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.

SUDS vs. Willingness: Values-Based ACT Exposure for OCD

Throughout the years, I’ve written a series of blogs posts on exposure therapy, including the use of exposure therapy in Acceptance and Commitment Therapy. In the absence of much guidance on using exposure in ACT, I co-authored a theoretical paper on its use in treating PTSD.

Recently I read an excellent paper outlining the use of ACT and exposure for OCD.

Exposure therapy for OCD from an acceptance and commitment therapy framework

The article is a collaboration of 2 major research labs: Utah State professor Michael Twohig, a pioneer in the use ACT for OCD, and Jonathan Abramowitz, a professor at the University of North Carolina – Chapel Hill, and an incredibly prolific researcher in the field of anxiety.

The article walks through how exposure in an ACT context is different from traditional exposure and includes an example case, Monica, to illustrate treatment.

The authors provide helpful examples of values-based exposure exercises that emphasize willingness (i.e., acceptance) towards uncomfortable thoughts and feelings over traditional reduction in discomfort (e.g., habituation). As I’ve written about previously, difficulty with acceptance may maintain and exacerbate OCD symptoms. The authors note an overlap between an ACT approach and newer inhibitory learning approaches to exposure.

As the article is very readable and straightforward, there’s not much for me to say about it. I thought I’d expand upon and share my experiences with a few of the authors suggestions about relinquishing the traditional use of SUDS scores (i.e., discomfort) in favor of tracking the ACT process willingness, and of some of the difficulties in creating values-based exposure exercises.

SUDS vs. Willingness

In place of a traditional SUDS scale, the authors recommend a Willingness Scale, defined as the degree to which clients are will to be open and accepting of inner experiences (i.e., thoughts, feelings, bodily sensations) during exposure in service of their values (i.e., qualities of living that are important to them).

As the authors note, when you ask a client for a Willingness score, you often receive an inverse SUDS score rather than willingness in a strict ACT sense. More simply, clients are typically more willing to accept lower distress and less willing to accept higher distress.

The authors describe how in these instances they help the client separate “one’s openness to the experience from the severity of the experience.” In my experience this can be tricky. Some clients take right away to the concept of willingness and it can be very powerful for them. Other clients I’ve worked with successfully complete treatment but (I suspect) may not quite understand willingness in the ACT sense.

I would also note that SUDS scores can be used as part of ACT for exposure. What would be inconsistent with an ACT approach would be to use SUDS to emphasize habituation to discomfort. I want to be clear that the article authors are not explicitly anti-SUDS—I only mention this because I have heard some people express the view that ACT-based exposure is incompatible with tracking SUDS. This is a misunderstanding.

For these reasons, I still ask about SUDS scores and Willingness scores when conducting exposure. For one, SUDS scores help me catch when Willingness score are simply an inverse of SUDS. Secondly, it provides a view into the client’s experience, as it’s often hard to gauge a client’s distress from the outside. Lastly, I see value in clients tracking distress—especially in people with OCD. Many people with OCD do not believe their obsessions 100%, but they fear their anxiety will spiral out of control if they don’t engage in their compulsions. SUDS scores can help clients observe if their actual experience matches what their minds tell them. Some notice distress doesn’t become overwhelming as predicted, or that it passes more quickly than expected.

Values-based exposure

I also want to comment on the authors’ discussion of values-based exposure. They have a really useful table (Table 2) in the article listing how exposure exercises were linked to values in the example case. Values can help motivate clients to engage in exposure and bring more meaning to the process. In my experience, though, it is not always easy to clearly link exposure exercises to values. This paper helps provide guidance.

Sometimes I’ve found it useful to start with a more basic exposure exercise that can be easily conducted in session even if it is less directly connected to values This can serve as an introduction and help orient clients to exposure work. When I was first experimenting with values-based exposure, I could spend entire sessions trying to identify one ERP exercise that a client really valued! Instead, I’ve found it simpler to come to session with some ideas and ask, “Would you be willing to start with X or Y?” to get started. As clients start to understand exposure work through experience, they can offer more precise guidance and feedback.

