The efficacy of habituation in decreasing subjective distress among high anxiety-sensitive college students

Mechanisms underlying interoceptive exposure: belief disconfirmation or extinction? A preliminary study

Interoceptive exposure, or exposure to one's feared physical sensations, has been shown to be an important technique in cognitive behavioral therapies for anxiety disorders and related constructs, such as anxiety sensitivity (AS). The current study sought to further clarify the underlying cognitive-behavioral mechanisms of interoceptive exposure in a lab-based, analog study with individuals high in AS. Participants (n = 59) were randomized into three groups: a cognitive-behavioral intervention emphasizing belief disconfirmation (CbI), a behavioral intervention emphasizing exposure (BI), and a control condition. Self-report measures assessing AS, catastrophizing of bodily sensations, and subjective units of distress (SUDS) were collected before, during and after the intervention. Participants also completed online questionnaires at a one-month follow-up. Following the CbI but not BI, a decrease was observed in both AS and catastrophizing interpretations. Furthermore, only the CbI group exhibited a decrease in SUDS ratings, whereas the BI group exhibited a significant increase. Notably, these effects were not maintained at a one-month follow-up. Findings suggest that cognitive interventions without repeated behavioral exposure may be sufficient in reducing self-reported anxiety-related symptoms and catastrophic misinterpretations, though not at maintaining them. This raises questions regarding the role of pure behavioral mechanisms in exposure.

Origins and outlook of interoceptive exposure

BACKGROUND AND OBJECTIVES

Interoceptive exposure (IE) is a behavioral intervention that reduces anxiety sensitivity and distress associated with somatic sensations. In this discussion, we describe the history, current applications and additional clinical potential of IE.

METHOD

We review the origins of IE and its historical application to panic disorder, as well as the accumulating evidence for transdiagnostic application to other disorders including post-traumatic stress disorder, social anxiety disorder, specific phobias and physical disorders. Then, we discuss ways in which IE could contribute to the treatment of additional disorders.

RESULTS

IE is well-established in the treatment of panic disorder and increasingly used to target anxiety-provoking physical sensations in other disorders. Research and clinical evidence suggests that anxiety sensitivity is present across a range of disorders, and may actually be one variation on a broader phenomenon of interoceptive sensitivity, or anxiety focused on physical sensations that have been conditioned to unpleasant emotional states. Moreover, somatic symptoms are central to the experience of most emotions and may contribute to avoidant coping, a maintenance factor for disorders of emotion. IE has potential as a transdiagnostic intervention targeting interoceptive sensitivity in disorders such as depression and eating disorders. Nevertheless, IE is underutilized by clinicians in practice. Recent research in inhibitory learning and extinction suggests strategies for maximizing the effectiveness of IE.

LIMITATIONS

This review is not exhaustive in nature, and systematic research on transdiagnostic applications of IE remains scarce.

CONCLUSIONS

IE is a potentially powerful yet understudied transdiagnostic intervention.

Anxiety sensitivity and sleep-related problems in anxious youth

Anxiety disorders constitute the most common mental health disturbance experienced by youth. Sleep-related problems (SRPs) are highly prevalent among anxious youth and encompass a variety of problems including nighttime fears, insomnia, and refusal to sleep alone. Given that chronic sleep disturbance is associated with a range of behavioral and physical problems in youth and predicts future psychopathology, it is important to elucidate the nature of SRPs in anxious youth. The present study investigated the relationship between sleep problems and anxiety sensitivity in a sample of 101 anxious youth, ages 6-17. Heightened anxiety sensitivity significantly predicted prolonged sleep onset latency across the sample, even after accounting for severity of anxiety, depression, and age. Results support previous research indicating that SRPs are common among anxious youth and suggest that anxiety sensitivity may play a particularly important role in sleep onset latency.

