Clinical Handbook

of Fear and Anxiety

Clinical Handbook
of Fear and Anxiety
Maintenance Processes and
Treatment Mechanisms

Edited by
JONATHAN S. ABRAMOWITZ and SHANNON M. BLAKEY

American Psychological Association

Washington, DC
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Library of Congress Cataloging-in-Publication Data

Names: Abramowitz, Jonathan S., editor. | Blakey, Shannon M., editor.

Title: Clinical handbook of fear and anxiety : maintenance processes and treatment
mechanisms / edited by Jonathan S. Abramowitz and Shannon M. Blakey.
Description: Washington, DC : American Psychological Association, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019012059 (print) | LCCN 2019012796 (ebook) |
ISBN 9781433831430 (eBook) | ISBN 1433831430 (eBook) |
ISBN 9781433830655 (hardcover)
Subjects: LCSH: Anxiety—Physiological aspects. | Anxiety disorders—Treatment.
Classification: LCC RC531 (ebook) | LCC RC531 .C55 2020 (print) |
DDC 616.85/22—dc23
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http://dx.doi.org/10.1037/0000150-000

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1
 To my loving family: Stacy, Emily, and Miriam
—JONATHAN S. ABRAMOWITZ

To Brett, Susan, Brittany, and Grant: Thank you

for your endless love and support
—SHANNON M. BLAKEY

To all of the patients and therapists we’ve worked

with and learned from
—JONATHAN S. ABRAMOWITZ & SHANNON M. BLAKEY
CONTENTS

Contributors ix
Preface xiii

I. MAINTENANCE PROCESSES 1
Introduction to Part I: Why Psychological Maintenance Processes? 3
Shannon M. Blakey and Jonathan S. Abramowitz

1. Overestimation of Threat 7
Jonathan S. Abramowitz and Shannon M. Blakey

2. Safety Behaviors 27
Michael J. Telch and Eric D. Zaizar

3. Intolerance of Uncertainty 45
Ryan J. Jacoby

4. Anxiety Sensitivity 65
Steven Taylor

5. Disgust Sensitivity 81
Peter J. de Jong and Charmaine Borg

6. Distress Intolerance 99
Caitlin A. Stamatis, Stephanie E. Hudiburgh, and Kiara R. Timpano

7. Experiential Avoidance 115

Sarah A. Hayes-Skelton and Elizabeth H. Eustis

8. Worry and Rumination 133

Thane M. Erickson, Michelle G. Newman, and Jamie L. Tingey

vii
viii Contents

9. Perfectionism 153
Ariella P. Lenton-Brym and Martin M. Antony

10. Metacognition 171

Adrian Wells and Lora Capobianco

11. Autobiographical Memory Bias 183

Mia Romano, Ruofan Ma, Morris Moscovitch, and David A. Moscovitch

12. Attention Bias 203

Omer Azriel and Yair Bar-Haim

13. Interpersonal Processes 219

Jonathan S. Abramowitz and Donald H. Baucom

II. TREATMENT MECHANISMS 239

Introduction to Part II: Why Mechanisms of Change? 241
Jonathan S. Abramowitz and Shannon M. Blakey

14. Habituation 249

Jessica L. Maples-Keller and Sheila A. M. Rauch

15. Inhibitory Learning 265

Amy R. Sewart and Michelle G. Craske

16. Cognitive Change via Rational Discussion 287

Lillian Reuman, Jennifer L. Buchholz, Shannon M. Blakey,
and Jonathan S. Abramowitz

17. Behavioral Activation 305

Matt R. Judah, Jennifer Dahne, Rachel Hershenberg, and Daniel F. Gros

18. Mindfulness and Acceptance 323

Clarissa W. Ong, Brooke M. Smith, Michael E. Levin, and Michael P. Twohig

19. Pharmacological Enhancement of Extinction Learning 345

Valérie La Buissonnière-Ariza, Sophie C. Schneider, and Eric A. Storch

20. Interpretation Bias Modification 359

Courtney Beard and Andrew D. Peckham

Index 379
About the Editors 399
CONTRIBUTORS

Jonathan S. Abramowitz, PhD, Department of Psychology and

Neuroscience, University of North Carolina at Chapel Hill
Martin M. Antony, PhD, Department of Psychology, Ryerson University,
Toronto, Ontario, Canada
Omer Azriel, MA, School of Psychological Sciences and Sagol School of
Neuroscience, Tel Aviv University, Tel Aviv, Israel
Yair Bar-Haim, PhD, School of Psychological Sciences and Sagol School
of Neuroscience, Tel Aviv University, Tel Aviv, Israel
Donald H. Baucom, PhD, Department of Psychology and Neuroscience,
University of North Carolina at Chapel Hill
Courtney Beard, PhD, Behavioral Health Partial Hospital Program,
McLean Hospital, Belmont, MA, and Department of Psychiatry,
Harvard Medical School, Boston, MA
Shannon M. Blakey, PhD, VA Mid-Atlantic Mental Illness Research,
Education and Clinical Center, Durham VA Health Care System,
Durham, NC
Charmaine Borg, PhD, Faculty of Behavioral and Social Sciences,
University of Groningen, Groningen, The Netherlands
Jennifer L. Buchholz, MA, Department of Psychology and Neuroscience,
University of North Carolina at Chapel Hill
Lora Capobianco, PhD, BA, CPsychol, MCT-PATHWAY, Greater
Manchester Mental Health NHS Trust, Manchester, United Kingdom
Michelle G. Craske, PhD, Department of Psychology, University of
California, Los Angeles

ix
x Contributors

Jennifer Dahne, PhD, Department of Psychiatry and Behavioral Sciences,

Medical University of South Carolina, Charleston
Peter J. de Jong, PhD, Faculty of Behavioral and Social Sciences, University
of Groningen, Groningen, The Netherlands
Thane M. Erickson, PhD, School of Psychology, Family, and Community,
Seattle Pacific University, Seattle, WA
Elizabeth H. Eustis, MA, Psychology Department, University of
Massachusetts Boston, and Department of Psychiatry and Human Behavior,
Warren Alpert Medical School of Brown University, Providence, RI
Daniel F. Gros, PhD, Health Services Research and Development,
Ralph H. Johnson Veterans Affairs Medical Center, and Department of
Psychiatry and Behavioral Sciences, Medical University of South Carolina,
Charleston
Sarah A. Hayes-Skelton, PhD, Psychology Department, University of
Massachusetts Boston
Rachel Hershenberg, PhD, Department of Psychiatry and Behavioral
Sciences, Emory University School of Medicine, Atlanta, GA
Stephanie E. Hudiburgh, BS, Department of Psychology, University of
Miami, Miami, FL
Ryan J. Jacoby, PhD, Obsessive-Compulsive Disorder and Related Disorders
Program, Massachusetts General Hospital, Boston, MA
Matt R. Judah, PhD, Department of Psychology, Old Dominion University,
Norfolk, VA
Valérie La Buissonnière-Ariza, PhD, Department of Psychiatry and
Behavioral Sciences, Baylor College of Medicine, Houston, TX
Ariella P. Lenton-Brym, MA, Department of Psychology, Ryerson University,
Toronto, Ontario, Canada
Michael E. Levin, PhD, Department of Psychology, Utah State University,
Logan
Ruofan Ma, BMath, Department of Psychology, University of Waterloo,
Waterloo, Ontario, Canada
Jessica L. Maples-Keller, PhD, Department of Psychiatry and Behavioral
Sciences, Emory University School of Medicine, Atlanta, GA
David A. Moscovitch, PhD, CPsych, Department of Psychology, University
of Waterloo, Waterloo, Ontario, Canada
Morris Moscovitch, PhD, Department of Psychology, University of Toronto,
Toronto, Ontario, Canada
Michelle G. Newman, PhD, Department of Psychology, The Pennsylvania
State University, University Park
Clarissa W. Ong, BA, Department of Psychology, Utah State University,
Logan
Andrew D. Peckham, PhD, Behavioral Health Partial Hospital Program,
McLean Hospital, Belmont, MA, and Department of Psychiatry, Harvard
Medical School, Boston, MA
 Contributors xi

Sheila A. M. Rauch, PhD, Mental Health Research and Program Evaluation,

VA Atlanta Healthcare System, and Department of Psychiatry and
Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
Lillian Reuman, MA, Veteran Affairs Boston Health System, Boston, MA,
and Department of Psychology and Neuroscience, University of North
Carolina at Chapel Hill
Mia Romano, PhD, Department of Psychology, University of Waterloo,
Waterloo, Ontario, Canada
Sophie C. Schneider, PhD, Department of Psychiatry and Behavioral
Sciences, Baylor College of Medicine, Houston, TX
Amy R. Sewart, MA, Department of Psychology, University of California,
Los Angeles
Brooke M. Smith, MS, Department of Psychology, Utah State University,
Logan
Caitlin A. Stamatis, MS, Department of Psychology, University of Miami,
Miami, FL
Eric A. Storch, PhD, Department of Psychiatry and Behavioral Sciences,
Baylor College of Medicine, Houston, TX
Steven Taylor, PhD, Department of Psychiatry, University of British Colum-
bia, Vancouver, British Columbia, Canada
Michael J. Telch, PhD, Department of Psychology, University of Texas at
Austin
Kiara R. Timpano, PhD, Department of Psychology, University of Miami,
Miami, FL
Jamie L. Tingey, MS, School of Psychology, Family, and Community,
Seattle Pacific University, Seattle, WA
Michael P. Twohig, PhD, Department of Psychology, Utah State University,
Logan
Adrian Wells, PhD, MSc, BSc, CPsychol, FBPsS, School of Psychological
Sciences, University of Manchester, Manchester, United Kingdom
Eric D. Zaizar, BA, Department of Psychology, University of Texas at Austin
PREFACE
Jonathan S. Abramowitz and Shannon M. Blakey

Clinicians and researchers in the field of mental health have traditionally

operated as if the Diagnostic and Statistical Manual of Mental Disorders (fifth ed.
[DSM–5]; American Psychiatric Association, 2013) and International Classification
of Diseases (11th ed. [ICD–11]; World Health Organization, 2018) carve nature
at its joints in delineating discrete anxiety and related disorders. This can
be seen in the siloed approaches taken by the field’s experts to developing
conceptual models and treatment protocols for various DSM- and ICD-defined
conditions. An array of empirically supported treatment manuals are available
for different disorders, as if each problem requires a distinct intervention
program. Yet, the DSM–5 and ICD–11 delineates these disorders superficially—
largely on the basis of how anxiety is manifested topographically (e.g., fear
of social situations vs. obsessions and compulsions). However, a more careful
look at the conceptual models and treatment packages across these conditions
reveals a high degree of redundancy in their core underlying psychological
processes (e.g., overestimates of threat), active treatment ingredients (e.g.,
exposure to feared situations/stimuli), and putative mechanisms of change
(e.g., changes in cognition). At this more fundamental, functional level,
anxiety and related disorders have more commonalities than differences.
Recognizing these issues, we take the perspective that the boundaries
around anxiety and related disorders imposed by the DSM–5 and ICD–11 are
illusory. Moreover, we argue that the disorder-driven approach in treat-
ment manuals compromises efficiency and efficacy in the treatment of clin-
ical anxiety. Clinicians are traditionally trained to follow separate treatment
manuals for each disorder, as if they were distinct, but this is a cumbersome
method for acquiring broad competency in providing psychological treatment.

xiii
xiv Preface

In addition, although manuals serve an important purpose in carefully con-

trolled research studies, they too often emphasize clinical technique and obscure
the recognition that the same evidence-based psychological processes and
active ingredients in therapy are broadly applicable across anxiety disorders.
Manuals are also generally written with an assumption that one size fits all,
though most patients with anxiety do not neatly fit diagnostic prototypes and
often present with multiple, diverse, and complex manifestations of fear.
Providing effective therapy for such individuals necessitates thinking beyond
manuals and flexibly applying theoretical principles when implementing
treatment.
Our blueprint for this handbook was to put under one cover a more efficient
framework for understanding and targeting the processes shown to contribute
to clinical anxiety in its various manifestations, irrespective of DSM–5 or ICD–11
diagnosis (often referred to as transdiagnostic processes). Specifically, and diverg-
ing from a disorder-based focus, the chapters in this handbook delineate key
empirically supported maintenance processes (e.g., threat overestimation)
and theorized mechanisms of change (e.g., inhibitory learning) driving treat-
ment efficacy. It is our view that understanding, assessing, and treating clinical
anxiety at this functional level allows clinicians to use cognitive and behavioral
methods to their maximum capacity. We have asked authors to produce clini-
cally oriented chapters that integrate conceptual and practical content across
the handbook’s two parts. The chapters in Part I focus on various processes
shown to maintain clinical anxiety, highlighting their conceptual significance,
methods of assessment, and implications for treatment. The chapters in Part II
focus on candidate mechanisms of change thought to explain how treatment
works, describing methods for implementing therapeutic techniques that acti-
vate the particular change mechanism.
This handbook represents a progressive, “post-DSM/ICD” approach to under-
standing and treating clinical anxiety. In our own clinical work—and in training
other therapists—we often encounter frustration with the existing diagnostic
paradigm and its barriers to the efficient use of empirically supported psycho-
logical treatments. It is our hope that this handbook enables clinicians work-
ing with patients with anxiety to slip the restrictive bonds of DSM–5 and
ICD–11 diagnoses and treatment manuals and operate more flexibly and with
a richer understanding of cognitive and behavioral principles and mechanisms
of change.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
World Health Organization. (2018). International classification of diseases, 11th revision.
Retrieved from https://icd.who.int/
I
MAINTENANCE
PROCESSES
Introduction to Part I
Why Psychological Maintenance Processes?
Shannon M. Blakey and Jonathan S. Abramowitz

A nxiety, broadly defined, is a natural reaction experienced by all living

animals to perceived threat and manifested via cognitive (e.g., racing
thoughts), physiological (e.g., autonomic arousal), and behavioral responses
(e.g., escape, avoidance). Anxiety is universal and normal, and it is essential
for survival. Consider our evolutionary ancestors: If early human beings did
not fear and avoid faster and stronger predators, our species would likely have
died out long ago. Yet despite this, many individuals experience recurrent
episodes of clinical anxiety—excessive or inappropriate anxiety that is dis-
proportionate to the true degree of danger present in a given (or anticipated)
situation. If anxiety can be considered a natural and adaptive “alarm reaction”
to perceived threat, then clinical anxiety represents a “false alarm.” In stan-
dard diagnostic and classification systems, problems with clinical anxiety are
often labeled as generalized anxiety disorder, panic disorder, agoraphobia,
social anxiety disorder, specific phobia, obsessive-compulsive disorder (OCD),
body dysmorphic disorder, posttraumatic stress disorder, and illness anxiety
disorder. These anxiety-related disorders constitute the most common class
of mental health complaints (Kessler, Chiu, Demler, & Walters, 2005) and
are associated with substantial functional impairment and economic burden
(e.g., DuPont et al., 1996; Greenberg et al., 1999).
Historically, the treatment and study of clinical anxiety have been domi-
nated by a “disorder focus” (Deacon, 2013). Indeed, clinicians and clinical
scientists tend to think in terms of the diagnostic labels described in standard
classification manuals, particularly the fifth edition of the American Psychiatric
Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders and
the 11th edition of the World Health Organization’s (2018) International Clas-
sification of Diseases. Researchers tend to be interested in understanding the

3
4 Why Psychological Maintenance Processes?

epidemiology, etiology, and maintenance of one or more specific disorders,

usually with the goal of developing more effective treatments for such disorders.
Clinicians are also likely to proceed by conducting diagnostic assessments and
then targeting disorders one at a time in treatment (especially because many
treatment programs are developed for single, specific disorders).
To be sure, the traditional diagnosis-driven approach has advanced the
understanding and treatment of many anxiety disorders as defined in standard
classification manuals. However, there is marked similarity in the psycho­
logical processes that are involved in the development and maintenance of
anxiety across conditions. Research has found stunning overlaps in particular
cognitive (e.g., the tendency to overestimate threat) and behavioral (e.g., the
use of safety behaviors) phenomena that are observed across anxiety and
related disorders. Such processes may exert varying amounts of influence,
depending on the manifestation of anxiety, or have different themes across
clinical disorders (e.g., selective attention toward feared contaminants in
OCD and toward internal sensations in panic disorder), but the fundamental
processes and their contribution to the maintenance of clinical anxiety are
relatively stable transdiagnostically.
Furthermore, these processes occur on a continuum with normality and
do not represent biological “defects” or “malfunctions.” Rather, they are biased
forms of thinking, fear-driven ways of behaving, and other individual differ-
ence variables and interpersonal processes that are also observed in people
who do not meet diagnostic criteria for anxiety disorders. Individuals given a
psychiatric diagnosis of an anxiety or related disorder differ from “nonclinical”
individuals only in the frequency, intensity, or duration of these processes.
There also is a marked similarity in the techniques used in effective psycho-
logical treatment for anxiety and related disorders (the topic of Part II of this
handbook), which mostly serve to correct the aforementioned psychological
maintenance processes.
Overemphasis on psychiatric diagnosis also becomes frustratingly unhelpful
for many clinicians. In some cases, an individual with clinically significant
anxiety does not actually meet diagnostic criteria for any anxiety-related dis-
order; in others, someone with a conceptually linked set of fears may receive
several anxiety-related diagnoses. In still other cases, the single “correct”
diagnosis is difficult to determine. Imagine a woman who describes fears that
she has colon cancer and reports that she pays close attention to the perceived
signs of such an ailment (e.g., tiredness, abdominal discomfort, changes in the
color and consistency of stool), seeks immediate reassurance and medical
attention whenever she notices these signs, and experiences panic symptoms
when she thinks about colon cancer or believes she has spotted a symptom.
Would a clinician be inclined to diagnose her with OCD, illness anxiety disorder,
or panic disorder? Alternatively, consider a man who reports crippling anxiety
in crowds because such situations elicit hyperventilation, fears of having a
“full blown” panic attack, and worries that he will not be able to control himself
such that other people will notice him screaming or acting foolishly. Would
 Introduction to Part I 5

a clinician diagnosis him with panic disorder, agoraphobia, or social anxiety

disorder? More important—and in line with the aims of this handbook—
would different answers to these questions dictate fundamentally different
treatment approaches? Should different answers to these questions dictate
fundamentally different treatment approaches?

OVERVIEW OF PART I

When these diagnostic dilemmas are considered with the transdiagnostic

overlap in psychological processes and their continuum with normality, then
the categorical conceptualization of the anxiety-related disorders does not
reflect reality. The purpose of Part I of this handbook is to facilitate a shift in
perspective away from the traditional disorder-focused approach and toward
an understanding of the psychological maintenance processes common across
the myriad presentations of anxiety. Research has shown that the anxiety-
related disorders share, to a great extent, several key psychological mechanisms
that contribute to the development and persistence of clinical anxiety. Most—
if not all—presentations of clinical anxiety may be understood in terms of
these overlapping phenomena, which also have key assessment and treatment
implications.
To this end, the chapters in Part I identify and elucidate 13 empirically
supported psychological processes relevant to the maintenance of clinical
anxiety. Transdiagnostic cognitive behavior theory recognizes (a) the impos-
sibility of definitively identifying the root cause of a psychological condition,
(b) the inability to undo the past (e.g., “unexperience” trauma), and (c) equi-
finality in the development of psychological conditions (i.e., that multiple
experiences—or combinations of experiences—may lead to the same psycho-
logical symptoms). Although potential etiological factors are acknowledged,
they do not necessarily serve as practical targets for change and are therefore
given minimal attention over the course of therapy. That is not to say that the
study of etiological variables is not important; such research may inform pre-
vention and early intervention programs. Rather, the cognitive and behavioral
factors demonstrated by empirical evidence to be involved in the maintenance
of anxiety problems serve as the focus of Part I of this handbook.
Each chapter in Part I follows a general format in which the psychological
maintenance process is first defined and described. Next, authors discuss the
process’s conceptual implications (i.e., how it contributes to the maintenance
of clinical anxiety) and describe methods for assessing the process, including
self-report, interview, and observational methods. Finally, authors highlight
the clinical implications of the process using case examples to illustrate how a
therapist might encounter this process in their clinical work with patients
presenting with clinical anxiety.1 We hope that these chapters will move the

All clinical case material has been altered to protect patient confidentiality.
1
6 Why Psychological Maintenance Processes?

reader from a disease-based understanding of clinical anxiety toward viewing

these problems as a self-perpetuating cycle in which an exaggerated threat
response to a particular set of stimuli is perpetuated by cognitive and behav-
ioral psychological processes.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its
validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33,
846–861. http://dx.doi.org/10.1016/j.cpr.2012.09.007
DuPont, R. L., Rice, D. P., Miller, L. S., Shiraki, S. S., Rowland, C. R., & Harwood, H. J.
(1996). Economic costs of anxiety disorders. Anxiety, 2, 167–172. http://dx.doi.org/
10.1002/(SICI)1522-7154(1996)2:4<167::AID-ANXI2>3.0.CO;2-L
Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson,
J. R., . . . Fyer, A. J. (1999). The economic burden of anxiety disorders in the 1990s.
The Journal of Clinical Psychiatry, 60, 427–435. http://dx.doi.org/10.4088/JCP.v60n0702
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity,
and comorbidity of 12-month DSM–IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62, 617–627. http://dx.doi.org/10.1001/
archpsyc.62.6.617
World Health Organization. (2018). International classification of diseases (11th ed.). Geneva,
Switzerland: Author.
1
Overestimation of Threat
Jonathan S. Abramowitz and Shannon M. Blakey

Elaine was a corporate accountant who had an intense fear of public speaking.1
Normally, because of the nature of her work, she was not required to speak in
front of groups. Every now and then, however, her supervisor would ask her to
provide account updates at department meetings. This involved getting up
and speaking about budgets and expenses for 15 minutes in front of a con­
ference room filled with her coworkers. Although Elaine’s presentations were
routinely satisfactory and she received only positive feedback after each one,
the days leading up to these meetings were always filled with dread. Elaine
would anticipate worst case scenarios, such as “I’ll mispronounce a patient’s
name,” “I’ll be so anxious that I’ll sweat in front of everyone—I would die from
the embarrassment,” and “What if I give inaccurate figures?” Before every pre­
sentation, Elaine would convince herself that she would be fired on the spot
because of her mistakes and miscues. Then, she told herself, she would never
be able to get another accounting job in the city where she lived. As a way of
preventing such feared disasters, Elaine rehearsed excessively for her presenta­
tions, making sure to pronounce everything correctly and checking her num­
bers at least five times. She also wore layered clothing and extra makeup to
make sure that any signs of anxiety such as blushing or sweating wouldn’t
be noticeable.

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-001
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
7
8 Abramowitz and Blakey

A close look at the components of Elaine’s fear reveals that she is over­
estimating the threat associated with public speaking. Indeed, despite her
negative thoughts, she had received only positive feedback about the presen-
tations she gave. Moreover, even if she did make mistakes or appear anxious,
this would probably not result in the drastic consequences she feared. To be
more specific, Elaine demonstrates two common types of threat overestima-
tions: (a) overestimates of the likelihood (or probability) of feared events and
(b) overestimates of the severity (or costs) of feared events.
Likelihood overestimation, also known as “jumping to conclusions,” occurs
when negative events are judged as being much more probable than they are
in reality. For example, the fear of flying is among the most common phobias
(Barlow, 2004; Fredrikson, Annas, Fischer, & Wik, 1996), and many sufferers
avoid flying based on the belief that their plane will crash. The probability of
a plane crash, however, is exceptionally low. In Elaine’s case, she overesti-
mated the likelihood of making mistakes and others noticing her anxiety
even though she routinely performed well and received positive feedback.
Severity overestimation, also termed “catastrophizing,” implies viewing an
event as “truly awful,” “unbearable,” or “devastating” (i.e., 101% bad) when,
in reality, it is tolerable, even if undesirable, unpleasant, or emotionally or
physically painful. Examples of severity overestimations include thinking that
a dog bite would be excruciating, a poor grade would mean a lifetime of fail-
ure and disappointment, and an emotional trauma would “ruin my life for-
ever.” Elaine’s beliefs that she would “die of embarrassment” and be fired are
overestimates of the severity of making mistakes and appearing anxious.
Whereas overestimates of threat are common in the general population
regardless of psychological well-being, these thinking errors are most fre-
quently observed among those with clinical anxiety. Moreover, the content
of such overestimates are typically specific to the nature and triggers of one’s
fear. Although these beliefs might map on to particular diagnostic categories
(e.g., disorders described in the Diagnostic and Statistical Manual of Mental Dis­
orders [fifth ed.; DSM–5; American Psychiatric Association, 2013]), as we dis-
cuss later in this chapter, they are a transdiagnostic process in that they
operate independent of diagnostic status.

CONCEPTUAL IMPLICATIONS

In this section, we place the phenomenon of threat overestimation within a

conceptual framework and discuss how it presents across different presenta-
tions of fear and anxiety.

Cognitive Model of Emotion

The concept of threat overestimation is drawn from cognitive and cognitive

behavioral models of emotion, which emphasize the role of thinking (e.g.,
 Overestimation of Threat 9

beliefs, assumptions) in the production of feelings. In particular, Beck’s (1976)

cognitive specificity model stipulates that feelings and emotions are caused
not by situations or stimuli per se, but rather (in large part) by how the
person ascribes meaning to certain situations or stimuli. Moreover, particular
emotional responses are linked with specific interpretations. For example,
interpretations concerned with loss lead to depression, whereas the percep-
tion that one has deliberately been treated with disrespect leads to anger. In
a similar vein, unrealistic (overestimated) perceptions of the degree of threat
or danger lead to anxiety (e.g., Amir, Foa, & Coles, 1998; Beck, Emery, &
Greenberg, 2005).
Elaine’s case illustrates this point: It is not the presentations that are the
problem per se, but rather how she thinks about what will happen in these
meetings that leads to her distress. From the cognitive perspective, Elaine’s
exaggerated beliefs about (a) what could happen during a presentation and
(b) how awful the fallout would be are the core process leading to her fear
and anxiety (depicted in Figure 1.1). In this way, overestimates of threat
maintain clinical anxiety and fear by directly generating these emotional
responses. Accordingly (and as is addressed in several chapters in Part II of
this handbook), a critical focus of the treatment of clinical fear and anxiety is
challenging and correcting overestimates of threat, as opposed to trying to
modify the feared situation or stimulus itself.
It is worth noting that many people overcome irrational fears on their
own—their overestimates of threat seem to self-correct. Yet for individuals
with clinical anxiety, something appears to prevent such self-correction. Again,
consider that Elaine remains fearful of giving work presentations despite
receiving positive feedback. She does not seem to notice that her actual perfor-
mance in the conference room fails to match her beliefs that she is at risk of
making mistakes and being fired. Why doesn’t she recognize that she is a more
skilled presenter than she thinks? Why doesn’t she realize she is unlikely to
lose her job? More generally, why don’t anxious and fearful individuals recog-
nize that they are making mistakes in their thinking and simply correct them?

