean anxiety and depression levels,
displayed in table 1, are in the normal range for the selected sample.
A listing of the prevalence of each diagnosis as assessed by the structured inter-
view (CIDI) is provided in Table 2. As can be seen, major depressive disorder was the
most common previous diagnosis followed by specific phobia and social anxiety disor-
der. Approximately 33% (n = 80) of the sample reported at least one anxiety disorder
over the course of their lifetime. This finding is similar to the 30.2% lifetime preva-
lence rate for 18-29 year olds reported by Kessler in the replication of the National
220 BLACK ET AL.

TABLE 1. Sample (n = 224) Characteristics

Mean SD Range
Age (yr) 21.2 5.47 17-55
Gender (% female) 62% — —
LMSQ Total Score 78.44 17.85 24-120
ASI Total Score 34.79 9.15 16-60
BAI Total Score 9.26 7.70 0-44
BDI Total Score 6.99 5.95 0-25

Note. LMSQ = Looming Maladaptive Style Questionnaire, ASI = Anxiety Sensitivity Index, BAI = Beck Anxiety Inventory, BDI
= Beck Depression Inventory

Comorbidity Study (Kessler et al., 2005). Very few participants met criteria for panic
disorder, agoraphobia – (with or without panic disorder), obsessive compulsive disor-
der (OCD), or generalized anxiety disorder (GAD). Because the frequency of GAD
diagnoses was so surprisingly low (n = 3), it was analyzed only as a part of a compos-
ite any anxiety disorder variable. Only one participant met criteria for dysthymia who
did not also meet criteria for major depression, suggesting that very little additional
information will be gleaned by analyzing the dysthymia data separately. Consequently,
only the any mood disorder variable will be analyzed in subsequent analyses. Table 3 lists
the correlations between study variables.
Cognitive Risk and Predictions of Previous Anxiety Episodes

Based on our cognitive vulnerability framework, we predicted that cognitively high-

risk participants would exhibit greater lifetime prevalence of anxiety than would cogni-
tively low-risk participants. The high cognitive risk group was composed of individu-
als who had composite standardized scores for LCS and ASI that were one SD above
the mean, while the low cognitive risk group had composite standardized scores that
were one SD below the mean. The analyses used more restrictive criteria than Alloy et
al. (2000), based on the lower and upper quartiles, because it was presently thought
that this might maximize the impact of cognitive risk. Table 4 shows F values, Wald
statistics, and odds ratios for risk group differences across all combined anxiety dis-
orders in general, as well as social phobia and specific phobia as separate disorders.
The diagnostic prevalence of the other individual disorders in the study was not high
enough to be included in these analyses. Consistent with a vulnerability model, cogni-
tive risk group did significantly predict the occurrence of a past anxiety disorder with a
large effect size (B = 2.08, Wald = 9.08, OR = 11.25, p = .001) when controlling for
gender, BAI, and PHQ. Specifically, participants at high cognitive risk had far higher
lifetime prevalence (approximately 65%) of anxiety disorders than participants at low
cognitive risk (approximately 8%) and were eleven times more likely to have a prior
anxiety disorder. In addition, participants at high cognitive risk also had specific higher
lifetime prevalence rates of social phobia, (p < .001), and simple phobia (p <.01),
than participants at low cognitive risk.
Additionally, there was no significant effect for cognitive risk predicting past ma-
jor depression, suggesting specificity to anxiety. Table 4 also shows that there were no
significant effects of cognitive risk when mood disorder was the outcome.
LIFETIME HISTORY OF ANXIETY AND MOOD DISORDERS 221

TABLE 2. Prevalence of Diagnosis for Anxiety and Mood Disorders

Diagnosis Prevalence N (%)
Specific Phobia 32 (13.3)
Social Phobia 26 (10.8)
PTSD 15 (6.2)
OCD 9 (4.0)
Agoraphobia 1(0.4)
Panic Disorder 4 (1.7)
GAD 3 (1.3)
Any Anxiety Disorder 80 (33.2)
Major Depressive Disorder 59 (24.5)
Dysthymia 3 (1.2)
Any Mood Disorder 60 (24.9)

Differences In Symptoms and Distress Between High and Low Risk Groups

A set of ANOVAS were also conducted to examine the effects of cognitive vulner-
ability on symptoms and distress. Table 5 shows that the high and low cognitive risk
groups significantly differed on ANOVAS conducted on scores in symptoms and dis-
tress in past anxiety disorders.
Exploratory Analyses

