Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2026 Jan 9.
Published in final edited form as: Cogn Behav Ther. 2025 Jan 9;54(5):596–612. doi: 10.1080/16506073.2024.2447722

Examining the use of Interoceptive Exposure Exercises in People with and without a History of Chronic Physical Health Problems

Samantha G Farris a, Michael J Zvolensky b,c,d, Lorra Garey b, Michael S Businelle e,f
PMCID: PMC12238293  NIHMSID: NIHMS2045473  PMID: 39784117

Abstract

Interoceptive exposure (IE) exercises are underused, especially in people with chronic physical health problems. Secondary data analyses were conducted to examine the use of and acute responses to IE exercises in individuals with and without a history of chronic physical health problem(s). Participants (N=413; Mage=38.6, 56.1% with chronic physical health problems) enrolled in a 6-month randomized controlled trial that aimed to reduce anxiety and depression. Participants had access to a smartphone-based intervention that included on-demand access to IE exercises: head rush, straw breathing, chair spinning, fast beathing, and running in place. Utilization of the IE exercises and acute responses to the exercises were evaluated in the context of chronic physical health problem history. Participants with versus without a chronic physical health problem completed statistically significantly more IE exercises. Acute effects of IE exercises on distress and physical sensations were similar for those with and without a history of chronic physical health problems, as well as those who were versus were not taking medication. There is no evidence that chronic disease history influences the acute response to IE exercises. Continued research is needed to further assess the safety of IE exercises in people with various medical conditions.

Keywords: exposure therapy, anxiety sensitivity, cardiovascular disease, pain, pulmonary disease, mHealth

1.0. Introduction

Interoceptive exposure (IE) is a cognitive-behavioral intervention that was originally used as a core component of cognitive-behavioral treatment (CBT) for panic disorder (Barlow, 1988) and is recognized as an intervention with transdiagnostic relevance (Boettcher, Brake, & Barlow, 2016). IE involves repeated elicitation of physical sensations in a safe and controlled manner for the purposes of reducing negative emotion (typically anxiety) associated with the sensations. The goal of IE is for individuals to intentionally and repeatedly experience and endure physical sensations without escape or avoidance (Barlow, 1988). Physical sensations can be elicited with various behavioral exercises, biological provocation (e.g., caffeine ingestion), deliberate focus to elicit/amplify symptoms, and naturalistic activities (e.g., wearing tight clothing, riding a roller coaster) that elicit bodily sensations (Taylor, 2000). The most well-studied IE exercises involve voluntary hyperventilation, running in place, breathing through straw, holding breath, spinning in an chair (or while standing), and lifting head or shaking head (Antony, Ledley, Liss, & Swinson, 2006; Hofmann, Bufka, & Barlow, 1999; Lee et al., 2006; Schmidt & Trakowski, 2004; Schmidt & Woolaway-Bickel, 2000). Exercises are typically practiced in short “bouts” with rest in between with guidance or supervision then assigned as homework for repeated practice.

There is a strong evidence basis for the efficacy of IE exercises as a specific treatment component in panic disorder (Craske, DeCola, Sachs, & Pontillo, 2003; Craske, Rowe, Lewin, & Noriega-Dimitri, 1997; Gould, Ott, & Pollack, 1995; Ito, Noshirvani, Basoglu, & Marks, 1996; Pompoli et al., 2018) as well as to target anxiety sensitivity (Fitzgerald et al., 2021). Indeed, IE is thought to target anxiety sensitivity – catastrophic misinterpretation of anxious arousal – by providing the opportunity for new learning (disconfirmation of expectancies) about bodily sensations through behavioral practice (Taylor, 2000). IE can also reduce anxiety by facilitating openness and tolerance of unpleasant sensations (Eifert et al., 2009). Despite the evidence-basis to support its use, IE remains understudied and underutilized (Deacon, Kemp, et al., 2013; Deacon, Lickel, Farrell, Kemp, & Hipol, 2013; Deacon et al., 2012) and is often overlooked as an intervention strategy (Blakey & Abramowitz, 2018).

Concerns about IE’s safety and tolerability are often raised by clinicians (Deacon, Lickel, et al., 2013) and the public (Olatunji, Deacon, & Abramowitz, 2009). For example, when outpatients and university students were provided vignettes about different exposure treatments, IE was perceived the least helpful, acceptable, and ethical) compared to all other forms of exposure (Richard & Gloster, 2007). Even among trained clinicians, the expectation of negative outcomes from IE (e.g., decompensation, worsening of symptoms, passing out/loss of consciousness) is greatly overestimated relative to the safety risks (Deacon, Lickel, et al., 2013). Further, early protocols asserted absolute contraindications of IE in patients with certain conditions like cardiovascular disease, chronic obstructive pulmonary disease (COPD), asthma, neurological conditions (e.g., seizures or migraine), pregnancy, pain disorders, and balance-related disorders (e.g., Craske & Barlow, 1990; Huppert & Baker-Morissette, 2003; Taylor, 2000). Unfortunately, these recommendations were based largely on (untested) assumptions about safety risk and continue to inform (limit) the way IE is studied and implemented. More data on the safety and testing of IE is essential to correct misperceptions and update evidence-based treatment guidelines.

There is a particular need to understand the use of IE exercises in those with chronic medical conditions. Not only is anxiety and chronic disease commonly comorbid (Roy-Byrne et al., 2008) as are concerns about somatic sensations (Horenstein, Potter, & Heimberg, 2018), patients with medical comorbidities have been systematically excluded from research on IE which has led to a gap in evidence on not only the use but also safety of IE in patients with chronic disease. Despite this, there is data to support the efficacy of various IE exercises when administered as part of a larger cognitive-behavioral intervention, including in those with cardiovascular disease when medically cleared or supervised (Farris & Kibbey, 2022; Oser et al., 2021; Särnholm et al., 2021, 2017; Smith, Fogel, & Friedman, 1998; Tully, Sardinha, & Nardi, 2017), asthma (Ross, Davis, & MacDonald, 2005; Tien, Goodie, Duncan, Szabo, & Larson, 2014), and chronic pain (Ashar et al., 2022; Ljótsson, Hesser, et al., 2014). However, these studies rarely report details about engagement in specific IE exercises or safety. To fully appreciate the potential of IE among those with chronic medical conditions, basic research is needed on IE exercises and the acute response among those with chronic physical health conditions.