Role of Safety Behaviors

One reason that threat overestimates persist in the face of even dramatic dis-
confirmatory evidence is that they lead to safety behaviors—efforts to detect,

FIGURE 1.1. The Relationship Between Events, Beliefs, and Emotional

Consequences

Activating event Beliefs Consequences

• I will make mistakes

Upcoming • I will appear anxious
presentation • I will be fired Anxiety, fear
• I will never be able
to find another job
10 Abramowitz and Blakey

escape from, or avoid the feared outcome (as discussed in detail in Chapter 2).
Such behaviors may be adaptive when an objective threat is present (e.g.,
washing one’s hands after touching raw meat while preparing a meal), yet
when threat is objectively low, safety behaviors maintain threat overestimates
by causing the person to erroneously think that he or she narrowly averted
catastrophe (Salkovskis, 1991). Elaine’s practice of excessive rehearsal before
her presentations may be considered a safety behavior because the risk and
cost of making a mistake are objectively low. Yet when her presentation goes
well and she does not get fired, she believes that it was the rehearsal that
prevented these negative outcomes, rather than concluding that she is gener-
ally adept at giving presentations. Thus, as long as she continues performing
safety behaviors, her overestimates of threat remain unchallenged (e.g.,
Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999).

Role of Information-Processing Biases

As part of the normal human fear (i.e., fight-or-flight) response, individuals

automatically filter information in ways that confirm their overestimates of
threat. Such a bias serves to protect us from harm when danger is actually
present; yet, this way of thinking preserves inaccurate overestimates of the
likelihood and severity of threat when the risk of harm is objectively low.
One such information-processing bias is selective attention to threat cues
(as discussed in detail in Chapter 12). It is adaptive to be vigilant for sources
of harm when danger is perceived—not doing so could be deadly. Accord-
ingly, the perception of threat is naturally accompanied by an automatic shift
in attention to the source of danger. As a result, the environment may seem
especially dangerous despite an objectively low risk of danger. Using Elaine
as an example, she might become highly attentive to anything that could be
perceived as a threatening response to her presentation, such as colleagues
whispering in the audience, which might be misinterpreted as a sign that
someone noticed a mistake.
A similar mechanism engendered by overestimates of threat is confir­
mation bias. The survival value of assuming that a situation is dangerous
is significantly higher than that of assuming safety. Accordingly, when we
perceive danger, we automatically seek information to confirm the risks.
Yet if the perception of danger is based on erroneous overestimates of threat,
this results in the collection and misinterpretation of benign or ambiguous
information as danger confirming (while simultaneously discounting danger-
disconfirming evidence), which maintains the faulty threat estimates. Elaine,
for example, might scan the conference room looking for signs of dis­approval
(e.g., a supervisor frowning) and may even misinterpret ambiguous feedback
(e.g., a colleague’s failure to nod in approval) as confirming her threat
overestimates.
Memory bias—the tendency to easily remember information that is con-
sistent with fear-related beliefs—also maintains overestimates of threat (as
 Overestimation of Threat 11

covered in detail in Chapter 11). Thus, someone like Elaine might easily remem-
ber and base her predictions on one instance in which she mis­pronounced a
word while rehearsing two years ago. Together, selective attention, confirma-
tion bias, and memory bias work to increase the probability that fear cues are
noticed, encoded into memory, and subsequently retrieved in related future
situations, thereby maintaining overestimates of threat.
Finally, the experience of anxiety itself in feared situations often gives rise
to the tendency to infer further danger. This phenomenon is often referred to
as emotional reasoning because people mistakenly look to their emotional state
for information about the dangerousness of a given situation (Arntz, Rauner,
& van den Hout, 1995). Returning to Elaine, as she begins to experience
shakiness and “butterflies” in her stomach in the moments before she stands
to give her presentation, her emotional reasoning that she will inevitably
make mistakes and be visibly anxious contributes to the vicious cycle that
maintains her threat overestimates over time.

Origins of Threat Overestimation

One way threat overestimates may develop is through a direct, negative

experience with an object or situation. Following a dog bite, for example, one
may come to expect that dogs are dangerous. Still, many people have traumatic
experiences but never develop overestimates of threat or excessive fear (e.g.,
Ollendick, King, & Muris, 2002). Vicarious conditioning (i.e., modeling), which
refers to learning that occurs through observing others, is another pathway to
the development of threat overestimates. Specifically, we may learn to over-
estimate the likelihood or severity of certain objects or situations simply by
witnessing other people’s experiences or by observing others act in a fearful
manner (Mineka & Zinbarg, 2006). Third, overestimates of threat might be
transmitted by parents, peers, the media, and other sources. For example, the
message that germs are ubiquitous, dangerous, and require diligent cleansing
is often conveyed by well-meaning family members, television commercials
for antibacterial products, and sensationalistic reports in the media.

ASSESSMENT

Overestimates of threat are idiosyncratic to particular situations and the

people who experience them. Many anxious individuals express these types
of beliefs quite readily during the initial interview—in fact, they might be
framed as the presenting problem or reason for seeking help. For example,
“I’ve stopped driving because I’m afraid I’ll cause an accident,” and “my
husband was diagnosed with high blood pressure and I’m afraid he’s going to
die and leave our family in financial ruin.” If such beliefs are not immediately
volunteered, they might be more or less easy to infer from any descriptions
of triggering situations or avoidance behavior. For example, it might be
12 Abramowitz and Blakey

anticipated that someone who carries hand sanitizer at all times overestimates
the threat of contamination. It is, however, important to consider such infer-
ences as hypotheses that can be tested by further interviewing. For example,
someone afraid of flying might fear this situation based on overestimates of
the likelihood of (a) a crash caused by engine failure, (b) a terrorist hijack, or
(c) a panic attack. Therefore, direct and open-ended questions are critical in
assessing overestimates of threat.
To this end, during a conceptually driven interview, a clinician might
explain the relationship between activating events (triggers), beliefs and
interpretations (e.g., overestimates of threat), and emotional and behavioral
consequences, soliciting personalized examples of each. Some questions can
help to elicit overestimates of threat:

• What goes through your mind when you are in a triggering situation?
• What specifically do you worry about in this situation?
• What leads you to avoid (or perform a safety behavior in) this situation?
• What is the worst thing that could happen in this situation?
• What do you tell yourself would be so bad about the situation?

Within such a clinical interview, the downward arrow technique (Beck, 1976;
Beck et al., 2005) is a helpful strategy for identifying specific overestimates of
threat (beliefs about probability and cost). This involves identifying an anxiety-
provoking situation and asking questions about the anticipated outcomes,
including how likely and how awful they would be. The clinician continues
to ask the same (or a similar) question until the patient provides a conclusive
statement that contains an exaggerated belief about likelihood or severity.
Extreme and unconditional statements (i.e., terms such as always, never, and
awful) also serve as verbal cues for overestimates of threat.
Because clinical interview data are not always complete, we recommend that
psychometrically validated self-report instruments be used as well. These have
the advantage of including carefully worded questions that have demonstrated
validity and reliability. Moreover, they allow a clinician to compare the patient’s
responses to well-established norms. Accordingly, questionnaires are valuable
for screening purposes, to corroborate information obtained in a clinical inter-
view, and to bring to light overestimates of threat that might not otherwise be
reported during the interview.
Several surveys and self-report measures assess overestimates of threat
across various fear domains, many of which are freely available online and in
the published literature. Examples are listed in Table 1.1.

CLINICAL IMPLICATIONS

As we have discussed, overestimates of threat drive the vicious cycle of

anxiety across domains of fear, whether or not they meet criteria for a psycho­
logical disorder as defined by the DSM–5 or the International Classification
 Overestimation of Threat 13

TABLE 1.1. Self-Report Assessment Measures of Overestimates of Threat

Across Different Types of Feared Stimuli
Category and measure name Source
Animals
   Spider Phobia Beliefs Questionnaire Arntz, Lavy, van den Berg, and
van Rijsoort (1993)

Natural environments and disasters

   The Claustrophobia Questionnaire Radomsky, Rachman, Thordarson,
McIsaac, and Teachman (2001)
   Agoraphobic Cognitions Questionnaire Chambless, Caputo, Bright, and
Gallagher (1984)

Negative evaluation
   Probability Questionnaire and Cost Foa, Franklin, Perry, and Herbert
  Questionnaire (1996)
   Beliefs About Appearance Scale Spangler and Stice (2001)

Unwanted intrusive thoughts

   Obsessive Beliefs Questionnaire–44 Steketee and Obsessive Compulsive
Cognitions Working Group (2005)
   Thought-Action Fusion Scale Shafran, Thordarson, and Rachman
(1996)

Somatic cues
   Anxiety Sensitivity Inventory–Revised Taylor and Cox (1998)

Contamination
   Contamination Cognitions Scale Deacon and Olatunji (2007)

Traumatic events and posttraumatic sequelae

   Posttraumatic Cognitions Inventory Foa, Ehlers, Clark, Tolin, and Orsillo
(1999)

Blood, injection, and injury

   Dental Anxiety Inventory Stouthard, Mellenbergh, and
Hoogstraten (1993)

of Diseases (10th ed. [ICD–10]; World Health Organization, 1992). Commonly

encountered overestimates of the probability and costs of harm for many fear
domains are presented in Table 1.2. Next, we discuss in detail the presenta-
tion of threat overestimates as they are observed in a number of anxiety- and
fear-related contexts.

Fear of Animals

Fears of animals are common across the lifespan and are typically classified as
specific phobias. Although commonly feared animals—such as dogs, spiders,
and snakes—can pose some inherent danger, these risks are generally low.
Overestimates of threat in people with animal fears tend to involve concerns
about physical harm, such as estimates of the likelihood of suffering pain or
physical injury from being bitten or otherwise attacked. For some animal
14 Abramowitz and Blakey

TABLE 1.2. Common Overestimates of Threat Across Different Types

of Feared Stimuli
Likelihood overestimates Severity overestimates
Animals
The snake will bite me. I will have to have my arm amputated.
The bee will sting me. The pain of a bee sting is unbearable.

Natural environments and disasters

I won’t be able to breathe in the elevator. I will die from suffocation.
The storm will turn into a tornado as it The tornado will tear apart my home and
passes over my home. I’ll die in the rubble.
Negative evaluation
People will think I am boring. No one will hire me and I will have to go
on Social Security.
Others will notice and be repulsed by my I will never find someone who will want
crooked nose. to marry me.

Unwanted intrusive thoughts

Violent thoughts lead to violent actions. I will smother and kill my husband in his
sleep.
If I can’t remember locking the door, I may Burglars will break into my home and kill
have forgotten to. my family.

Somatic cues
I will have a panic attack on the bus. I’ll go crazy and cause an awful scene.
If I get dizzy, it probably means I have a The tumor will be cancerous and fatal.
brain tumor.

Contamination
If I eat milk on the “best by” date, I will Getting sick will ruin my whole week.
get sick.
If I use a public toilet, I could contract a If I use a public toilet, I will get HIV/AIDS
disease. and die.

Traumatic events and posttraumatic sequelae

If I am alone with a man, he will assault me.If I am assaulted, I couldn’t have a
meaningful future.
If my son hasn’t texted me, it means his My son might be dying in a field
plane crashed. somewhere.

Blood, injection, and injury

If I get an IV put in, I will faint. If I faint, I’ll fall out of the chair and get a
concussion.
If I play baseball, I’ll end up breaking The pain would be unbearable and I’d
my arm. cause a scene.

“Not just right experiences”

If the picture frames are crooked, I’ll have My child’s school will burn down and it
bad luck. will be my fault.
If I don’t put my left shoe on first, I’ll feel The discomfort would spiral out of
“uneven.” control and never go away.
 Overestimation of Threat 15

fears, anxiety stems from overestimates of the severity of an attack, such as

choking to death from an allergic reaction to a bee sting. These threat esti-
mates are usually easily articulated by individuals with animal fears.
In other instances, overestimates of severity relate to the emotional and
physical reaction experienced when one encounters a feared animal or
insect (e.g., disgust, nausea), such as the belief that the unpleasant feelings
will persist forever or spiral to unbearable levels. For example, someone
afraid of cockroaches may report that roaches are “gross” or “disgusting.”
Similarly, over­estimates of the dangerousness of anxious arousal and possi-
ble panic attacks (i.e., anxiety sensitivity, as discussed in Chapter 4) can play
a role in animal phobias (Mcnally & Steketee, 1985). For instance, a man
may believe that being in the same room as a spider will lead to such intense
anxiety that it will spiral out of control and lead to a loss of conscious-
ness, perhaps placing him at elevated risk of harm and negative evaluation
from others.
In response to their exaggerated estimates of threat, individuals who fear
animals may avoid proximity to the feared animal and situations in which
they believe they will encounter the animal. This avoidance pattern prevents
the person from having opportunities to learn that the risk of harm from such
animals (as well as associated emotional reactions) is acceptably low. If a
child, for instance, never goes to her friend’s home because there is a dog, she
won’t have the opportunity to learn that the dog is much more likely to sniff
or lick her than to bite her.

Fear of Natural Environments and Disasters

Overestimates of threat, in various forms, also play a role in the fear of certain
situations such as standing on a high ledge, driving a car, being in or on water,
or being in a crowded or confined place or a storm (i.e., specific phobias of
natural environments). Likelihood overestimates often relate to rare (although
possible) occurrences, such as a plane crash, elevator accident, drowning, or
having one’s home (or life) destroyed by a lightning strike. Severity over­
estimates often concern beliefs about catastrophes seemingly linked to the
feared situation (e.g., “if lightning hits the house, it will cause an explosion
and we will all die”).
Clinicians, however, should be aware that individuals with situational fears
may also overestimate the dangerousness of experiencing anxiety symptoms
in the feared situation. For instance, a man who avoided riding escalators
believed that if he became too anxious, he would lose control and wildly push
people out of his way in his attempt to escape. People with fears of enclosed
places, such as being in a magnetic resonance imaging scanner (as well as
other claustrophobic situations), often interpret anxiety-related sensations,
such as shortness of breath, as indicating that they are running out of air and
suffocating (e.g., Radomsky, Rachman, Thordarson, McIsaac, & Teachman,
2001). Those who fear crowded areas, such as busy shopping centers and
16 Abramowitz and Blakey

stadiums, overestimate the danger of not being able to “escape” in the event
they become anxious or have a panic attack. Other times, severity overesti-
mates focus on the embarrassment of becoming anxious, having a panic
attack, or losing one’s composure in public.
The idiosyncratic nature of these beliefs and interpretations highlights the
need for a thorough assessment of the cognitive aspects of the fear symptoms.
Such overestimates often lead to avoidance, safety cues (e.g., being with a
“safe” person), or the use of antianxiety medication (i.e., benzodiazepines),
which might decrease anxiety in the short run but prevent the correction of
threat overestimates in the long term.

Fear of Negative Evaluation

As the example of Elaine illustrates, overestimates of threat contribute a great

deal to fears of social and performance situations and are often observed
among individuals diagnosed with social anxiety disorder or body dysmorphic
disorder. The fundamental overestimates of threat concern the probability
and costs of being observed by others, appearing foolish, being criticized, and
experiencing embarrassment. People with this presentation of fear thus
overestimate the likelihood that others are paying close attention to them
and scrutinizing them for minor mistakes, instances of imperfect speech
or behavior, or flaws in their appearance. Although interpersonal criticism
and rejection is rarely life threatening, socially anxious individuals often
over­estimate the costs of negative evaluation or ridicule, and perceive it as
catastrophic—perhaps on par with serious injury or death. Some might believe
it will manifest in the disapproving thoughts and feelings of others, or perhaps
in overt ridicule or discrimination.
Overestimates of threat lead to avoidance and other behaviors to reduce
the possibility of being noticed, appearing foolish, and being negatively eval-
uated. These actions maintain the overestimates of threat by preventing the
individual from learning that others are generally unconcerned with mistakes
and imperfections, and that the anxiety associated with negative evaluation is
actually transient and manageable.

Fear of the Significance or Meaning of Thoughts

People can also overestimate the threat associated with unwanted thoughts.
Obsessions, as defined in the DSM–5 criteria for obsessive-compulsive disorder
(OCD), for example, are characterized by overestimates of the costs of having
certain unwanted or senseless thoughts about topics such as sex, violence,
blasphemy, and harm. Indeed, research shows that people diagnosed with
OCD catastrophically misinterpret their intrusive, unwanted thoughts, images,
and doubts as personally significant or as signs of some deeply rooted fail-
ing. They might fear punishment from God for thinking “sinful” thoughts
or be concerned that they will impulsively act on their sexual or violent
 Overestimation of Threat 17

intrusions (Obsessive Compulsive Cognitions Working Group, 2005; e.g.,

“If I think too much about incest, I will lose control and rape my mother”).
Others believe that their intrusive unwanted thoughts mean that deep down
they want something awful to happen (e.g., “Thinking about rape means
I want to rape someone”).
To prevent the feared consequences of unwanted thoughts (and to reduce
the thought itself, along with its associated discomfort), individuals with cata-
strophic beliefs about thoughts often resort to strategies such as mental rituals
(e.g., replacing a “bad” thought with a “good” one), overanalyzing, or seeking
reassurance about their thoughts. They might also avoid situations and stim-
uli that trigger such thoughts, and repeat simple behaviors (e.g., flipping light
switches) until the activity can be completed without the unwanted thought.
Research, however, demonstrates that negative unwanted thoughts are harm-
less normal occurrences (i.e., mental noise; e.g., Rachman & de Silva, 1978;
Salkovskis & Harrison, 1984), and thus the sorts of strategies mentioned above
block the person from correcting overestimates of threat and learning that it
is normal to have even very unpleasant thoughts.

Fear of Somatic Cues

Concerns about one’s bodily changes and sensations feature prominently in

most anxiety and related disorders. The specific fears associated with somatic
cues are principally differentiated by three factors: (a) focus on immediate
versus long-term feared health outcomes (e.g., the belief that one either
currently has or will eventually acquire a disease), (b) preoccupation with
arousal-related (i.e., anxiety-related) versus nonarousal-related sensations,
and (c) anticipation of an individual versus interpersonal negative outcome
(e.g., the fear that having a panic attack in public will lead to medical catastro-
phe or social humiliation). Despite the partitioning of psychological disorders
in formal diagnostic manuals such as the DSM–5 and ICD–10, individuals who
fear somatic cues often present with symptoms that cut across these diagnostic
categories, anxious individuals meeting diagnostic criteria for different dis­
orders may endorse identical fears about somatic cues, and many individuals
who fear somatic cues may not formally meet diagnostic criteria for any psycho­
logical disorder. Therefore, a transdiagnostic approach to conceptualizing
the fear of somatic cues is especially advantageous over the disorder-driven
approach embodied by diagnostic manuals.
Overestimates of the likelihood of the harm resulting from benign and
ubiquitous somatic cues such as anxious arousal (e.g., pounding heart),
un­expected sensations (e.g., muscular twitching), or ambiguous bodily cues
(e.g., rash) tend to be focused on possible negative physical, mental–cogni-
tive, or social consequences (Taylor, 1999; Taylor et al., 2007). For example,
someone with panic disorder may misinterpret a pounding heart as a heart
attack, someone with illness anxiety disorder may mistake bloodshot eyes for
a symptom of Ebola, and someone with generalized anxiety disorder might
18 Abramowitz and Blakey

appraise muscle tension as a sign that something awful might happen. Alter-
natively, someone with OCD might interpret trembling hands to mean that
she is about to lose control and act on unwanted impulses to harm, whereas
someone with posttraumatic stress disorder may be afraid that difficulties
concentrating indicate that he is “going crazy.” Finally, someone with agora-
phobia may fear that fainting at the grocery store would cause an “embarrassing
scene,” while someone with social anxiety disorder might predict that others
would negatively evaluate him for blushing while on a date. Individuals with
such beliefs tend to pay close attention to their bodies in order to detect feared
somatic cues and prevent anticipated negative consequences (Schmidt, Lerew,
& Trakowski, 1997).
Overestimates of the severity of harm related to feared somatic cues can be
easily elicited through clinical interview and self-report assessments. Fears
about the physical or medical consequences of bodily cues tend to involve
immediate threats to one’s life (e.g., heart attack) or serious and potentially
fatal long-term illnesses (e.g., lung cancer). People who are preoccupied with
the potential cognitive effects of feared somatic cues tend to anticipate com-
plete mental breakdown (e.g., permanent insanity, “losing control and doing
something horrible,” having a “psychotic break”). Yet other individuals may
be more concerned with being negatively evaluated by others for publicly
exhibiting anxiety symptoms or afraid of experiencing intolerable levels of
discomfort associated with intense physical arousal.

Fear of Contamination

The fear of contamination is most pertinent to illness anxiety disorder and

OCD. Individuals with this concern fear stimuli or situations perceived to be
contaminated, such as public restrooms, household chemicals, hospitals, or
even people who have a serious illness (e.g., HIV/AIDS). Although the proto-
typical case of contamination fear involves a preoccupation with physical con-
taminants, some people instead experience mental contamination: feelings of
internal dirtiness that arise from thinking about or imagining a subjectively
unpleasant, immoral, or disgusting scenario (e.g., imagining committing incest
or touching feces; Rachman, 2006). To reduce the physical and emotional
feelings of contamination and associated distress, individuals often avoid sources
of contamination or “dirty thoughts” and tend to engage in excessive washing,
cleaning, thought neutralization, and other “decontamination” efforts.
Like any other condition involving clinical fear or anxiety, the fear of con-
tamination is largely driven by overestimates of the likelihood and severity of
contamination. Contracting an illness is the most obvious and common feared
outcome of coming into contact with contaminants. Yet one may be con-
cerned with spreading or passing on contamination to others. For example, a
woman who worked as a nurse feared that if her hands were contaminated
with traces of “fecal matter germs,” she would endanger her entire family by
preparing a dinner that they all would eat. Exaggerated beliefs about one’s
 Overestimation of Threat 19

own susceptibility to illness often go hand in hand with overestimates of the

likelihood of contracting a disease from a contaminant, in that individuals
tend to believe that germs are lurking everywhere, they are guaranteed to
ingest germs, and the germs will inevitably cause them to contract an awful
disease.
A less common class of feared consequences involves taking on the char-
acteristics, typically undesirable ones, of other people through being contam-
inated with their “germs.” For example, one woman feared that if she touched
items belonging to her grandmother who had Alzheimer’s disease, she would
develop this disease within a year. Thus, overestimates of the probability of
certain feared outcomes may derive from illogical or magical beliefs about the
transmission and spread of illness (Rachman, 2004).
Contamination-fearful individuals also tend to overestimate the severity of
physical or mental contamination. Although some may even become fearful at
the prospect of coming down with the common cold (e.g., “If I had to stay
home from work, I would never be able to make up the hours I missed before
payday”), most anxious individuals tend to fear contamination because they
anticipate more catastrophic outcomes (e.g., contracting a sexually transmitted
disease, developing a serious long-term or deadly illness). In some instances,
individuals experience disgust rather than fear when they are near sources of
contamination; accordingly, severity overestimates may also manifest as pre-
dictions that contamination-related disgust will be intolerable or incapacitating
(e.g., “I can’t stand feeling contaminated,” “It would be too gross to be covered
in germs,” “If I were to be contaminated, I would never feel clean again”).
As mentioned earlier, contamination fears generate urges to engage in
unnecessary and excessive cleansing rituals (e.g., hour-long showers) or even
avoid potential sources of contamination altogether. Unfortunately, when-
ever an individual avoids perceived contamination, he or she is deprived of
the opportunity to learn firsthand that the feared contaminant does not pose
a significant threat and that his or her distress would have decreased natu-
rally over time anyway; consequently, mistaken estimates of threat remain
unchallenged.