When asked about valued activity, additionally, some clients will tell you they are engaged in valued living but that dealing with obsessions is exhausting and interferes with connecting with joy. In these instances, the value may simply be learning to be more present with their experiences of activities in which they are already engaged.

Summary

This collaborative article `from two major OCD/anxiety research labs provides one of the best illustrations of using ACT and ERP for OCD that I’ve read. I highly recommend it to anyone interested in ACT and exposure, and even non-ACT people who are interested in advancing models for exposure. I’ve offered a few opinions based on my experience conducting exposure in an ACT context that I hope readers find helpful.

If you’d like to read the article and, like me, don’t have access to journals behind paywalls, you can download an uncorrected proof from the authors’ ResearchGate page. You’ll notice a few typos in the proof such as “fiend” instead of ”friend.” 🙂

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.

Study Suggests Clients Don’t Dropout of ERP for OCD More than for Any Other Treatment

A common figure for the dropout rate of exposure and response prevention (ERP) for people with obsessive-compulsive disorder is about 25%.  During one OCD workshop I attended, 2 different presenters insinuated that these high rates of dropout were the result of one particularly overzealous researcher who pushed clients too hard! They suggested that, anecdotally, most people with OCD can tolerate exposure-work reasonably well.

A recent study from Utah State professor Michael Twohig’s lab decided to take a closer look at this.

Meta-Analysis

The researchers collected 21 studies of ERP for OCD and conducted a meta-analysis of dropout rates. In a meta-analysis, researchers try to compute variables in order to compare results across multiple studies with different methodologies.

The researchers looked at refusal of treatment and dropout. They also defined what they called “attrition” as a combination of: a.) people who refuse the treatment (i.e., ERP) altogether; b.) people who begin ERP treatment and dropout prematurely. They noted that few researchers track refusal rates, so this remains an understudied variable.

What they found

The researchers found that overall attrition (refusal + dropout) was 18.7%, 12.0% refused treatment, and 14.7% began treatment before dropping out. They did not find any strong predictors of dropout.

In comparing their results to other published research, the authors observed that the dropout rate of 18.7% is similar to those found for PTSD (18.3%) and major depressive disorder (17.5%) and for cognitive behavioral therapy across disorders (26.2%).

Summary

As many therapists are reluctant to use exposure, this study is important in providing evidence that people with OCD may be as open to ERP as they are to any other evidence-based treatment. This is important because ERP has the greatest research support and many people with OCD struggle to find therapists who offer effective treatment.

If you’d like to read the study yourself, you can download a pdf here.

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.

An Interview with Michelle Craske, PhD, on “Maximizing Exposure Therapy for Anxiety Disorders”

An Interview with Michelle Craske, PhD, on “Maximizing Exposure Therapy for Anxiety Disorders”

In my ongoing series of posts about exposure therapy, I’ve written several times about the work of UCLA professor Michelle Craske, PhD. Dr. Craske has been on the cutting edge of exposure research, and her work has undermined the traditional notion posited in in the emotional processing theory that habituation to a feared stimulus is important in exposure work.

The Society for a Science of Clinical Psychology has posted an interview that Dr. Jacqueline Persons conducted with Dr. Craske on “Maximizing Exposure Therapy for Anxiety Disorders.” This approximately 47-minute interview is an excellent introduction to and distillation of Dr. Craske’s work. The webpage also includes a pdf of a 2014 paper Craske authored summarizing this model.

Dr. Craske’s model focuses on using exposure to cultivate inhibitory learning to create new learning that overrides the fear-based association called excitatory meaning. The idea is that through repeated exposure, new learning occurs that contradicts the unhelpful more fear-based associations that result in anxiety and avoidance behavior.

