Interoceptive Exposure: An Overlooked Modality in the Cognitive-Behavioral Treatment of OCD,☆☆

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Highlights

  • Anxiety sensitivity (AS) refers to the fear of anxious arousal sensations

  • AS may influence outcome of cognitive-behavioral treatment for OCD

  • Clinicians should assess and target AS during treatment for OCD

  • Two case examples illustrate how clinicians may address AS during treatment for OCD

Abstract

Accumulated research implicates anxiety sensitivity (AS) as a transdiagnostic construct important to the maintenance of OCD. Yet despite the clinical implications of targeting fears of body-related sensations during treatment, interoceptive exposure (IE) is an often-overlooked therapeutic procedure in the cognitive-behavioral treatment of OCD. In this article, we discuss the rationale for—and procedures of—addressing AS during treatment for OCD. We provide two case examples, illustrating how a clinician might approach clinical assessment, case formulation, and treatment planning with each of these patients. We conclude by discussing future research directions to better understand if (and how) targeting AS during therapy might enhance OCD treatment outcome.

Section snippets

The Nature and Treatment of OCD

Obsessive-compulsive disorder (OCD) is a psychological condition that is characterized by obsessions (i.e., unwanted, intrusive, and anxiety-provoking, thoughts, images, impulses, or doubts) and/or compulsions (i.e., urges to perform repetitive, deliberate rituals and other anxiety-reduction strategies to offset feared consequences and/or neutralize obsessional fear; American Psychiatric Association [APA], 2013). Obsessions, compulsions, and other avoidance strategies are idiosyncratic and tend

Explanatory models of ERP

Despite its established efficacy (e.g., Olatunji, Davis, Powers, & Smits, 2013), ERP’s underlying mechanisms of change are not fully understood. A recently proposed explanatory model for ERP’s effectiveness is inhibitory learning theory (Craske et al., 2008). In contrast to previous explanatory models of ERP (e.g., emotional processing theory; Foa and Kozak, 1986, Foa and McNally, 1996, Rachman, 1980), inhibitory learning theory pulls from basic learning research and posits that during

Anxiety Sensitivity

Anxiety sensitivity (AS) refers to the fear of anxious arousal (e.g., rapid heart rate, dizziness) that results from mistaken beliefs about the dangerousness of anxiety-related body sensations (e.g., Reiss and McNally, 1985, Taylor, 1995). Individuals with high levels of AS are hypervigilant to ambiguous body sensations and (mis)appraise these sensations as particularly threatening along physical, cognitive, and social domains. Examples include misinterpreting an increased heart rate as a sign

AS and OCD treatment

There is preliminary empirical support for the hypothesis that AS influences OCD treatment outcome, as there is a dearth of research examining the relationship between AS and ERP using clinical samples. One study (Blakey et al., 2016), however, did find that in a sample of OCD patients receiving treatment at a residential program specializing in CBT for OCD, AS predicted poorer treatment outcome, even after controlling for pretreatment OCD and depressive symptom severity. Although not directly

IE: The Overlooked Modality in CBT for OCD

It is our observation that given the emphasis on in vivo and imaginal exposure, IE to anxiety-related body sensations is an often-overlooked strategy in the treatment of OCD. In striving to optimize evidence-based practice, it is important for treatment approaches to mirror relevant empirical and conceptual advances. The literature on AS and OCD (as described above) indicates that IE would be an important component of CBT for many individuals with obsessions and compulsions that in one way or

Assessment and Case Formulation

For some patients with OCD, fear is triggered by the perception of body sensations (e.g., awareness of blood flow to the genital area) as well as by mental stimuli (e.g., intrusive thoughts of committing molestation) and external cues (e.g., a child). Changes in skin, hair, or the color, odor, or form of bodily secretions may also trigger obsessional fear (i.e., somatic obsessions; “I might have Ebola”). As discussed above (and shown in Table 1), patients high in AS may be especially prone to

Tips and Troubleshooting

Clinicians should be flexible in their delivery, tailoring IE exercises to match patients’ maladaptive and mistaken beliefs about the importance and meaning of feared body sensations (those that might be related to OCD symptoms as well as those which might provoke the fear of doing exposures). In order to maximally violate negative predictions for harm and foster greater distress tolerance, patients should conduct IE exercises in a prolonged and intense manner (Abramowitz & Arch, 2014). This is

Case examples

In the following section, we present two illustrations of how AS influenced the conceptualization and treatment of patients with OCD. We describe how a clinician might approach assessment, case formulation, and treatment planning with each of these patients.

Conclusions

Accumulated research (and clinical experience) implicates AS as a transdiagnostic construct important to the development, maintenance, and treatment of OCD. Yet despite the clinical implications of targeting fears of body-related sensations during treatment, IE is an often overlooked therapeutic procedure in exposure-based treatments for OCD. We emphasized the need for conceptually driven (rather than treatment manual-driven; see Abramowitz, 2013) assessment of AS in clients with OCD so that

Directions for Future Research

Although our clinical recommendations are derived from theoretical and empirical work, there is still need for continued examination of AS in OCD patients. Importantly, the mechanisms for how unaddressed AS might interfere with treatment outcome are undetermined. We emphasized two plausible processes (i.e., AS reinforces obsessive beliefs and compromises patient adherence), but these hypothesized mechanisms deserve empirical attention. Similarly, although the inhibitory learning approach to ERP

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    The authors declare that they have no conflict of interest (i.e., no financial, personal, or other relationships with other people or organizations within three years of beginning the work submitted that could inappropriately influence or bias this work).

    ☆☆

    Funding Sources. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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