Interoceptive Exposure in OCD Treatment

Interoceptive exposure (IE) involves using exercises (e.g., hyperventilation) to deliberately evoke feared bodily sensations (e.g., shortness of breath; tightness in chest). It is most commonly associated with panic disorder treatment. In a recent paper, anxiety disorders expert and UNC professor Dr. Jonathan Abramowitz and his grad student Shannon Blakely make a case for its use in OCD treatment.

Anxiety Sensitivity as a Transdiagnostic Process

At the 2016 International OCD Foundation Conference, I attended a workshop by the authors on this topic. They talked about anxiety sensitivity. Anxiety sensitivity refers to proneness towards interpreting physical symptoms of anxiety (e.g., increased heart rate) as signs of something dangerous (e.g., heart attack). People with anxiety sensitivity may assume that their anxiety is a sign of something dangerous.  For example, they may fear that they developed disease, are imminently in danger of dying, or are losing their minds.

Drawing from research, the authors suggest that anxiety sensitivity may contribute to OCD-related obsessions about symmetry (i.e., “just right”) or serve to reinforce obsessions (e.g., because arousal is high, the obsession must be true).

One relatively common obsession focuses on attraction, especially that one is attracted to children or to the same sex. These individual often constantly check their groin area for signs of sexual stimulation. During the workshop, the presenters played an amusing clip from Seinfeld of George receiving a massage from an attractive male masseuse and being upset that he may have been aroused during the massage (e.g., “I think it moved!”). The problem is that if we pay attention to our bodies long enough, we’re likely to perceive some sort of sensation.

The authors offer anxiety sensitivity transdiagnostic process cutting across a range of anxiety-related disorders. After that workshop, I downloaded the Anxiety Sensitivity Scale and Body Vigilance Scale from Abramowitz’s research lab page and have been using the measures to track progress in clients who report concerns with physical symptoms of anxiety ranging from panic to health-related anxiety.

Using interoceptive exposure to augment in vivo and imaginal exposure

In drawing from inhibitory learning research, the authors make the case that, in addition to being a standalone exposure, IE can be used to heighten in vivo and imaginal exposure. Combining exposure to OCD-related triggers with interoceptive exposure may help deepen learning.

For example, a heterosexual-identifying man who obsesses he might be gay may: 1. jog in place to increase heart rate and quicken breathing; 2. and then look at pictures of attractive men in order to increase contact with ambiguous physiological arousal.

Someone who fears they may become psychotic might: 1. engage in hyperventilation to induce feelings of derealization and deprersonalization (e.g., “signs” one is detaching from reality) and then 2. read first-person accounts of people who develop schizophrenia.

These combinations may help clients increase contact with a greater variety of related cues and triggers. The authors provide a useful case example to illustrate their points.

IE as a way to introduce exposure

The authors recommend beginning with IE before moving onto other types of exposure for OCD as a way to help clients practice willingness with increased distress to boost confidence that they can engage in exposure work. Of note, the authors abandon the term exposure hierarchy in favor of “exposure to-do list” to emphasis that treatments does not need to progress in a graduated fashion and that, consistent with inhibitory learning research, variability during exposure work may improve learning.

Summary

Although the focus of the article is interoceptive exposure for OCD, I think the article provides a compelling argument for how IE can enhance in vivo and imaginal exposure for a range of anxiety and obsessive-compulsive and related disorders where physical sensations are a trigger. Additionally, it provides clear examples of how to conduct exposure according to inhibitory learning theory. I’ve followed with interest the inhibitory learning research, but because much of the early research (e.g., Craske’s lab at UCLA) was lab-based, I’ve struggled with how to incorporate it into treatment. This article provides some very clear examples and conceptualizations. I’ve been very impressed with Dr. Abramowitz and his lab’s contributions to inhibitory learning research.

If you’d like to read the article, you can download an “in press” copy from the authors’ ResearchGate page.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

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