Anxiety Sensitivity and Interoceptive Exposure: A Transdiagnostic Construct and Change Strategy

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N = 54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS.     

Posttraumatic Stress Disorder and Chronic Pain Arising from Motor Vehicle Accidents: Efficacy of Interoceptive Exposure Plus Trauma-Related Exposure Therapy

Preliminary data are presented on the pattern of treatment response of combining interoceptive exposure (IE) with trauma-related exposure therapy (TRE) in five female patients with posttraumatic stress disorder (PTSD) and comorbid chronic musculoskeletal pain originating from motor vehicle accidents. Treatment consisted of four sessions of IE followed by eight sessions of TRE. Four participants reported a reduction in PTSD symptoms after completing treatment, and three no longer met diagnostic criteria for PTSD. Although both interventions were associated with reductions in PTSD symptoms, TRE was associated with greater reductions in PTSD symptoms than IE and was particularly effective at reducing avoidance. IE was associated with larger reductions in anxiety sensitivity than TRE. Pain symptoms lessened slightly during IE and then worsened following TRE. Anxiety decreased after completing treatment, whereas panic and depressive symptoms responded less so. Three individuals completed a 3-month follow-up assessment. There was no change in their PTSD diagnostic status, and all experienced a slight loss of pre–post gains, particularly involving the return of pain. Clinical and research implications are discussed.     

Cognitive-Behavioral Treatment of Emetophobia: The Role of Interoceptive Exposure

Emetophobia, or the fear of vomiting, is among the least studied phobias. The literature on the etiology, symptomatology, and treatment of this problem is just beginning to develop. Research to date suggests that for many people with emetophobia, anxiety is triggered by both external and internal factors, but to date only one English-language report describes an intervention that directly targets both external and internal triggers. This paper presents a case in which a cognitive-behavioral treatment (including education about the origin and implications of physical symptoms of anxiety, graduated exposure to feared situations, interoceptive exposure, and cognitive restructuring) was used successfully in the treatment of emetophobia.     

The Struggle of Behavioral Therapists With Exposure: Self-Reported Practicability,Negative Beliefs,and Therapist Distress About Exposure-Based Interventions

Exposure-based interventions are a core ingredient of evidence-based cognitive-behavioral treatment (CBT) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). However, previous research has documented that exposure is rarely utilized in routine care, highlighting an ongoing lack of dissemination. The present study examined barriers for the dissemination of exposure from the perspective of behavioral psychotherapists working in outpatient routine care (N = 684). A postal survey assessed three categories of barriers: (a) practicability of exposure-based intervention in an outpatient private practice setting, (b) negative beliefs about exposure, and (c) therapist distress related to the use of exposure. In addition, self-reported competence to conduct exposure for different anxiety disorders, PTSD, and OCD was assessed. High rates of agreement were found for single barriers within each of the three categories (e.g., unpredictable time management, risk of uncompensated absence of the patient, risk of decompensation of the patient, superficial effectiveness, or exposure being very strenuous for the therapist). Separately, average agreement to each category negatively correlated with self-reported utilization of exposure to a moderate degree (-.35 ≤ r ≤ -.27). In a multiple regression model, only average agreement to barriers of practicability and negative beliefs were significantly associated with utilization rates. Findings illustrate that a multilevel approach targeting individual, practical, and systemic barriers is necessary to optimize the dissemination of exposure-based interventions. Dissemination efforts may therefore benefit from incorporating strategies such as modifying negative beliefs, adaptive stress management for therapists, or increasing practicability of exposure-based interventions.     

Measuring Change in OCD: Sensitivity of the Obsessive-Compulsive Inventory-Revised

This study examined the sensitivity to change and specificity of response of the Obsessive-Compulsive Inventory-Revised (OCI-R), an 18-item self-report measure of obsessive-compulsive disorder (OCD) severity. Seventy-seven OCD patients received cognitive-behavioral therapy incorporating exposure and response prevention (ERP). Change from pre- to posttest on the OCI-R was compared to changes as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and other measures of OCD and related symptoms. Results suggest the OCI-R is sensitive to treatment effects and that pre- to posttest change on this instrument reflects improvement in OCD and related symptoms of depression, anxiety, and global functioning. The OCI-R was not sensitive to improvement in patients’ insight into the senselessness of their OCD symptoms. The OCI-R appears suitable for use in clinical settings and naturalistic outcome studies where time and resources do not permit administration of lengthy symptom interviews.     