The primary aim of the current study was to describe the use of and acute responses to IE exercises that were embedded into a smartphone-based intervention (Garey, Zvolensky, M. J., et al., 2022) in adults with or without a history of chronic physical health conditions to inform acceptability, safety, and efficacy. This sort of test is important to evaluate how this type of mobile health technology can aid in mental health management (Debon, Coleone, Bellei, & De Marchi, 2019). First, we aimed to evaluate how individuals with a history of chronic physical health conditions (versus those without) would use IE exercises when made available via a mobile application for “on demand” access (Businelle et al., 2022; Garey, Zvolensky, M. J., et al., 2022). Mobile application delivery of IE allows for an evaluation of its use when delivered in a client-controlled and unsupervised manner, which would provide valuable data on efficacy and safety of non-traditional IE delivery, especially for patients with chronic disease(s) who are typically excluded from IE exercises, or medically evaluated and cleared for IE exercise. Second, we evaluated whether people with chronic physical health condition(s) responded differently to IE exercises in terms of the severity of subjective distress and physical sensations, as well as the influence of medication use for chronic disease. These aims were considered exploratory and no a priori directional hypotheses were made.

2.0. Material and Methods

2.1. Participants and Procedures

Participants were adults participating in a larger trial aimed at monitoring and improving mental health during the COVID-19 pandemic, particularly among racially and ethnically minoritized groups (clinicaltrials.gov #: NCT05074693). Participants were recruited between 2021 and 2023 throughout the United States via social media and internet-based advertisements. Eligibly was based on: (1) being ≥18 years of age; (2) self-identifying as Black, Hispanic, American Indian, or non-Hispanic White; (3) having elevated anxiety and/or depressive symptoms (score ≥8 on the Overall Anxiety Severity and Impairment Scale [OASIS] (Campbell-Sills et al., 2009) and/or Overall Depression Severity and Impairment Scale [ODSIS] (Bentley, Gallagher, Carl, & Barlow, 2014); (4) residing in the United States; (5) willingness to complete daily assessments on study provided or personal smartphone for 6-month study period; (6) willingness to complete the 3- and 6-month follow-up assessments via Insight™ app and over the phone; and (7) having > 6th grade English literacy level (score ≥ 4 on the Rapid Estimate of Adult Literacy in Medicine-Short Form [REALM-SF] (Arozullah et al., 2007). Exclusion criteria included lack of English fluency and significant cognitive impairment.

Eligibility was determined via a brief screening form completed via REDCap and confirmed via phone-assessment by study staff. Once eligibly was confirmed, study staff reviewed the nature of the study, obtained informed consent, and collected a digital signature via REDCap. Eligible participants then downloaded the Insight™ mobile application (‘app’) to their personal smartphone or were mailed a study provided smartphone with the Insight™ mobile app preloaded. The Insight™ app was used to administer all study assessments and intervention materials. Participants were given instructions on how to use the app and then used it to complete the baseline survey. Upon completion of the baseline survey, participants were randomized to one of two intervention conditions: a digital mental health intervention that addressed anxiety sensitivity and anxiety and depression in real-time (Easing Anxiety Sensitivity for Everyone; EASE) or a standard-of-care digital mental health application that offered mindfulness and relaxation training content (Control). Participants randomized to EASE were prompted via daily assessments to access and complete on-demand IE exercises via the home screen; participants randomized to the Control group did not have access to IE exercises and were excluded from the current analyses. For additional study details, please see (Garey, Zvolensky, M. J., et al., 2022). The University of Houston Institutional Review Board served as the primary oversight board for this study, with a reliance agreement from The University of Oklahoma Health Sciences Center; both institutions approved the parent trial.

2.2. On-Demand “Stress Management Training” (Interoceptive Exposure (IE) Exercises)

The EASE app included multiple intervention components that addressed anxiety sensitivity (Garey, Zvolensky, M. J., et al., 2022), including psychoeducation on anxiety sensitivity and IE exercises to reduce anxiety sensitivity. Psychoeducation on anxiety sensitivity was delivered via multiple videos that included topics related to the definition of anxiety sensitivity, the relation between anxiety sensitivity and mental health, and IE as a method to reduce anxiety sensitivity. Videos also provided a rationale for IE, the safety of IE exercises, and specific instructions on how to complete IE exercises. Furthermore, participants were provided access to a clickable “Stress Management Trainings” button within the app home screen that initiated IE exercises. Upon clicking the button, the app provided information on the purpose of the exercise and its relevance to the experience of stress. Specifically, the instructions read: “Practicing the stress management training routinely will help you become more familiar and comfortable with the sensations that often come with stress. Please note that the app will select one of the five exposure exercises each time you practice. Let’s complete an exercise now, together. Once you finish the exercise, it’s important that you do not try to distract yourself from any uncomfortable feelings that may arise. Avoid using devices like your phone and try to do the exercise for the entire 60 second period. It is important to acknowledge these feelings, and tell yourself that although you feel uncomfortable, you are not in danger. These feelings will pass. Ok, let’s begin”.

When the participant was ready to begin, the app prompted them to complete two distress ratings (see IE ratings described in section 2.3.6). Then, the participant was randomly assigned one of five IE exercises to practice. A countdown timer was displayed while the exercise was being completed. Following completion of the IE exercise, participants were asked to complete the two distress ratings again. Participants were encouraged to repeat the IE up to three additional times (for a total of 4 times) if their reported distress rating was >50/100 following the exercise.

2.2.1. Head Rush exercise (60 seconds).

We’re now ready to begin the exercise. First, take a seat in a comfortable chair. For this exercise, you will bend forward in the chair so that your head is between your knees, or you head is resting on your thighs. Put your phone in front of you on the ground. When you click next, a timer will indicate how long you should continue the exercise. When the time runs out, sit up quickly.

2.2.2. Chair Spin exercise (60 seconds).

We’re now ready to begin the exercise. First, take a seat in a comfortable chair. For this exercise, you will slowly start to spin in a chair, and pick up speed as you go. If you do not have a chair, you may spin in a circle while standing. Ensure that you have enough space around you before you begin the exercise. When you are ready to begin, put your phone in front of you on the ground, or on a table/desk next to you. When you click next, a timer will indicate how long you should continue the exercise. When the time runs out, stop spinning.

2.2.3. Straw Breathing exercise (60 seconds).

We’re now ready to begin the exercise. First, take out the straw that we sent you. For this exercise, you will put the straw between your lips and pinch your nose, and begin breathing only through the straw in your mouth. Put your phone in front of you on the ground. When you click next, a timer will indicate how long you should continue the exercise. When the timer runs out, remove the straw from your mouth and breathe normally.

2.2.4. Fast Breathing exercise (60 seconds).

We’re now ready to begin the exercise. First, take a seat in a comfortable chair. For this exercise, you will tilt your head forward (put your chin on your chest) and start taking in quick, shallow breaths. Put your phone in front of you on the ground or on a table/desk next to you. When you click next, a timer will indicate how long you should continue the exercise. When the time runs out, start breathing normally again.

2.2.5. Running in place exercise (60 seconds).

We’re now ready to begin the exercise. First, make sure you have plenty of space around you. For this exercise, you will run in place for 60 seconds as fast as you can. Put your phone in front of you on the ground or on a desk/table. When you click next, a timer will indicate how long you should continue the exercise. When the time runs out, take a seat in a chair.