In an exploratory analysis, we divided the composite risk factor to look at the effects of
LCS and ASI risk groups separately. Groups for each factor were defined by scores one
SD above or below the mean. In this exploratory analysis, neither LCS (B = 2.24, Wald
= 1.64, OR = 9.41, p <.20) nor ASI (B = -1.16, Wald = .44, OR = .31, p <.60) risk
groups predicted anxiety disorder outcomes. Taken together, the results suggest that
there is a strong effect for cognitive risk when individuals have membership in both
extreme groups, but not when only one of the vulnerability factors is present.
In addition, other exploratory analyses were conducted using cognitive risk as
continuous standardized scores on from the whole sample (not just the extreme scores
for LCS and ASI) to predict previous lifetime prevalence of anxiety disorders. Com-
posite cognitive risk as a continuous predictors did not predict lifetime prevalence of
anxiety disorders in general (B = 0.0, Wald = 0.17, OR = 0.10, p <.64). The only
significant finding to emerge from these logistic regression analyses was that compos-
ite cognitive risk scores as a continuous risk factor predicted past lifetime prevalence of
social phobia disorders. However, it is noted that these results were much less signifi-
cant and had a small effect size (B = 0.00, Wald = 1.07, OR = 1.00 p = .04).
Finally, exploratory or secondary analyses were conducted to look at LCS and ASI
separately as continuous scores. This regression analysis produced a small significant
effect for LCS-continuous scores on previous history of anxiety disorder in general (B
= 0.03, Wald = 6.58, OR = 1.03, p = .01) but no significant effect for ASI continu-
ous-scores (B = 0.03, Wald = 1.19, OR = 1.03, p = .28). No other findings emerged
from the analyses on the prevalence of specific anxiety disorders.
222 BLACK ET AL.

TABLE 3. Correlations Between Study Variables

1 2 3 4 5 6 7
1. LMSQ —
2. ASI .530*** —
3. BAI .416*** .593*** —
4. PHQ .361*** .401*** .576*** —
5. BDI .351*** .454*** .654*** .643*** —
6. All Anxiety Disorders .367*** .392*** .435*** .388*** .407*** —
7. Major Depression .184** .253*** .378*** .451*** .453*** .388*** —
8. Gender .037 .133 .133* .183** .090 .218** .084

Note. ***p <.001, **p < .01, *p < .05. LMSQ = Looming Maladaptive Style Questionnaire, ASI = Anxiety Sensitivity Index,
BAI = Beck Anxiety Inventory, PHQ = Physician’s Health Questionnaire, All anxiety disorders/Major depression = sum of
anxiety/depression diagnoses from the Composite International Diagnostic Interview.

DISCUSSION

As hypothesized by cognitive vulnerability models, our results indicate that college

students who were without current anxiety or mood disorders, but were cognitively
at risk had a higher lifetime prevalence of anxiety disorders than college students who
lacked cognitive risk. Our first analysis paralleled the approach customarily used by the
Temple-Wisconsin behavioral high risk studies (Alloy & Abramson, 1999; Alloy et al.,
2000). Using two different cognitive constructs, looming cognitive style and anxiety
sensitivity, we identified extreme groups that were either at high or low cognitive risk
for anxiety. Results showed that cognitively at risk college students were 11.25 times
more likely to have exhibited a past anxiety disorder than college students who were
without cognitive risk. In fact, nearly 65% of the participants in the high cognitive risk
group exhibited a past history of anxiety disorder compared to approximately 8% of
the low cognitive risk group. The effects of cognitive risk were specific to anxiety and
not found for mood disorders.
We found when looking at LCS and AS risk groups separately, these factors
yielded no significant effects. These findings suggest that LCS and AS are strongly
predictive of previous lifetime prevalence of anxiety disorders when both vulnerability
factors are present but not when just one of the factors is present. Thus, the two vul-
nerability factors seem to synergistically augment each other’s effects when both are
present at very high levels (one SD above the mean) as compared to both being at low
levels (one SD below the mean). These results imply that high levels of AS and LCS
create a particularly potent vulnerability combination that increases risk for anxiety
disorders. One possible explanation for these findings is that the presence of more than
one cognitive vulnerability factor places an additional burden on coping resources that
results in additional self-regulatory depletion (Muraven, Tice, & Baumeister, 1998;
Schmeichel & Baumeister, 2004). This depletion would disproportionately increase
risk of developing anxiety disorders. This reasoning is consistent with the reasoning
and hypotheses of a recent study of stress generation. We found evidence for a syner-
gistic effect on the influence that LCS and ASI had on the stress generation process
(Riskind, Shahar, & Black, 2010).
In secondary analyses, we took an alternative approach to cognitive risk some-
times used in vulnerability research and assessed the effects of the total continuum of
LIFETIME HISTORY OF ANXIETY AND MOOD DISORDERS 223

