Interoceptive Exposure: An Overlooked Modality in the Cognitive-Behavioral Treatment of OCD☆,☆☆
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
References (72)
The practice of exposure therapy: Relevance of cognitive-behavioral theory and extinction theory
Behavior Therapy
(2013)- et al.
Strategies for improving long-term outcomes in cognitive behavioral therapy for obsessive-compulsive disorder: Insights from learning theory
Cognitive and Behavioral Practice
(2014) - et al.
Exposure therapy for obsessive-compulsive disorder: An optimizing inhibitory learning approach
Journal of Obsessive-Compulsive and Related Disorders
(2015) - et al.
Integrating anxiety sensitivity, distress tolerance, and discomfort intolerance: A hierarchical model of affect sensitivity and tolerance
Behavior Therapy
(2009) - et al.
The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective
Clinical Psychology Review
(2016) - et al.
Optimizing inhibitory learning during exposure therapy
Behaviour Research and Therapy
(2008) - et al.
Maximizing exposure therapy: An inhibitory learning approach
Behaviour Research and Therapy
(2014) - et al.
Incremental specificity of disgust sensitivity in the prediction of obsessive-compulsive disorder symptoms: Cross-sectional and prospective approaches
Journal of Behavior Therapy and Experimental Psychiatry
(2009) - et al.
Anxiety sensitivity and its dimensions across the anxiety disorders
Journal of Anxiety Disorders
(2006) - et al.
Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learning: A randomized controlled trial
Behaviour Research and Therapy
(2013)
The effects of safety behaviors on the fear of contamination: An experimental investigation
Behaviour Research and Therapy
Do negative beliefs about exposure therapy cause its cautious delivery? An experimental investigation
Journal of Anxiety Disorders
Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain
Behaviour Research and Therapy
Extinction in human fear conditioning
Biological Psychiatry
Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder
Clinical Psychology Review
Anxiety symptomatology: The association with distress tolerance and anxiety sensitivity
Behavior Therapy
Reactivated memories compete for expression after Pavolovian extinction
Behavioural Processes
Distress tolerance in OCD and anxiety disorders, and its relationship with anxiety sensitivity and intolerance of uncertainty
Journal of Anxiety Disorders
Why do clinicians exclude anxious clients from exposure therapy?
Behaviour Research and Therapy
Understanding the associations among anxiety sensitivity, distress tolerance, and discomfort intolerance: A comparison of three models
Journal of Anxiety Disorders
Efficacy of cognitive behavioral therapy for anxiety disorders: A review of meta-analytic findings
Psychiatric Clinics of North America
Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators
Journal of Psychiatric Research
The effects of safety behaviors on health anxiety: An experimental investigation
Behaviour Research and Therapy
Emotional processing
Behaviour Research and Therapy
Obsessive compulsive disorder and anxiety sensitivity: Identification of specific relations among symptom dimensions
Journal of Obsessive-Compulsive and Related Disorders
Emotion and internal experience in Obsessive Compulsive Disorder: Reviewing the role of alexithymia, anxiety sensitivity and distress tolerance
Clinical Psychology Review
Anxiety sensitivity: Prospective prediction of panic attacks and Axis I pathology
Journal of Psychiatric Research
Anxiety sensitivity: Theoretical perspectives and recent findings
Behaviour Research and Therapy
How does anxiety sensitivity vary across the anxiety disorders?
Journal of Anxiety Disorders
Dimensions of anxiety sensitivity in the anxiety disorders: Evaluation of the Anxiety Sensitivity Index-Third Version
Journal of Anxiety Disorders
The relationship between anxiety sensitivity and obsessive-compulsive symptom dimensions
Journal of Behavior Therapy and Experimental Psychiatry
Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale
Psychological Assessment
Exposure therapy for anxiety: Principles and practice
Obsessive-compulsive disorder in adults: Advances in psychotherapy—Evidence based practice
Diagnostic and statistical manual of mental disorders
Are exposure-based cognitive behavioral therapies safe during pregnancy?
Archives of Women’s Mental Health
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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).
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Funding Sources. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.