If prompted to repeat the exercise, the message read: “Great work! We know these exercises can be difficult when you are not used to the sensations they bring on. Remember that repeatedly doing these exercises will better allow you to handle these uncomfortable sensations. Would you like to repeat the exercise now?”. Otherwise, the app displayed the final message: “Great job! You can stop now. Remember to take slow deep breaths and pay attention to any physical sensations you may be feeling. Our goal is to help you learn how to accept these sensations, and any discomfort they may cause. Remember, as you continue to practice this exercise, your ability to tolerate these sensations will improve.”

2.3. Measures

2.3.1. Demographics.

Participant demographic characteristics including age, sex, race, and ethnicity were collected at baseline. These items were used to describe the sample.

2.3.2. History of Chronic Physical Disease.

History of chronic physical disease was determined based on responses to a group of baseline questions on a self-reported medical history form. Participants indicated whether they had ever been diagnosed with: cardiovascular diseases (heart/circulatory disease: coronary heart disease/coronary artery disease, stroke, peripheral artery disease, aortic aneurysm, other); pulmonary diseases (lung diseases: chronic bronchitis, chronic obstructive pulmonary disease, emphysema, tuberculosis, other); cancers (lung/bronchial, urinary/bladder, kidney/renal pelvis, pancreas, oral cavity/pharyngeal, prostate, colon/rectal, cervix, melanoma of skin, non-Hodgkin lymphoma, leukemia, breast, uterine corpus, thyroid, ovary, other); diabetes; high blood pressure; high cholesterol; or Arthritis. Any respondents who endorsed “yes” to any of these items were coded as having chronic disease (=1) and the rest were coded as having no history (=0).

2.3.3. Medication use for Chronic Physical Disease.

Current use of medication for chronic disease management was also assessed via self-report. Any respondents who endorsed “yes” to any of these items were coded as currently taking medication for their chronic disease (=1) and the rest were coded as not using medication for their chronic disease management (=0).

2.3.4. Anxiety and Depression.

Levels of anxiety and depression were assessed at baseline. The OASIS (Campbell-Sills et al., 2009) is a 5-item measure of anxiety severity and impairment in the past week with items rated from 0 to 4, and a summed total score (possible range 0 to 20) is derived; higher scores reflecting higher anxiety. The ODSIS is a 5-item measure of the severity of depressive symptoms and impairment in the past week, with items rated from 0 to 4, and a summed total score (possible range 0 to 20) is derived; higher scores reflecting more severe depressive symptoms. Internal consistency of OASIS and ODSIS items in the current study ranged from α=.827 (anxiety) to .905 (depression).

2.3.5. Short-Scale Anxiety Sensitivity Index (SSASI).

The Short-Scale Anxiety Sensitivity Index (SSASI) (Zvolensky et al., 2018) is a 5-item brief measure of anxiety sensitivity derived from the Anxiety Sensitivity Index-3 (ASI-3)(Taylor et al., 2007). Items are rated from 0 to 4 and summed for a total possible range of 0 to 20 with higher scores reflecting greater tendency to catastrophically misappraise anxious arousal symptoms. Internal consistency of the five items was α=.792. The SSASI was administered at baseline and used here to describe the sample.

2.3.6. IE Ratings.

Two ratings were administered prior to and following each self-initiated IE exercise. Specifically, participants were asked to rate their current level of distress (SUDS) on a scale from 0 (totally relaxed) to 100 (highest distress you have ever felt). They were also asked to rate the severity of physical sensations on a scale of 1 (no sensations) to 7 (severe sensations).

2.4. Data Analytics Approach

Analyses were conducted in SPSS v27 and SAS v9.4. Records of IE exercises were summarized both between- and within-person. Initial descriptive statistics were used to characterize the sample in terms of any occurrence and average frequency of IE exercise use (between-subject) and IE exercise use completion and acute effects (within-subject). The intraclass correlation coefficient (ICC) was calculated using a multi-level model with random effect of participant to provide an indication of the degree to which variance in the acute effects of IE exercises (i.e., distress: SUDS, physical sensations) were attributable to individual differences (i.e., participant characteristics) versus unmeasured contextual factors. A total of 1,586 completed IE exercises were used in these. ICCs indicated that within-person variability accounted for 51.0% and 48.0% of variance in post-IE SUDS and physical sensations, respectively. Therefore, multi-level models were fit using SAS PROC MIXED to account for the multilevel structure of the data, namely the within-person variance in SUDS and physical sensations, as well as the between-person variance in chronic physical condition status and demographics. A random coefficient model was specified, with the random covariance structure specified as unstructured. In each model, post-IE ratings of SUDS and physical sensations were entered as independent outcomes, with pre-IE exercise ratings for the specific outcome entered as a covariate to examine the acute change in SUDS and physical sensations following the IE exercise. History of chronic physical condition (y/n) was the primary predictor of interest. Current use of medication for chronic physical health condition (y/n) was also entered into each model. Additional models were run to identify the specific acute effects and any influence of chronic physical condition or medication status that might emerge in the context of a particular IE exercise. Model covariates included sex (1=male, 0=female), race/ethnicity (1=Black, 2=American Indian, 3=Latinx, 4=White[reference]), age, and baseline anxiety sensitivity. All tests of statistical significance were two-tailed, set a p < .05.

3. Results

3.1. Sample Characteristics

Participants (N=413; Mage=38.6, SD=13.0; 65.1% female) identified race/ethnicity as Latinx (25.2%), Black (24.9%), American Indian (24.9%) and White (24.9%). A history of chronic physical health condition was reported by 56.1% (n=232) of participants, and included: hypertension (32.4%, n=134), hyperlipidemia (25.2%, n=104), arthritis (24.0%, n=99), diabetes (13.1%, n=54), pulmonary disease (11.9%, n=49), cardiovascular disease (9.9%, n=41), and cancer (4.8%). The average number of chronic physical health conditions reported was 2.1 (SD=1.25). More than half (60.3%) of people with a history of a chronic physical health condition reported use of medication for one or more of their health conditions, which included medication for (% of those within chronic disease group): high blood pressure (39.2%), high cholesterol (20.7%), diabetes (19.8%), arthritis (18.5%), lung disease (9.1%), heart disease (4.7%), and cancer (1.3%). People with a history of a chronic physical health condition, compared to those without, were significantly older (t(410.7)=−10.89, p<.001), more likely to be American Indian and less likely to be Latinx (x2(3)=27.46, p<.001). The groups did not differ in biological sex (x2(1)=0.05, p=.817), baseline anxiety severity (t(411)=0.22, p=.413), baseline depression severity (t(411)=−.702, p=.242), or baseline anxiety sensitivity (t(411)=−.138), p=.890. See Table 1 for additional descriptive information.

Table 1.

