Anxiety Sensitivity, Emotional Intolerance, and Expansion of the Application of Interoceptive Exposure: Commentary on the Special Issue
Otto, Michael W. PhD, Journal of Cognitive Psychotherapy
Starting with the success of interoceptive exposure in the treatment of panic disorder and encouraged by the importance of anxiety sensitivity and emotional intolerance for understanding a wide range of conditions, interoceptive exposure techniques have been applied in a variety of new and useful ways. This commentary provides a review of a number of the core themes evident in this special issue on novel applications of interoceptive exposure. Targets and strategies for dissemination are discussed along with research achievements and future directions for inquiry.
Keywords: interoceptive exposure; panic disorder; anxiety sensitivity; emotional intolerance; dissemination strategies
The purpose of this article is to provide a general commentary on the articles in the special issue on "Interoceptive Exposure in Treatment of Anxiety and Related Disorders: Novel Applications and Mechanisms of Action." The five articles and the introduction to the issue (i.e., Stewart & Watt, this issue) are exemplary for underscoring the potential of interoceptive exposure (IE) for the treatment of a range of conditions apart from panic disorder. In this article, I discuss some of the central themes that underlie and are illustrated by the articles in this issue.
IE emerged strongly in the 1980s as a strategy to eliminate fears of somatic sensations of anxiety that characterize panic disorder. Early reports included case studies of the application of biological provocation procedures in a stepwise exposure format. For example, Grieze and van den Hout (1983) used CO 2 inhalation to induce feared sensations during the first week of intensive exposure, followed by 3 weeks of situational exposure for the treatment of panic attacks. More clinically facile strategies included activities such as hyperventilation, straw breathing, or spinning in a chair; these strategies were combined with a more comprehensive program of cognitive-behavioral therapy (CBT) that showed strong efficacy for treating panic disorder (e.g., Barlow, Craske, Cerny, & Klosko, 1988; Margraf, Barlow, Clark, & Telch, 1993). Treatment protocols using IE proved especially effective (Gould, Otto, & Pollack, 1995) such that CBT has emerged as a first-line treatment (Furukawa, Watanabe, & Churchill, 2006) and perhaps the most cost-effective treatment for panic disorder (McHugh et al., 2007).
The success of IE in the treatment of panic disorder also helped validate the importance of attention to fears of interoceptive stimuli. This fear has been most successfully operationalized as anxiety sensitivity, the fear of anxiety-related sensations based on beliefs about the harmfulness of these sensations. The Anxiety Sensitivity Index (Peterson & Reiss, 1992) has been a particularly successful instrument as assessed by its utility across studies and disorders. Relative to anxiety disorders, anxiety sensitivity has been identified as a correlate of panic disorder that is significantly reduced with successful treatment with CBT (Otto & Reilly-Harrington, 1999; Taylor, Koch, & McNally, 1992), with evidence that overall clinical improvements are mediated by these changes in anxiety sensitivity (Smits, Powers, Cho, & Telch, 2004). In addition, anxiety sensitivity prospectively predicts recurrent panic attacks (e.g., Ehlers, 1995) and helps identify people at risk for the emergence of panic disorder or panic attacks following stress (Gardenswartz & Craske, 2001; Schmidt, Lerew, & Jackson, 1997).
Anxiety sensitivity is conceptualized as a fundamental fear that may underlie other phobic conditions (see McNally, 2002). For example, individuals may fear a range of stimuli-heights, snakes, enclosed places-because they fear the internal sensations of anxiety these stimuli induce (e.g., "I can't stand the way I feel when I am in a high place"). As such, anxiety sensitivity can amplify the aversiveness of anxiety. It is this property of modulating the aversiveness of affect that has led anxiety sensitivity to have useful applications outside the anxiety disorders as a more general measure of affect intolerance (see Zvolensky & Otto, 2007). …