TABLE 4. Lifetime Prevalence of Anxiety Disorder Diagnosis as a Function of

High and Low Cognitive Risk
Low Risk High Risk
Disorder % (n = 36) % (n = 37) Risk F Wald OR 95% CI
Any Anxiety Disorder 8.3 64.9 37.02*** 9.08 11.25 2.33-54.23
Social Phobiaa 0 32.4 19.41*** n/a n/a n/a
Specific Phobia 5.6 21.6 6.01** 2.59 4.95 0.71- 34.70
Depression 11.4 37.5 1.48 0.321 1.48 0.27 – 8.10

Note. ***p <.001,**p < .01,*p < .05. Cognitive risk = +/- 1SD on combined standardized ASI/LMSQ scores. Degrees of
freedom for high and low risk scores was (1,72). aValues for Wald and OR cannot be calculated because the low risk group
is not populated for social phobia.

cognitive risk scores for the entire sample. When we did this, rather than look at the
high and low risk groups, we found no significant effect on lifetime prevalence of all
anxiety disorders in general. However, a single significant finding with a small effect
size was found for social anxiety disorder. We then looked at the effects of LMSQ and
ASI separately as continuous scores. This regression analysis produced a small signifi-
cant effect for LCS continuous scores on previous history of anxiety disorder but no
significant effect was obtained for anxiety sensitivity.
Together, these results suggest that using the behavioral high risk approach devel-
oped by Alloy and Abramson (1999; Alloy et al., 2000), which compares extreme risk
groups defined by scores on two cognitive vulnerabilities, had the strongest predictive
effects on lifetime prevalence of anxiety disorders. When we examined the effects of
just one vulnerability factor, or relied on continuous scores of the two factors, this
yielded little or less consistent effect in predicting lifetime prevalence of anxiety. Thus,
in the present data set, it appears that the behavioral high risk design approach used
by Alloy, Abramson and colleagues (2000) was more powerful than using the whole
range of the continuous data for the risk factors. However, the continuous scores
for LCS had a significant, small effect on prevalence of previous anxiety disorders in
general but scores for ASI did not. This finding might imply that LCS was a slightly
more sensitive cognitive risk factor in the present study. Yet, caution is needed in gen-
eralizing from this one finding because Schmidt et al. (2006) found in their two-year
prospective design that ASI was a robust predictor of anxiety disorders.
The prevalence of anxiety disorders for the present sample of approximately 33%
is generally very close to the expected prevalence of 30.2% in the 18-29 age range
(Kessler et al., 2005). Yet, it is somewhat surprising that there were so few cases of
GAD (1.3 %) as the expected prevalence in the 18-29 age range would be 4.1% (Kes-
sler et al., 2005). However, our GAD prevalence rate is the same as the found in a
recent study of high school students by Zinbarg et al. (2010). Moreover, it should be
mentioned that the inter-rater reliability for diagnosing GAD on the CIDI is the low-
est of all anxiety disorders (.43) (Peters, Clark, & Caroll, 1998). On a similar note,
our prevalence rate of Obsessive Compulsive Disorder (4.0%) was slightly higher than
the prevalence rate reported for the same age group (2.0%) by Kessler et al., 2005).
However, the prevalence rate for Social Anxiety Disorder and Specific Phobias were
similar to those found by Kessler et al. (2005).
Some limitations of the results must be acknowledged. One of the chief limita-
tions of this study is that retrospective designs are clearly not the preferred designs for
testing cognitive vulnerability. Such designs are unable to establish the direction of the
224 BLACK ET AL.