An Open Trial of Acceptance and Commitment Therapy With Exposure and Response Prevention in an Intensive Outpatient Setting for Adults With OCD

Intensive outpatient treatment settings for adults with obsessive-compulsive disorder (OCD) are common, but data on their effectiveness are limited. The effectiveness of IOP treatment for adults with OCD using combined acceptance and commitment therapy (ACT) and exposure and response prevention (ERP) was studied with eight adults. The intervention was 15 hours per week for 3 weeks. Measures were collected at pretreatment, 1-week, 2-weeks, posttreatment, and at 1-month follow-up. At the end of treatment, all participants were in the mild range of OCD symptom severity with a mean symptom decrease of 58%. Psychological inflexibility, depression, anxiety, and stress significantly decreased through treatment and participants ended treatment below clinical range for psychological inflexibility and nonclinical to mild range for depression, anxiety, and stress. The results of this study provide preliminary support for the effectiveness of ACT and ERP in an intensive outpatient setting for adults with OCD. The focus of this paper is on the clinical application of this treatment.     

Investigating Treatment Outcomes Across OCD Symptom Dimensions in a Clinical Sample of OCD Patients

Despite the heterogeneous nature of obsessive-compulsive disorder (OCD), many self-report assessments do not adequately capture the clinical picture presenting within each symptom dimension, particularly unacceptable thoughts (UTs). In addition, obsessions and ordering/arranging compulsions are often underrepresented in samples of treatment outcome studies for OCD. Such methodological discrepancies may obscure research findings comparing treatment outcomes across OCD symptom dimensions. This study aimed to improve upon previous research by investigating treatment outcomes across OCD symptom dimensions using the Dimensional Obsessive-Compulsive Scale, which offers a more comprehensive assessment of UTs. The study included a primarily residential sample of 134 OCD patients. Results indicated that there were no significant differences in treatment outcomes across symptom dimensions. However, the severity of UTs remained significantly greater than other symptom dimensions at both admission and discharge. Thus, it is possible that UTs may exhibit uniquely impairing features, compared with other symptom dimensions. It is also possible that these findings may reflect the characteristics of the residential OCD samples. These speculations as well as implications for OCD treatment and future research are discussed.     

The Practice of Exposure Therapy: Relevance of Cognitive-Behavioral Theory and Extinction Theory

Exposure therapy is the most effective psychological intervention for people with anxiety disorders. While many therapists learn how to implement exposure techniques through clinical training programs or instructional workshops, not all of these educational efforts include a focus on the theory underlying this treatment. The availability of treatment manuals providing step-by-step instructions for how to implement exposure makes it easier for clinicians to use these techniques with less training than they might otherwise receive. This raises questions regarding whether it is necessary to understand the theory behind the use of exposure. This article argues that knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome. Specific ways in which theory is relevant to using exposure techniques are discussed.     

New Directions in the Cognitive-Behavioral Treatment of OCD: Theory,Research, and Practice

The beneficial effects of cognitive-behavioral interventions (particularly exposure and response prevention) for OCD are among the most consistent research findings in the mental health literature. Nevertheless, even after an adequate trial, many individuals experience residual symptoms, and others never receive adequate treatment due to limited access. These and other issues have prompted clinicians and researchers to search for ways to improve the conceptual and practical aspects of existing treatment approaches, as well as look for augmentation strategies. In the present article, we review a number of recent developments and new directions in the psychological treatment of OCD, including (a) the application of inhibitory learning approaches to exposure therapy, (b) the development of acceptance-based approaches, (c) involvement of caregivers (partners and parents) in treatment, (d) pharmacological cognitive enhancement of exposure therapy, and (e) the use of technology to disseminate effective treatment. We focus on both the conceptual/scientific and practical aspects of these topics so that clinicians and researchers alike can assess their relative merits and disadvantages.     

Interoceptive sensitivity,body image dissatisfaction,and body awareness in healthy individuals

Relationships among interoceptive sensitivity (IS), body image dissatisfaction, body mass index (BMI), and self‐reported body awareness were investigated in a cross‐sectional study. Eighty‐two Norwegian high school students and 70 Hungarian undergraduate university students participated in the study. Subjects completed two questionnaires (Body Image Ideals Questionnaire – BIQ; Body Awareness Questionnaire – BAQ) followed by the assessment of interoceptive sensitivity using the Mental Tracking Method (MTM). An inverse, medium‐level relationship between body image dissatisfaction and IS was found in both the Norwegian and the Hungarian samples. The relationships between IS and self‐reported body awareness, and between body image dissatisfaction and BMI were uniformly non‐significant in both samples. Predictors of body image dissatisfaction were resting heart rate, gender, and IS in the regression analysis after controlling for BMI, age, and nationality. The negative relationship between IS and body image dissatisfaction described in patients with anorexia nervosa also exists in healthy individuals. There is no direct connection between IS and self‐reported body awareness.     