Fear of Traumatic Events and Posttraumatic Sequelae

Although most people who witness or directly experience traumatic events

(e.g., sexual assault, severe motor vehicle accidents) do not suffer long-
term psychological consequences, some develop posttraumatic stress disorder
symptoms in the wake of such an incident (e.g., Rothbaum, Foa, Riggs,
Murdock, & Walsh, 1992). That is, whereas “normal” posttraumatic reactions
(e.g., nightmares, increased startle) typically dissipate over time as the person
processes the event, these symptoms persist and cause clinically significant
distress and impairment for trauma survivors who go on to meet diagnostic
criteria for posttraumatic stress disorder. Symptoms are often classified along
four clusters (intrusion, avoidance, negative alterations in cognition and mood,
20 Abramowitz and Blakey

and alterations in arousal and reactivity; American Psychiatric Association,

2013), but a common clinical feature of this condition is that survivors tend
to hold exaggerated beliefs about the dangerousness of the world, other
people, and even themselves (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). For
example, depending on the nature of the traumatic event(s), individuals
with post­traumatic stress disorder might endorse beliefs such as “the world
is a dangerous place” and “people cannot be trusted.”
Clinicians working with trauma survivors should assess for two common
themes related to overestimates of threat. The first concerns the fear of being
retraumatized; because many survivors begin to view the world as unpredict-
able and unsafe after a trauma, they may feel especially vulnerable in situa-
tions they associate with their traumatic event (e.g., the neighborhood in
which they were held at gunpoint). In effect, this may result in inflated esti-
mates regarding the probability of transportation accidents, physical or sexual
assault, or natural disasters. These likelihood overestimates tend to be accom-
panied by overestimates of the severity of retraumatization. Specifically, trauma
survivors may believe that experiencing another traumatic event would be the
end of the world (i.e., catastrophic), when in reality many individuals who
experience multiple traumatic events are still able to live a meaningful and
rewarding life. That is not to say that future traumatic events would not be
horrific or frightening; rather, individuals who overestimate the likelihood and
severity of retraumatization also tend to underestimate their ability to cope
with and recover from trauma.
The second theme concerns catastrophic interpretations of the posttrau-
matic symptoms themselves as indicating an ongoing threat (e.g., Ehlers &
Clark, 2000). For example, trauma survivors may come to believe extreme
statements such as “Having uncontrollable nightmares mean I am losing my
mind,” “Being constantly ‘on guard’ will cause me to pass out from exhaus-
tion,” and “Being disconnected from others means I’ll never be able to form
meaningful relationships again.” Moreover, mistaken beliefs about the likeli-
hood and severity of posttraumatic symptoms often engender urges to avoid
trauma-related distress altogether or engage in counterproductive coping efforts
(e.g., self-medicate with alcohol or substances). These anxiety-reduction strat-
egies ultimately exacerbate distress related to posttraumatic stress disorder,
however, because they perpetuate overestimates of threat associated with the
experience of posttraumatic stress symptoms.
The fear of traumatic events may also be clinically relevant to generalized
anxiety disorder. Specifically, despite no evidence that a traumatic event will
or has occurred, individuals with this disorder report substantial fear or dread
that “something terrible” (e.g., a major accident) might happen and that the
consequences of such an event would be disastrous (e.g., paralysis, death).
Alternatively, people with generalized anxiety disorder may acknowledge
that their anxiety and worry is disproportionate to the true probability of a
feared event occurring, yet nevertheless believe that the worry surrounding
the fear of a traumatic event is intolerable, unyielding, or will “spiral out of
control.”
 Overestimation of Threat 21

Fear of Blood, Injection, and Injury

Fears related to blood, injection, or injury typically map onto the diagnostic
category of specific phobia, although some people with OCD or illness anxiety
disorder may also report these fears. Individuals preoccupied with blood, injec-
tion, and injury fear a range of stimuli including seeing blood, receiving injec-
tions, and undergoing dental and medical procedures. Some individuals are so
distressed by blood, injection, and injury that they refuse (or find it extremely
difficult) to undergo important medical procedures, become pregnant, or take
careers in health care and medicine. The fear of blood, injection, and injury is
also unique to clinical anxiety in that individuals may, in fact, faint upon expo-
sure to these fear cues (Öst, 1992).
Overestimates regarding the likelihood and severity of exposure to blood,
injection, and injury are heterogeneous and idiosyncratic. For some, these
fears are driven by exaggerated beliefs about the probability and intensity of
physical pain and its possible consequences (e.g., “The pain will be extreme
and intolerable, and it will cause me to lose control and scream like crazy”).
Others overestimate the probability of being directly harmed by the stimulus;
for example, dying during a medical procedure or being contaminated by
blood or needles that results in the acquisition of a serious illness. Many
sufferers report prominent and aversive feelings of disgust (rather than fear)
upon exposure to stimuli such as blood, wounds, and needles, which they
report to be incredibly difficult to tolerate (e.g., “Blood is gross and I can’t stand
being near it or having it on me”). For individuals with a history of fainting,
blood, injury, and injection cues may be feared because of their ability to
cause this reaction. In these cases, although a person’s estimates regarding the
likelihood of fainting may be accurate (Öst, 1992), they often overestimate
the severity of fainting (e.g., they mistakenly fear that fainting will lead to
injury, medical emergency, or intolerable social embarrassment).
Most individuals with fears of blood, injection, and injury avoid these
stimuli altogether (e.g., going years without a dental cleaning) to mitigate the
perceived likelihood and/or severity of their feared outcome(s). In the long
term, however, extreme avoidance not only comes at the price of their health
and quality of life but also serves to maintain maladaptive beliefs about (a) the
dangerousness of feared stimuli themselves, (b) the extreme emotional reac-
tions they elicit, and (c) their inability to tolerate such reactions.

Fear of “Not Just Right Experiences”

The need to reorder, realign, repeat, or engage in other types of seemingly

senseless ordering or arranging behaviors is consistent with one “type” of
OCD (although individuals with OCD or high levels of perfectionism who do
not meet diagnostic criteria for any psychological disorder might also display
these symptoms). Individuals who present with complaints about “not just
right experiences” (NJREs) tend to overestimate the negative consequences
of feelings of “incompleteness,” “asymmetry,” and the sense that things are
22 Abramowitz and Blakey

not “just right.” Clinical observations and research studies suggest that the
distress associated with asymmetry can result from a fear of NJREs either
(a) leading to negative events or (b) initiating an unending sense of incom-
pleteness. Although these two manifestations of NJRE fears may seem similar
at the surface level, the underlying overestimates of threat driving clinically
significant distress are in fact distinct (e.g., Summerfeldt, 2004, 2008).
In the first form of this problem, the distress associated with NJREs precip-
itates from magical thinking that links the incompleteness–asymmetry with
disastrous events that can only be prevented through ordering and arranging
rituals. For example, “If the books are not arranged perfectly on the shelf,
I will have bad luck.” Fear-based interpretations that a NJRE portends an
external disaster (e.g., accidents), however, is less common than the fear that
if allowed to continue, the feelings of incompleteness, imbalance, and imper-
fection will persist indefinitely. Thus, the second form of NJRE-related distress
is driven by dysfunctional beliefs that subjective feelings of incompleteness,
imbalance, or incorrectness will increase to intolerable levels and cause some
sort of internal harm (e.g., a physical or emotional “breakdown” or other loss
of control). In other words, the person believes that he or she cannot cope
with the emotional or physical discomfort engendered by NJREs (a phenom-
enon akin to difficulties tolerating distress, as described in detail in Chapter 6).
Whether NJREs are fueled by overestimates of external (e.g., bad luck)
or internal (e.g., overwhelming distress) harm, these concerns are often
accompanied by certain corrective actions. The restoration of order through
rearranging (and similar behaviors) and the subsequent neutralization of dis-
comfort function to negatively reinforce mistaken beliefs about the likelihood
or severity of aversive outcomes related to NJREs, thus leading to the habitual
use of ordering and other compulsive behaviors to reduce this sort of dis­
comfort. Unfortunately, the reduction of distress associated with incomplete-
ness (a) prevents the natural extinction of the distress (i.e., habituation) and
(b) prevents the individual from learning that his or her estimates of NJRE-
related threat are inaccurate.

CONCLUSION

The tendency to overestimate threat is among the key transdiagnostic cogni-

tive processes that play a role in the maintenance of clinical anxiety. In this
chapter, we defined the phenomenon and discussed its particular role in the
persistence of inappropriate fear. We then considered the assessment of threat
overestimation before turning to an overview of how this process manifests
itself and can be addressed in clinical treatment across the diverse landscape
of anxiety-related problems. The overestimation of threat may take a variety
of forms, including the tendency to catastrophically miscalculate the proba-
bility of negative events, misjudge the presumed severity (or cost) of adverse
outcomes, misinterpret the behavior of others as signs of negative evaluation,
 Overestimation of Threat 23

and inflate the importance of unwanted thoughts. It also overlaps concep-

tually with the tendency to catastrophically misinterpret the meaning and
consequences of arousal-related body sensations (anxiety sensitivity; see Chap­
ter 4), as well as with catastrophic beliefs about the experience of uncertainty
(intolerance of uncertainty; Chapter 3), although research indicates that anxiety
sensitivity and intolerance of uncertainty contribute uniquely (beyond threat
overestimates) to the development and maintenance of clinical anxiety. As a
funda­mental cognitive bias in clinical anxiety, a variety of clinical interven-
tions and treatment mechanisms explicitly or implicitly address over­estimates
of threat, including exposure therapy focused on habituation (Chapter 14) or
inhibitory learning (Chapter 15), rational discussion to promote cognitive
change (Chapter 16), and interpretation bias modification (Chapter 20), as
discussed in Part II of this handbook.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis­
orders (5th ed.). Washington, DC: Author.
Amir, N., Foa, E. B., & Coles, M. E. (1998). Negative interpretation bias in social phobia.
Behaviour Research and Therapy, 36, 945–957. http://dx.doi.org/10.1016/S0005-
7967(98)00060-6
Arntz, A., Lavy, E., van den Berg, G., & van Rijsoort, S. (1993). Negative beliefs of spider
phobics: A psychometric evaluation of the Spider Phobia Beliefs Questionnaire.
Advances in Behaviour Research and Therapy, 15, 257–277. http://dx.doi.org/10.1016/
0146-6402(93)90012-Q
Arntz, A., Rauner, M., & van den Hout, M. (1995). “If I feel anxious, there must be
danger”: Ex-consequentia reasoning in inferring danger in anxiety disorders. Behaviour
Research and Therapy, 33, 917–925. http://dx.doi.org/10.1016/0005-7967(95)00032-S
Barlow, D. H. (2004). Anxiety and its disorders: The nature and treatment of anxiety and
panic. New York, NY: Guilford Press.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: Inter­
national Universities Press.
Beck, A., Emery, G., & Greenberg, R. (2005). Anxiety disorders and phobias: A cognitive
perspective (15th ed.). Cambridge, MA: Basic Books.
Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear
in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cog­
nitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090–1097.
http://dx.doi.org/10.1037/0022-006X.52.6.1090
Deacon, B., & Olatunji, B. O. (2007). Specificity of disgust sensitivity in the prediction
of behavioral avoidance in contamination fear. Behaviour Research and Therapy, 45,
2110–2120. http://dx.doi.org/10.1016/j.brat.2007.03.008
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
Behaviour Research and Therapy, 38, 319–345. http://dx.doi.org/10.1016/S0005-
7967(99)00123-0
Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The post­
traumatic cognitions inventory (PTCI): Development and validation. Psychological
Assessment, 11, 303–314. http://dx.doi.org/10.1037/1040-3590.11.3.303
Foa, E. B., Franklin, M. E., Perry, K. J., & Herbert, J. D. (1996). Cognitive biases in gen-
eralized social phobia. Journal of Abnormal Psychology, 105, 433–439. http://dx.doi.org/
10.1037/0021-843X.105.3.433
24 Abramowitz and Blakey

Fredrikson, M., Annas, P., Fischer, H., & Wik, G. (1996). Gender and age differences in
the prevalence of specific fears and phobias. Behaviour Research and Therapy, 34,
33–39. http://dx.doi.org/10.1016/0005-7967(95)00048-3
Mcnally, R. J., & Steketee, G. S. (1985). The etiology and maintenance of severe animal
phobias. Behaviour Research and Therapy, 23, 431–435. http://dx.doi.org/10.1016/
0005-7967(85)90171-8
Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective on the
etiology of anxiety disorders: It’s not what you thought it was. American Psychologist,
61, 10–26. http://dx.doi.org/10.1037/0003-066X.61.1.10
Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation
of the obsessive belief questionnaire and interpretation of intrusions inventory—
Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy,
43, 1527–1542. http://dx.doi.org/10.1016/j.brat.2004.07.010
Ollendick, T. H., King, N. J., & Muris, P. (2002). Fears and phobias in children: Phe-
nomenology, epidemiology, and aetiology. Child and Adolescent Mental Health, 7,
98–106. http://dx.doi.org/10.1111/1475-3588.00019
Öst, L.-G. (1992). Blood and injection phobia: Background and cognitive, physio­
logical, and behavioral variables. Journal of Abnormal Psychology, 101, 68–74. http://
dx.doi.org/10.1037/0021-843X.101.1.68
Rachman, S. (2004). Fear of contamination. Behaviour Research and Therapy, 42,
1227–1255. http://dx.doi.org/10.1016/j.brat.2003.10.009
Rachman, S. (2006). The fear of contamination: Assessment and treatment. New York, NY:
Oxford University Press. http://dx.doi.org/10.1093/med:psych/9780199296934.
001.0001
Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research
and Therapy, 16, 233–248. http://dx.doi.org/10.1016/0005-7967(78)90022-0
Radomsky, A. S., Rachman, S., Thordarson, D. S., McIsaac, H. K., & Teachman, B. A.
(2001). The Claustrophobia Questionnaire. Journal of Anxiety Disorders, 15, 287–297.
http://dx.doi.org/10.1016/S0887-6185(01)00064-0
Rothbaum, B., Foa, E., Riggs, D., Murdock, T., & Walsh, W. (1992). A prospective
examination of post-traumatic stress disorder in rape victims. Journal of Traumatic
Stress, 5, 455–475. http://dx.doi.org/10.1002/jts.2490050309
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety
and panic: A cognitive account. Behavioural Psychotherapy, 19, 6–19. http://dx.doi.org/
10.1017/S0141347300011472
Salkovskis, P. M., Clark, D. M., Hackmann, A., Wells, A., & Gelder, M. G. (1999). An
experimental investigation of the role of safety-seeking behaviours in the mainte-
nance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559–574.
http://dx.doi.org/10.1016/S0005-7967(98)00153-3
Salkovskis, P. M., & Harrison, J. (1984). Abnormal and normal obsessions—A repli-
cation. Behaviour Research and Therapy, 22, 549–552. http://dx.doi.org/10.1016/
0005-7967(84)90057-3
Schmidt, N. B., Lerew, D. R., & Trakowski, J. H. (1997). Body vigilance in panic dis­
order: Evaluating attention to bodily perturbations. Journal of Consulting and Clinical
Psychology, 65, 214–220. http://dx.doi.org/10.1037/0022-006X.65.2.214
Shafran, R., Thordarson, D., & Rachman, S. (1996). Thought-action fusion in obsessive
compulsive disorder. Journal of Anxiety Disorders, 10, 379–391. http://dx.doi.org/
10.1016/0887-6185(96)00018-7
Spangler, D. L., & Stice, E. (2001). Validation of the Beliefs About Appearance
Scale. Cognitive Therapy and Research, 25, 813–827. http://dx.doi.org/10.1023/
A:1012931709434
Steketee, G., & Obsessive Compulsive Cognitions Working Group. (2005). Psychometric
validation of the obsessive belief questionnaire and interpretation of intrusions
inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research
and Therapy, 43, 1527–1542. http://dx.doi.org/10.1016/j.brat.2004.07.010
 Overestimation of Threat 25

Stouthard, M. E. A., Mellenbergh, G. J., & Hoogstraten, J. (1993). Assessment of

dental anxiety: A facet approach. Anxiety, Stress, and Coping: An International Journal,
6, 89–105. http://dx.doi.org/10.1080/10615809308248372
Summerfeldt, L. J. (2004). Understanding and treating incompleteness in obsessive-
compulsive disorder. Journal of Clinical Psychology, 60, 1155–1168. http://dx.doi.org/
10.1002/jclp.20080
Summerfeldt, L. J. (2008). Symmetry, incompleteness, and ordering. In J. Abramowitz,
D. McKay, & S. Taylor (Eds.), Clinical handbook of obsessive-compulsive disorder and
related problems (pp. 44–60). Baltimore, MD: Johns Hopkins University Press.
Taylor, S. (Ed.). (1999). Anxiety sensitivity: Theory, research, and treatment of the fear of
anxiety. Mahwah, NJ: Erlbaum.
Taylor, S., & Cox, B. J. (1998). An expanded anxiety sensitivity index: Evidence for a
hierarchic structure in a clinical sample. Journal of Anxiety Disorders, 12, 463–483.
http://dx.doi.org/10.1016/S0887-6185(98)00028-0
Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., . . .
Cardenas, S. J. (2007). Robust dimensions of anxiety sensitivity: Development and
initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19,
176–188. http://dx.doi.org/10.1037/1040-3590.19.2.176
World Health Organization. (1992). International classification of diseases (10th ed.).
Geneva, Switzerland: Author.
2
Safety Behaviors
Michael J. Telch and Eric D. Zaizar

Marcus is a 32-year-old executive working for a major software company.1

Anticipating having to stay up all night to complete a final report for an import-
ant patient, Marcus consumed three energy drinks over a span of 3 hours. All of
a sudden, he noticed his heart pounding and racing and felt that he couldn’t
catch his breath. He called 911 in a state of panic, believing that he might be
having a heart attack. When the paramedics arrived at his house, they ques-
tioned him and performed a standard EKG. The paramedics informed Marcus
that he had experienced a panic attack but that his heart was fine and that there
was no need to take him to the hospital.
Although reassured initially, over the next several weeks Marcus began to
experience significant apprehension over the possibility that the paramedics
had missed something and that his heart was not fine. He became more
focused on his heart and started to take his pulse and blood pressure several
times a day. At night, he found himself rehashing the precise words the para-
medics used during their evaluation. Over that same period, he started to
notice discomfort and tightness in his chest during the day and adopted the
habit of keeping an aspirin in his shirt pocket at all times. Although Marcus was
a regular exerciser, he started to avoid the gym for fear that the exertion may
be too much for his heart to take. Likewise, he cut out his morning cup of coffee
and even started to avoid chocolate for fear that the caffeine might trigger a
cardiac event. While at work, he started to worry that the stress of his job might
be harmful to his heart. He found himself shying away from bringing up areas of

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-002
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
27
28 Telch and Zaizar

concern or conflict with clients or coworkers. Despite these efforts, he noticed

his anxiety escalating to the point where he had trouble concentrating at work
and his interactions with his wife became consumed by talking about his phys-
ical and emotional symptoms. Even quality time with his two children took a
back seat to his anxiety.

Marcus’s case is fairly typical of someone who develops debilitating cardiac

anxiety in response to a panic attack elicited by the threatening misinterpre-
tation of a harmless and natural bodily reaction to stimulant ingestion. Note
that although safety behaviors had nothing to do with his initial panic reac-
tion, they played a significant role in fueling his anxiety and disability follow-
ing the event. Note too that Marcus’s use of safety behaviors started with
checking his pulse and blood pressure but soon expanded to the avoidance of
previously routine activities such as exercise, drinking coffee, consuming choc-
olate, and other safety behaviors like avoiding stressful encounters at work,
carrying aspirin in his shirt pocket, and mentally rehearsing what the para-
medics told him after his panic attack. Marcus’s case also illustrates the close
connection between the underlying perceived threat (heart problem) and the
kinds of safety behaviors he adopted in an attempt to cope with it.
The anxiety disorder literature offers several definitions of safety behav-
iors. In his seminal paper, Salkovskis (1991) defined safety behaviors as overt or
covert avoidance of feared outcomes that are carried out within a specific
situation. This definition has several limitations. First, it does not distinguish
between safety behaviors that are adaptive, such as the wearing of seat belts,
and those that maintain or even exacerbate anxiety disorder symptoms, such
as the repeated checking of one’s pulse when anxious. Second, it does not
capture a central feature of the safety behaviors observed in anxiety patients—
namely, the erroneous or exaggerated nature of the threats driving the urge
to engage in unnecessary protective actions.
In their review of anxiety-related safety behaviors, Helbig-Lang and
Petermann (2010) defined safety behaviors as dysfunctional emotion regula-
tion strategies. Borrowing from the early observations of anxiety-maintaining
behaviors in obsessive-compulsive disorder (OCD; Rachman & Hodgson, 1980),
dysfunctional emotion regulation strategies were categorized as either serving
a preventive function (i.e., preventing future anxiety increases) or a restor-
ative function (i.e., impeding anxiety in a feared situation). Defining safety
behaviors as dysfunctional emotion regulation strategies is also problematic
insofar as it implies that the motivation to perform safety behaviors is always
to reduce or prevent anxiety. Although this is often the case, many patients
perform safety behaviors to prevent, escape from, or lessen the severity of
perceived threats other than anxiety. Examples include the person with
claustrophobia who avoids elevators out of concern that they will be trapped
or the individual with health anxiety who avoids caffeine in order to avoid a
 Safety Behaviors 29

fatal cardiac event. In an attempt to address these limitations, we defined

anxiety-related safety behaviors as unnecessary actions taken to prevent, escape
from, or reduce the severity of a perceived threat (Telch & Lancaster, 2012).

CONCEPTUAL IMPLICATIONS

Human beings are hardwired to engage in protective actions when faced with
perceived threats. Examples of such actions include wearing seat belts to
improve one’s chances of surviving a car crash, wearing warm clothing when
venturing outside on a winter’s day in North Dakota to avoid hyperthermia,
or using condoms when having sex with a new partner to prevent contracting
a sexually transmitted disease. Engaging in such protective actions when no
real threats exist, however, has been shown to actually fuel clinical anxiety
and may even play a role in the maintenance of other problems such as
insomnia and chronic pain.
Over the past several decades there has been a burgeoning of research in
the anxiety literature on safety behaviors. This research has tackled important
questions relevant to (a) the phenomenology of safety behaviors across vari-
ous anxiety-related presentations, (b) the role of safety behaviors in the
development or exacerbation of pathological fear, (c) the impact of safety
behaviors during fear extinction on threat expectancies and return of fear in
healthy controls, (d) the effects of making safety behaviors available during
exposure therapy in anxious populations, and (e) the effects of fading safety
behaviors during exposure therapy. Comprehensive reviews of this literature
are available (see Blakey & Abramowitz, 2016; Goetz, Davine, Siwiec, & Lee,
2016; Helbig-Lang & Petermann, 2010; Meulders, Van Daele, Volders, &
Vlaeyen, 2016; Telch & Lancaster, 2012). The following subsections address
those issues and questions in turn.

Phenomenology of Safety Behaviors Observed in Anxiety Patients

Although safety behaviors are ubiquitous across the full range of anxiety dis-
orders, patients’ specific profile of safety behaviors has been shown to be con-
ceptually linked to the patients’ specific threat perceptions (Salkovskis, 1991).
Examples of this threat–safety behavior linkage include the cardiac anxiety
patient who feels compelled to check his pulse and avoid exercise, caffeine, or
stressful encounters for fear of having a heart attack; the socially anxious
student who avoids raising his hand in class for fear of being perceived as
stupid; or the person with a roach phobia who feels compelled to visually scan
the floor of each room before entering. Table 2.1 illustrates some of the common
threats observed in various anxiety syndromes and their corresponding safety
behaviors.
Factor analytic techniques have also been used to categorize safety behaviors
for certain anxiety populations. For example, Kamphuis and Telch (1998) factor
30 Telch and Zaizar

TABLE 2.1. Examples of Safety Behaviors and Associated Threats Across

Anxiety-Related Disorders
DSM–5 disorder Perceived threats Safety behaviors
Panic disorder Concern about dying Eliminating all caffeine intake
from cardiac arrest Carrying an anxiolytic “rescue”
because of a panic medication at all times
attack
Agoraphobia Concern about embar- Avoiding leaving the house as
rassing oneself if a much as possible
panic attack occurs When leaving the house, taking a
in a public place companion who could help in
case of a panic attack
Social anxiety disorder Concern that other Going to the bathroom regularly to
people at a party check for excessive sweating or
will be likely to blushing
notice signs of Mentally reviewing the conversation
anxiety and will be afterwards to make sure there
judgmental of it were no signs of nervousness
Generalized anxiety Concern about being Checking with boss regularly to
disorder fired from a stable receive reassurance about
job adequate job performance
Continuous research on other job
opportunities to prepare back-up
options
Specific phobia Concern about being Avoiding certain streets where dog
(animal) attacked by an owners live
unprovoked dog Carrying a large stick to use as
while on a walk in protection if attacked
the neighborhood
Obsessive-compulsive Concern about Using a paper towel to open doors
disorder contracting a fatal Cleaning with hand sanitizer after
illness when eating touching tables, chairs, and
at a restaurant menus
Posttraumatic stress Concern about being Carrying pepper spray at all times
disorder assaulted when Avoiding going out alone
going shopping
Illness anxiety disorder Concern about high Checking changes in moles by
probability of taking pictures every week
getting skin cancer Extensively researching signs
Note. DSM–5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (American Psychiatric
Association, 2013).

analyzed safety behavior data from 105 panic disorder and agoraphobia patients
based on their responses on the Texas Safety Maneuver Scale (Kamphuis &
Telch, 1998). Five interpretable factors emerged: (a) classic agoraphobic avoid-
ance (e.g., avoidance of crowded stores and public transportation), (b) use of
relaxation techniques to relieve anxiety, (c) avoidance of stressful encounters,
(d) avoidance of somatic perturbations (e.g., avoidance of caffeine or vigorous
exercise), and (e) use of distraction techniques.
 Safety Behaviors 31

More recent factor analytic work examining global patterns of safety

behaviors in social anxiety revealed two primary safety behavior categories:
avoidance and impression management. These same two factors also emerged
in a second study investigating situational use of safety behaviors during a
controlled social interaction in a meeting of a large sample of participants
with generalized social anxiety disorder (Plasencia, Alden, & Taylor, 2011).
Interestingly, the two safety behavior subtypes were associated with different
social outcomes. Avoidance was associated with higher state anxiety during
the interaction and negative reactions from participants’ interaction partners,
whereas impression-management strategies hindered corrections in negative
appraisals of subsequent interactions (Plasencia et al., 2011).

Preventive Versus Restorative Safety Behaviors

In their review of safety behaviors and anxiety, Helbig-Lang and Petermann

(2010) proposed a taxonomy for conceptualizing safety behaviors along
two primary dimensions strategy and function, with each dimension having
two levels: for strategy, behavioral strategies and cognitive strategies; for func-
tion, preventive function and restorative function. Much attention has recently
been given to the restorative versus preventive distinction and for good reason
(see Goetz et al., 2016). Preventive safety behaviors are those that reduce the
strength or intensity of contact with a core threat in the immediate threat-pro-
voking context. Examples for fear of flying include carrying rescue medication
on the plane, repeated checking of the weather on one’s phone, and scanning
the passengers for potential terrorists. In contrast, restorative safety behaviors are
those that remedy a situation back to a desired state following confrontation
with a perceived threat. Sticking with the fear of flying example, having a stiff
drink after the plane lands or calling home to let your family members know
you arrived safely would be examples of restorative safety behaviors given
that the function of the action is to return one to a state of perceived safety.

Role of Safety Behaviors in the Development or Escalation of Anxiety

Several studies have provided support for the anxiogenic effects of safety
behaviors on the development and/or exacerbation of anxiety. In a clever field
study, Deacon and Maack (2008) used an A-B-A within-subjects design (1 week
baseline [A], 1 week of prescribed contamination-related safety behaviors [B],
and 1 week return to baseline [A]) to investigate the effects of safety behaviors
on contamination fear among undergraduate students scoring either low or
high in contamination fear. Following the safety behavior manipulation, par-
ticipants in both the high and low contamination fear groups showed statis-
tically significant increases in threat overestimation, contamination fear, and
heightened emotional and behavioral responding to three contamination-
related behavioral avoidance tasks. However, the absence of a control group
precludes strong causal inferences that the performance of safety behaviors was
responsible for the observed increases in contamination fear.
32 Telch and Zaizar

This limitation was addressed in a follow-up experiment (Olatunji, Etzel,

Tomarken, Ciesielski, & Deacon, 2011) in which undergraduates were
randomized to either monitor or monitor and perform a series of health-
related safety behaviors (e.g., checking body temperature, checking lymph
nodes by palpitation, and monitoring pulse rate). After 3 weeks, those
assigned to the safety behavior condition (relative to those in the monitoring-
only control group) displayed significantly higher health anxiety, lower behav-
ioral approach scores, and heightened perceived risk ratings of contracting
a cold, the flu, or mononucleosis. Although these findings provide the first
experimental data suggesting that safety behaviors play a causal role in health
anxiety development, participants’ daily monitoring of safety behaviors can-
not be ruled out as an alternative explanation for the observed increases in
health-related anxiety.
In a similar experiment investigating checking behavior and obsession-
related cognitions, van Uijen and Toffolo (2015) added a no-instruction con-
trol group. Participants were randomized to one of three groups: (a) engage
in increased checking behavior for one week, (b) monitor checking behavior
without altering it, or (c) no instruction. Consistent with prediction, increases
in checking-related threat appraisals were observed in the experimental
group but not in the monitoring or no-instruction groups. These findings sug-
gest that it is the increased use of safety behaviors as opposed to the mere
self-monitoring of them that is responsible for the pathogenic effects on sub-
sequent threat appraisals.