Sample Characteristics and Between-Subject IE Exercise Utilization

Sample Characteristics Total Sample (N=413) History of Chronic Physical Health Condition (n=232) No History of Chronic Physical Health Condition (n=181)
Age (M±SD) 38.6±13.01 44.1±12.71* 31.7±9.67
Sex
 Male n (%) 144 (34.9) 82 (35.3) 62 (34.3)
 Female n (%) 269 (65.1) 150 (64.7) 119 (65.7)
Race
 Black n (%) 103 (24.9) 56 (24.1) 47 (26.0)
 American Indian n (%) 103 (24.9) 73 (31.5)* 30 (16.6)
 Latinx n (%) 104 (25.2) 38 (16.4)* 66 (36.5)
 White n (%) 103 (24.9) 65 (28.0) 38 (21.0)
Anxiety (OASIS) (M±SD) 10.6±3.37 10.6±3.45 10.7±3.28
Depression (ODSIS) (M±SD) 9.7±4.17 9.9±4.27 9.6±4.05
Short Anxiety Sensitivity Scale (SSASI) 9.8±5.06 9.8±5.06 9.8±5.08
Taking medication for chronic disease n (%) 140 (60.3)
Between-Subject IE Exercise Use
Clicked “Stress Management Training” button n (%Y) 377 (91.3) 217 (93.5) 160 (88.4)
# “Stress Management Training” button clicks (M±SD) 7.4±9.72 8.5±11.42* 6.0±6.73
Assigned IE exercise n (%Y) 345 (83.5) 198 (85.3) 147 (81.2)
# times IE exercise assigned (M±SD) 5.3±8.51 6.3±10.30* 4.0±5.20
Completed IE exercise n (%Y) 292 (70.7) 172 (74.1) 120 (66.3)
# times IE completed (M±SD) 3.8±7.81 4.8±9.60* 2.7±4.35
# times IE completed among those who completed at least one (M±SD) 5.4 (8.81) 6.5 (10.95)* 4.1 (4.94)
Open in a new tab
*

Note: denotes significant difference by chronic physical health condition status.

3.2. Overall IE Exercise Use

The “Stress Management Training” button was clicked a total of 3,070 times, an IE exercise was assigned in 2186 instances, and a total of 1,586 IE exercises were completed. Between-subject use of the IE feature is summarized in Table 1. Most of the sample (91.3%) clicked the “Stress Management Training” button, and 83.5% of the sample were assigned an IE exercise. Most (n=292, 70.7%) of the sample completed at least one IE exercise (84.6% of those who were assigned an exercise). The average number of completed IE trials, among those who completed at least one, was 5.4 (SD=8.81). Regarding specific exercises, 71.6% (n=209) completed the straw breathing exercise (M=2.6, SD=3.07, Max=35), 70.5% (n=206) completed the chair spinning exercise (M=2.5, SD=2.62, Max=27), 70.5% (n=206) completed the fast breathing exercise (M=2.5, SD=2.6, Max=25), 48.3% (n=141) completed the running in place exercise (M=1.9, SD=2.60, Max=25), and 47.6% (n=139) completed the head rush exercise (M=1.8 times, SD=1.90, Max=21). The lower frequency running in place and head rush exercises is a result of these two being randomly assigned less often than the others (bias in the randomization). At the IE trial-level (Table 2), the proportion of IE trial completion was 72.6% with a higher proportion of completed for fast breathing exercise trials (78.4%) and lower proportion of completed chair spinning exercise trials relative to what was assigned. The incidence of being prompted to repeat an IE exercise due to high distress was 27.6% (437 instances). Few participants chose to repeat an exercise (n=49 instances, 11.2% of all repeat prompts).

Table 2.

Completed specific IE exercises in the context of chronic physical condition history

All Exercises Headrush Chair Spin Straw Breathing Fast Breathing Running
Total Assigned 2,186 (100%) 268 (12.3%) 548 (25.1%) 568 (26.0%) 523 (23.9%) 279 (12.8%)
Total Completed1 1,586 (72.6%) 193 (72.0%) 377 (68.8%) 416 (73.2%) 410 (78.4%) 190 (68.1%)
Completed x Disease
  Any Disease2 (N=1456) 1,103 (75.8%) 139 (76.4%) 263 (72.1%) 279 (75.4%) 290 (81.7%) 132 (71.7%)
  Cardiovascular3 (N=261) 213 (81.6%) 19 (59.4%) 60 (85.7%) 61 (60.4%) 52 (88.1%) 21 (80.8%)
  Pulmonary4 (N=288) 217 (75.3%) 17 (65.4%) 56 (70.9%) 57 (75.0%) 55 (82.1%) 32 (80.0%)
  Diabetes5 (N= 313) 221 (70.6%) 25 (61.0%) 52 (68.4%) 63 (73.3%) 58 (78.4%) 23 (63.9%)
  Cancer6 (N=153) 107 (69.9%) 12 (54.5%) 28 (68.3%) 18 (69.2%) 32 (84.2%) 17 (65.4%)
  Arthritis7 (N=659) 515 (78.1%) 56 (74.7%) 107 (71.3%) 128 (76.7%) 145 (84.8%) 69 (83.1%)
  Hypertension8 (N=979) 743 (75.9%) 101 (78.3%) 117 (69.7%) 199 (79.9%) 187 (81.7%) 79 (66.9%)
  Hyperlipidemia9 (N=608) 457 (75.2%) 53 (73.6%) 117 (75.0%) 105 (71.4%) 127 (80.4%) 55 (73.3%)
Current Medication10 (N=1039) 788 (75.8%) 101 (75.4%) 182 (70.8%) 208 (78.2%) 203 (81.5%) 94 (70.7%)
Open in a new tab
1

Assigned x Completed: x2(4)=15.80, p=.003

2

Any Chronic x Completed: x2(4)=11.208, p=.024

3

Cardiovascular x Completed: x2(4)=13.05, p=.011

4

Pulmonary x Completed: x2(4)=4.35, p=.361

5

Diabetes x Completed: x2 (4)=5.24, p=.264

6

Cancer x Completed: x2 (4)=6.48, p=.166

7

Arthritis x Completed: x22(4)=10.48, p=.033

8

Hypertension x Completed: x2(4)=17.29, p=.002

9

Hyperlipidemia x Completed: x2(4)=3.63, p=.458

10

Current medication use x Completed: x2(4)=10.69, p=.030

People with a history of chronic health conditions were just as likely as those without to click the “Stress Management Training” button (x2(1)=3.37, p=.066), be assigned an IE exercise (x2(1)=1.26, p=.262), and complete at least one IE exercise (x2(1)=3.02, p=.082). However, people with chronic health conditions accessed the IE exercise feature statistically significantly more times (t(384.5)=−2.65, p=.005), were displayed an IE exercise significantly more times (t(357.8)=−2.68, p=.004), and completed statistically significantly more IE exercises (t(338.5)=−2.95, p=.003) than those without a history of chronic health condition. Among those who completed an IE exercise (n=292), people with a chronic health condition history completed 1.5 times more exercises than those without a chronic health condition (t(254.1)=−2.59, p = .010).