Trait Emotional Intelligence, Anxiety Sensitivity, and Experiential Avoidance in Stress Reactivity and Their Improvement Through Psychological Methods

Stress pervades daily society, often with deleterious consequences for those prone to react intensely to it. Intervention techniques to attenuate stress reactivity are thus paramount. With that goal in mind, researchers have sought to identify and alter malleable psychological dispositional variables that influence stress reactivity. Trait emotional intelligence (TEI), anxiety sensitivity (AS), and experiential avoidance (EA) are increasingly receiving attention in these research efforts. The self-reported emotional component of stress reactivity has been emphasized in investigations and is our focus. Specifically, this paper overviews the role of TEI, AS, and EA in self-reported stress responses. We also discuss empirically supported psychological methods to adjust suboptimal levels of these variables in normal populations. Both psycho-educational (information, skills) and mindfulness-based interventions (specific mindfulness therapies or components) are covered. Findings include that (1) TEI, AS, and EA are each correlated with the emotional component of stress reactivity to both naturalistic and lab-based stressors; (2) preliminary support currently exists for psycho-educational intervention of TEI and AS but is lacking for EA; (3) adequate evidence supports mindfulness-based interventions to target EA, with very limited but encouraging findings suggesting mindfulness methods improve TEI and AS; and (4) although more research is needed, stress management approaches based on mindfulness may well target all three of these psychological variables and thus appear particularly promising. Encouragingly, some methods to modify dispositional variables (e.g., a mindfulness-based format of guided self-help) are easily disseminated and potentially applicable to the general public.

Therapist perceptions and delivery of interoceptive exposure for panic disorder

Interoceptive exposure (IE) is widely regarded as an essential procedure in the cognitive-behavioral treatment of panic disorder (PD). However, treatment manuals differ substantially in their prescribed delivery of IE, and little research exists to inform the optimal manner of its implementation. The present study examined therapists' perceptions and delivery of IE for PD. Results revealed substantial variability in how clinicians provide IE. In contrast to the prolonged and intense manner in which exposure techniques are traditionally applied, many therapists reported delivering a low dose of IE accompanied by controlled breathing strategies. Concerns about the potential adverse effects of IE were common despite the fact that participants reported the actual occurrence of negative outcomes of IE in their own practice to be extremely infrequent. It is possible that some therapists deliver IE in a cautious manner in an attempt to minimize the perceived risks associated with this treatment.

Do Cognitive Reappraisal and Diaphragmatic Breathing Augment Interoceptive Exposure for Anxiety Sensitivity?

Interoceptive exposure (IE) is an effective procedure for reducing anxiety sensitivity (AS) and the symptoms of panic disorder. However, considerable variance exists in how IE is delivered among clinicians, and the extent to which IE is enhanced by the concurrent use of cognitive reappraisal (CR) and diaphragmatic breathing (DB) is unclear. Participants (N = 58) with high AS were randomly assigned to one of four single-session interventions: (a) IE only, (b) IE 1 CR, (c) IE 1 CR 1 DB, or (d) expressive writing control. IE was superior to expressive writing in reducing AS and associated anxiety symptoms. The addition of CR and DB did not enhance the benefits of IE at either posttreatment or 1-week follow-up. These findings highlight the specific efficacy of IE in reducing AS and call into question the common practice of combining IE with cognitive and breathing strategies. Theoretical and clinical implications are discussed.

Aberrant neural function during emotion attribution in female subjects with fragile X syndrome

OBJECTIVE

Fragile X (FraX) syndrome is caused by mutations of the FraX mental retardation-1 gene-a gene responsible for producing FraX mental retardation protein. The neurocognitive phenotype associated with FraX in female subjects includes increased risk for emotional disorders including social anxiety, depression, and attention deficit. Here, the authors investigated the neurobiological systems underlying emotion attribution in female subjects with FraX syndrome.

METHOD

While undergoing functional magnetic resonance imaging, 10 high-functioning female subjects with FraX syndrome and 10 typically developing (TD) female subjects were presented with photographs of happy, sad, and neutral faces and instructed to determine the facial emotion.