Impact of Safety Behaviors During Extinction of Conditioned Fear

Based on work in rodents (Rescorla, 2003) suggesting that fear extinction can be
impeded by the presentation of a concurrent conditioned stimulus (safety cue)
signaling the absence of the unconditioned stimulus (shock), Lovibond and col-
leagues (Lovibond, Mitchell, Minard, Brady, & Menzies, 2009) conducted a
clever experiment in which 65 undergraduates were taken through a Pavlovian
shock acquisition phase in which students learned that two colored squares (A
and C) were followed by a shock whereas another (B) was not. In Phase 2
(avoidance acquisition phase), students were trained in the presence of stimulus
A to press a button that prevented the shock. Next, half the students (experi-
mental group) underwent extinction with the avoidance response available,
whereas for the other half (control group), the avoidance response was unavail-
able. In the final critical test phase, both the experimental and control groups
were exposed to the conditioned stimulus without the avoidance response
available. Consistent with the researchers’ prediction, students in the control
condition showed normal extinction to stimulus C, whereas those who under-
went extinction with a voluntary safety behavior showed significantly less
extinction or “protection from extinction” as indexed by shock expectancy rat-
ings and physiological arousal. This “protection from extinction” effect has been
replicated in two independent experiments using a voluntary joystick move-
ment shock conditioning paradigm (Volders, Meulders, De Peuter, Vervliet, &
 Safety Behaviors 33

Vlaeyen, 2012). Relatedly, Engelhard, van Uijen, van Seters, and Velu (2015)
showed that participants who performed a safety behavior to a stimulus that
was never directly paired with shock displayed an increased threat appraisal
(expectancy of shock) to that stimulus at a later test phase relative to controls
who were not able to use safety behaviors. This important finding suggests that
safety behaviors increase threat appraisal through indirect means. Moreover,
consistent with behavioral observations of individuals treated for anxiety dis­
orders, evidence from human fear conditioning studies also suggests that safety
behaviors persist even after fear has extinguished and that when present, safety
behaviors increase threat appraisal (shock expectancy), especially among indi-
viduals with high trait anxiety (Vervliet & Indekeu, 2015).

WHAT MIGHT EXPLAIN THE ANXIOGENIC EFFECTS

OF SAFETY BEHAVIORS?

Numerous theories have been put forth to explain the anxiogenic effects of
safety behaviors and how safety behaviors may impede exposure-based ther-
apies; space limitations permit only a brief description of these theories below.
For an excellent review of these theories and their supporting evidence, see
Blakey and Abramowitz (2016).

Misattribution of Safety Hypothesis

Salkovskis (1991) suggested that when engaging in safety behaviors while

confronting a fear-provoking target, the anxious person misattributes one’s
safety (i.e., threat nonoccurrence) to the safety behavior, thus leaving intact
one’s faulty threat perception related to the feared target (e.g., “thank good-
ness I sat down when my heart started pounding, or else it would have esca-
lated to a heart attack”). Evidence in support of this theory comes from
correlational studies showing that panic patients who attribute their therapeu-
tic gains to their medication have poorer outcomes than those who attribute
their gains to their own efforts (Başoğlu et al., 1994; Biondi & Picardi, 2003).
Surprisingly, few experimental tests of the misattribution hypothesis have
appeared. We experimentally manipulated claustrophobic subjects’ postexpo-
sure expectancy of a presumed memory pill they had ingested prior to expo-
sure therapy (Powers, Smits, Whitley, Bystritsky, & Telch, 2008). Consistent
with the misattribution of safety hypothesis, those told that the pill they
ingested was an herbal tranquilizer showed poorer outcomes at follow-up rel-
ative to those in a group who were told they had ingested an herbal stimulant.

Attentional Resources Hypothesis

Some have suggested that safety behaviors maintain pathological fear by

interfering with the processing of threat disconfirmation through a redirection
of attentional resources to the presence of safety cues and the execution of
34 Telch and Zaizar

safety behaviors (Sloan & Telch, 2002; Telch & Lancaster, 2012). In support of
this formulation, Telch and colleagues (Kamphuis & Telch, 2000; Telch et al.,
2004) found that adding a heavy cognitive load task during exposure therapy
for claustrophobia reduces treatment efficacy. In contrast, experimental manip-
ulations designed to explicitly increase attention to threat-disconfirming infor-
mation have been shown to enhance exposure treatment outcomes (Kamphuis
& Telch, 2000; Sloan & Telch, 2002; Telch, Valentiner, Ilai, Petruzzi, & Hehmsoth,
2000). Additional support for this hypothesis comes from a social anxiety treat-
ment study showing that safety behaviors mediated the negative effects of
self-focused attention on treatment outcome regardless of treatment modality
(i.e., cognitive behavior group treatment vs. mindfulness and acceptance-based
treatment; Desnoyers, Kocovski, Fleming, & Antony, 2017).

Threat Transmission Hypothesis

It has also been suggested that the mere engagement in protective actions
transmits threat signaling through lower level, limbic-type activation (Telch &
Lancaster, 2012). Consistent with this idea, Niedenthal (2007) introduced the
theory of embodied emotion, suggesting that physical enactments consistent
with a given emotion action tendency (e.g., flight) lead to increased activation
of the target emotion (e.g., fear). Data supporting the threat transmission
model come from studies reviewed earlier demonstrating that having non­
anxious populations engage in unnecessary protective actions is anxiogenic
(Deacon & Maack, 2008; Olatunji et al., 2011) as well as the human Pavlovian
fear conditioning studies suggesting that the mere availability of safety cues
interfere with fear extinction by increasing threat appraisals (Engelhard et al.,
2015; Lovibond et al., 2009; Volders et al., 2012).

Threat Disconfirmation Attenuation Hypothesis: A Unifying Theory

A common assumption of the theories described above is that safety behaviors

interfere with the emotional processing of threat disconfirming information,
a central putative change mechanism for fear attenuation (Foa & Kozak, 1986).
Consequently, it is reasonable to assume that under some conditions, mis­
attribution effects, attentional resource allocation effects, and direct threat
transmission effects may all be operating in combination to account for the
pathogenic effects of safety behaviors on the development and maintenance
of pathological fear expression.

ASSESSMENT OF SAFETY BEHAVIORS

Prior to performing a formal assessment of patients’ safety behaviors, we typ-

ically provide education about safety behaviors in the larger context of edu-
cating patients about the nature and treatment of anxiety. Providing patients
with education about safety behaviors and their anxiety maintaining effects is
 Safety Behaviors 35

an important first step in the assessment process. Didactic instruction and

instructional handouts are used to educate the patient with respect to (a) the
nature and types of safety behaviors displayed, (b) how safety behaviors
become strengthened, and (c) how safety behaviors may serve to maintain
or even worsen anxiety symptoms.2 We have found that using the phrase
un­necessary protective actions interchangeably with safety behaviors can some-
times be helpful for patients who are having trouble grasping the concept of
anxiety-promoting safety behaviors.
Four primary sources of data can be helpful in constructing an accurate
formulation of the patient’s safety behavior profile: (a) data from inter-
views with the patient and significant others, (b) data from psychometric
scales, (c) data collected during direct in vivo observation of the patient in
the office or the field, and (d) data collected by the patient using daily self-
monitoring forms.

Clinical Interview With Patient and Significant Others

Given that safety behaviors are threat driven (Salkovskis, 1991; Salkovskis,
Clark, & Gelder, 1996), a thorough case formulation of the patient’s internal
and external threats provide vital information for identifying patients’ safety
behaviors. It is also important to confirm that the protective actions described
by the patient are actually serving a perceived safety function. This can often
be accomplished by probing whether patients would experience greater anx-
iety if they were prevented from performing the safety behavior in question.
It should be noted that patients differ markedly with respect to insight about
their safety behaviors. For some, a safety behavior may become so automatic
that they do not recognize that their actions are serving a safety function.
When possible, it is useful to interview one or more family members as a
means of forming a more complete picture of the patient’s safety behaviors.
Moreover, family members often unwittingly become involved in assisting the
patient in performing safety behaviors (i.e., “accommodation,” as discussed in
Chapter 13) and are often under the misguided impression that they are help-
ing the patient in doing so. For example, seeking reassurance from family
members is a frequently observed safety behavior observed in both children
and adults with various anxiety presentations such as health anxiety, general-
ized anxiety disorder, and separation anxiety. In patients with OCD or panic
disorder, family members are often asked to perform multiple safety behaviors
ranging from helping an OCD patient perform cleaning rituals to driving the
panic patient to the emergency room during a panic attack.
Mental safety behaviors also pose a challenge to the clinician. Interview
probes such as “Are there any intentional mental activities you perform to
cope with your anxiety or prevent something bad from happening?” can be
helpful when assessing covert threat neutralizing or anxiety reduction

Patient handout is available upon request from Michael J. Telch.

2
36 Telch and Zaizar

strategies. Examples of mental safety behaviors include repetitive mental

checking, reviewing, or analyzing past events or conversations with others.

Self-Report Safety Behavior Scales

Administering one or more self-report scales specifically developed for assess-

ing anxiety-related safety behaviors is a cost-effective strategy for identifying
and quantifying patients’ safety behaviors. They also have the advantage of
easy readministration during treatment to evaluate whether treatment is lead-
ing to reduced safety behavior utilization. Table 2.2 provides examples of estab-
lished scales used to assess safety behaviors across various anxiety domains.

Direct In Vivo Observation of the Patient in the Office or in the Field

Direct observation of the patient’s behavior during an anxiety challenge can be

quite helpful in identifying patient’s safety behaviors. For example, the driving
phobia patient may tightly grip the steering wheel, drive under the speed limit,
use unnecessary breaking, avoid driving in the left-hand lane, or pull over to the
side of the road when anxious. In contrast, the socially anxious patient may use
a variety of impression management safety behaviors such as avoiding clothing

TABLE 2.2. Self-Report Assessment Measures of Safety Behaviors Across

Anxiety-Related Disorders
Disorder and measure name Source
Panic disorder–agoraphobia
Texas Safety Maneuver Scale Kamphuis and Telch (1998)
Social anxiety disorder
Social Behavior Questionnaire Clark et al. (1995)
Presentation-Related Safety Behaviors Scale Kim (1999)
Social Phobia Safety Behaviors Scale Pinto-Gouveia, Cunha, and do Céu
Subtle Avoidance Frequency Examination Salvador (2003)
Cuming et al. (2009)
Posttraumatic stress disorder
Safety Behaviors Questionnaire Dunmore, Clark, and Ehlers (2001);
Ehring, Ehlers, and Glucksman (2008)a
Generalized anxiety disorder
The Worry Behaviors Inventory Mahoney et al. (2016)
Health anxiety
Questionnaire for Assessing Safety Behavior Weck, Brehm, and Schermelleh-Engel
in Hypochondriasis/Health Anxiety (2012)
Safety Behavior Checklist Olatunji, Etzel, Tomarken, Ciesielski,
and Deacon (2011)b
Obsessive-compulsive disorder
Safety Behavior Checklist Deacon and Maack (2008)b
Note. aMeasure developed over a series of studies. bUseful checklist from an experimental study that
has not yet been experimentally validated.
 Safety Behaviors 37

that might show perspiration (or wearing excessive clothing to conceal perspira-
tion) as well as mentally rehearsing possible topics or questions to talk about
with others to avoid appearing incompetent. Although less cost-effective, direct
behavioral observation of patients’ safety behavior engagement provides a
high-fidelity assessment strategy for assessing observable safety behaviors.

Individually Tailored Patient Self-Monitoring Forms

Having patients complete daily self-monitoring forms of their safety behaviors

can be a useful assessment strategy with several added benefits over the assess-
ment approaches discussed above. The assessment form itself can be individu-
ally tailored for each patient’s safety behavior profile. Online survey platforms
such as Survey Monkey provide convenient tools for designing self-monitoring
forms and data summary tools for the clinician and patient to review progress
and examine relationships between safety behaviors and anxiety symptoms.
Moreover, daily self-monitoring can be used to support patients’ efforts in
safety behavior fading by providing more fine-grained data to identify poten-
tial obstacles to target in session. For example, we often have patients rate
their self-efficacy to resist performing the safety behavior along with their
anticipated threat(s) if they were not to perform the safety behavior.

CLINICAL IMPLICATIONS

In the following sections, we provide brief descriptions of commonly observed

safety behaviors for various anxiety disorder profiles.

Fear of Fear

Individuals presenting with a heightened “fear of fear” (often referred to as

anxiety sensitivity; see Chapter 4) display a heightened sense of threat in response
to the experience of stress, anxiety, or panic. Evidence suggests that the spe-
cific threat forecasts governing the fear of panic tend to fall into one of three
panic appraisal dimensions: (a) physical threats (e.g., heart attack, suffocation,
fainting); (b) social threats (e.g., making a scene in front of others, embarrassing
family or friends); and (c) threats focused on loss of control/mental illness (e.g.,
“I will lose control during a panic attack and jump out a window,” or “I will
become mentally disabled”; Telch, Brouillard, Telch, Agras, & Taylor, 1989).
The safety behaviors typical of individuals presenting with panic disorder and
agoraphobia are illustrated in the case example provided in the opening of
the chapter.

Fear of Negative Evaluation

Individuals with social anxiety disorder carry out a variety of behaviors to

avoid or attenuate the perceived risk of negative evaluation. The specific
38 Telch and Zaizar

threat forecasts in socially anxious individuals varies considerably and may

include one or more of the following: appearing weird, stupid, incompetent,
or overly anxious. The socially anxious person may not only engage in safety
behaviors during social situations but also before or after a social encounter.
As noted earlier, the specific configuration of concerns dictates the safety
behaviors that the person is likely to display. For example, a socially anxious
college student who believes he may appear incompetent will mentally
rehearse what to say before entering a classroom in anticipation of being
called upon by the professor. Once in the classroom, he will likely avoid rais-
ing his hand to express his opinion. If asked a question, he may pause for
extended periods of time and think very carefully about what to say before
uttering a single word.
Socially anxious people often display an exaggerated concern that others
will notice their anxiety and judge them unfavorably because of it. Typical
safety behaviors associated with this threat include actions such as going to
the bathroom to check if one’s face is flushed, excessively applying deodorant to
reduce sweat accumulation, writing a check to a grocery store in advance
to avoid the threat of displaying trembling hands at the register, or pretend-
ing to talk on one’s cell phone at parties. Following a social interaction,
individuals preoccupied with hiding their anxiety may mentally review and
overly analyze the interaction out of concern that they may have appeared
anxious.

Fear of Contamination

Anxiety and avoidance behavior related to contamination concerns is a fre-

quent clinical presentation seen in individuals with OCD. Individuals with
unrealistic contamination concerns engage in a host of behaviors to both pre-
vent being contaminated and to restore cleanliness after coming into contact
with a perceived contaminant. A few classic examples of preventive safety
behaviors linked to a fear of contracting a fatal illness are avoiding touching
public door handles (especially restroom door handles), money, elevator
buttons, animals, and railing in public stairwells. Persons with these concerns
may also rely on tissues or gloves to distance themselves from contacting
perceived contaminants with their bare skin if contact is unavoidable. If these
individuals do come into contact with a perceived contaminant such as raw
meat or equipment at the gym, they will likely attempt to restore cleanliness
through excessive handwashing or applying antibacterial hand sanitizer.
Indeed, carrying hand sanitizer on one’s person or having it readily available
in one’s car is a common safety behavior motivated by contamination fears. If
a method for restoring sanitation is not readily available, patients with these
concerns will surely avoid touching their face and mouth to prevent patho-
gens from entering their body.
Not all contamination concerns are bacterial, viral, or parasitic. In some
instances, patients may fear chemical contamination. For example, an
 Safety Behaviors 39

individual who believes that the chemicals used to clean her bathroom floor
could burn her skin or render her permanently blind may avoid leaving a bar
of soap on the shower floor because of the possibility that the dangerous
chemicals will seep into the soap and cause harm. Repeatedly checking labels
on bottles and tubes of toothpaste to prevent the accidental ingestion of
harmful chemicals is also common.
Some individuals with contamination-related OCD show an interesting
clinical presentation in which the person perceives that (s)he is internally
contaminated, a phenomenon Rachman (1994) referred to as mental pollution,
which he defined as a “sense of internal un-cleanness, which can and usually
does arise and persist regardless of the presence or absence of external, observ-
able dirt” (p. 1). Individuals with this presentation are not concerned with
objective germs but rather may experience significant washing or cleaning
urges in response to immoral or blasphemous thoughts. Although some might
wash to reinstate a sense of internal cleanliness, the types of safety behaviors
performed in response to mental pollution also differ from more traditional
contamination concerns in part because the emotion of guilt and disgust are
predominant. For instance, individuals with mental pollution often attempt
to avoid certain repugnant or immoral thoughts, as well as avoid external
cues such as seedy parts of town or people who they perceive as morally
defective.

Fear of Unacceptable Thoughts

Patients with OCD often endorse concerns related to thoughts or images they
deem unacceptable. Furthermore, these individuals go to great lengths to
attempt to “undo” or neutralize a repugnant obsession by adopting idiosyn-
cratic mental maneuvers. It is important to understand that covert mental
compulsions are functionally equivalent to the more obvious overt rituals. As
an example, take the case of a religious individual who experiences obses-
sions about having sex with Jesus. This person is likely to attempt to suppress
or discharge this image from his or her mind. Another mental maneuver that
might be adopted is excessively praying for forgiveness for having experi-
enced the obsession. Additionally, the individual may try to cancel out or
replace the intrusive sexual image by thinking “good” thoughts (e.g., “Praise
the Lord”) or conjuring opposite images (e.g., Jesus smiling). Mental distrac-
tion such as counting until the image dissipates is another common mental
safety behavior observed in patients with these concerns. Although some
OCD patients may primarily engage in mental compulsions, the use of mental
compulsions does not preclude the deployment of overt safety behaviors as
well. For example, the individual previously described may repeatedly con-
fess to a priest that he or she had the grotesque image and ask for advice or
seek reassurance from others such as asking friends whether they have ever
had similar images come to mind. These examples highlight the ample diver-
sity in safety behaviors used by individuals with these concerns.
40 Telch and Zaizar

Fear of Traumatic Memories

Individuals presenting with posttraumatic stress disorder (PTSD) display

exaggerated threat perception in connection with memories of a previous
traumatic event. Although the traumatic event itself was objectively dan-
gerous at the time, memories of these events are not. Avoidance and other
unnecessary protective actions following the traumatic event may play a
causal role in the development of PTSD in response to a traumatic event as
well as maintain or exacerbate existing PTSD symptoms. Female sexual
assault victims may avoid certain activities or situations that trigger mem-
ories of the traumatic event (e.g., avoiding nightclubs). They may also
engage in more subtle avoidance maneuvers such as refraining from wear-
ing low-cut blouses and excessive checking of window and door locks.
Victims of serious motor vehicle accidents may avoid driving altogether
or engage in more restricted avoidance such as avoiding driving in the
rain, breaking while driving, or avoiding the intersection where the crash
occurred. Combat veterans presenting with PTSD often display excessive
visual scanning of their environment, avoidance of sitting with their
back exposed to others, and avoidance of barbecues because they trigger
memories of burning flesh. Regardless of the type of traumatic event,
PTSD sufferers often use mental maneuvers such as distraction or inten-
tional thought suppression in an effort to avoid thinking about the trau-
matic event.

Circumscribed Fears (Specific Phobias)

Four specific categories of specific phobias and one residual category are
recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 2013). These include (a) animal
(e.g., snakes, spiders, dogs), (b) natural environment (e.g., heights, storms,
water), (c) blood-injection injury (e.g., hospitals, needles, blood draws), (d) situa-
tional (e.g., airplanes, elevators, enclosed places), and (e) other (e.g., choking
or vomiting, loud sounds, clowns). Each specific fear is associated with spe-
cific perceived threats; for example, height phobia, falling; claustrophobia,
entrapment or suffocation; dog phobia, being attacked; blood injury, fainting;
and airplanes, crashing. Of the various safety behaviors observed in specific
phobias, none is more pervasive and pathogenic than avoidance of the feared
object or situation. In addition to avoidance, other safety behaviors com-
monly observed in specific phobias include (a) visual scanning of the environ-
ment (e.g., checking for roaches, dogs, smoke coming from the jet engine,
weather); (b) use of protective aids (e.g., one of our spider phobia patients
would put aluminum foil over the openings of his boots to prevent spiders
from crawling inside); (c) reassurance seeking from others (e.g., asking the
flight attendant whether the plane has sufficient fuel to make the flight);
(d) physical maneuvers (e.g., tightly gripping one’s steering wheel while
driving); (e) ingesting or carrying tranquilizers, alcohol, or other relaxing
 Safety Behaviors 41

herbs when confronting a phobic target (e.g., magnetic resonance imaging

scan for a person with claustrophobia); (f) mental acts (e.g., praying while on
the ski resort chairlift); and (g) subtle forms of avoidance (e.g., avoiding the
left lanes on the freeway). These are just a small representation of the diverse
safety behaviors that are commonly observed among those presenting with
specific phobias.

Pathological Worrying (Generalized Anxiety Disorder)

Although worrying serves an adaptive function in response to real threat or

danger, individuals with generalized anxiety disorder engage in unnecessary
pathological worry. Some might even construe worrying itself as a form of
safety behavior. Like other anxiety-related problems, those presenting with
generalized anxiety disorder display exaggerated threat perceptions related
to one or more life spheres such as relationships, work, family, and health.
Often these individuals partake in a host of maladaptive safety behaviors in
an effort to avert or attenuate threatening outcomes in one or more of these
life spheres. Examples include the husband who worries that his wife no
longer loves him and begins to engage in excessive questioning (e.g., “Honey,
do you still love me?”). That same husband may begin to check her email or
cell phone for signs that she has taken on a lover. Other examples include the
administrative assistant who copes with her worry that her supervisor is
unhappy with her work by engaging in repeated time-consuming checking of
each email or memo before sending it, for fear that one mistake may lead to
her termination.