3 considerations in the inhibitory learning model for conducting exposure with a client

In her interview, Dr. Craske emphasized three important things to consider in using exposure:

  1. What does this person really need to learn (i.e., inhibitory learning) in order to be less afraid of the fear stimulus (i.e., excitatory meaning) that will lead to improvement?
  2. How can the exposure exercise be designed to maximally benefit that learning; that is, how can the exposure exercise “violate” what that person expects will happen (e.g., usually something bad) based on the excitatory learning?
  3. New learning will occur both during the exposure exercise and long afterward through a period of consolidation. Consequently, whether someone’s distress diminishes (i.e., habituation) during the actual exposure exercise is not as important as the actual learning that may occur during and following the exposure.

Role of cognitive restructuring

Dr. Craske also had some interesting things to say about the role of cognitive restructuring in exposure work.  In traditional CBT, exposure work may be preceded by cognitive restructuring. According to Dr. Craske, preceding exposure work with cognitive restructuring may actually undermine the exposure work by softening the violation of the person’s expectations—the expectations based on the excitatory meaning of the feared stimulus. Consequently, Dr. Craske stated her lab will do cognitive restructuring after the exposure work as a means to help consolidate the new learning (i.e., inhibitory learning).

Check out the tables on the linked research paper!

Dr. Craske’s work can be a bit dense to read. Even if you don’t intend to read it, I encourage you to download the 2014 paper that is linked to the interview. Following the Reference section are 6 tables that offer concrete examples for using inhibitory learning to conduct exposure with specific anxiety-related problems and deepening the impact of the exposure. The paper also includes clinical examples and can serve as a useful reference for the interview.

In conclusion

If you have any interest in exposure at all, I encourage you to listen to this interview with Michelle Craske on “Maximizing Exposure Therapy for Anxiety Disorders.” She speaks very clearly and elegantly about her work on inhibitory learning in manner that is very accessible.

The link also allows you to download a research paper summarizing this work. Download it. Even if you’re not up to reading a 30-page research article, it provides a nice reference and includes clinical examples and tables with suggested wording for setting up exposure exercises.

A special “thank you” to Dr. Jacqueline Person for conducting the interview, and to the Society for a Science of Clinical Psychology for posting it!

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.

An Alternative to Exposure and Response Prevention for OCD

An Alternative to Exposure and Response Prevention for OCD

Numerous studies have now shown that Exposure and Response (or Ritual) Prevention (ERP) remains  our most effective treatment for obsessive-compulsive disorder (OCD).  In ERP, clients deliberately confront feared stimuli while learning to refrain from engaging in compulsions.

Even with the effectiveness of ERP, the search continues for how to get even better results, as not everyone benefits from ERP and some clients are resistant to it. Recent research on Acceptance and Commitment Therapy (ACT) suggests that other approaches—such as learning to observe obsessions without engaging or “buying into” the content of the obsessions—can supplement ERP. One of the core ideas of ACT is helping clients to mindfully observe obsessions with greater distance.

I recently came across a new paper that focuses on these newer approaches to OCD and thought it might be helpful for clinicians working with OCD. The authors provide a nice summary of recent research on the use of ACT, Dialectical Behavior Therapy, mindfulness-based approaches, and Metacognitive Therapy in the treatment of OCD.  They also provide some background on the roots of ERP in behaviorism and (later) cognitive therapy. The authors summarize what makes these approaches unique in the treatment of OCD:

In general we agree that most approaches to OCD address the function of inner experiences to some degree; in addition arguing that what makes the approaches covered here unique is the greater or complete shift toward addressing the function of inner experiences and a substantial reduction in categorizations of types or styles of inner experiences. (p. 34)

I would like to emphasize that none of these newer strategies are incompatible with ERP. I often find they are a useful complement to exposure work in my clinical work. My sense is that these strategies can help us expand our range of effective treatment interventions for OCD to help prepare clients for exposure work or as an alternative for those who are not willing to engage in ERP.

If you’d like to read the paper, you can currently download a pdf for free here. For a list of other blog posts I’ve written about exposure, click on this link.

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