An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

An Integrative Brief Treatment Approach for Obsessive-Compulsive Disorder

This article reports on the integrated application of cognitive therapy, transactional analysis techniques, and the behavioral technique of response prevention using self-instructional training and behavioral substitution in a brief therapy approach. These methods were applied in the case of a young man who presented with compulsions to perform repetitive and ordering rituals with the belief that it would prevent his girlfriend from becoming pregnant. A 21-year-old white male who had performed 3 to 5 hours of rituals daily for several years was able to eliminate the majority of his compulsive behaviors and reduce his level of anxiety after eight clinical therapy sessions. Results were maintained at 6-month follow-up. The clear precipitating factors and the unusual maintaining variables for the disorder in the client are described. The author discusses the case in light of current theoretical, therapeutic, and biomedical understandings of the disorder.     

Treatment of Obsessive Compulsive Disorder in Young Children: An Intervention Model and Case Series

This article presents an intervention model for young children with obsessive-compulsive disorder (OCD). The intervention, designed to reduce compulsive behavior and improve parenting practices, was tested using a multiple baseline design with 7 children (M = 6 years old; 57% female) in which participants were randomly assigned to 1, 2, or 3 weeks of baseline (i.e., no treatment). All children were diagnosed with OCD using a semi-structured diagnostic interview. Baseline and weekly ratings of obsessive-compulsive (OC) symptoms and family accommodation were obtained. In addition, at pre- and post-treatment and 1-month follow-up, independent evaluators and/or parents completed measures assessing the severity and impact of OC symptoms and child and family functioning. Findings revealed that participants had a 33–66% reduction in OC symptoms (as measured by the Children's Yale-Brown Obsessive Compulsive Scale; CYBOCS) at posttreatment and 6 of the 7 children were rated as treatment responders on the Clinical Global Impression-Improvement (CGI-I) Scale. At the 1-month follow-up, participants had a 17–82% reduction in OC symptoms. Treatment was also effective in reducing parental accommodation of child OC behaviors. Overall treatment satisfaction was high and parents found most core treatment ingredients (e.g., psychoeducation, exposure and ritual prevention, contingency management) very helpful. Implications for further developing and testing psychosocial treatments for young children are discussed.     

Treatment of Hypochondriasis with Exposure

Cognitive-behavioral therapy has been shown to be an effective treatment for hypochondriasis. An important element of most of the empirically validated CBT protocols for this problem is exposure. Various approaches to exposure may be useful including in vivo exposure to health and death-related situations, interoceptive exposure to feared bodily symptoms, and imaginal exposure to symptoms and feared illnesses that are difficult to reproduce in real life. Strategies for enhancing the effectiveness of exposure, such as response prevention, cognitive reappraisal, and acceptance, are also discussed. Practical suggestions for implementation of exposure with this population are provided.     

强迫症诊断研究的新变化

临床实践与相关研究表明,强迫症的诊断标准已不能满足复杂的临床工作需要。首先,有关患者的自知力以及主观痛苦程度等诊断指标需要进一步修订。其次,就强迫症的核心症状而产生的争议,研究者提出应重新考虑强迫症、焦虑障碍、强迫谱系障碍和囤积障碍这四个概念之间的从属关系和诊断标准。未来研究应考虑从认知神经科学的视角探索强迫症的核心症状和病理机制,为强迫症的诊断标准提供新的依据。     

Feasibility and Acceptability of Cognitive Bias Modification for Interpretation as an Adjunctive Treatment for OCD and Related Disorders: A Pilot Randomized Controlled Trial