CONCLUSION

Anxiety-related safety behaviors are unnecessary actions taken to prevent,

escape from, or reduce the severity of a perceived threat (Telch & Lancaster,
2012). In this chapter, we discussed the critical role safety behaviors play in
the emergence, maintenance, and escalation of all forms of anxiety-related
pathology. Furthermore, we have provided a brief overview of the various
theories that aim to explain the anxiogenic effects of safety behaviors with
a special emphasis on threat disconfirmation attenuation as a unifying ele-
ment across theories. Clinicians will likely find our chapter particularly use-
ful for getting a sense of the multiplicity of unnecessary protective actions
that anxious patients use. Additionally, we hope this chapter clearly depicts
how different safety behaviors map onto specific perceived threats. We
highly encourage clinicians to use our section on safety behavior assessment
as guidance for implementing more targeted interventions. Irrespective of
their specific diagnosis, a patient’s idiosyncratic safety behaviors must be
accurately assessed and then eliminated to maximize treatment of clinical
anxiety.
42 Telch and Zaizar

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Arlington, VA: Author.
Başoğlu, M., Marks, I. M., Kiliç, C., Swinson, R. P., Noshirvani, H., Kuch, K., . . .
Brewin, C. R. (1994). Alprazolam and exposure for panic disorder with agora­
phobia: Attribution of improvement to medication predicts subsequent relapse. The
British Journal of Psychiatry, 164, 652–659. http://dx.doi.org/10.1192/bjp.164.5.652
Biondi, M., & Picardi, A. (2003). Attribution of improvement to medication and increased
risk of relapse of panic disorder with agoraphobia. Psychotherapy and Psychosomatics,
72(2), 110–111. http://dx.doi.org/10.1159/000068687
Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during expo-
sure therapy for anxiety: Critical analysis from an inhibitory learning perspective.
Clinical Psychology Review, 49, 1–15. http://dx.doi.org/10.1016/j.cpr.2016.07.002
Clark, D. M., Butler, G., Fennell, M., Hackmann, A., McManus, F., & Wells, A. (1995).
Social Behaviour Questionnaire. Unpublished manuscript.
Cuming, S., Rapee, R. M., Kemp, N., Abbott, M. J., Peters, L., & Gaston, J. E. (2009).
A self-report measure of subtle avoidance and safety behaviors relevant to social
anxiety: Development and psychometric properties. Journal of Anxiety Disorders, 23,
879–883. http://dx.doi.org/10.1016/j.janxdis.2009.05.002
Deacon, B., & Maack, D. J. (2008). The effects of safety behaviors on the fear of contam-
ination: An experimental investigation. Behaviour Research and Therapy, 46, 537–547.
http://dx.doi.org/10.1016/j.brat.2008.01.010
Desnoyers, A. J., Kocovski, N. L., Fleming, J. E., & Antony, M. M. (2017). Self-focused
attention and safety behaviors across group therapies for social anxiety disorder.
Anxiety, Stress, and Coping: An International Journal, 30, 441–455. http://dx.doi.org/
10.1080/10615806.2016.1239083
Dunmore, E., Clark, D. M., & Ehlers, A. (2001). A prospective investigation of the role
of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical
or sexual assault. Behaviour Research and Therapy, 39, 1063–1084. http://dx.doi.org/
10.1016/S0005-7967(00)00088-7
Ehring, T., Ehlers, A., & Glucksman, E. (2008). Do cognitive models help in predicting
the severity of posttraumatic stress disorder, phobia, and depression after motor
vehicle accidents? A prospective longitudinal study. Journal of Consulting and Clinical
Psychology, 76, 219–230. http://dx.doi.org/10.1037/0022-006X.76.2.219
Engelhard, I. M., van Uijen, S. L., van Seters, N., & Velu, N. (2015). The effects of
safety behavior directed towards a safety cue on perceptions of threat. Behavior
Therapy, 46, 604–610. http://dx.doi.org/10.1016/j.beth.2014.12.006
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to correc-
tive information. Psychological Bulletin, 99, 20–35. http://dx.doi.org/10.1037/
0033-2909.99.1.20
Goetz, A. R., Davine, T. P., Siwiec, S. G., & Lee, H. J. (2016). The functional value of
preventive and restorative safety behaviors: A systematic review of the literature.
Clinical Psychology Review, 44, 112–124. http://dx.doi.org/10.1016/j.cpr.2015.12.005
Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review
on the effects of safety behavior across anxiety disorders. Clinical Psychology: Science
and Practice, 17, 218–233. http://dx.doi.org/10.1111/j.1468-2850.2010.01213.x
Kamphuis, J. H., & Telch, M. J. (1998). Assessment of strategies to manage or avoid
perceived threats among panic disorder patients: The Texas Safety Maneuver Scale
(TSMS). Clinical Psychology & Psychotherapy, 5, 177–186. http://dx.doi.org/10.1002/
(SICI)1099-0879(199809)5:3<177::AID-CPP166>3.0.CO;2-%23
Kamphuis, J. H., & Telch, M. J. (2000). Effects of distraction and guided threat
reappraisal on fear reduction during exposure-based treatments for specific
fears. Behaviour Research and Therapy, 38, 1163–1181. http://dx.doi.org/10.1016/
S0005-7967(99)00147-3
 Safety Behaviors 43

Kim, E. J. (1999). Social self-processing and safety behaviors in social phobics (Unpublished
doctoral dissertation). Seoul National University, Seoul, South Korea.
Lovibond, P. F., Mitchell, C. J., Minard, E., Brady, A., & Menzies, R. G. (2009). Safety
behaviours preserve threat beliefs: Protection from extinction of human fear condi-
tioning by an avoidance response. Behaviour Research and Therapy, 47, 716–720.
http://dx.doi.org/10.1016/j.brat.2009.04.013
Mahoney, A. E. J., Hobbs, M. J., Newby, J. M., Williams, A. D., Sunderland, M., &
Andrews, G. (2016). The Worry Behaviors Inventory: Assessing the behavioral
avoidance associated with generalized anxiety disorder. Journal of Affective Disorders,
203, 256–264. http://dx.doi.org/10.1016/j.jad.2016.06.020
Meulders, A., Van Daele, T., Volders, S., & Vlaeyen, J. W. S. (2016). The use of safety-
seeking behavior in exposure-based treatments for fear and anxiety: Benefit or bur-
den? A meta-analytic review. Clinical Psychology Review, 45, 144–156. http://dx.doi.org/
10.1016/j.cpr.2016.02.002
Niedenthal, P. M. (2007, May 18). Embodying emotion. Science, 316, 1002–1005.
http://dx.doi.org/10.1126/science.1136930
Olatunji, B. O., Etzel, E. N., Tomarken, A. J., Ciesielski, B. G., & Deacon, B. (2011). The
effects of safety behaviors on health anxiety: An experimental investigation. Behaviour
Research and Therapy, 49, 719–728. http://dx.doi.org/10.1016/j.brat.2011.07.008
Pinto-Gouveia, J., Cunha, M. I., & do Céu Salvador, M. (2003). Assessment of social
phobia by self-report questionnaires: The social interaction and performance anxiety
and avoidance scale and the social phobia safety behaviours scale. Behavioural and
Cognitive Psychotherapy, 31, 291–311. http://dx.doi.org/10.1017/S1352465803003059
Plasencia, M. L., Alden, L. E., & Taylor, C. T. (2011). Differential effects of safety
behaviour subtypes in social anxiety disorder. Behaviour Research and Therapy, 49,
665–675. http://dx.doi.org/10.1016/j.brat.2011.07.005
Powers, M. B., Smits, J. A., Whitley, D., Bystritsky, A., & Telch, M. J. (2008). The effect
of attributional processes concerning medication taking on return of fear. Journal
of Consulting and Clinical Psychology, 76, 478–490. http://dx.doi.org/10.1037/
0022-006X.76.3.478
Rachman, S. (1994). Pollution of the mind. Behaviour Research and Therapy, 32, 311–314.
http://dx.doi.org/10.1016/0005-7967(94)90127-9
Rachman, S. J., & Hodgson, R. J. (1980). Obsessions and compulsions. Upper Saddle
River, NJ: Prentice Hall.
Rescorla, R. A. (2003). Protection from extinction. Learning & Behavior, 31(2), 124–132.
http://dx.doi.org/10.3758/BF03195975
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety
and panic: A cognitive account. Behavioural and Cognitive Psychotherapy, 19(1), 6–19.
http://dx.doi.org/10.1017/S0141347300011472
Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition–behaviour links
in the persistence of panic. Behaviour Research and Therapy, 34, 453–458. http://
dx.doi.org/10.1016/0005-7967(95)00083-6
Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided
threat reappraisal on fear reduction during exposure: An experimental investiga-
tion. Behaviour Research and Therapy, 40, 235–251. http://dx.doi.org/10.1016/
S0005-7967(01)00007-9
Telch, M. J., Brouillard, M., Telch, C. F., Agras, W. S., & Taylor, C. B. (1989). Role of
cognitive appraisal in panic-related avoidance. Behaviour Research and Therapy, 27,
373–383. http://dx.doi.org/10.1016/0005-7967(89)90007-7
Telch, M. J., & Lancaster, C. L. (2012). Is there room for safety behaviors in exposure
therapy for anxiety disorders? In P. Neudeck & H. U. Wittchen (Eds.), Exposure
therapy: Rethinking the model–refining the method (pp. 313–334). New York, NY: Springer.
http://dx.doi.org/10.1007/978-1-4614-3342-2_18
Telch, M. J., Valentiner, D. P., Ilai, D., Petruzzi, D., & Hehmsoth, M. (2000). The facil-
itative effects of heart-rate feedback in the emotional processing of claustrophobic
44 Telch and Zaizar

fear. Behaviour Research and Therapy, 38, 373–387. http://dx.doi.org/10.1016/

S0005-7967(99)00038-8
Telch, M. J., Valentiner, D. P., Ilai, D., Young, P. R., Powers, M. B., & Smits, J. A. (2004).
Fear activation and distraction during the emotional processing of claustrophobic fear.
Journal of Behavior Therapy and Experimental Psychiatry, 35, 219–232. http://dx.doi.org/
10.1016/j.jbtep.2004.03.004
van Uijen, S. L., & Toffolo, M. B. J. (2015). Safety behavior increases obsession-
related cognitions about the severity of threat. Behavior Therapy, 46, 521–531.
http://dx.doi.org/10.1016/j.beth.2015.04.001
Vervliet, B., & Indekeu, E. (2015). Low-cost avoidance behaviors are resistant to
fear extinction in humans. Frontiers in Behavioral Neuroscience, 9(184), 351. http://
dx.doi.org/10.3389/fnbeh.2015.00351
Volders, S., Meulders, A., De Peuter, S., Vervliet, B., & Vlaeyen, J. W. (2012). Safety
behavior can hamper the extinction of fear of movement-related pain: An experi-
mental investigation in healthy participants. Behaviour Research and Therapy, 50,
735–746. http://dx.doi.org/10.1016/j.brat.2012.06.004
Weck, F., Brehm, U., & Schermelleh-Engel, K. (2012). Development and validation of a
questionnaire for the assessment of hypochondriacal safety behavior [in German].
Zeitschrift für Klinische Psychologie und Psychotherapie, 41, 271–281. http://dx.doi.org/
10.1026/1616-3443/a000174
3
Intolerance of Uncertainty
Ryan J. Jacoby

After watching a documentary about organic farming in her senior year biology
class in college, Michaela became increasingly preoccupied with fears of con-
tracting a terminal illness (e.g., brain cancer, heart disease) from long-term
exposure to pesticides and other chemicals in her food.1 She began removing
all nonorganic fruits and vegetables from her diet as well as any premade foods
with unnatural ingredients she feared were toxic (e.g., preservatives). She went
to great lengths to track down information about where her food came from,
until she felt “certain” it was not contaminated from chemicals, and she used
websites like WebMD to investigate whether any symptoms she had were signs
of cancer. She would repeatedly ask her fiancé for reassurance that any food he
had selected or prepared was safe in order to reduce her doubts and anxiety,
and she visited the doctor every few months in order to ensure she was healthy
because the mounting uncertainty of her health status began to feel unman-
ageable. Still, Michaela was plagued with doubts over whether she would
develop cancer later in life (e.g., 10 years from now). Given that it was ultimately
impossible for her to obtain certain and lasting proof that she was cancer-free,
she experienced continued daily distress over these matters.

From reading Michaela’s case, it becomes clear that she has difficulty
managing the uncertainty, doubt, and unpredictability about something as
ambiguous, unknown, and subject to change as her health. As a result of this

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-003
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
45
46 Ryan J. Jacoby

distress, she engages in maladaptive efforts (never fully satisfactory) to reach a

sense of certainty about whether she is cancer-free. Indeed, most aspects of life
are instilled with implicit uncertainty—for instance, when we use the stove in
our home, drive our car to work, or speak up in a meeting, we are accepting
some level of risk that our home may burn down, we may be in a car accident,
or we may be embarrassed. To navigate life’s uncertainties, most people learn
to tolerate some degree of the unknown and feel “certain enough” that situa-
tions are safe in the absence of clear-cut danger cues. In contrast, some indi-
viduals, such as Michaela, display an intolerance of uncertainty (IU), which is a
transdiagnostic cognitive vulnerability factor in the development and mainte-
nance of anxiety-related disorders (also termed a dispositional fear of the unknown;
Carleton, 2012, p. 939). Specifically, IU involves beliefs about the necessity of
having guarantees in life and one’s inability to cope with unpredictability or
ambiguity (Carleton, Mulvogue, et al., 2012; Dugas, Schwartz, & Francis, 2004;
Obsessive Compulsive Cognitions Working Group, 1997). In other words, those
with elevated IU inflate the importance of not knowing “for sure” whether a
feared outcome might occur at some point in the future (e.g., the possibility of
developing cancer one day from nonorganic produce) and experience a great
deal of discomfort over this uncertainty.
More specifically, IU can be broken down into two subcomponents (e.g.,
McEvoy & Mahoney, 2012). First, prospective IU, the information-seeking
dimension, refers to a desire for predictability, preferences for knowing what
the future holds, anxiety about future uncertain events, and active engage-
ment in seeking information to increase certainty. Michaela, for instance,
experiences a foreboding need to know whether she has cancer and makes
repeated trips to the doctor for health testing. Inhibitory IU, on the other hand,
is the avoidant dimension and is characterized by avoidance and paralysis in
the face of uncertainty. For example, in order to manage her uncertainty,
Michaela avoids consuming certain products if she is unable to confirm that
the ingredients are pesticide-free.
Although difficulties with uncertainty are commonplace in the general
population and occur along a dimensional spectrum (Carleton, Weeks, et al.,
2012), IU is elevated among those with clinical fear and anxiety. Research
indicates that IU is a transdiagnostic phenomenon that functions similarly
across diagnoses in the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association, 2013; Carleton, Mulvogue,
et al., 2012). However, content themes of uncertainty are typically tied to an
individual’s particular fears; thus, specific presentations of IU may differ by
diagnosis and presentation of fear (Mahoney & McEvoy, 2012), as is dis-
cussed further in this chapter.

CONCEPTUAL IMPLICATIONS

Cognitive behavioral models of anxiety-related problems (e.g., Abramowitz,

Deacon, & Whiteside, 2019) can be applied to explain the development
and persistence of IU. This model implicates the key role of (a) negative
 Intolerance of Uncertainty 47

under­lying core beliefs about uncertainty, (b) biased information processing

in the context of ambiguity, (c) threatening interpretations of uncertainty,
and (d) negatively reinforcing certainty-seeking behaviors (see Figure 3.1).

Role of Core Beliefs About Uncertainty

Cognitive approaches to psychopathology suggest that emotional disorders

arise from distinct types of dysfunctional cognitions (i.e., core beliefs and inter-
pretations; Beck, 1976). Indeed, IU can be seen as a cognitive “filter” through
which individuals view an ambiguous and uncertain world (Buhr & Dugas,
2002). Specifically, individuals with elevated IU endorse global negative beliefs
about uncertainty, such as inflating the importance of not knowing something

FIGURE 3.1. Cognitive Behavior Model of Intolerance of Uncertainty

Core Beliefs About Uncertainty

Must know things for sure
Uncertainty is unmanageable and should be avoided
Prevents
disconfirmation
Ambiguity cue(s)

Biased Ambiguous Information Processing

Lower threshold of ambiguity and
uncertainty

Reduced
Hypervigilance
memory
Uncertainty/Doubt for ambiguity
confidence

Threatening Interpretations of Uncertainty

Uncertainty-based reasoning (i.e., “I feel
uncertain, so there must be danger”)

Anxiety/Distress

Certainty-Seeking Behaviors
Avoidance of ambiguity, reassurance-seeking, checking, worrying

Negative Reinforcement
Temporary anxiety and ambiguity reduction;
long-term sensitivity to doubts and uncertainty
48 Ryan J. Jacoby

“for sure” and viewing uncertainty as distressing, unmanageable, and some-

thing to be avoided (e.g., Buhr & Dugas, 2002; Dugas, Gagnon, Ladouceur,
& Freeston, 1998; Dugas et al., 2007). For instance, Michaela’s case dem­
onstrates how her health-related fears are driven by powerful underlying
beliefs about uncertainty, such as “I need to know for sure that I am healthy”
and “I can’t stand feeling uncertain.” Thus, for individuals with elevated IU,
normative ambiguous cues in daily life activate underlying maladaptive core
beliefs about uncertainty.

The Role of Biased Ambiguous Information Processing

Biased information processing of threat and danger cues also plays a central role
in the development and maintenance of fear-based disorders (Beck & Clark,
1997). As has been discussed, most aspects of life are imbued with implicit
uncertainty. However, for those with elevated IU, life’s ambiguities have become
a more explicit focus. Indeed, research suggests that individuals with elevated IU
have a lower perceptual threshold for ambiguity such that situations that seem
“certain enough” to most are perceived as unclear (Ladouceur, Talbot, & Dugas,
1997). Those with high levels of IU also demonstrate enhanced retrieval of stim-
uli denoting uncertainty (e.g., in a word-learning task in which participants
were asked to recall a series of words, half that involved uncertainty [e.g.,
unknown] and half that did not [e.g., uniform]), indicating selective attention
for ambiguous cues in the environment and/or selective recall of uncertainty-
laden information (Dugas et al., 2005; see Chapter 12 for a more detailed
discussion of selective attention processes in anxiety disorders). Michaela, for
example, is likely to perceive and attend to an innocuous skip of her heart beat
out of fear that it is sign of heart disease and be acutely aware of commercials
on TV that relate to health and wellness. These information-processing biases
of ambiguity, in turn, lead to experiences of enhanced uncertainty and doubt.

The Role of Threatening Interpretations of Uncertainty

Whereas most individuals feel “certain-enough” that situations are “safe” in

the absence of clear-cut danger cues, as a result of these pansituational nega-
tive beliefs about uncertainty and heightened perception of ambiguous infor-
mation, individuals with IU make threatening interpretations of uncertainty
in the moment. Since people mistakenly look to their emotional state for
information about the dangerousness of a given situation (Arntz, Rauner, &
van den Hout, 1995), the experience of uncertainty serves as a threat cue
for some individuals (i.e., uncertainty-based reasoning; Reuman, Jacoby,
Fabricant, Herring, & Abramowitz, 2015). For instance, Michaela has learned
to interpret uncertainty about her health as threatening (i.e., “If I feel uncer-
tain, there must be danger”).
Furthermore, these threatening interpretations of uncertainty lead to
heightened daily distress for people like Michaela. In a series of studies,
 Intolerance of Uncertainty 49

experimentally increasing uncertainty in nonclinical samples (e.g., by making

it an explicit focus in discussing the probability of winning money in a gam-
bling simulation) led to increased worry, anxiety, and urges to perform a
safety behavior, suggesting a causal association between threatening interpre-
tations of uncertainty and symptoms of anxiety (de Bruin, Rassin, & Muris, 2006;
Grenier & Ladouceur, 2004; Ladouceur, Gosselin, & Dugas, 2000; Reuman
et al., 2015; Rosen & Knäuper, 2009). Furthermore, given these threatening
interpretations of uncertainty, individuals become hypervigilant for ambigu-
ities in life, thus fueling the likelihood that they will process information as
ambiguous in the future.

The Role of Certainty-Seeking Behaviors

In attempts to manage their distress, individuals with elevated IU have difficulty

functioning in uncertain or ambiguous situations and engage in unnecessary
(and personally costly) certainty-seeking behaviors. Indeed, many behaviors
observed across fear and anxiety disorders (e.g., reassurance-seeking, double-
checking, worries, mental rituals, excessive information-seeking) can be con-
ceptualized as attempts to restore a sense of “certainty” and reduce anxious
arousal (e.g., Behar, DiMarco, Hekler, Mohlman, & Staples, 2009; Einstein,
2014; Holaway, Heimberg, & Coles, 2006). In addition, more avoidant behav-
iors (e.g., procrastination, avoiding novelty, indecision) can also be construed
as methods to minimize uncertainty in situations where one feels it is impos-
sible to be sure (e.g., taking a long time to make a decision for fear it will be
the “wrong” one). In laboratory-based studies, individuals with elevated IU
apply ineffective problem-solving strategies (Jacoby, Abramowitz, Buck, &
Fabricant, 2014) and prioritize decisions that are more certain but less advan-
tageous in the long run (e.g., in ambiguous gambling tasks; Kim et al., 2015;
Pushkarskaya et al., 2015; Starcke, Tuschen-Caffier, Markowitsch, & Brand,
2010; Zhang et al., 2015). Michaela has also displayed a number of certainty-
seeking behaviors, ranging from asking her fiancé for reassurance to exces-
sively researching her health symptoms on WebMD. Paradoxically, studies
indicate that repeated checking and similar attempts to obtain certainty lead
to reduced memory confidence (Tolin et al., 2001), thus maintaining feelings
of uncertainty and doubt in this cycle. (Memory biases are covered in more
detail in Chapter 11.)

The Role of Negative Reinforcement

Although certainty-seeking behaviors may reduce fear and anxiety temporar-

ily (e.g., the momentary sense of relief Michaela feels when her doctor gives
her a clean bill of health), given that an absolute guarantee of safety is not
possible, these behaviors become habitual maladaptive strategies to manage
uncertainty (through negative reinforcement; e.g., Einstein, 2014). Such
behaviors also maintain long-term preoccupations and sensitivities to doubts
and uncertainties about the potential risk of harm and fuel core beliefs about
50 Ryan J. Jacoby

uncertainty as undesirable, unmanageable, and something to be avoided. In

other words, the more Michaela relies on certainty-seeking behaviors, the
more such behaviors have begun to escalate her perceived inability to tolerate
the ambiguity about her health.

Summary of the Conceptualization of Intolerance of Uncertainty

In summary, Michaela’s core beliefs about the necessity of being certain lead
to biased information processing and a lower threshold for perceiving the
(usually implicit) ubiquity of ambiguity in daily life. The resulting experience
of uncertainty and doubt triggers threatening interpretations of uncertainty
as something aversive and dangerous and leads to mounting levels of anxiety
and distress. Given this discomfort, individuals like Michaela experience urges
to gain assurance that feared disasters have not or will not materialize. Check-
ing and other certainty-seeking behaviors reduce such uncertainty, but only
temporarily, since an absolute guarantee of safety is not possible. Yet the dis-
tress reduction leads to the habitual use of such strategies (through negative
reinforcement) as well as increased preoccupation with doubts and uncer-
tainty. Accordingly, a critical focus of the treatment of clinical fear and anxiety
is learning to tolerate ambiguity and uncertainty, as opposed to trying to obtain
absolute certainty that feared negative outcomes will never occur (see Part II
of this handbook).

ASSESSMENT

In initial clinical interviews, uncertainty may or may not be expressed as an

explicit focus of patients’ concerns. For instance, anxious individuals may
emphasize feared worst case scenarios when describing their presenting prob-
lems: “I’m anxious about making a mistake in presentations at work”; “I’m
worried that my husband will die in a plane crash on one of his business
trips”; “I keep having traumatic flashbacks, and I am terrified I will be assaulted
again.” Thus, it may not be immediately apparent that these individuals grap-
ple with intolerance of uncertainty. However, further probing may reveal
beliefs such as “I can’t stand not knowing for sure if I will say the wrong thing,
so I practice my presentations repeatedly weeks in advance”; “I have so many
doubts about whether an accident may have happened, so I compulsively check
his flight status trying to be sure everything is okay”; “I can never be certain that
I am safe when I leave my house, so I’ve been avoiding public places.” Thus,
even if maladaptive beliefs about uncertainty are not immediately volunteered,
patients may be making threatening interpretations of daily uncertainties as
well as engaging in problematic certainty-seeking behaviors that are import-
ant targets for treatment. Accordingly, during an initial assessment, a clinician
might provide education about the role of uncertainty beliefs in fear-based
disorders and probe whether they relate to the patient’s presenting concerns
(e.g., “People with anxiety tend to struggle with the possibility of something
 Intolerance of Uncertainty 51

bad happening, even when the real chance of danger is very low. Because of
this they don’t tolerate uncertainty well and often feel as if they have to check
things over and over to be absolutely sure. Is this something you relate to?”).

Self-Report Measures

To complement the information gathered in a clinical interview, there are sev-

eral self-report measures that assess the degree to which individuals endorse
uncertainty-related beliefs. These assessment tools have the advantage of using
standardized questions with demonstrated reliability and validity that can used
to screen for elevated IU. While disorder-specific measures of IU also exist, such
as the Perfectionism/Certainty subscale of the Obsessive Beliefs Question-
naire (Obsessive Compulsive Cognitions Working Group, 2001, 2005) and the
dis­order-specific Intolerance of Uncertainty Scales (Thibodeau et al., 2015), the
following measures are applicable across presentations of anxiety and fear.
The Intolerance of Uncertainty Scale (IUS-12; Carleton, Norton, &
Asmundson, 2007) measures everyday cognitive, behavioral, and emotional
reactions to uncertainty, ambiguous situations, and the future.2 Participants
rate each item on a scale from 1 (Not at all characteristic of me) to 5 (Entirely
characteristic of me). The measure consists of the two dimensions of IU men-
tioned previously (Jacoby, Fabricant, Leonard, Riemann, & Abramowitz, 2013):
Prospective IU (e.g., “I always want to know what the future has in store for
me”) and Inhibitory IU (e.g., “When I am uncertain I can’t function very
well”). The IUS-12 demonstrates good psychometric properties in both clini-
cal and nonclinical samples (e.g., Jacoby et al., 2013) as well as associations
with symptoms of obsessive-compulsive disorder (OCD), generalized anxiety
disorder, social anxiety, panic disorder, health anxiety, neuroticism, and trait
anxiety (e.g., McEvoy & Mahoney, 2012). While no formal clinical cut-offs on
the IUS-12 have been developed, mean total scores tend to be around or
above 40 in clinical samples (Carleton, Mulvogue, et al., 2012; Jacoby et al.,
2013). Versions of the IUS-12 have also been adapted in order to tailor the
measure to patient’s idiosyncratic concerns (i.e., the IUS—Situation-Specific
Version; Mahoney & McEvoy, 2012).
The Intolerance of Uncertainty Index (Carleton, Gosselin, & Asmundson,
2010; Gosselin et al., 2008) was created to address concerns that the IUS-12
primarily measures the emotional and behavioral consequences and reactions
to IU (e.g., frustration, doubt, avoidance) and does not capture beliefs about
uncertainty being intolerable or unacceptable. Specifically, Part A (15 items)
assesses general unacceptability of uncertainty, and Part B (30 items) assesses
manifestations of uncertainty across anxiety disorders. The measure refrains

2
The shorter 12-item version of the IUS is preferred because several of the original
items in the 27-item version (Freeston et al., 1994) might better account for symp-
toms of generalized anxiety disorder than those of other anxiety disorders (Gentes &
Ruscio, 2011).
52 Ryan J. Jacoby

from using emotion words (e.g., anxiety) in order to avoid artificially inflating
relationships between IU and anxiety-related psychopathology. Both subscales
have excellent internal consistency and acceptable test–retest reliability, are
associated with symptoms of worry and depression (Carleton, Gosselin, &
Asmundson, 2010), and are highly correlated with the IUS (rs ranging from .68
to .72; Gosselin et al., 2008).

Behavioral Tasks

Although these instruments demonstrate strong psychometric properties, they

are designed to be trait measures that capture participants’ self-reported gen-
eral and stable beliefs about uncertainty. Most are limited, therefore, in their
use as dependent variables in studies seeking to examine predictors and mod-
erators of state IU (i.e., feelings of IU-related distress captured in the moment).
Thus, researchers have begun to evaluate laboratory paradigms as in vivo
behavioral measures of IU. These tasks have the advantage of experimentally
inducing uncertainty in the laboratory and capturing participants’ cognitive,
emotional, and behavioral responses to actual ambiguous scenarios.
For instance, previous research has indicated that individuals with high
levels of self-reported IU (a) report less confidence over time when making
repeated decisions in hypothetical high-risk vignette scenarios (e.g., a fire
in one’s dorm) given limited and changing information (Jensen, Kind,
Morrison, & Heimberg, 2014), (b) sacrifice potential rewards in order to avoid
uncertainty-related distress in a laboratory gambling task (Luhmann, Ishida,
& Hajcak, 2011), (c) evidence slower typing speed, suggesting greater need
for certainty before selecting a key (Thibodeau, Carleton, Gómez-Pérez, &
Asmundson, 2013), (d) select gambling options that appear more certain
despite being less advantageous (Carleton et al., 2016),3 and (e) request more
information before feeling certain enough to make a decision during a prob-
abilistic inference task (Jacoby et al., 2014; Ladouceur et al., 1997). These
tasks, therefore, have begun to elucidate the degree to which individuals with
elevated IU evidence impaired performance and heightened distress in the
context of ambiguity; however, many tasks have not been used in more than
one investigation, and replication of these findings is needed.