TABLE 5. Differences Between High and Low Cognitive Risk Groups

in Distress and Symptomology
Combined Risk ASI LMSQ
F p F P F p
Distress (df)
All Anxiety 10.21 .002 13.45 .000 3.37 .071
Specific Phobia 4.73 .033 11.33 .001 0.64 .428
Social Phobia 52.10 .000 42.55 .000 23.32 .000
Agoraphobia 9.66 .003 9.30 .003 4.92 .000
Symptoms (df)
All Anxiety 34.51 .000 29.96 .000 17.86 .000
Specific Phobia 3.37 .071 11.36 .001 0.09 .764
Social Phobia 40.42 .000 21.54 .000 20.66 .000
Agoraphobia 10.86 .002 5.81 .018 6.39 .014

Note. Combined risk = +/- 1SD on combined standardized ASI/LMSQ scores. ASI = Anxiety Sensitivity Index, LMSQ = Loom-
ing Maladaptive Style Questionnaire. Degrees of freedom were (1,76) for ASI, (1,62) for LMSQ, and (1,72) for combined
scores. Distress and Symptoms = Sum distress and symptom scores from the Composite International Diagnostic Interview.

relationship between cognitive risk factors and first episodes of anxiety disorder. That
is, the designs cannot rule out the possibility that cognitive factors are consequences
(or “scars”; Lewsinsohn et al., 1981) rather than true antecedents or risk factors for
anxiety disorders. Prospective behavioral high risk designs are preferred because they
do not face this conceptual limitation. That said, it can be noted that other research
has provided strong support for the use of retrospective designs. Alloy and Abram-
son’s research (1999), which represents the gold standard for cognitive vulnerability
research, established that prospective and retrospective behavioral high risk designs
yielded similar support for cognitive vulnerability models of depression. Ultimately, of
course, it will be essential to replicate and extend the present results with studies that
use prospective behavioral high risk designs.
Another important limitation on the results is that diagnoses of present or past
anxiety or mood disorders were not made using structured clinical interviews with
skilled clinicians. Lifetime diagnoses of anxiety and mood disorders were obtained
using structured computer assisted interviews and diagnoses of current disorders were
made with the PHQ, a self-report measure. Although there is evidence for the psycho-
metric properties and validity of these measures, structured clinical interviews such as
the Structured Clinical Interview for DSM-IV Diagnoses (SCID; First et al., 2002)
would be the gold standard. In addition, despite the ethnic diversity of the participants
they were all college students. This being so, caution must also be considered in gen-
eralizing results to the outside community.
Another possible limitation is that the original ASI used in this study was not
designed to be multidimensional. The different dimensions, however, may be critical.
The new edition of the ASI (Taylor, Zvolensky, Cox, Deacon et al., 2007), which reli-
ably assesses three sub-factors, was not available at the time of data collection in this
study. In future studies, it would be advantageous to use this third edition of the ASI
which includes more reliable measures of sub-factors identified in studies of the ASI
in past (Taylor, 1999).
LIFETIME HISTORY OF ANXIETY AND MOOD DISORDERS 225

A further issue is that the present study did not asses Neuroticism, which has
been found to predict past lifetime history of anxiety disorders (Zinbarg et al., 2010).
In view of such findings, it is important to establish in future studies that cognitive
vulnerability factors have an effect, independent of neuroticism which is a generalized
personality characteristic but not a cognitive risk factor. Thus future studies should
examine whether LCS and ASI predict lifetime prevalence or future onset of anxiety
disorders controlling for neuroticism.
Future research can also begin to explore possible psychological and behavioral
mechanisms by which LCS and ASI may contribute to the prevalence or onset of
anxiety disorders. Both LCS and ASI are conceptualized as diatheses within a vulner-
ability/stress paradigm. It would be desirable in future studies to assess stressful events
and examine whether they synergistically interact with the cognitive risk factors to
increase risk of anxiety disorders. Research can also examine whether vulnerability fac-
tors play an active role within a stress generation process. Extensive literature suggests
that people do not simply differ in the degree to which they suffer from negative life
events, but also in the extent that they themselves actively propagate, or generate, un-
fortunate circumstances and environments (Hammen, 2006; Shahar, 2006). LCS and
AS have been shown in combination to influence individuals to self-generate stressful
events that may trigger or propagate their problems and thus conceivably increase risk
of anxiety disorders (Riskind et al., 2010).
In summary, using a retrospective behavioral high risk design, two cognitive vul-
nerability constructs, LCS and AS, were examined as potential risk factors in the de-
velopment of past anxiety disorders. Participants who did not meet criteria for any cur-
rent anxiety or mood disorder were recruited for study participation. Results provide
preliminary evidence that cognitively-at-risk individuals (high in looming cognitive
style and anxiety sensitivity) had a significantly greater lifetime prevalence of anxiety
disorder than individuals who were not cognitively at risk. Finally, it should be noted
that a small but significant effect was found for LMSQ but not AS continuous scores
on past lifetime history. Further study is clearly warranted on the role of LCS and AS
as cognitive vulnerability factors for anxiety disorders.

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