RESULTS

No significant group differences were found for the recognition of happy faces, although the FraX group showed a trend toward a significant difference for the recognition of sad faces and significantly poorer recognition of neutral faces. Controlling for between-group differences in IQ and performance accuracy, the TD group had greater activation than the FraX group in the anterior cingulate cortex (ACC) for neutral faces compared with scrambled faces and the caudate for sad faces compared with scrambled faces (but not for sad faces compared with neutral faces). In the FraX group, FraX mental retardation protein levels positively correlated with activation in the dorsal ACC for neutral, happy, and sad faces when independently compared with scrambled faces. Significantly greater negative correlation between IQ and insula activation for neutral faces relative to scrambled faces was observed in the FraX group compared with the TD group. Significantly greater positive correlation between IQ and ACC activation for neutral faces relative to scrambled faces was observed in the TD group compared with the FraX group.

CONCLUSIONS

Although emotion recognition is generally spared in FraX syndrome, the emotion circuit (i.e., ACC, caudate, insula) that modulates emotional responses to facial stimuli may be disrupted.

Anxiety trait modulates psychophysiological reactions, but not habituation processes related to affective auditory stimuli

BACKGROUND

It is well known that there are specific peripheral activation patterns associated with the emotional valence of sounds. However, it is unclear how these effects adapt over time. The personality traits influencing these processes are also not clear. Anxiety disorders influence the autonomic activation related to emotional processing. However, personality anxiety traits have never been studied in the context of affective auditory stimuli.

METHODS

Heart rate, skin conductance, zygomatic muscle activity and subjective rating of emotional valence and arousal were recorded in healthy subjects during the presentation of pleasant, unpleasant, and neutral sounds. Recordings were repeated 1 week later to examine possible time-dependent changes related to habituation and sensitization processes.

RESULTS AND CONCLUSION

There was not a generalized habituation or sensitization process related to the repeated presentation of affective sounds, but rather, specific adaptation processes for each physiological measure. These observations are consistent with previous studies performed with affective pictures and simple tones. Thus, the measures of skin conductance activity showed the strongest changes over time, including habituation during the first presentation session and sensitization at the end of the second presentation session, whereas the facial electromyographic activity habituated only for the neutral stimuli and the heart rate did not habituate at all. Finally, we showed that the measure of personality trait anxiety influenced the orienting reaction to affective sounds, but not the adaptation processes related to the repeated presentation of these sounds.

The utility of the ASI factors in predicting response to voluntary hyperventilation among nonclinical participants

Empirical research has demonstrated that the Anxiety Sensitivity Index (ASI) contains three separable factors and that ASI total scores are useful in predicting response to physiological challenge procedures. Little is known, however, of the predictive capability of the ASI factors. This study investigated the utility of the three factors of the ASI compared to ASI total scores and the STAI-T, a more general measure of trait anxiety, in predicting response to hyperventilation. As expected, the ASI total score was a significant predictor of response to hyperventilation, while the STAI-T was not. Using multiple regression, when the physical concerns factor was entered first, the social concerns and mental incapacitation factors of the ASI were not significant predictors of response to hyperventilation. Furthermore, when the physical concerns factor was entered into a regression equation followed by the remainder of the ASI items, only the physical concerns factor remained a significant predictor of response to hyperventilation. These results suggest that while response to physiological challenge procedures is predicted by ASI total scores, it may be best predicted by the physical concerns factor, and that the mental incapacitation and social concerns subscales do not play key roles in predicting response to physiological challenge procedures.

Response to repeated CO2 in individuals with elevated anxiety sensitivity: replication with 20% CO2

The present report replicates and extends previous work examining response patterns to repeated presentation of CO2. In previous studies, two distinct response patterns to repeated presentation of 35% CO2 were noted, representing habituation and nonhabituation of anxiety. In this report, 21 participants who had never experienced a panic attack but who reported high levels of anxiety sensitivity were presented with 12 trials of 20% CO2, followed by a trial involving inhalation of room air (to examine dishabituation) and two more trials of 20% CO2. Results indicated that 67% of the sample reported habituation of anxiety. Reductions in anxiety across inhalations were paralleled by changes in tidal volume, perceived panic symptom severity, and feelings of panic. Notable dishabituation was observed in the nonhabituation sample. Results are discussed in the light of basic learning processes underlying the treatment of Panic Disorder (PD).