CLINICAL IMPLICATIONS

As discussed, intolerance of uncertainty is a central transdiagnostic mainte-

nance factor across domains of fear and anxiety disorders (Boswell, Thompson-
Hollands, Farchione, & Barlow, 2013; Carleton, 2012; Carleton, Mulvogue et al.,

3
Although see the article for more detailed findings from this study in which results
from community volunteers and psychology student undergraduates did not always
align.
 Intolerance of Uncertainty 53

2012; Einstein, 2014) even above and beyond other cognitive vulnerability
factors such as anxiety sensitivity, distress tolerance, and trait anxiety (Norr
et al., 2013). Commonly encountered themes of uncertainty for many fear
domains are presented in Table 3.1 and each is discussed in turn.

Uncertainty About Safety, Harm, and Disasters

Perhaps the most characteristic presentation of IU revolves around uncer-

tainty regarding potential harm and disasters befalling oneself or one’s loved
ones. First, such fears could manifest themselves as excessive worries about
everyday concerns characteristic of generalized anxiety disorder (e.g., “What if
I lose my job? What if my elderly mother slips and falls? What if I’m late to this
appointment?”). Theoretical models of generalized anxiety disorder posit that
the extreme worry represents an attempt to control the uncertainty associated

TABLE 3.1. Clinical Examples of Intolerance of Uncertainty Across Different

Fear Domains
Fear domain Sample intolerance of uncertainty beliefs
Uncertainty about safety, harm, and disasters
Generalized worry I always prepare in advance to make absolutely sure
I won’t be late to my appointments.
Specific phobias I would rather be safe than sorry, so I avoid dogs just in
case they might bite me.
Responsibility for harm The smallest doubt that I might have forgotten to turn
off the stove stops me from being able to leave
for work.
Posttraumatic stress When I think about returning to the scene of the attack,
uncertainty about whether I may be assaulted again
paralyses me.
Uncertainty about social evaluation
Social anxiety I can’t function in social situations if I feel uncertain
about whether other people are judging me.
Body-dysmorphic concerns I do anything I can to avoid feeling uncertain about how
I look.
Uncertainty about the significance or meaning of thoughts
Unacceptable thoughts Not knowing for sure whether I might one day molest a
child is unacceptable and intolerable.
Uncertainty about health, somatic cues, and contamination
Panic attacks I can’t stand being taken by surprise by unexpected
physical sensations like being unable to catch
my breath.
Illness anxiety I always want to know what my future health will be.
Contamination fears I need to be absolutely sure that I’m not spreading
germs to my loved ones.
Uncertainty regarding symmetry or exactness
“Not just right” experiences I can’t stop rereading until I’m certain that it feels
“just right.”
54 Ryan J. Jacoby

with feared future situations (i.e., problem-solving gone awry; Dugas, Buhr, &
Ladouceur, 2004; Freeston, Rhéaume, Letarte, Dugas, & Ladouceur, 1994),
and a large body of research supports strong associations between self-
reported IU and worry symptoms (e.g., Buhr & Dugas, 2006; Dugas, Gosselin,
& Ladouceur, 2001; Sexton, Norton, Walker, & Norton, 2003). In addition to
worry itself as a certainty-seeking behavior, patients with generalized anxiety
disorder also engage in maladaptive reassurance seeking (e.g., asking for
additional performance reviews from a boss; checking up on an elderly rela-
tive) as well as avoidance of situations that may be unclear (e.g., procrastinat-
ing on a job assignment in which the outcome may be uncertain). Additionally,
although many specific phobias center around fears that something cata-
strophic will happen in the moment (e.g., “This dog is going to bite me!”; see
Chapter 1 on overestimates of threat), certain fears characteristic of specific
phobias may also involve uncertainty (e.g., fears leading up to a plane flight,
such as “What if the engine of this plane fails and we crash?”). Thus, threat-
ening interpretations of uncertainty in the context of a phobic stimulus as
well as maladaptive attempts to resolve it (e.g., researching recent plane
crashes, driving instead of flying) may also be present in individuals with
specific phobias.
In addition to excessive worries about everyday concerns and catastrophes,
uncertainties about safety could also present as unwanted obsessions and
doubts concerning responsibility for harm as seen in OCD (e.g., Abramowitz
& Nelson, 2007; Holaway, Heimberg, & Coles, 2006; Tolin, Abramowitz, Brigidi,
& Foa, 2003). Individuals with this presentation of OCD fear that they will
make a decision, action, or mistake that will lead to emotional or physical
injury to themselves or their loved ones (e.g., causing a fire, hitting a pedes-
trian). For example, someone may experience intrusive images of a spouse
being the victim of a violent break-in if he were to accidentally leave the door
unlocked, which leads to surges of doubt and uncertainty as well as the urge
to know for certain that this crime is not going to happen. Characteristically,
patients with obsessions about responsibility for harm rely on various forms
of checking and other compulsive rituals (e.g., examining the home security
alarm system for any breaches; calling loved ones for reassurance that every-
thing is okay) and avoidance (e.g., making sure not to be the last one to leave
the house) with the aim of restoring a sense of “certainty” and reducing anx-
iety. Given that an absolute guarantee that one will not be to blame for
adverse outcomes is not possible, those with OCD become excessively pre­
occupied with doubts about safety and responsibility.
Finally, IU can play a role in fears regarding safety following a traumatic
event as seen in posttraumatic stress disorder (PTSD; Bardeen, Fergus, & Wu,
2013; Fetzner, Horswill, Boelen, & Carleton, 2013; Oglesby, Boffa, Short,
Raines, & Schmidt, 2016). Central uncertainties characteristic of indivi­
duals with PTSD are both about the traumatic event itself (e.g., “Could I
have responded differently and prevented this from happening? Do others
blame me for what happened?”), as well as about one’s future safety (e.g.,
 Intolerance of Uncertainty 55

“What if I am assaulted again?”). Theories suggest that individuals with PTSD

see the possibility that a negative event will occur in the future as inherently
threatening and that IU beliefs fuel hypervigilance for threat (a hallmark
symptom of PTSD). While hypervigilance may be an attempt to eliminate
uncertain danger (i.e., by preparing for possible catastrophic events so as to
not be caught off guard), these behaviors paradoxically interfere with the
ability to emotionally process traumatic experiences (White & Gumley, 2009),
thus maintaining posttraumatic stress symptoms.

Uncertainty About Social Evaluation

Social and performance situations are another domain imbued with uncer-
tainty. Individuals with social anxiety disorder exhibit marked and persistent
fear of potential embarrassment and negative scrutiny from others (Hofmann
& Barlow, 2004), and as a result struggle with uncertainty in social settings
(Boelen & Reijntjes, 2009; Carleton, Collimore, & Asmundson, 2010; McEvoy
& Mahoney, 2012; Whiting et al., 2014). Similarly, although fewer studies
have been conducted, IU also has implications for the development and main-
tenance of body-dysmorphic disorder (Lavell, Farrell, & Zimmer-Gembeck,
2014; Summers, Matheny, Sarawgi, & Cougle, 2016). For patients with this
disorder, the focus is uncertainty about how others view their appearance,
which leads to maladaptive appearance-related certainty-seeking behaviors
(e.g., excessive body and mirror checking; Phillips, 2005). In these types of
evaluative social situations, it is impossible to know what will happen (e.g.,
“Will I be rejected by the group because of how monstrous I look?”) or what
others truly think (e.g., “Does my date think I’m awkward?”), which individ-
uals with social anxiety disorder and body dysmorphic disorder have difficul-
ties managing and can lead to social isolation (e.g., avoidance of talking to
strangers or even leaving the house). Theories also suggest that IU beliefs fuel
postevent processing of social situations in attempts to resolve ambiguities in
one’s memory of how an interaction transpired (e.g., Did I say the wrong thing
and make a bad impression?; Shikatani, Antony, Cassin, & Kuo, 2016).

Uncertainty About the Significance or Meaning of Thoughts

While some individuals with OCD report obsessional doubts about feared
disasters that might occur at some point in the future (e.g., fires, break-ins,
accidents, as described above), others exhibit doubts concerning truly
unknowable questions. These presentations of OCD typically revolve around
unwanted, ego-dystonic obsessional thoughts and impulses regarding “taboo”
topics (i.e., violence, sex, religion; e.g., “What if I suddenly ‘snap’ and murder
my roommate? What if I commit a religious sin without meaning to?”), which
also are associated with high levels of IU (Abramowitz & Deacon, 2006;
Holaway et al., 2006; Jacoby et al., 2013; Tolin, Brady, & Hannan, 2008).
Individuals with unacceptable thoughts often engage in unobservable mental
56 Ryan J. Jacoby

rituals in attempts to obtain certainty (e.g., rereading Bible passages to con-

firm one is a pious person, mentally reviewing actions throughout the day to
ensure one didn’t molest a child without meaning to) and avoidance of trig-
gers of unacceptable thoughts (e.g., knives, places of worship, children).
Given that such questions of one’s morality are ultimately unanswerable,
individuals with this presentation of OCD struggle with the inability to obtain
certainty about matters most individuals take for granted as “certain enough.”

Uncertainty About Health, Somatic Cues, and Contamination

As was evident with the case of Michaela, individuals with anxiety-related

disorders may also struggle with uncertainty about their physical health,
bodily cues, and potential illness or contamination. First, these fears may
manifest as uncertainty about a future panic attack in the context of panic
disorder (PD; Carleton et al., 2014; Mahoney & McEvoy, 2012; McEvoy &
Mahoney, 2012). Specifically, individuals with PD have difficulties managing
uncertainty about what internal signs and symptoms may mean (e.g., “Is my
racing pulse a sign of a heart attack?”). While in certain contexts an elevated
heart rate may be expected (e.g., in the midst of vigorous exercise), when the
cause of such sensations is unknown, individuals with PD struggle to manage
not knowing whether such symptoms are indicative of something ominous
such as death, incapacity, or a loss of control. Second, by their very nature,
panic attacks in PD are recurrent and unexpected (American Psychiatric
Association, 2013), and accordingly uncertainties about when and where the
next attack may occur, how long it will last, and whether others will notice
are central concerns. Consequently, maladaptive certainty-seeking behaviors
such as checking one’s pulse and avoiding panic-inducing activities and sub-
stances (e.g., caffeine, exercise, sex) contribute to the vicious cycle of PD.
Such fears may also generalize to more pervasive health anxiety con-
cerns characteristic of illness anxiety disorder (IAD; Boelen & Carleton, 2012;
Deacon & Abramowitz, 2008; Fergus & Valentiner, 2011). Individuals with
IAD hold dysfunctional beliefs about uncertainty of their health status (e.g.,
To be in good health means one should be completely symptom-free) that
lead to hypervigilance to both external (e.g., hearing about the rise in heart
disease on the news) and internal somatic cues (e.g., headaches, an abnormal
skin blemish). This hypervigilance increases opportunities to notice (and make
catastrophic misinterpretations of) benign bodily changes (e.g., “Is this a
tension headache or a sign of brain cancer?”; Olatunji, Deacon, Abramowitz, &
Valentiner, 2007). The resulting anxious arousal patients with IAD experience
while worrying about illness further reinforces beliefs that there is something
seriously wrong with their health and leads to maladaptive certainty-seeking
behaviors (e.g., online research about medical conditions, repeated visits to
specialists for second opinions).
Finally, such fears may manifest themselves as fears of future contami-
nation from coming into contact with dirt or germs, as observed in some
individuals with OCD (e.g., Jensen & Heimberg, 2015; Sarawgi, Oglesby, &
 Intolerance of Uncertainty 57

Cougle, 2013). Although exposures for contamination fears often focus on

the here and now (e.g., the ability to touch surfaces in a public restroom),
typically patients with contamination fears are not concerned that they will
exhibit signs and symptoms of contamination in the hour-long session, but
rather are flooded with uncertainty about germs they may have contracted
that will lead to future consequences either for themselves or others (e.g.,
“Will I contract HIV and develop signs of AIDS 10 years from now?”). As a
result, decontamination rituals (e.g., excessive hand washing, showering, use
of chemical cleaners and solvents) are an attempt to feel “certain” that the
contaminant threat has been eliminated.

Uncertainty Regarding “Not Just Right Experiences”

Finally, IU contributes to the distress of individuals who experience uncer-

tainty regarding “not just right experiences” (NJREs; Bottesi, Ghisi, Sica, &
Freeston, 2017); this is a less common presentation of IU compared with
other forms. These individuals grapple with uncertainty about whether an
action can be stopped or has been completed (e.g., when a passage in a book
has been read “correctly”). They may also fear “what if” the uncomfortable
sensation that something is “not just right” continues or escalate indefinitely.
Moreover, NJRE-related behaviors may be performed in attempts to obtain
certainty that a catastrophic event will not occur (i.e., magical thinking). For
instance, someone may perform certain tasks such as turning a light switch off
and on an “even,” “balanced,” or “symmetrical” number of times in response
to a sense of dread or “bad luck” resulting from unevenness. While individuals
with this presentation of OCD typically recognize that the link between their
behaviors and catastrophic outcomes (e.g., one’s parents’ safety) is illogical,
they typically feel it is “better to be safe than sorry,” and so they perform
rituals “just in case” to resolve doubts and uncertainty.

CONCLUSION

In summary, IU (defined as the fear of the unknown) is a transdiagnostic cog-

nitive vulnerability factor that contributes to the development and mainte-
nance of anxiety disorders. Cognitive behavior models suggest that individuals
with elevated IU hold underlying negative core beliefs about uncertainty,
have biased information processing in the context of ambiguity, and make
threatening interpretations of uncertainty. In attempts to manage the result-
ing distress, these individuals perform unnecessary and personally costly
certainty-seeking behaviors that are negatively reinforcing, but only provide
temporary relief since an absolute guarantee of safety is not possible. Clinical
presentations of IU manifest transdiagnostically across anxiety and fear-based
disorders including uncertainty about safety, harm, and disasters (e.g., as seen
in GAD or PTSD); social evaluation (as seen in SAD or BDD); the significance
58 Ryan J. Jacoby

or meaning of thoughts (as seen in OCD); or health, somatic cues, and con-
tamination (e.g., as seen in PD and IAD).
Although the treatment of anxiety and related disorders is discussed in
greater detail in the chapters of Part II of this handbook, an important lesson
patients should draw from anxiety-based treatment is the willingness to live with
acceptable levels of uncertainty. Cognitive techniques (Wilhelm & Steketee,
2006) can be used to challenge a patient’s need to be certain. Here it is import-
ant not to get into a debate over the likelihood of feared consequences occur-
ring, since IU persists even if individuals recognize that their feared consequences
are unlikely, and such challenges will likely have only a transient effect. Rather,
cognitive strategies should target the patient’s IU directly to modify beliefs that
uncertainty is unmanageable. Exposure exercises can also be viewed as vehi-
cles for fostering better tolerance of uncertainty. The goal of these exercises is
to help patients learn that uncertainty is more manageable than expected and
to disconfirm the expectation that they need to perform certainty-seeking
behaviors in order to deal with these feelings (Craske, Treanor, Conway,
Zbozinek, & Vervliet, 2014).

REFERENCES
Abramowitz, J. S., & Deacon, B. J. (2006). Psychometric properties and construct valid-
ity of the Obsessive-Compulsive Inventory—Revised: Replication and extension
with a clinical sample. Journal of Anxiety Disorders, 20, 1016–1035. http://dx.doi.org/
10.1016/j.janxdis.2006.03.001
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for
anxiety: Principles and practice (2nd ed.). New York, NY: Guilford Press.
Abramowitz, J. S., & Nelson, C. A. (2007). Treating doubting and checking concerns.
In M. M. Antony, C. Purdon, & L. J. Summerfeldt (Eds.), Psychological treatment of
obsessive-compulsive disorder: Fundamentals and beyond (pp. 169–186). Washington,
DC: American Psychological Association. http://dx.doi.org/10.1037/11543-007
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Arlington, VA: Author.
Arntz, A., Rauner, M., & van den Hout, M. (1995). “If I feel anxious, there must be
danger”: Ex-consequentia reasoning in inferring danger in anxiety disorders.
Behaviour Research and Therapy, 33, 917–925. http://dx.doi.org/10.1016/0005-
7967(95)00032-S
Bardeen, J. R., Fergus, T. A., & Wu, K. D. (2013). The interactive effect of worry and
intolerance of uncertainty on posttraumatic stress symptoms. Cognitive Therapy
and Research, 37, 742–751. http://dx.doi.org/10.1007/s10608-012-9512-1
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: Inter­
national Universities Press.
Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Auto-
matic and strategic processes. Behaviour Research and Therapy, 35, 49–58. http://
dx.doi.org/10.1016/S0005-7967(96)00069-1
Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current
theoretical models of generalized anxiety disorder (GAD): Conceptual review and
treatment implications. Journal of Anxiety Disorders, 23, 1011–1023. http://dx.doi.org/
10.1016/j.janxdis.2009.07.006
Boelen, P. A., & Carleton, R. N. (2012). Intolerance of uncertainty, hypochondriacal
concerns, obsessive-compulsive symptoms, and worry. Journal of Nervous and Mental
Disease, 200, 208–213. http://dx.doi.org/10.1097/NMD.0b013e318247cb17
 Intolerance of Uncertainty 59

Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and social anxiety. Jour-
nal of Anxiety Disorders, 23, 130–135. http://dx.doi.org/10.1016/j.janxdis.2008.04.007
Boswell, J. F., Thompson-Hollands, J., Farchione, T. J., & Barlow, D. H. (2013). Intol-
erance of uncertainty: A common factor in the treatment of emotional disorders.
Journal of Clinical Psychology, 69, 630–645. http://dx.doi.org/10.1002/jclp.21965
Bottesi, G., Ghisi, M., Sica, C., & Freeston, M. H. (2017). Intolerance of uncertainty,
not just right experiences, and compulsive checking: Test of a moderated media-
tion model on a non-clinical sample. Comprehensive Psychiatry, 73, 111–119. http://
dx.doi.org/10.1016/j.comppsych.2016.11.014
Buhr, K., & Dugas, M. J. (2002). The Intolerance of Uncertainty Scale: Psychometric
properties of the English version. Behaviour Research and Therapy, 40, 931–945.
http://dx.doi.org/10.1016/S0005-7967(01)00092-4
Buhr, K., & Dugas, M. J. (2006). Investigating the construct validity of intolerance of
uncertainty and its unique relationship with worry. Journal of Anxiety Disorders, 20,
222–236. http://dx.doi.org/10.1016/j.janxdis.2004.12.004
Carleton, R. N. (2012). The intolerance of uncertainty construct in the context of
anxiety disorders: Theoretical and practical perspectives. Expert Review of Neuro­
therapeutics, 12, 937–947. http://dx.doi.org/10.1586/ern.12.82
Carleton, R. N., Collimore, K. C., & Asmundson, G. J. G. (2010). “It’s not just the
judgements—It’s that I don’t know”: Intolerance of uncertainty as a predictor of
social anxiety. Journal of Anxiety Disorders, 24, 189–195. http://dx.doi.org/10.1016/
j.janxdis.2009.10.007
Carleton, R. N., Duranceau, S., Freeston, M. H., Boelen, P. A., McCabe, R. E., &
Antony, M. M. (2014). “But it might be a heart attack”: Intolerance of uncertainty
and panic disorder symptoms. Journal of Anxiety Disorders, 28, 463–470. http://
dx.doi.org/10.1016/j.janxdis.2014.04.006
Carleton, R. N., Duranceau, S., Shulman, E. P., Zerff, M., Gonzales, J., & Mishra, S.
(2016). Self-reported intolerance of uncertainty and behavioural decisions. Journal
of Behavior Therapy and Experimental Psychiatry, 51, 58–65. http://dx.doi.org/10.1016/
j.jbtep.2015.12.004
Carleton, R. N., Gosselin, P., & Asmundson, G. J. G. (2010). The intolerance of uncer-
tainty index: Replication and extension with an English sample. Psychological
Assessment, 22, 396–406. http://dx.doi.org/10.1037/a0019230
Carleton, R. N., Mulvogue, M. K., Thibodeau, M. A., McCabe, R. E., Antony, M. M., &
Asmundson, G. J. G. (2012). Increasingly certain about uncertainty: Intolerance of
uncertainty across anxiety and depression. Journal of Anxiety Disorders, 26, 468–479.
http://dx.doi.org/10.1016/j.janxdis.2012.01.011
Carleton, R. N., Norton, M. A. P., & Asmundson, G. J. G. (2007). Fearing the unknown:
A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders,
21, 105–117. http://dx.doi.org/10.1016/j.janxdis.2006.03.014
Carleton, R. N., Weeks, J. W., Howell, A. N., Asmundson, G. J. G., Antony, M. M., &
McCabe, R. E. (2012). Assessing the latent structure of the intolerance of uncertainty
construct: An initial taxometric analysis. Journal of Anxiety Disorders, 26, 150–157.
http://dx.doi.org/10.1016/j.janxdis.2011.10.006
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maxi-
mizing exposure therapy: An inhibitory learning approach. Behaviour Research and
Therapy, 58, 10–23. http://dx.doi.org/10.1016/j.brat.2014.04.006
Deacon, B., & Abramowitz, J. S. (2008). Is hypochondriasis related to obsessive
compulsive-disorder, panic disorder, or both? An empirical evaluation. Journal of
Cognitive Psychotherapy, 22, 115–127. http://dx.doi.org/10.1891/0889-8391.22.2.115
de Bruin, G. O., Rassin, E., & Muris, P. (2006). Worrying in the lab: Does intolerance
of uncertainty have predictive value? Behaviour Change, 23(2), 138–147. http://
dx.doi.org/10.1375/bech.23.2.138
60 Ryan J. Jacoby

Dugas, M. J., Buhr, K., & Ladouceur, R. (2004). The role of intolerance of uncertainty
in etiology and maintenance. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.),
Generalized anxiety disorder: Advances in research and practice (pp. 143–163). New York,
NY: Guilford Press.
Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety
disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy,
36, 215–226. http://dx.doi.org/10.1016/S0005-7967(97)00070-3
Dugas, M. J., Gosselin, P., & Ladouceur, R. (2001). Intolerance of uncertainty and
worry: Investigating specificity in a nonclinical sample. Cognitive Therapy and
Research, 25, 551–558. http://dx.doi.org/10.1023/A:1005553414688
Dugas, M. J., Hedayati, M., Karavidas, A., Buhr, K., Francis, K., & Phillips, N. A. (2005).
Intolerance of uncertainty and information processing: Evidence of biased recall
and interpretations. Cognitive Therapy and Research, 29, 57–70. http://dx.doi.org/
10.1007/s10608-005-1648-9
Dugas, M. J., Savard, P., Gaudet, A., Turcotte, J., Laugesen, N., Robichaud, M., . . .
Koerner, N. (2007). Can the components of a cognitive model predict the severity
of generalized anxiety disorder? Behavior Therapy, 38, 169–178. http://dx.doi.org/
10.1016/j.beth.2006.07.002
Dugas, M. J., Schwartz, A., & Francis, K. (2004). Intolerance of uncertainty, worry, and
depression. Cognitive Therapy and Research, 28, 835–842. http://dx.doi.org/10.1007/
s10608-004-0669-0
Einstein, D. A. (2014). Extension of the transdiagnostic model to focus on intolerance
of uncertainty: A review of the literature and implications for treatment. Clinical
Psychology: Science and Practice, 21, 280–300. http://dx.doi.org/10.1111/cpsp.12077
Fergus, T. A., & Valentiner, D. P. (2011). Intolerance of uncertainty moderates the rela-
tionship between catastrophic health appraisals and health anxiety. Cognitive
Therapy and Research, 35, 560–565. http://dx.doi.org/10.1007/s10608-011-9392-9
Fetzner, M. G., Horswill, S. C., Boelen, P. A., & Carleton, R. N. (2013). Intolerance of
uncertainty and PTSD symptoms: Exploring the construct relationship in a commu-
nity sample with a heterogeneous trauma history. Cognitive Therapy and Research, 37,
725–734. http://dx.doi.org/10.1007/s10608-013-9531-6
Freeston, M. H., Rhéaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why
do people worry? Personality and Individual Differences, 17, 791–802. http://dx.doi.org/
10.1016/0191-8869(94)90048-5
Gentes, E. L., & Ruscio, A. M. (2011). A meta-analysis of the relation of intolerance
of uncertainty to symptoms of generalized anxiety disorder, major depressive dis­
order, and obsessive-compulsive disorder. Clinical Psychology Review, 31, 923–933.
http://dx.doi.org/10.1016/j.cpr.2011.05.001
Gosselin, P., Ladouceur, R., Evers, A., Laverdière, A., Routhier, S., & Tremblay-Picard, M.
(2008). Evaluation of intolerance of uncertainty: Development and validation
of a new self-report measure. Journal of Anxiety Disorders, 22, 1427–1439. http://
dx.doi.org/10.1016/j.janxdis.2008.02.005
Grenier, S., & Ladouceur, R. (2004). Manipulation de l’intolérance a l’incertitude et
inquiétudes. [Manipulation of Intolerance of Uncertainty and worries]. Canadian
Journal of Behavioural Science/Revue Canadienne Des Sciences Du Comportement, 36(1),
56–65. http://dx.doi.org/10.1037/h0087216
Hofmann, S. G., & Barlow, D. H. (2004). Social phobia (social anxiety disorder). In
D. H. Barlow (Ed.), Anxiety and its disorders: The nature and treatment of anxiety and
panic (2nd ed., pp. 454–476). New York, NY: Guilford Press.
Holaway, R. M., Heimberg, R. G., & Coles, M. E. (2006). A comparison of intolerance
of uncertainty in analogue obsessive-compulsive disorder and generalized anxiety
disorder. Journal of Anxiety Disorders, 20, 158–174. http://dx.doi.org/10.1016/
j.janxdis.2005.01.002
 Intolerance of Uncertainty 61