Among those with a history of a chronic health condition, people taking medication for a chronic disease were more likely to complete IE exercises (78.6%) than those not taking medication (67.4%) although this difference was not statistically significant (x2(1)=3.62, p=.057). Among those with a chronic health condition that completed at least one IE exercise (n=172), the number of completed IE exercises did not significantly differ for those taking medication (M=7.2±11.80, n=110) versus those not taking medication (M=5.1±8.19, n=62), (t(170)=−1.23, p=.220).

At the IE exercise-level (Table 2), of the 1456 instances when IE was assigned to be completed by a participant with chronic disease, 75.8% of these trials were completed, with a higher proportion of completed trials for fast breathing (81.7%); this was specifically true in the context of a history of cancer, arthritis, and hypertension. A lower proportion of exercises were completed in the following cases: headrush (in cardiovascular disease), chair spinning (arthritis, hypertension), and running in place (hypertension). The incidence of being prompted to repeat an exercise based on distress level did not statistically significantly differ by chronic disease status (27.7% with disease history versus 27.3% without disease; x2(1)=0.01, p=.911).

3.3. Acute Effects of IE

See Table 3 for the unadjusted mean changes in SUDS and physical sensations from each IE exercise, and effect size estimates for the whole sample, and those with chronic disease. IE generally produced small-medium sized decreases in both SUDS and physical sensations, with the largest decreases in distress resulting from fast breathing and head rush. The results from the MLM models are presented in Table 4. Analyzing the 1,586 trials when IE was completed, there was no statistically significant effect of chronic physical illness history on the acute effects of IE exercises for SUDS or physical sensations. There was also no statistically significant effect of medication status on the acute effects of IE exercises. These effects were adjusted for the non-significant effects of sex, race, age, and baseline anxiety sensitivity. When modeling of instances where high acute distress (>50% severity) was reported from IE (n=437 instances), there was non-statistically significant effect of chronic physical health condition history or medication status on acute IE response for either SUDS or physical sensations. Regarding each IE exercise, there was no significant effect of chronic physical health condition on the acute effects of the headrush exercise, chair spinning exercise, straw breathing exercise, fast breathing exercise, or running in place. These models adjusted for the non-significant effects of sex, race, age, and medication use.

Table 3.

Acute responses to IE exercises

SUDS (0–100 scale) Sensations (1–7 scale)
Total Sample n Mean Δ SD t Cohen’s d Mean Δ SD t Cohen’s d
All IE Exercises 1586 −7.16 20.24 −14.07*** .354 −0.12 1.37 −3.57*** .090
Headrush 193 −8.35 19.14 −6.06*** .436 −0.13 1.27 −1.42 .102
Chair Spinning 377 −5.30 23.58 −4.35*** .225 0.14 1.54 1.77 −.091
Straw Breathing 416 −7.55 19.97 −7.72*** .378 −0.30 1.36 −4.44*** .218
Fast breathing 410 −8.28 17.75 −9.44*** .466 −0.26 1.16 −4.57*** .226
Running in place 190 −6.31 19.77 −4.41*** .320 +0.04 1.43 0.41 −.029
Chronic Disease n Mean Δ SD t Cohen’s d Mean Δ SD t Cohen’s d
All IE Exercises 1103 −9.04 19.37 −15.50*** .469 −0.16 1.33 −4.09*** .123
Headrush 139 −10.92 16.49 −7.81*** .662 −0.12 1.34 −1.01 .086
Chair Spinning 263 −7.64 22.08 −5.61*** .346 0.04 1.41 0.44 −.027
Straw Breathing 279 −8.81 19.69 −7.48*** .448 −0.21 1.34 −2.98** .179
Fast breathing 290 −9.75 17.85 −9.31*** .546 −0.33 1.18 −4.83*** .284
Running in place 132 −8.76 18.97 −5.31*** .468 −0.08 1.37 −0.63 .055
Open in a new tab

Note: a negative mean change reflects a decrease in SUDs or sensations from pre-post IE. A positive mean change reflects an increase in SUDS or sensations from pre-post IE.

Table 4.

Results of MLM models

DV: SUDS
Effect b SE t p Lower Upper
Overall Effect Disease −0.393 2.2793 −0.17 .863 −4.865 4.079
Medication −1.554 2.3318 −0.67 .505 −6.129 3.021
Exercise 1 Disease −6.440 4.1777 −1.54 .127 −14.754 1.874
Medication 1.599 4.0142 0.40 .692 −6.390 9.587
Exercise 2 Disease 1.730 4.0964 0.42 .673 −6.345 9.804
Medication −5.917 3.891 −1.52 .130 −13.59 1.753
Exercise 3 Disease −0.796 3.5728 −0.22 .824 −7.833 6.242
Medication −0.578 3.5559 −0.16 .871 −7.583 6.426
Exercise 4 Disease −1.146 2.8951 −0.4 .693 −6.851 4.556
Medication −1.809 2.8655 −0.63 .529 −7.455 3.838
Exercise 5 Disease −5.479 4.6756 −1.17 .245 −14.78 3.821
Medication −4.418 4.404 −1.00 .319 −13.18 4.342
High Distress Disease −4.337 2.6539 −1.63 .103 −9.560 0.886
Medication −1.238 2.4309 −0.51 .611 −6.022 3.547
DV: Physical Sensations
Effect b SE t p Lower Upper
Overall Effect Disease 0.050 0.165 0.30 .762 −0.274 0.374
Medication 0.094 0.171 0.55 .583 −0.241 0.428
Exercise 1 Disease 0.049 0.290 0.17 .866 −0.529 0.627
Medication −0.195 0.283 −0.69 .494 −0.759 0.367
Exercise 2 Disease 0.183 0.297 0.61 .539 −0.403 0.768
Medication −0.199 0.289 −0.69 .491 −0.768 0.370
Exercise 3 Disease 0.190 0.250 0.76 .448 −0.303 0.683
Medication −0.015 0.250 −0.06 .951 −0.507 0.476
Exercise 4 Disease −0.046 0.217 −0.21 .831 −0.474 0.382
Medication 0.164 0.218 0.75 .453 −0.266 0.594
Exercise 5 Disease 0.243 0.362 0.67 .503 −0.476 0.962
Medication −0.264 0.345 −0.76 .447 −0.950 0.423
High Distress Disease −0.050 0.278 −0.18 .857 −0.597 0.497
Medication 0.080 0.259 0.31 .757 −0.429 0.590
Open in a new tab

Note: Disease = chronic physical condition status [0=no, 1=yes]; Medication = current medication use status [0=no, 1=yes]; model covariates included sex (1=male, 0=female), race/ethnicity (1=Black, 2=American Indian, 3=Latinx, 4=White[reference]), age, and baseline anxiety sensitivity.

