'Fear of Fear' May Influence OCD, PTSD Outcomes

Nancy A. Melville

April 17, 2018

WASHINGTON — Anxiety sensitivity (AS), commonly referred to as the "fear of fear," may affect treatment outcomes in patients with obsessive-compulsive disorder (OCD), and treatment preference may influence AS outcomes in patients with posttraumatic stress disorder (PTSD), new research suggests.

A study of 187 patients with OCD showed that those with greater AS at baseline had significantly more severe symptoms of OCD after treatment with cognitive-behavioral therapy (CBT).

Another study, which included 200 patients with PTSD, showed that both for those who received prolonged exposure (PE) therapy and for those who received sertraline (Zoloft, Pfizer), symptoms of AS were decreased.

The largest decrease was found in those who chose to use sertraline; the smallest decrease was in those who were randomly assigned to receive sertraline. Treatment choice had no effect for those undergoing PE.

Both studies were presented here at the Anxiety and Depression Association of America (ADAA) 2018.

"Given the immense body of work documenting anxiety sensitivity as a risk and maintenance factor for anxiety-related disorders, clinicians working with patients who suffer from anxiety should consider incorporating the measurement of anxiety sensitivity into their practice," session discussant Teresa M. Leyro, PhD, assistant professor in the Department of Psychology at Rutgers University, Piscataway, New Jersey, told Medscape Medical News.

Effect on OCD

AS specifically refers to false perceptions of the consequences of an anxiety episode. Symptoms range from fainting to losing control or to experiencing excessive sweating. AS is known to be associated with OCD symptom severity and is often linked with panic disorder.

The first study included 187 patients with OCD who were undergoing residential treatment at the Obsessive-Compulsive Disorders Center at Rogers Memorial Hospital in Oconomowoc, Wisconsin. All participants were treated with CBT and self-reported their symptoms in pre- and posttreatment assessments.

Most of the patients (87.2%) were taking psychiatric medications, such as antidepressants. Most (81.8%) also had secondary diagnoses, such as mood disorders.

Residential treatment included an average of 28.5 hours per week of exposure response prevention therapy and other interventions.

Results showed that patients' baseline symptoms of AS, as measured by the Anxiety Sensitivity Index, significantly correlated with baseline OCD symptoms on the Dimensional Obsessive-Compulsive Scale (P < .001).

Baseline AS also prospectively predicted increased posttreatment OCD symptom severity after controlling for pretreatment OCD and depression severity (P = .04).

"These findings indicate that anxiety sensitivity does matter in OCD," presenting author Lillian Reuman, a graduate student in the doctoral program in clinical psychology at the University of North Carolina at Chapel Hill, told meeting attendees.

She noted that among the reasons why AS may negatively affect response to CBT is that exposure therapy can provoke anxious arousal.

"Individuals with high anxiety sensitivity may be more likely to experience panic and avoid exposure or interpret arousal during exposure as failure," said Reuman.

Although standard treatments for OCD, such as CBT and exposure therapy, are often effective, not all patients respond to those treatments, she added. She noted that this study is among the first to examine the role of AS as a predictor of improvements with CBT in OCD.

The findings were published in the Journal of Behavior Therapy and Experimental Psychiatry.

Questions Remain

Reuman told Medscape Medical News that key emerging strategies for addressing anxiety in patients with OCD include interoceptive exposure. "We recommend directly discussing and confronting feared/aversive body sensations," she said.

"One recent, clinically oriented publication from our lab presents the conceptual rationale for this recommendation," added Reuman.

Session discussant Leyro noted that the effect sizes were relatively small, and the study leaves open the question of whether AS changed over the course of treatment.

"What remains missing from this area of work are tightly controlled randomized controlled trials that examine pre- to posttreatment changes in anxiety sensitivity and whether these changes are related to symptom improvement," she said.

Another important consideration is that it is unlikely that AS affects all individuals with OCD, Leyro added.

"We need to learn how elevations in anxiety sensitivity are related to the heterogeneous symptoms observed in OCD," she said.

Another study presented during the session assessed the role of AS in PTSD. In it, 200 patients with PTSD (75% women) were randomly assigned to receive treatment with either prolonged exposure or sertraline.

For each group, treatment consisted of 10 sessions. The prolonged exposure sessions lasted 90 to 120 minutes; sessions for those receiving sertraline lasted less than 30 minutes. Patients were shown video rationales for each treatment prior to randomization.

Large decreases in AS were found in both groups after controlling for pretreatment depression and PTSD stress severity. There were no significant differences between the treatment groups.

Interestingly, although there were no differences in outcomes among those who did and those who did not express a choice of treatment or in those receiving prolonged exposure therapy, those who expressed preference for and received sertraline experienced the largest decreases in AS.

Markedly lower decreases in symptoms were found among those who were treated with sertraline but who had not expressed a preference for the therapy.

Findings from this double-blind trial were published in March in Quality of Life Research.

Receipt of a preferred treatment has been shown in previous studies to have a significant role in PTSD treatment, with some evidence showing improved outcomes and greater perceived control over treatment, said presenting author Allison Baier, Case Western Reserve University, Cleveland, Ohio.

The clinical implications of treatment preferences may be important, note the authors.

"Individuals higher in anxiety sensitivity who did not prefer sertraline may be more reluctant to titrate to a therapeutic dose or have greater sensitivity to side effects that may subtly alter this titration," they write.

Baier added that adherence could play an important role in the differences in sertraline outcomes. "Perhaps not having a choice leads patients to be less adherent, a problem likely with more adverse consequences in sertraline than prolonged exposure," she said.

The findings underscore that "anxiety sensitivity may be a risk factor for PTSD symptom severity that is modifiable with treatment," Baier concluded.

Important Finding

Commenting on the study, Leyro stressed the importance of the finding that all patients who received PE experienced reductions in AS, regardless of whether they expressed a preference for it.

"This suggests prolonged exposure may more directly target anxiety sensitivity," she said.

Although it is likely that AS is assessed more frequently by researchers and by clinicians who specialize in treating anxiety, other clinicians can easily assess patients with the Anxiety Sensitivity Index–3 (ASI-3) tool; and they can potentially improve outcomes with the appropriate therapies, Leyro noted.

The ASI-3 "is an empirically validated, 18-item measure that can quickly be administered in clinical settings. Anxiety sensitivity is thought to be relatively stable, but malleable with intervention," she said.

"In this way, it can be used to measure progress over the course of treatment, as well. Yet, the incorporation of its measurement should be accompanied by the use of interoceptive exposure strategies to target anxiety sensitivity," she said.

Allison Baier's study was funded by grants from the National Institute of Mental Health, Pfizer, Inc, and the William T. Dahms Clinical Research Unit. Lillian Reuman's study was unfunded. She and Dr Lyro have disclosed no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) 2018. Session 300R, presented April 8, 2018.

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