Jacoby, R. J., Abramowitz, J. S., Buck, B. E., & Fabricant, L. E. (2014). How is the
Beads Task related to intolerance of uncertainty in anxiety disorders? Journal of
Anxiety Disorders, 28, 495–503. http://dx.doi.org/10.1016/j.janxdis.2014.05.005
Jacoby, R. J., Fabricant, L. E., Leonard, R. C., Riemann, B. C., & Abramowitz, J. S.
(2013). Just to be certain: Confirming the factor structure of the intolerance of
uncertainty scale in patients with obsessive-compulsive disorder. Journal of Anxiety
Disorders, 27, 535–542. http://dx.doi.org/10.1016/j.janxdis.2013.07.008
Jensen, D., & Heimberg, R. G. (2015). Domain-specific intolerance of uncertainty
in socially anxious and contamination-focused obsessive-compulsive individuals.
Cognitive Behaviour Therapy, 44(1), 54–62. http://dx.doi.org/10.1080/16506073.
2014.959039
Jensen, D., Kind, A. J., Morrison, A. S., & Heimberg, R. G. (2014). Intolerance of
uncertainty and immediate decision-making in high-risk situations. Journal of
Experimental Psychopathology, 5, 178–190. http://dx.doi.org/10.5127/jep.035113
Kim, H. W., Kang, J. I., Namkoong, K., Jhung, K., Ha, R. Y., & Kim, S. J. (2015).
Further evidence of a dissociation between decision-making under ambiguity and
decision-making under risk in obsessive-compulsive disorder. Journal of Affective
Disorders, 176, 118–124. http://dx.doi.org/10.1016/j.jad.2015.01.060
Ladouceur, R., Gosselin, P., & Dugas, M. J. (2000). Experimental manipulation of intol-
erance of uncertainty: A study of a theoretical model of worry. Behaviour Research
and Therapy, 38, 933–941. http://dx.doi.org/10.1016/S0005-7967(99)00133-3
Ladouceur, R., Talbot, F., & Dugas, M. J. (1997). Behavioral expressions of intolerance
of uncertainty in worry. Experimental findings. Behavior Modification, 21, 355–371.
http://dx.doi.org/10.1177/01454455970213006
Lavell, C. H., Farrell, L. J., & Zimmer-Gembeck, M. J. (2014). Do obsessional belief
domains relate to body dysmorphic concerns in undergraduate students? Journal
of Obsessive-Compulsive and Related Disorders, 3, 354–358. http://dx.doi.org/10.1016/
j.jocrd.2014.10.001
Luhmann, C. C., Ishida, K., & Hajcak, G. (2011). Intolerance of uncertainty and deci-
sions about delayed, probabilistic rewards. Behavior Therapy, 42, 378–386. http://
dx.doi.org/10.1016/j.beth.2010.09.002
Mahoney, A. E. J., & McEvoy, P. M. (2012). Trait versus situation-specific intolerance
of uncertainty in a clinical sample with anxiety and depressive disorders. Cognitive
Behaviour Therapy, 41, 26–39. http://dx.doi.org/10.1080/16506073.2011.622131
McEvoy, P. M., & Mahoney, A. E. J. (2012). To be sure, to be sure: Intolerance of uncer-
tainty mediates symptoms of various anxiety disorders and depression. Behavior
Therapy, 43, 533–545. http://dx.doi.org/10.1016/j.beth.2011.02.007
Norr, A. M., Oglesby, M. E., Capron, D. W., Raines, A. M., Korte, K. J., & Schmidt,
N. B. (2013). Evaluating the unique contribution of intolerance of uncertainty
relative to other cognitive vulnerability factors in anxiety psychopathology. Journal
of Affective Disorders, 151, 136–142. http://dx.doi.org/10.1016/j.jad.2013.05.063
Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of
obsessive-compulsive disorder. Behaviour Research and Therapy, 35, 667–681. http://
dx.doi.org/10.1016/S0005-7967(97)00017-X
Obsessive Compulsive Cognitions Working Group. (2001). Development and initial
validation of the obsessive beliefs questionnaire and the interpretation of intrusions
inventory. Behaviour Research and Therapy, 39, 987–1006. http://dx.doi.org/10.1016/
S0005-7967(00)00085-1
Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of
the obsessive belief questionnaire and interpretation of intrusions inventory—
Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy,
43, 1527–1542. http://dx.doi.org/10.1016/j.brat.2004.07.010
Oglesby, M. E., Boffa, J. W., Short, N. A., Raines, A. M., & Schmidt, N. B. (2016). Intol-
erance of uncertainty as a predictor of post-traumatic stress symptoms following a
62 Ryan J. Jacoby

traumatic event. Journal of Anxiety Disorders, 41, 82–87. http://dx.doi.org/10.1016/

j.janxdis.2016.01.005
Olatunji, B. O., Deacon, B. J., Abramowitz, J. S., & Valentiner, D. P. (2007). Body vigi-
lance in nonclinical and anxiety disorder samples: Structure, correlates, and pre­
diction of health concerns. Behavior Therapy, 38, 392–401. http://dx.doi.org/
10.1016/j.beth.2006.09.002
Phillips, K. A. (2005). The broken mirror: Understanding and treating body dysmorphic
disorder (Rev expanded ed.). Oxford, England: Oxford University Press.
Pushkarskaya, H., Tolin, D., Ruderman, L., Kirshenbaum, A., Kelly, J. M., Pittenger, C.,
& Levy, I. (2015). Decision-making under uncertainty in obsessive-compulsive
disorder. Journal of Psychiatric Research, 69, 166–173. http://dx.doi.org/10.1016/
j.jpsychires.2015.08.011
Reuman, L., Jacoby, R. J., Fabricant, L. E., Herring, B., & Abramowitz, J. S. (2015).
Uncertainty as an anxiety cue at high and low levels of threat. Journal of Behavior
Therapy and Experimental Psychiatry, 47, 111–119. http://dx.doi.org/10.1016/j.jbtep.
2014.12.002
Rosen, N. O., & Knäuper, B. (2009). A little uncertainty goes a long way: State and
trait differences in uncertainty interact to increase information seeking but also
increase worry. Health Communication, 24, 228–238. http://dx.doi.org/10.1080/
10410230902804125
Sarawgi, S., Oglesby, M. E., & Cougle, J. R. (2013). Intolerance of uncertainty and
obsessive-compulsive symptom expression. Journal of Behavior Therapy and Experi-
mental Psychiatry, 44, 456–462. http://dx.doi.org/10.1016/j.jbtep.2013.06.001
Sexton, K. A., Norton, P. J., Walker, J. R., & Norton, G. R. (2003). Hierarchical model
of generalized and specific vulnerabilities in anxiety. Cognitive Behaviour Therapy, 32,
82–94. http://dx.doi.org/10.1080/16506070302321
Shikatani, B., Antony, M. M., Cassin, S. E., & Kuo, J. R. (2016). Examining the role
of perfectionism and intolerance of uncertainty in postevent processing in social
anxiety disorder. Journal of Psychopathology and Behavioral Assessment, 38, 297–306.
http://dx.doi.org/10.1007/s10862-015-9516-8
Starcke, K., Tuschen-Caffier, B., Markowitsch, H. J., & Brand, M. (2010). Dissocia-
tion of decisions in ambiguous and risky situations in obsessive-compulsive dis­
order. Psychiatry Research, 175(1–2), 114–120. http://dx.doi.org/10.1016/j.psychres.
2008.10.022
Summers, B. J., Matheny, N. L., Sarawgi, S., & Cougle, J. R. (2016). Intolerance of
uncertainty in body dysmorphic disorder. Body Image, 16, 45–53. http://dx.doi.org/
10.1016/j.bodyim.2015.11.002
Thibodeau, M. A., Carleton, R. N., Gómez-Pérez, L., & Asmundson, G. J. G. (2013).
“What if I make a mistake?” Intolerance of uncertainty is associated with poor
behavioral performance. Journal of Nervous and Mental Disease, 201, 760–766.
http://dx.doi.org/10.1097/NMD.0b013e3182a21298
Thibodeau, M. A., Carleton, R. N., McEvoy, P. M., Zvolensky, M. J., Brandt, C. P.,
Boelen, P. A., . . . Asmundson, G. J. G. (2015). Developing scales measuring disorder-
specific intolerance of uncertainty (DSIU): A new perspective on transdiagnostic.
Journal of Anxiety Disorders, 31, 49–57. http://dx.doi.org/10.1016/j.janxdis.2015.01.006
Tolin, D. F., Abramowitz, J. S., Brigidi, B. D., Amir, N., Street, G. P., & Foa, E. B. (2001).
Memory and memory confidence in obsessive-compulsive disorder. Behaviour Research
and Therapy, 39, 913–927. http://dx.doi.org/10.1016/S0005-7967(00)00064-4
Tolin, D. F., Abramowitz, J. S., Brigidi, B. D., & Foa, E. B. (2003). Intolerance of uncer-
tainty in obsessive-compulsive disorder. Journal of Anxiety Disorders, 17, 233–242.
http://dx.doi.org/10.1016/S0887-6185(02)00182-2
Tolin, D. F., Brady, R. E., & Hannan, S. (2008). Obsessional beliefs and symptoms of
obsessive-compulsive disorder in a clinical sample. Journal of Psychopathology and
Behavioral Assessment, 30(1), 31–42. http://dx.doi.org/10.1007/s10862-007-9076-7
 Intolerance of Uncertainty 63

White, R. G., & Gumley, A. I. (2009). Postpsychotic posttraumatic stress disorder: Asso-
ciations with fear of recurrence and intolerance of uncertainty. Journal of Nervous
and Mental Disease, 197, 841–849. http://dx.doi.org/10.1097/NMD.0b013e3181bea625
Whiting, S. E., Jenkins, W. S., May, A. C., Rudy, B. M., Davis, T. E., III, & Reuther, E. T.
(2014). The role of intolerance of uncertainty in social anxiety subtypes. Journal of
Clinical Psychology, 70, 260–272. http://dx.doi.org/10.1002/jclp.22024
Wilhelm, S., & Steketee, G. S. (2006). Desire for certainty. In Cognitive therapy for
obsessive compulsive disorder: A guide for professionals (pp. 111–120). Oakland, CA:
New Harbinger.
Zhang, L., Dong, Y., Ji, Y., Zhu, C., Yu, F., Ma, H., . . . Wang, K. (2015). Dissociation of
decision making under ambiguity and decision making under risk: A neurocogni-
tive endophenotype candidate for obsessive-compulsive disorder. Progress in Neuro-
Psychopharmacology & Biological Psychiatry, 57, 60–68. http://dx.doi.org/10.1016/
j.pnpbp.2014.09.005
4
Anxiety Sensitivity
Steven Taylor

When Dave was a kid, he was stung by a wasp while playing in the park.1
His face puffed up like a balloon, and his eyelids swelled until he couldn’t see.
His throat closed up until her could hardly breathe. His mom rushed him to
the hospital, where they gave Dave adrenaline. The doctor said he was lucky to
be alive.
Ever since that experience, Dave has been worried about his health, and
particularly about allergic reactions. This morning the air was so humid and
smoggy that he had trouble catching his breath. He started to worry that he
might be allergic to smog. Dave’s mouth went dry and he felt a lump in his
throat, which scared him. He started to breathe faster so that he would get
enough air. But things only got worse. Dave felt dizzy, his face went numb, and
his heart started pounding. His chest was so tight that he could hardly catch his
breath. He was paralyzed with fear and sure he was going to die. Frantically,
Dave grabbed his cell phone and called for an ambulance. By the time it arrived
he felt better. It wasn’t an allergic reaction. Just his nerves. He was afraid that
the next time he would not be so lucky.

Dave has elevated anxiety sensitivity (AS), that is, an intense fear of
arousal-related bodily sensations, arising from dysfunctional beliefs about
the meaning and consequences of the sensations (Reiss, Peterson, Gursky, &

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-004
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
65
66 Steven Taylor

McNally, 1986). AS varies in severity. People with high levels of AS tend to

believe that arousal-related bodily sensations are dangerous. People with
high AS tend to harbor beliefs such as “If my heart beats rapidly, it means
that I might be having a heart attack,” or “If my hands tremble, people will
reject me,” or “If I feel lightheaded, it means that I might have a brain
tumor.” People with low levels of AS tend to believe that arousal-related
sensations such as palpitations, trembling, or lightheadedness are harmless
and inconsequential.
An older concept, similar to AS, is “fear-of-fear” (Goldstein & Chambless,
1978, p. 47). According to Goldstein and Chambless (1978), the experience of
recurrent panic attacks in people with panic disorder and agoraphobia was
said to cause these individuals to acquire a heightened fear-of-fear, which
exacerbated their panic, anxiety, and agoraphobic avoidance. In comparison
to the conceptualization of fear-of-fear, heightened AS need not be exclusively
a consequence of panic attacks. AS may be an antecedent factor, predating
any panic- or anxiety-related psychopathology.
Another concept similar to AS is found in Clark’s (1986) cognitive model
of panic. Here, panic attacks are said to arise from a catastrophic misinter­
pretation of bodily sensations. People who are prone to recurrent panic attacks
are said to have an enduring tendency to catastrophically misinterpret bodily
sensations, especially arousal-related bodily sensations. This is very similar to
the concept of AS, with the main difference being that AS is broader, being
implicated in a range of anxiety or distress related disorders and not limited
to panic attacks or panic disorder.

CONCEPTUAL IMPLICATIONS

Empirical and Conceptual Foundations

AS is conceptualized as an amplification factor that exacerbates anxiety, panic,

and other forms of distress (Reiss et al., 1986). For example, by becoming
anxious about arousal-related bodily sensations, the feared sensations them-
selves become amplified and anxiety escalates. Accumulating evidence indicates
that AS is a predisposing factor for many different types of psychopathology,
although research shows that AS is most strongly related to panic disorder,
generalized anxiety disorder, and posttraumatic stress disorder (PTSD; Naragon-
Gainey, 2010).
Longitudinal investigations have found that AS predicts the first onset of
panic attacks and the development of other forms of pathology, particularly
anxiety and related disorders (e.g., Schmidt et al., 2010; Schmidt, Lerew, &
Jackson, 1999). Longitudinal research further suggests that AS can interact
with stressful life events to give rise to panic and anxiety (Schmidt et al.,
1999). That is, stressful events can produce intense arousal-related sensations.
People with high AS interpret these sensations as being highly dangerous,
which in turn leads to a cycle of heightened anxiety, distress, and panic.
 Anxiety Sensitivity 67

Stability

AS, as assessed by contemporary instruments such as the Anxiety Sensitivity

Index-3 (ASI-3; Taylor et al., 2007), tends to be stable (traitlike) in the absence
of treatment (e.g., Farris et al., 2015; Taylor et al., 2007). However, the severity
of a person’s AS can be reduced by various interventions, as described later in
this chapter. Thus, AS is a modifiable risk factor for psychopathology. It is of
transdiagnostic relevance in that elevated scores on AS or its factors is associ-
ated with a range of psychiatric disorders.

Structure

Structurally, people can be classified into high versus low AS (e.g., Bernstein
et al., 2007; Bernstein et al., 2010). High AS is associated with anxiety dis­
orders, particularly panic disorder, whereas low AS is characteristic of most
controls. Within these classes AS is composed of multiple dimensions, with
the three most robust (reliably identified) dimensions being (a) cognitive
concerns (e.g., beliefs that symptoms like racing thoughts are harbingers
of danger), (b) physical concerns (e.g., beliefs that palpitations lead to heart
attacks), and (c) social concerns (e.g., beliefs that publicly observable anxiety
reactions such as trembling lead to social rejection; Taylor et al., 2007).

Etiology

Behavioral-genetic (twin) studies show that individual differences in AS are

the result of a combination of genetic and environmental factors (Brown et al.,
2012; Taylor, Jang, Stewart, & Stein, 2008). The genetic factors are additive in
nature rather than being dominance effects. That is, it appears likely that
numerous genes, each with small effects, incrementally add to the person’s
risk for having high AS. The actual genes (polymorphisms) involved in AS
are currently unknown. Such genes likely play a role in the brain structures
involved in the processing of threat, such as the anterior cingulate cortex,
medial prefrontal cortex, and insula. Neuroimaging research suggests that a
person’s level of AS is positively correlated with the degree of activation of
these structures when a person is present with threat-related stimuli (Holtz,
Pané-Farré, Wendt, Lotze, & Hamm, 2012; Poletti et al., 2015).
With regard to the environmental factors involved in AS, learning expe-
riences may play a role, especially those experiences that cause a person
to believe that arousal-related sensations are dangerous (Knapp, Frala,
Blumenthal, Badour, & Leen-Feldner, 2013; Stewart et al., 2001). This was
illustrated in the case of Dave at the beginning of this chapter. Relevant
learning experiences include information transmission (e.g., being told that
palpitations are dangerous), modeling and observational learning (e.g., having
a parent who avoids physical exertion because of beliefs that their lungs
or heart are weak), and possibly interoceptive (Pavlovian) conditioning
(Stewart et al., 2001).
68 Steven Taylor

ASSESSMENT

AS is assessed in three types of ways: self-report measures (questionnaires),

clinical interview, and interoceptive exposure exercises in which the latter
are used elicit bodily sensations and thereby observe the person’s response.
Each method has its particular strengths and so each are commonly used
in the assessment of AS. Self-report measures have the advantage of being
standardize and yield scores that can be compared to norms. A clinical inter-
view offers a more nuanced assessment, in which the clinician can assess
idiosyncratic or highly unusual AS-related beliefs that might not be assessed
in questionnaires. Interoceptive exposure exercises are useful because, unlike
questionnaires or interviews, the exercises assess how patients actually
think and feel, in real time, when they experience arousal-related bodily
sensation. A patient might, for whatever reason, minimize or under-report
AS concerns on a questionnaire but experience intense distress and fearful
thoughts when bodily sensations are induced via interoceptive exposure.
Thus, each of the three methods have their place in the comprehensive
assessment of AS.

Self-Report Measures

Agoraphobic Cognitions Questionnaire

and Body Sensations Questionnaire
Two scales, the Agoraphobic Cognitions Questionnaire and the Body Sensa-
tions Questionnaire (Chambless, Caputo, Bright, & Gallagher, 1984), were
developed as measures of fear-of-fear, which was a forerunner to the concept
of AS. The Body Sensations Questionnaire asks respondents to rate their fear
of each of 17 arousal-related body sensations (e.g., palpitations). The ques-
tionnaire has generally performed adequately on various tests of reliability
and validity (e.g., Chambless & Gracely, 1989). A limitation of the Body
Sensations Questionnaire is that it provides no information on the reasons
why the person is frightened of body sensations.
The Agoraphobic Cognitions Questionnaire asks respondents to rate how
often each of 14 threat-related thoughts occur when the person is feeling
anxious. Examples include thoughts pertaining to physical threat (e.g., “I must
have a brain tumor”) and those to do with social threat (e.g., “I’m going to act
foolish”). The scale has mixed support for its reliability and validity (Taylor,
2000). A further limitation is that its scores are ambiguous. The scale is based
on the assumption that high scores indicate a greater tendency to become
frightened by anxiety; that is, thoughts like “I have a brain tumor” are assumed
to be triggered by anxiety. However, it might be that the items assess thoughts
that cause anxiety. The Agoraphobic Cognitions Questionnaire also fails to
clearly distinguish thoughts from sensations (Taylor, 2000). That is, scores on
the questionnaire are ambiguous. The questionnaire is based on the assump-
tion that higher scores indicate a greater tendency to be frightened by anxiety;
 Anxiety Sensitivity 69

for example, items like “I have a brain tumor” are assumed to assess thoughts
that are triggered by anxiety. However, it could be that the items actually assess
thoughts that cause anxiety.

Anxiety Sensitivity Index

High scores on the 16-item self-report scale Anxiety Sensitivity Index (ASI;
Reiss, Peterson, Taylor, Schmidt, & Weems, 2008) indicate a strong tendency
to catastrophically misinterpret arousal-related body sensations. Moderate
scores indicate a tendency to believe these sensations have harmful but
not necessarily catastrophic consequences. People with low scores believe
that arousal-related sensations are harmless. The ASI has performed well on
numerous tests of reliability and validity, and is sensitive to treatment-related
effects (Reiss et al., 2008). However, a major limitation is that as a unidimen-
sional measure, it does not delineate the major (i.e., most widely replicated)
dimensions of AS; physical, cognitive, and social concerns.

Anxiety Sensitivity Index-3

Several revised versions to the ASI have been developed, with the most
widely used version being the 18-item Anxiety Sensitivity Index-3 (ASI-3;
Taylor et al., 2007). The ASI-3 consists of three six-item subscales, which assess
physical, cognitive, and social concerns. The ASI-3 has good reliability and
validity (e.g., Farris et al., 2015; Kemper & Hock, 2017; Rifkin, Beard, Hsu,
Garner, & Björgvinsson, 2015). The scale and scoring information are included
in the supplemental materials for Taylor et al. (2007).

Other Questionnaires
Several other measures of arousal-related beliefs have been developed,
primarily for research purposes, and none have been extensively evaluated
in terms of their psychometric properties. Examples of these scales include
the Body Sensations Interpretations Questionnaire (Clark et al., 1997) and the
Panic Belief Inventory (Wenzel, Sharp, Brown, Greenberg, & Beck, 2006).

Clinical Interview

The assessment of arousal beliefs is not limited to self-report questionnaires.

Valuable information can be obtained through a clinical interview, which
allows the therapist to collect information on the nature of beliefs about
arousal-related sensations, along with information about any environmental
events (e.g., learning experiences) that might have contributed to the forma-
tion of the beliefs. Among the most useful interview methods for eliciting
catastrophic beliefs is the downward arrow method (Burns, 1981). This uses a
series of questions to identify catastrophic beliefs, including beliefs about the
dangerousness of bodily sensations. To use the downward arrow method, the
therapist can ask the patient to describe a distressing event, such as a recent
episode of panic. Systematic questioning is then used to identify what the
70 Steven Taylor

patient regards as the worst part of the event, and why they think that is bad.
Questions such as the following are asked:

• “What was most upsetting about _____?”

• “Supposing _____ did happen, why would that be bad?”
• “If _____ was true, what would that mean to you?”
• “What could happen if _____ did occur?”

Interoceptive Exposure Exercises

Interoceptive exposure tasks are a series of exercises that induce arousal-related

sensations. These can be performed in the therapist’s office for either assess-
ment purposes or therapeutically to challenge catastrophic beliefs about the
meaning or consequence(s) of physiological arousal. When used for assessment,
they serve as exposure probes. If the patient catastrophically misinterprets
the sensations, then a full or limited symptom panic attack would ensue, or the
patient would prematurely terminate the exercise. Thus, the probes can
be used to assess the patient’s interpretations of body sensations in vivo. There
are many different interceptive exposure exercises. A list of commonly used
exercises appears in Table 4.1. The exercises in Table 4.1 are also used in
therapy to test catastrophic beliefs about arousal-related sensations. Some
patients have medical conditions (e.g., asthma, epilepsy) that make it unadvis-
able to use interoceptive exposure (see Table 4.2). Other patients might
require slight modifications to otherwise safe interoceptive tasks (e.g., women
who are pregnant; Arch, Dimidjian, & Chessick, 2012). If there is any doubt
about the safety of a given exercise for a given patient, then either the exercise
should not be used or it could be used only after a consultation with the
patient’s treating physician.
After each exercise is completed, the therapist can ask the patient to rate the
intensity of the sensations experiences on a 0-to-10 intensity scale (0 = absent,
10 = maximum intensity), to list thoughts or images arising during the exercise,
and to indicate whether a panic attack occurred. The therapist also can
observe whether the patient is attempting to avoid completing the exercise.
That is, terminating the task before the allotted time, or trying to avoid the
sensations evoked by the task (e.g., by taking shallow breaths during the
hyperventilation exercise).
Interoceptive exposure tests are useful for following up on unusually
low scores on paper-and-pencil indices of arousal beliefs. To illustrate, con-
sider the case of Edna, who obtained a score of 9 on the ASI-3, which is a
score lying in the lower end of the norm range. Yet Edna’s descriptions
of her panic attacks suggested that the attacks typically occurred because
she misinterpreted dizziness as a sign she was about to go crazy. When
I raised this possibility with her, she seemed convinced that thoughts had
nothing to do with her attacks. To gain further information, I asked Edna
to hyperventilate for 1 minute. She began the exercise but stopped after
30 seconds because she was starting to panic. Edna observed that as she
 Anxiety Sensitivity 71

TABLE 4.1. Interoceptive Exposure Exercises

Examples of catastrophic beliefs
Examples of exercises that can be tested*
Shake head rapidly from side to side, or “Dizziness leads to insanity.”
roll head in circles (30 seconds)
Place head between knees for 30 seconds “When I feel lightheaded it means
and then lift head quickly up to a I could be having a stroke.”
normal (upright) position
Spin around while standing up with arms “I will throw up if I let myself feel
stretched out (1 minute) nauseous.”
Hold breath (30 seconds) “Chest tightness means I’m having
a heart attack.”
Hyperventilate (1 minute) “If I start to feel unsteady it means
I will physically collapse.”
Breathe through a narrow straw without “Choking sensations are dangerous.”
breathing through nose (2 minutes)
Stare continuously at a ceiling fluorescent “If my surroundings start to look weird
light (1 minute) it means I’m going mad.”
Stare continuously at reflection in mirror “If I let myself feel spacey I could
(2 minutes) permanently lose touch with reality.”
Stare continuously at spot on wall or at “Feeling unreal is a sign that I’m having
one’s hand (3 minutes) a stroke.”
Stare for 3 minutes at a visual grid that “Staring at visual illusions or other
induces visual illusions (e.g., https:// unsettling images could tip me over
en.wikipedia.org/wiki/Grid_illusion) the edge into permanent insanity.”
Tense all muscles in body while sitting in “People will laugh at me if I start to
a chair (1 minute) tremble.”
Jog on the spot or run up stairs (1 minute) “I will have a heart attack if my heart
starts pounding.”
Face a heater, hair dryer, or hand dryer: “People will ridicule me if they see
Heater blowing hot air at the face I’m having hot flushes.”
(5 minutes)
Tongue depressor: Place tongue depressor “If my stomach gets upset I’ll vomit
at back of throat (30 seconds) uncontrollably.”
Drink hot coffee (2–3 cups) “I could go crazy if I get too jittery.”
To induce throat tightness, one can ask “If my throat feels tight it means
the patient to start to swallow and then I’m about to choke to death.”
hold the throat in the “mid-swallow”
position for 5–10 seconds.
To induce chest pain, ask the patient to “Chest pain means I’m having a heart
interlock their fingers and place hands attack.”
behind the head while stretching the
elbows backwards. The patient then
takes a deep breath and then tries to
chest breath at a rate of 1 breath per
second for 1 minute.
Note. From Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches (p. 6),
by S. Taylor, 2000, New York, NY: Wiley. Copyright 2000 by Wiley and Sons. Reprinted with permission.
*These exercises are also used to test noncatastrophic alternative explanations of the sensations
(e.g., “Palpitations are simply due to my lack of physical fitness”).
72 Steven Taylor

TABLE 4.2. Potential Contraindications for Using Interoceptive

Exposure Exercises
Exercise Potential contraindication
Shake or roll head Cervical pain or disease (e.g., whiplash injury),
history of falling due to dizziness or balance
disorder*
Place head between knees and Postural hypotension, lower-back pain,
stand up history of falling due to dizziness or
balance disorder*
Spin around Pregnancy, history of falling due to dizziness
or balance disorder*
Hold breath Chronic obstructive lung disease
Hyperventilate Chronic obstructive lung disease, severe
asthma, cardiac conditions, epilepsy,
renal disease, pregnancy
Breathe through a narrow straw Chronic obstructive pulmonary disease
Stare at fluorescent light History of seizures caused by staring at
flickering lights
Stare at reflection in mirror No apparent contraindications
Stare at spot on wall or at one’s hand No apparent contraindications
Stare at a visual grid that induces History of seizures or migraine headaches
visual illusions (these can be triggered by the grids)
Tense all muscles Pain disorders. If pain is localized, patients
could tense all but the afflicted region.
Jog on the spot or run up stairs Cardiac conditions, severe asthma, lower
back pain, pregnancy
Heater blowing hot air at face No apparent contraindications
Tongue depressor at back of throat Prominent gag reflex (stimulation of which
will induce vomiting)
Drink hot coffee History of severe insomnia
Hold throat in “mid-swallow” Prominent gag reflex
Hands behind head while stretching Chronic obstructive pulmonary disease,
elbows backwards severe asthma, cardiac conditions, epilepsy,
pregnancy, pain disorders. If pain is
localized, patients could tense all but
the afflicted region.
Note. From Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches
(p. 341), by S. Taylor, 2000, New York, NY: Wiley. Copyright 2000 by Wiley and Sons. Reprinted
with permission.
*Some forms of vertigo habituate to these exercises.

hyperventilated she had difficulty thinking clearly and became increasingly

frightened she was losing control of her mind. This case shows that paper-
and-pencil measures are not invariably accurate and that interoceptive probes
provide important additional information. Interoceptive exposure probes not
only serve as in vivo assessment tools, but also help educate patients about
the panic attacks. For example, Edna’s experience with the hyperventilation
probe led her to conclude that “maybe my thoughts do have an effect on my
panic attacks.”
 Anxiety Sensitivity 73

CLINICAL IMPLICATIONS

Rationale for Targeting Anxiety Sensitivity in Treatment

If AS is a vulnerability factor for various forms of psychopathology, partic-

ularly anxiety disorders and related clinical conditions, then the risk of
developing these disorders can be reduced by identifying people with high
AS and then encouraging them to complete a brief AS reduction program.
To illustrate, military service personnel might be assessed with a measure of
AS and those individuals with high scores could be offered an AS-reduction
intervention, as a means of reducing the risk of combat-induced anxiety
disorders such as PTSD.
For people presenting to tertiary care clinics for treatment of anxiety dis­
orders, an AS-reduction intervention might be an important component of
their treatment. AS reduction might not be sufficient to treat all of their pre-
senting problems, but it might play an important role. For example, in the
treatment of panic disorder with agoraphobia, AS-reduction exercises (e.g.,
interoceptive exposure) could be combined with exposure exercises to reduce
agoraphobic avoidance (Taylor, 2000). Several different types of transdiag-
nostic vulnerability factors have been identified, of which AS is one (Boswell
et al., 2013; see chapters throughout Part I of this handbook for discussions of
other transdiagnostic vulnerability factors). For patients with multiple trans-
diagnostic vulnerability factors, an intervention for reducing AS might be one
of several interventions that are implemented.