4.0. Discussion

This is the first study of its kind to document the naturalistic use of IE exercises in the context of chronic disease among a large and racially diverse sample. On average, people with a history of chronic disease completed roughly double the number of IE trials than those without a history of chronic disease, perhaps reflecting interest in, and acceptability of, IE. These findings are particularly compelling given that IE was delivered without medical monitoring or clearance, and without the support of a clinician. In contrast, most published studies of IE exclude individuals with chronic medical conditions (e.g., cardiopulmonary conditions) or require medical evaluation and/or clearance (Ashar et al., 2022; Farris & Kibbey, 2022; Ljótsson, Atterlöf, et al., 2014; Oser et al., 2021; Särnholm et al., 2021, 2017; Smith et al., 1998; Tully et al., 2017). The only medical exclusion for this study was cognitive impairment, which was not pertinent to safety of IE exercises but instead relevant for the integrity of the assessment protocol used in the study.

There was significant variability in the acute response to IE, both between- and within-person, which is consistent with previous investigations of IE (Boettcher & Barlow, 2019). Roughly one-fourth of the IE trials were characterized by elevated SUDS and sensations post-exercise. Importantly, the presence of chronic disease or medication use did not influence the acute response to any of the IE exercises. The proportion of IE trials that resulted in elevated distress were equivalent in people with and without a history of chronic disease. It is worth noting that, on average, IE exercises produced small-medium sized reductions in acute distress and physical sensations. This finding is surprising given that IE exercises typically produce mild to moderate increases in acute distress and physical sensations when conducted in controlled laboratory settings (e.g., Antony et al., 2006; Collimore & Asmundson, 2014; Dixon, Kemp, Farrell, Blakey, & Deacon, 2015; Lickel, Nelson, Lickel, & Deacon, 2008; Schmidt & Trakowski, 2004) and in one prior pilot study of a mobile-delivered app that included an IE feature (Garey, Hébert, et al., 2022). It is possible that the framing of IE exercises as a “stress management” strategy could have served as an (incidental) prime (Weingarten et al., 2016) to expect stress reduction. It is also possible that the unsupervised nature of the exercises may have led people self-pace in a manner that led arousal sensations to feel more controllable or otherwise engage in arousal-reduction behaviors (Farrell, Deacon, Kemp, Dixon, & Sy, 2013), which could explain the dampening of acute responding. Although the scalability of mobile applications are highly favorable, more work is needed to understand the efficacy of IE exercises when exclusively controlled by the patient, especially because patient-controlled exposure has been shown to produce suboptimal outcomes compared to therapist-controlled exposure (Abramowitz, 1996; Gloster et al., 2011).

There are several limitations of this work. The chief limitation of this work is that due to the nature in which the intervention was delivered (unaided, unobserved), it is impossible to know for sure if and how the IE exercises were completed. It is unknown whether IE was done well (i.e., with the ideal form, at the ideal intensity, duration) or whether any participant behaviors (e.g., arousal-reduction behaviors during IE exercises) may have inadvertently undermined the exposure. This issue is a particular concern given that SUDS typically acutely decreased rather than increased from the beginning to end of the minute-long exercises. It is also unknown whether an IE trial was completed or not. Our classification of a completed IE trial was based solely on whether post-IE ratings of SUDs and sensations were recorded in the app.

Second, the protocol did not involve systematic collection of data on safety or adverse events immediately after IE trials. The repeated use of the IE exercise (on average five times per person) may indicate safety. However, we cannot make any definitive conclusions that IE exercises did not result in adverse outcomes.

Third, we relied on self-reported medical history rather than medical diagnosis to determine presence of chronic disease. We hope that these data spur subsequent clinical investigations into the use of IE in patients with chronic medical conditions Finally, 60% of people in the chronic disease group reported current use of medication. Medication use could distinguish between people who have more or less severe conditions, or condition stability (e.g., if pharmacotherapy is not needed). Current medication use could also distinguish between people with a current versus remitted condition. Thus, although there was no indication that medication status was predictive of iatrogenic outcomes, it is difficult to draw conclusions from these data. Collectively, we believe that empirical evidence gained from this secondary data analysis meaningfully adds to an otherwise scant literature and the benefit of this work outweighs the methodological limitations.

5.0. Conclusions

There is no evidence that people with a history of chronic disease respond differently to IE exercises (head rush, chair spinning, straw breathing, fast breathing or running in place) than those without a history of disease. Although speculative, the current data suggest people with a history of chronic disease may have more interest in IE exercises based on the finding that these individuals completed more IE trials than those without chronic disease. Continued research is needed to understand the safety and acceptability of IE exercises among people with current (and acute) medical conditions to expand the available literature upon which evidence-based recommendations for IE safety can be determined.

Funding:

This work was supported by the National Institute of Mental Health (grant #R01MH126586) and used the Stephenson Cancer Center mHealth Shared resource which is partially funded by the National Cancer Institute (grant #P30CA225520).

Data Availability Statement:

Data for the current study are available upon request.