Cognitive models implicate interpretation bias in the development and maintenance of obsessive compulsive and related disorders (OCRDs), and research supports Cognitive Bias Modification for Interpretation (CBM-I) in targeting this mechanism. However, prior studies in OCRDs have been limited to nonclinical populations, adolescents, and adults in a laboratory setting. This study evaluated the feasibility and acceptability of CBM-I as an adjunctive intervention during intensive/residential treatment (IRT) for adults with OCRDs. We modified a lab-based CBM-I training for adults seeking IRT for OCRDs, and conducted a feasibility trial (N = 4) and subsequent pilot RCT; participants (N = 31) were randomized to receive CBM-I or psychoeducation. Benchmarks were met for feasibility, acceptability, and target engagement. From pre- to post-intervention, the CBM-I group showed a large effect for change in interpretation bias (d = .90), whereas this effect was trivial (d = .06) for psychoeducation. This was the first study to evaluate CBM-I in naturalistic treatment for adults seeking IRT for OCRDs. Findings support the feasibility and acceptability of CBM-I in this novel sample and setting. A larger scale RCT is needed to determine whether CBM-I can enhance OCRD treatment response.     

Nature and Role of Change in Anxiety Sensitivity During NRT-Aided Cognitive-Behavioral Smoking Cessation Treatment

This study evaluated the associations between change in anxiety sensitivity (AS; fear of the negative consequences of anxiety and related sensations) and lapse and relapse during a 4-week group NRT-aided cognitive-behavioral Tobacco Intervention Program. Participants were 67 (44 women; M _age = 46.2 years, SD = 10.4) adult daily smokers. Results indicated that participants who maintained high levels of AS from pretreatment to 1 month posttreatment, compared to those who demonstrated a significant reduction in AS levels during this time period, showed a significantly increased risk for lapse and relapse. Further inspection indicated that higher continuous levels of AS physical and psychological concerns, specifically among those participants who maintained elevated levels of AS from pre- to posttreatment, predicted significantly greater risk for relapse. Findings are discussed with respect to better understanding change in AS, grounded in an emergent taxonic-dimensional factor mixture model of the construct, with respect to lapse and relapse during smoking cessation.     

Optimizing Exposure Therapy for Pathological Health Anxiety: Considerations From the Inhibitory Learning Approach

Exposure therapy has demonstrated its efficacy in the treatment of pathological health anxiety—however, psychotherapy research reveals that many patients do not show a clinically significant change. Therefore, improvements are necessary to optimize psychotherapy for pathological health anxiety. Most treatment rationales refer to habituation during exposure as the central mechanism of change. However, there is evidence that extinction learning is mediated by inhibitory learning processes. Targeting these processes may help to improve treatment outcomes in pathological health anxiety. The aim of this review was to adapt, from the inhibitory learning approach and empirical findings, the most promising strategies for the exposure-based treatment of pathological health anxiety. The exposure-optimizing strategies adapted are expectancy violation, combination, variability in contexts and stimuli, affect labeling, and removal of safety signals. A case example illustrates how to implement these methods for patients with pathological health anxiety.     

Ritual Behavior in Obsessive and Normal Individuals: Moderating Anxiety and Reorganizing the Flow of Action

ABSTRACT— Ritualized behavior is characteristic of obsessive-compulsive disorder (OCD), but it is also observed in other, nonclinical contexts such as children's routines and cultural ceremonies. Such behaviors are best understood with reference to a set of human vigilance–precaution systems in charge of monitoring potential danger and motivating the organism toward appropriate precautions. Ritualized behavior focuses attention on low-level representations of actions, probably leading to some measure of intrusion suppression. Cultural rituals too may be understood in this framework.     

Competitive Memory Training (COMET) for OCD: A Self-treatment Approach to Obsessions

Competitive Memory Training (COMET) is a cognitive intervention that aims to change the maladaptive cognitive-emotional networks underlying obsessive-compulsive disorder (OCD). COMET has not been previously tried as a self-help intervention. The present study tested the preliminary feasibility, acceptability, and effectiveness of COMET for OCD implemented as a self-help intervention. Sixty-five participants with OCD recruited through online OCD self-help fora completed an online baseline assessment including measures of OCD symptoms, self-esteem, and depression. Participants were randomly assigned to either COMET or a wait-list control group. All participants were approached 4 weeks later to complete an online post-assessment. There was no evidence for a greater decline of OCD symptoms or depression under COMET. When analyses were limited to only those participants who reported reading the entire manual at least once, self-esteem was higher at post-assessment in the COMET group. Although 78.1% of patients in the COMET group rated it as appropriate for self-administration, only 56.5% performed COMET exercises regularly and 26.4% read the entire manual at least once. The feasibility and effectiveness of COMET as a self-help internet intervention for OCD was not supported in this study. Further work is needed to better understand if modifications to our implementation of COMET may yield improved outcomes.