References

  1. Abramowitz JS (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583–600. 10.1016/S0005-7894(96)80045-1 [DOI] [Google Scholar]
  2. Antony MM, Ledley DR, Liss A, & Swinson RP (2006). Responses to symptom induction exercises in panic disorder. Behaviour Research and Therapy, 44(1), 85–98. 10.1016/j.brat.2004.12.005 [DOI] [PubMed] [Google Scholar]
  3. Arozullah AM, Yarnold PR, Bennett CL, Soltysik RC, Wolf MS, Ferreira RM, … Davis T (2007). Development and validation of a short-form, rapid estimate of adult literacy in medicine. Medical Care, 45(11), 1026–1033. [DOI] [PubMed] [Google Scholar]
  4. Ashar YK, Gordon A, Schubiner H, Uipi C, Knight K, Anderson Z, … Wager TD (2022). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA Psychiatry, 79(1), 13–23. 10.1001/jamapsychiatry.2021.2669 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Barlow DH (1988). Anxiety and its disroders: The nature and treatment of anxiety and panic. New York: Guilford Press. [Google Scholar]
  6. Bentley KH, Gallagher MW, Carl JR, & Barlow DH (2014). Development and validation of the overall depression severity and impairment scale. Psychological Assessment, 26, 815–30. 10.1037/a0036216 [DOI] [PubMed] [Google Scholar]
  7. Blakey SM, & Abramowitz JS (2018). Interoceptive exposure: An overlooked modality in the cognitive-behavioral treatment of OCD. Cognitive and Behavioral Practice, 25(1), 145–155. 10.1016/j.cbpra.2017.01.002 [DOI] [Google Scholar]
  8. Boettcher H, & Barlow DH (2019). The unique and conditional effects of interoceptive exposure in the treatment of anxiety: A functional analysis. Behaviour Research and Therapy, 117(December 2018), 65–78. 10.1016/j.brat.2018.12.002 [DOI] [PubMed] [Google Scholar]
  9. Boettcher H, Brake CA, & Barlow DH (2016). Origins and outlook of interoceptive exposure. Journal of Behavior Therapy and Experimental Psychiatry, 53, 41–51. 10.1016/j.jbtep.2015.10.009 [DOI] [PubMed] [Google Scholar]
  10. Businelle MS, Garey L, Gallagher MW, Hebert ET, Vujanovic A, Alexander A, … Zvolensky MJ (2022). An integrated mHealth app for smoking cessation in black smokers with anxiety: Protocol for a randomized controlled trial. JMIR Research Protocols, 11(5). 10.2196/38905 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Campbell-Sills L, Norman SB, Craske MG, Sullivan G, Lang AJ, Chavira DA, … Stein MB (2009). Validation of a brief measure of anxiety-related severity and impairment: the Overall Anxiety Severity and Impairment Scale (OASIS). Journal of Affective Disorders, 112, 92–101. 10.1016/j.jad.2008.03.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Collimore KC, & Asmundson GJG (2014). Fearful responding to interoceptive exposure in social anxiety disorder. Journal of Anxiety Disorders, 28(2), 195–202. 10.1016/j.janxdis.2013.10.003 [DOI] [PubMed] [Google Scholar]
  13. Craske MG, & Barlow DH (1990). Therapist’s guide for the mastery of your anxiety and panic (MAP) program. Graywind Publishing Company. [Google Scholar]
  14. Craske MG, DeCola JP, Sachs AD, & Pontillo DC (2003). Panic control treatment for agoraphobia. Journal of Anxiety Disorders, 17, 321–333. [DOI] [PubMed] [Google Scholar]
  15. Craske MG, Rowe M, Lewin M, & Noriega-Dimitri R (1997). Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. British Journal of Clinical Psychology, 36, 85–99. [DOI] [PubMed] [Google Scholar]
  16. Deacon BJ, Kemp JJ, Dixon LJ, Sy JT, Farrell NR, & Zhang AR (2013). Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learning: A randomized controlled trial. Behaviour Research and Therapy, 51(9), 588–596. 10.1016/j.brat.2013.06.006 [DOI] [PubMed] [Google Scholar]
  17. Deacon BJ, Lickel JJ, Farrell NR, Kemp JJ, & Hipol LJ (2013). Therapist perceptions and delivery of interoceptive exposure for panic disorder. Journal of Anxiety Disorders, 27(2), 259–264. 10.1016/j.janxdis.2013.02.004 [DOI] [PubMed] [Google Scholar]
  18. Deacon BJ, Lickel JJ, Possis EA, Abramowitz JS, Mahaffey B, & Wolitzky-Taylor KB (2012). Do cognitive reappraisal and diaphragmatic breathing augment interoceptive exposure for anxiety sensitivity? Journal of Cognitive Psychotherapy: An International Quarterly, 26(3), 257–269. [Google Scholar]
  19. Debon R, Coleone JD, Bellei EA, & De Marchi ACB (2019). Mobile health applications for chronic diseases: A systematic review of features for lifestyle improvement. Diabetes Metab Syndr, 13(4), 2507–2512. 10.1016/j.dsx.2019.07.016 [DOI] [PubMed] [Google Scholar]
  20. Dixon LJ, Kemp JJ, Farrell NR, Blakey SM, & Deacon BJ (2015). Interoceptive exposure exercises for social anxiety. Journal of Anxiety Disorders, 33, 25–34. 10.1016/j.janxdis.2015.04.006 [DOI] [PubMed] [Google Scholar]
  21. Eifert GH, Forsyth JP, Arch J, Espejo E, Keller M, & Langer D (2009). Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cognitive and Behavioral Practice, 16(4), 368–385. 10.1016/j.cbpra.2009.06.001 [DOI] [Google Scholar]
  22. Farrell NR, Deacon BJ, Kemp JJ, Dixon LJ, & Sy JT (2013). Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation. Journal of Anxiety Disorders, 27(8), 763–771. 10.1016/j.janxdis.2013.03.007 [DOI] [PubMed] [Google Scholar]
  23. Farris SG, & Kibbey MM (2022). Be brave, BE-FIT! An ACT-based exposure intervention to reduce exercise fear-avoidance in older adults. Cognitive Behaviour Therapy, 51(4), 273–294. 10.1080/16506073.2022.2037017 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Fitzgerald HE, Hoyt DL, Kredlow MA, Smits JAJ, Schmidt NB, Edmondson D, & Otto MW (2021). Anxiety sensitivity as a malleable mechanistic target for prevention interventions: A meta-analysis of the efficacy of brief treatment interventions. Clinical Psychology: Science and Practice, 28(4), 323–337. 10.1037/cps0000038 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Garey L, Hébert ET, Mayorga NA, Chavez JF, Shepherd JM, Businelle MS, & Zvolensky MJ (2022). Evaluating the feasibility and acceptability of a mobile-based health technology for smoking cessation: Mobile Anxiety Sensitivity Program. British Journal of Clinical Psychology, 61(S1), 111–129. 10.1111/bjc.12294 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Garey L, Zvolensky MJ, Gallagher MW, Vujanovic AA, Kendzor DE, Stephens L, … Businelle MS (2022). A smartphone-based intervention for anxiety and depression in racially and ethnically diverse adults (EASE): Protocol for a randomized controlled trial. JMIR Research Protocols, 11(2), e40713. 10.2196/40713 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Gloster AT, Wittchen HU, Einsle F, Lang T, Helbig-Lang S, Fydrich T, … Arolt V (2011). Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT. Journal of Consulting and Clinical Psychology, 79(3), 406–420. 10.1037/a0023584 [DOI] [PubMed] [Google Scholar]
  28. Gould RA, Ott MW, & Pollack MH (1995). A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 15(8), 819–844. 10.1016/0272-7358(95)00048-8 [DOI] [Google Scholar]
  29. Hofmann SG, Bufka LF, & Barlow DH (1999). Panic provocation procedures in the treatment of panic disorder: Early perspectives and case studies. Behavior Therapy, 30(2), 305–317. 10.1016/S0005-7894(99)80010-0 [DOI] [Google Scholar]
  30. Horenstein A, Potter CM, & Heimberg RG (2018). How does anxiety sensitivity increase risk of chronic medical conditions? Clinical Psychology: Science and Practice, 25(3), 1–22. 10.1111/cpsp.12248 [DOI] [Google Scholar]
  31. Huppert JD, & Baker-Morissette SL (2003). Beyond the manual: The insider’s guide to panic control treatment. Cognitive and Behavioral Practice, 10(1), 2–13. 10.1016/S1077-7229(03)80003-2 [DOI] [Google Scholar]
  32. Ito LM, Noshirvani H, Basoglu M, & Marks IM (1996). Does exposure to internal cues enhance exposure to external cues in agoraphobia with panic? A pilot controlled study of self-exposure. Psychotherapy and Psychosomatics, 65, 24–28. [DOI] [PubMed] [Google Scholar]
  33. Lee K, Noda Y, Nakano Y, Ogawa S, Kinoshita Y, Funayama T, & Furukawa TA (2006). Interoceptive hypersensitivity and interoceptive exposure in patients with panic disorder: Specificity and effectiveness. BMC Psychiatry, 6, 1–9. 10.1186/1471-244X-6-32 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Lickel J, Nelson E, Lickel AH, & Deacon B (2008). Interoceptive exposure exercises for evoking depersonalization and derealization: A pilot study. Journal of Cognitive Psychotherapy, 22(4), 321–330. 10.1891/0889-8391.22.4.321 [DOI] [Google Scholar]
  35. Ljótsson B, Atterlöf E, Lagerlöf M, Andersson E, Jernelöv S, Hedman E, … Wicksell RK (2014). Internet-delivered acceptance and values-based exposure treatment for fibromyalgia: A pilot study. Cognitive Behaviour Therapy, 43(2), 93–104. 10.1080/16506073.2013.846401 [DOI] [PubMed] [Google Scholar]
  36. Ljótsson B, Hesser H, Andersson E, Lackner JM, El Alaoui S, Falk L, … Hedman E (2014). Provoking symptoms to relieve symptoms: A randomized controlled dismantling study of exposure therapy in irritable bowel syndrome. Behaviour Research and Therapy, 55(1), 27–39. 10.1016/j.brat.2014.01.007 [DOI] [PubMed] [Google Scholar]
  37. Olatunji BO, Deacon BJ, & Abramowitz JS (2009). The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cognitive and Behavioral Practice, 16(2), 172–180. 10.1016/j.cbpra.2008.07.003 [DOI] [Google Scholar]
  38. Oser M, Khan A, Kolodziej M, Gruner G, Barsky AJ, & Epstein L (2021). Mindfulness and interoceptive exposure therapy for anxiety sensitivity in atrial fibrillation: A pilot study. Behavior Modification, 45(3), 462–479. 10.1177/0145445519877619 [DOI] [PubMed] [Google Scholar]
  39. Pompoli A, Furukawa TA, Efthimiou O, Imai H, Tajika A, & Salanti G (2018). Dismantling cognitive-behaviour therapy for panic disorder: A systematic review and component network meta-analysis. Psychological Medicine, 48(12), 1945–1953. 10.1017/S0033291717003919 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Richard DCS, & Gloster AT (2007). Exposure therapy has a public relations problem: A dearth of litigation amid a wealth of concern. In Richard DCS & Lauterbach D (Eds.), Handbook of Exposure Therapies (pp. 409–425). 10.1016/B978-012587421-2/50019-3 [DOI] [Google Scholar]
  41. Ross CJM, Davis TMA, & MacDonald GF (2005). Cognitive-behavioral treatment combined with asthma education for adults with asthma and coexisting panic disorder. Clinical Nursing Research, 14(2), 131–157. 10.1177/1054773804273863 [DOI] [PubMed] [Google Scholar]
  42. Roy-Byrne PP, Davidson KW, Kessler RC, Asmundson GJG, Goodwin RD, Kubzansky L, … Stein MB (2008). Anxiety disorders and comorbid medical illness. General Hospital Psychiatry, 30(3), 208–225. 10.1016/j.genhosppsych.2007.12.006 [DOI] [PubMed] [Google Scholar]
  43. Särnholm J, Skúladóttir H, Rück C, Klavebäck S, Ólafsdóttir E, Pedersen SS, … Ljótsson B (2021). Internet-delivered exposure-based therapy for symptom preoccupation in atrial fibrillation: Uncontrolled pilot trial. JMIR Cardio, 5(1). 10.2196/24524 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Särnholm J, Skúladóttir H, Rück C, Pedersen SS, Braunschweig F, & Ljótsson B (2017). Exposure-based therapy for symptom preoccupation in atrial fibrillation: An uncontrolled pilot study. Behavior Therapy, 48(6), 808–819. 10.1016/j.beth.2017.06.001 [DOI] [PubMed] [Google Scholar]
  45. Schmidt NB, & Trakowski J (2004). Interoceptive assessment and exposure in panic disorder: A descriptive study. Cognitive and Behavioral Practice, 11(1), 81–92. 10.1016/S1077-7229(04)80010-5 [DOI] [Google Scholar]
  46. Schmidt NB, & Woolaway-Bickel K (2000). The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: Quality versus quantity. Journal of Consulting and Clinical Psychology, 68(1), 13–18. 10.1037//0022-006x.68.1.13 [DOI] [PubMed] [Google Scholar]
  47. Smith LC, Fogel D, & Friedman S (1998). Cognitive-behavioral treatment of panic disorder with agoraphobia triggered by AICD implant activity. Psychosomatics, 39(5), 474–477. 10.1016/S0033-3182(98)71311-8 [DOI] [PubMed] [Google Scholar]
  48. Taylor S (2000). Interoceptive and situational expsoure. In Taylor S (Ed.), Understanding and treating panic disorder: Cognitive-behavioral approaches (pp. 339–365). Wiley & Sons. [Google Scholar]
  49. Taylor S, Zvolensky MJ, Cox BJ, Deacon B, Heimberg RG, Ledley DR, … Cardenas SJ (2007). Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19(2), 176–188. 10.1037/1040-3590.19.2.176 [DOI] [PubMed] [Google Scholar]
  50. Tien KJ, Goodie JL, Duncan CL, Szabo MM, & Larson NA (2014). Is it asthma or a panic attack? A case study of asthma and anxiety in an adolescent male. Clinical Practice in Pediatric Psychology, 2(2), 142–152. 10.1037/cpp0000057 [DOI] [Google Scholar]
  51. Tully PJ, Sardinha A, & Nardi AE (2017). A new CBT model of Panic Attack Treatment in Comorbid Heart Diseases (PATCHD): How to calm an anxious heart and mind. Cognitive and Behavioral Practice, 24(3), 329–341. 10.1016/j.cbpra.2016.05.008 [DOI] [Google Scholar]
  52. Weingarten E, Chen Q, McAdams M, Yi J, Hepler J, & Albarracin D (2016). From Primed Concepts to Action: A Meta-Analysis of the Behavioral Effects of Incidentally-Presented Words. Psychological Bulletin, 142(5), 472–497. 10.1037/bul0000030 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Zvolensky MJ, Garey L, Fergus TA, Gallagher MW, Viana AG, Shepherd JM, … Schmidt NB (2018).Zvolensky, M. J., Garey, L., Fergus, T. A., Gallagher, M. W., Viana, A. G., Shepherd, J. M., Mayorga, N. A., Kelley, L. P., Griggs, J. O., & Schmidt, N. B. (2018). (2018). Refinement of anxiety sensitivity measurement: The Short Scale Anxiety Sensitivity Index (SSASI). Psychiatry Research, 269, 549–557. 10.1016/j.psychres.2018.08.115 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data for the current study are available upon request.

RESOURCES