Historical Perspective

Historically, the development and implementation of AS-related interven-

tions has proceeded in three overlapping phases. In the first phase, cognitive
behavior therapy (CBT) was developed for specific disorders, such as CBT for
panic disorder and for other specific disorders (e.g., Clark, 1989). AS reduc-
tion exercises—consisting of psychoeducation, cognitive restructuring, and
interoceptive exposure, and situational exposure—were included as part of
the CBT package for panic disorder. Later, AS reduction exercises were applied
to other disorders.
It later became apparent that there were psychological vulnerability factors
and interventions that were common to many different kinds of emotional
disorders. This led to the development of transdiagnostic forms of CBT
(e.g., Barlow et al., 2011; Norton, 2012). As discussed earlier in this chapter,
AS is considered to be a transdiagnostic vulnerability factor. Accordingly,
interventions for reducing AS were included in transdiagnostic CBT protocols
(Boswell et al., 2013).
The third phase involved the development of brief (e.g., one session) inter-
ventions that specifically targeted AS. These were developed for people who
had high levels of AS but did not necessarily meet diagnostic criteria for
a mental disorder. The goal of these programs was preventative, that is, to
74 Steven Taylor

reduce the risk of high-AS people developing disorders in the future, such as
panic disorder. Meta-analytic research shows that CBT in its various forms, as
compared with control conditions, reduces AS, both in treatment-seeking
samples (e.g., samples of patients seeking treatment for anxiety disorders)
and in prevention studies of at-risk samples (e.g., samples of people with high
AS and therefore at risk for developing future psychopathology; Smits, Berry,
Tart, & Powers, 2008). Thus, there appears to be both a conceptual and empirical
basis for including AS-reduction strategies in prevention and transdiagnostic
treatment programs.

Anxiety Sensitivity–Related Interventions as Part

of Disorder-Specific Treatment Protocols

AS-reducing interventions were developed for, and extensively investigated

with, panic disorder. Researchers are now beginning to investigate how AS
interventions can be based applied to other types of disorders.

Panic Disorder
AS reduction interventions were initially used primarily in the treatment of
panic disorder. This gradually changed when clinical investigators developed
a greater appreciation of the importance of AS in treatment many different
disorders. AS-related interventions, as part of CBT for panic disorder, consist
of the following: psychoeducation about the nature of AS, cognitive restruc-
turing to correct distorted or maladaptive beliefs about the dangerousness
of arousal-related sensations, interoceptive exposure (e.g., voluntary hyper­
ventilation), and naturalistic exposure exercises (e.g., drinking caffeinated
beverages to induce rapid heartrate to test mistaken beliefs about the danger-
ousness of palpitations). Details of these interventions are discussed elsewhere
(Taylor, 2000, 2019). This discussion includes a review of ways of enhancing
interoceptive exposure by consuming arousal-related but harmless substances
(e.g., coffee) and using environmental manipulations (e.g., increasing the
heat in the therapist’s office) to induce sensations such as flushing and sweat-
ing. Essentially all of the AS-reducing interventions used in panic disorder
can be used, with modification, in the treatment of other disorders.

Posttraumatic Stress Disorder

Given that AS is elevated in PTSD, this suggests that interoceptive exposure may
play a useful role in treating PTSD. That is, interoceptive exposure reduces
AS, which in turn was hypothesized to reduce PTSD symptoms (Taylor, 2017).
Interoceptive exposure was also hypothesized to facilitate trauma-related
exposure (for a description of this form of exposure, see Taylor, 2017). That
is, it can be difficult to conduct trauma-related exposure if the person is highly
fearful of arousal sensations. Accordingly, by reducing AS it becomes easier
for the patient to complete a course of trauma-related exposure. Research
from our investigations (e.g., Wald & Taylor, 2008, 2010) and other studies
 Anxiety Sensitivity 75

(reviewed in Taylor, 2017) suggests that interoceptive exposure is useful in

the treatment of PTSD. Interoceptive exposure for PTSD proceeds in much the
same way as it does for panic disorder. The exception is that for PTSD, intero-
ceptive exposure sometimes triggers trauma-related memories. Examples are
as follows (from Wald & Taylor, 2008): In one patient, the breath-holding
exercise triggered memories of childhood abuse in which she, as a child, hid
in a closet and held her breath, hoping not to be discovered by her drunken,
abusive father. Jogging on the spot or running up stairs triggers memories of
running away from an abusive parent in another patient. A tongue depressor
on the back of the throat triggered memories of being choked during a sexual
assault. In such cases, interoceptive exposure would appear to serve a dual
purpose: It can directly reduce AS and also enhance the potency of trauma-
related exposure therapy to help reduce the patient’s distress about trauma-
related memories long term (for further details, see Taylor, 2017).

Obsessive-Compulsive Disorder
Little is known about the role and utility of AS-reduction interventions in
obsessive-compulsive disorder (OCD). Case reports suggest that interoceptive
exposure can play a useful role in the cognitive behavioral treatment of OCD
(Blakey & Abramowitz, 2017). For example, interventions targeting the
cognitive dyscontrol facet of AS (characterized by beliefs such as, “If my mind
races, it means I’m losing control and going crazy”) may be useful, especially
for patients who worry about acting on their unwanted intrusive thoughts.
Interoceptive exercises also can be helpful in reducing distress during expo-
sure therapy for OCD (i.e., exposure and response prevention), as in PTSD
treatment.

Social Anxiety Disorder

The AS social-concerns facet can be targeted in the treatment of social anxiety
disorder. Many of the interoceptive exposure tasks in Table 4.1 (e.g., hyper-
ventilation) elicit publicly observable anxiety reactions, such as facial flushing
and sweating, and evoke distress in people with social anxiety disorder (Dixon,
Kemp, Farrell, Blakey, & Deacon, 2015). It is therefore possible that inducing
anxious arousal during social anxiety exposures might enhance the ecological
validity of such “behavioral experiments” and result in more powerful or
durable learning.

Specific Phobias
Case reports suggest that emetophobia (fear of vomiting) can be successfully
treated by CBT protocols that include interoceptive exposure exercises that
induce gastrointestinal discomfort (e.g., eating beyond feeling full) and other
exercises that evoke gastrointestinal, cardiovascular, and respiratory sensations
that triggered a patient’s fear of vomiting (e.g., hyperventilating, wearing
a heavy sweater so that one feels hot; Boettcher, Brake, & Barlow, 2016).
Similarly, specific phobia of choking can be treated by using interoceptive
76 Steven Taylor

exposure tasks that trigger the gag reflex, such as the use of a tongue depressor,
rapid swallowing, or hold swallow in mid-action.

Other Clinical Problems

Interoceptive exposure exercises can be readily adapted and applied to a range
of clinical conditions, with the choice of exposure exercises limited only by
the therapist’s ingenuity. For example, in a case series of patients presenting
for treatment of depersonalization, McKay and Moretz (2008) used 3-D glasses
to induce depersonalization as an interoceptive exposure exercise. Other intero-
ceptive exercises such as hyperventilation also can produce depersonalization
and derealization (Lickel, Nelson, Lickel, & Deacon, 2008).
Interoceptive exposure exercises can similarly be applied to health anxiety
and fear of pain, and used in smoking cessation programs in which patients
have difficulty tolerating the discomfort associated with withdrawal symptoms
(e.g., Walker & Furer, 2008; Zvolensky, Bogiaizian, Salazar, Farris, & Bakhshaie,
2014). Interoceptive exposure can also reduce alcohol consumption in high
AS people who drink in order to cope with anxiety (Olthuis, Watt, Mackinnon,
& Stewart, 2015).

Transdiagnostic Treatments

A number of transdiagnostic treatment protocols have been developed in which

a common protocol is used to treat patients with any of a range of anxiety
disorders and comorbid clinical conditions. The rationale is that many different
disorders are influenced by transdiagnostic etiological factors (e.g., AS) and that
the interventions used to treat these factors (e.g., interoceptive exposure) can
therefore be beneficial for a range of clinical conditions, including comorbid
cases. The most widely studied transdiagnostic treatment is the Unified Protocol
developed by Barlow and colleagues (2011). The protocol, administered indi-
vidually or in groups, includes interoceptive exposure. The unified protocol,
particularly its interoceptive exposure component, leads to a reduction in AS
(Boswell et al., 2013). For a range of anxiety disorders, a growing number of
treatment studies support the efficacy of this protocol (e.g., Farchione et al.,
2012; Reinholt et al., 2017).

Programs Specifically Targeting Anxiety Sensitivity

A number of brief CBT-based programs have been developed for reducing AS,
including single-session programs and weekend workshops. The best known,
and most intensely studied, of these programs were developed by Schmidt
and colleagues (e.g., Keough & Schmidt, 2012; Schmidt, Capron, Raines, &
Allan, 2014). These have been shown to be efficacious in reducing AS and in
reducing associated distress-related psychopathology, such as the risk for
developing anxiety disorders. These investigators have developed several dif-
ferent programs, which differ in details but are consistent in their essential
 Anxiety Sensitivity 77

ingredients of psychoeducation and interoceptive exposure. A screen-and-

treatment procedure is adopted; participants are selected for such programs if
they have elevated levels of AS, such as scores that were at least 1.5 standard
deviations above the mean on the ASI or ASI-3. Selected participants then
receive a session of treatment. The intervention may be administered by a
clinician or may be largely computer based.

CONCLUSION

This chapter reviewed the theory, research, and practice concerning the
treatment of AS—the fear of arousal-related bodily sensations arising
from dysfunctional beliefs about the meaning and consequences of these
sensations—in anxiety and related disorders. Though conceptually related
to other transdiagnostic constructs including distress intolerance (Chap-
ter 6) and experiential avoidance (Chapter 7), substantial empirical work
points to the unique role of AS in the development, maintenance, and treat­
ment of anxiety and related conditions. AS can be assessed via self-report
measures, clinical interview, and behavioral exercises designed to elicit feared
arousal. The recognized importance of AS in treatment planning has led to
the development of AS-focused treatment strategies, either as stand-alone
interventions or procedures incorporated in multicomponent treatment pro-
grams. Fortunately, dysfunctional beliefs about the importance and meaning
of anxious arousal may be effectively targeted through the activation of
empirically supported treatment mechanisms, as discussed in Part II of this
handbook.

REFERENCES
Arch, J. J., Dimidjian, S., & Chessick, C. (2012). Are exposure-based cognitive behavioral
therapies safe during pregnancy? Archives of Women’s Mental Health, 15, 445–457.
http://dx.doi.org/10.1007/s00737-012-0308-9
Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B.,
& May, J. T. (2011). Unified protocol for transdiagnostic treatment of emotional disorders.
New York, NY: Oxford University Press.
Bernstein, A., Stickle, T. R., Zvolensky, M. J., Taylor, S., Abramowitz, J., & Stewart, S.
(2010). Dimensional, categorical, or dimensional-categories: Testing the latent
structure of anxiety sensitivity among adults using factor-mixture modeling. Behavior
Therapy, 41, 515–529. http://dx.doi.org/10.1016/j.beth.2010.02.003
Bernstein, A., Zvolensky, M. J., Norton, P. J., Schmidt, N. B., Taylor, S., Forsyth, J. P., . . .
Cox, B. (2007). Taxometric and factor analytic models of anxiety sensitivity: Inte-
grating approaches to latent structural research. Psychological Assessment, 19, 74–87.
http://dx.doi.org/10.1037/1040-3590.19.1.74
Blakey, S. M., & Abramowitz, J. S. (2017). Interoceptive exposure: An overlooked
modality in the cognitive-behavioral treatment of OCD. Cognitive and Behavioral
Practice, 25, 145–155.
Boettcher, H., Brake, C. A., & Barlow, D. H. (2016). Origins and outlook of interoceptive
exposure. Journal of Behavior Therapy and Experimental Psychiatry, 53, 41–51. http://
dx.doi.org/10.1016/j.jbtep.2015.10.009
78 Steven Taylor

Boswell, J. F., Farchione, T. J., Sauer-Zavala, S., Murray, H. W., Fortune, M. R., &
Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A trans­
diagnostic construct and change strategy. Behavior Therapy, 44, 417–431. http://
dx.doi.org/10.1016/j.beth.2013.03.006
Brown, H. M., Trzaskowski, M., Zavos, H. M. S., Rijsdijk, F. V., Gregory, A. M., & Eley,
T. C. (2012). Phenotypic and genetic structure of anxiety sensitivity in adolescence
and early adulthood. Journal of Anxiety Disorders, 26, 680–688. http://dx.doi.org/
10.1016/j.janxdis.2012.05.001
Burns, D. D. (1981). Feeling good: The new mood therapy. New York, NY: Signet.
Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear
of fear in agoraphobics: The body sensations questionnaire and the agoraphobic
cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090–1097.
http://dx.doi.org/10.1037/0022-006X.52.6.1090
Chambless, D. L., & Gracely, E. J. (1989). Fear of fear and the anxiety disorders.
Cognitive Therapy and Research, 13, 9–20. http://dx.doi.org/10.1007/BF01178486
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24,
461–470. http://dx.doi.org/10.1016/0005-7967(86)90011-2
Clark, D. M. (1989). Anxiety states: Panic and generalized anxiety. In K. Hawton, P. M.
Salkovskis, J. Kirk, & D. M. Clark (Eds.), Cognitive behaviour therapy for psychiatric
problems: A practical guide (pp. 52–96). New York, NY: Oxford University Press.
Clark, D. M., Salkovskis, P. M., Öst, L.-G., Breitholtz, E., Koehler, K. A., Westling,
B. E., . . . Gelder, M. (1997). Misinterpretation of body sensations in panic disorder.
Journal of Consulting and Clinical Psychology, 65, 203–213. http://dx.doi.org/10.1037/
0022-006X.65.2.203
Dixon, L. J., Kemp, J. J., Farrell, N. R., Blakey, S. M., & Deacon, B. J. (2015). Intero-
ceptive exposure exercises for social anxiety. Journal of Anxiety Disorders, 33, 25–34.
http://dx.doi.org/10.1016/j.janxdis.2015.04.006
Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J.,
Carl, J. R., . . . Barlow, D. H. (2012). Unified protocol for transdiagnostic treatment of
emotional disorders: A randomized controlled trial. Behavior Therapy, 43, 666–678.
http://dx.doi.org/10.1016/j.beth.2012.01.001
Farris, S. G., DiBello, A. M., Allan, N. P., Hogan, J., Schmidt, N. B., & Zvolensky, M. J.
(2015). Evaluation of the Anxiety Sensitivity Index-3 among treatment-seeking
smokers. Psychological Assessment, 27, 1123–1128. http://dx.doi.org/10.1037/
pas0000112
Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior
Therapy, 9, 47–59. http://dx.doi.org/10.1016/S0005-7894(78)80053-7
Holtz, K., Pané-Farré, C. A., Wendt, J., Lotze, M., & Hamm, A. O. (2012). Brain
activation during anticipation of interoceptive threat. NeuroImage, 61, 857–865.
http://dx.doi.org/10.1016/j.neuroimage.2012.03.019
Kemper, C. J., & Hock, M. (2017). New evidence on the construct validity of the
ASI-3 and the dimensional conceptualization of trait anxiety sensitivity from IRT
modeling. European Journal of Psychological Assessment, 33, 181–189.
Keough, M. E., & Schmidt, N. B. (2012). Refinement of a brief anxiety sensitivity
reduction intervention. Journal of Consulting and Clinical Psychology, 80, 766–772.
http://dx.doi.org/10.1037/a0027961
Knapp, A. A., Frala, J., Blumenthal, H., Badour, C. L., & Leen-Feldner, E. W. (2013).
Anxiety sensitivity and childhood learning experiences: Impacts on panic symptoms
among adolescents. Cognitive Therapy and Research, 37, 1151–1159. http://dx.doi.org/
10.1007/s10608-013-9558-8
Lickel, J., Nelson, E., Lickel, A. H., & Deacon, B. (2008). Interoceptive exposure exercises
for evoking depersonalization and derealization: A pilot study. Journal of Cognitive
Psychotherapy, 22, 321–330. http://dx.doi.org/10.1891/0889-8391.22.4.321
 Anxiety Sensitivity 79

McKay, D., & Moretz, M. W. (2008). Interoceptive cue exposure for depersonalization:
A case series. Cognitive and Behavioral Practice, 15, 435–439. http://dx.doi.org/
10.1016/j.cbpra.2008.05.002
Naragon-Gainey, K. (2010). Meta-analysis of the relations of anxiety sensitivity to
the depressive and anxiety disorders. Psychological Bulletin, 136, 128–150. http://
dx.doi.org/10.1037/a0018055
Norton, P. J. (2012). Cognitive-behavioral therapy of anxiety: A transdiagnostic treatment
manual. New York, NY: Guilford Press.
Olthuis, J. V., Watt, M. C., Mackinnon, S. P., & Stewart, S. H. (2015). CBT for high anxiety
sensitivity: Alcohol outcomes. Addictive Behaviors, 46, 19–24. http://dx.doi.org/
10.1016/j.addbeh.2015.02.018
Poletti, S., Radaelli, D., Cucchi, M., Ricci, L., Vai, B., Smeraldi, E., & Benedetti, F.
(2015). Neural correlates of anxiety sensitivity in panic disorder: A functional
magnetic resonance imaging study. Psychiatry Research: Neuroimaging, 233, 95–101.
http://dx.doi.org/10.1016/j.pscychresns.2015.05.013
Reinholt, N., Aharoni, R., Winding, C., Rosenberg, N., Rosenbaum, B., & Arnfred, S.
(2017). Transdiagnostic group CBT for anxiety disorders: The unified protocol in
mental health services. Cognitive Behaviour Therapy, 46, 29–43. http://dx.doi.org/
10.1080/16506073.2016.1227360
Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (1986). Anxiety sensitivity,
anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy,
24, 1–8. http://dx.doi.org/10.1016/0005-7967(86)90143-9
Reiss, S., Peterson, R. A., Taylor, S., Schmidt, N., & Weems, C. F. (2008). Anxiety Sensitivity
Index consolidated user manual: ASI, ASI-3, and CASI. Worthington, OH: IDS.
Rifkin, L. S., Beard, C., Hsu, K. J., Garner, L., & Björgvinsson, T. (2015). Psychometric
properties of the anxiety sensitivity index-3 in an acute and heterogeneous treat-
ment sample. Journal of Anxiety Disorders, 36, 99–102. http://dx.doi.org/10.1016/
j.janxdis.2015.09.010
Schmidt, N. B., Capron, D. W., Raines, A. M., & Allan, N. P. (2014). Randomized clini-
cal trial evaluating the efficacy of a brief intervention targeting anxiety sensitivity
cognitive concerns. Journal of Consulting and Clinical Psychology, 82, 1023–1033.
http://dx.doi.org/10.1037/a0036651
Schmidt, N. B., Keough, M. E., Mitchell, M. A., Reynolds, E. K., Macpherson, L.,
Zvolensky, M. J., & Lejuez, C. W. (2010). Anxiety sensitivity: Prospective prediction
of anxiety among early adolescents. Journal of Anxiety Disorders, 24, 503–508. http://
dx.doi.org/10.1016/j.janxdis.2010.03.007
Schmidt, N. B., Lerew, D. R., & Jackson, R. J. (1999). Prospective evaluation of
anxiety sensitivity in the pathogenesis of panic: Replication and extension. Journal
of Abnormal Psychology, 108, 532–537. http://dx.doi.org/10.1037/0021-843X.108.3.532
Smits, J. A. J., Berry, A. C., Tart, C. D., & Powers, M. B. (2008). The efficacy of cognitive-
behavioral interventions for reducing anxiety sensitivity: A meta-analytic review.
Behaviour Research and Therapy, 46, 1047–1054. http://dx.doi.org/10.1016/j.brat.
2008.06.010
Stewart, S. H., Taylor, S., Jang, K. L., Cox, B. J., Watt, M. C., Fedoroff, I. C., & Borger,
S. C. (2001). Causal modeling of relations among learning history, anxiety sensitivity,
and panic attacks. Behaviour Research and Therapy, 39, 443–456. http://dx.doi.org/
10.1016/S0005-7967(00)00023-1
Taylor, S. (2000). Understanding and treating panic disorder: Cognitive-behavioural approaches.
New York, NY: Wiley.
Taylor, S. (2017). Clinician’s guide to PTSD: Cognitive-behavioral approaches (2nd ed.).
New York, NY: Guilford Press.
Taylor, S. (2019). Treating anxiety sensitivity in adults with anxiety and related disorders.
In J. Smits, M. Otto, M. Powers, & S. Baird (Eds.), Anxiety sensitivity: A clinical guide
to assessment and treatment (pp. 55–75). New York, NY: Elsevier.
80 Steven Taylor

Taylor, S., Jang, K. L., Stewart, S. H., & Stein, M. B. (2008). Etiology of the dimensions
of anxiety sensitivity: A behavioral-genetic analysis. Journal of Anxiety Disorders, 22,
899–914. http://dx.doi.org/10.1016/j.janxdis.2007.09.005
Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., . . .
Cardenas, S. J. (2007). Robust dimensions of anxiety sensitivity: Development and
initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19,
176–188. http://dx.doi.org/10.1037/1040-3590.19.2.176
Wald, J., & Taylor, S. (2008). Responses to interoceptive exposure in people with post-
traumatic stress disorder (PTSD): A preliminary analysis of induced anxiety reactions
and trauma memories and their relationship to anxiety sensitivity and PTSD symp-
tom severity. Cognitive Behaviour Therapy, 37, 90–100. http://dx.doi.org/10.1080/
16506070801969054
Wald, J., & Taylor, S. (2010). Implementation and outcome of combining interoceptive
exposure with trauma-related exposure therapy in a patient with combat-related
posttraumatic stress disorder. Clinical Case Studies, 9, 243–259. http://dx.doi.org/
10.1177/1534650110373387
Walker, J. R., & Furer, P. (2008). Interoceptive exposure in the treatment of health
anxiety and hypochondriasis. Journal of Cognitive Psychotherapy, 22, 366–378. http://
dx.doi.org/10.1891/0889-8391.22.4.366
Wenzel, A., Sharp, I. R., Brown, G. K., Greenberg, R. L., & Beck, A. T. (2006). Dysfunc-
tional beliefs in panic disorder: The Panic Belief Inventory. Behaviour Research and
Therapy, 44, 819–833. http://dx.doi.org/10.1016/j.brat.2005.06.001
Zvolensky, M. J., Bogiaizian, D., Salazar, P. L., Farris, S. G., & Bakhshaie, J. (2014). An
anxiety sensitivity reduction smoking-cessation program for Spanish-speaking
smokers (Argentina). Cognitive and Behavioral Practice, 21, 350–363. http://dx.doi.org/
10.1016/j.cbpra.2013.10.005
5
Disgust Sensitivity
Peter J. de Jong and Charmaine Borg

Emma and Olivia were hiking with their dog, Bailey, on their favorite trail in a
beautiful and peaceful state park.1 While enjoying the magnificent views, they
suddenly noticed a strong, disgusting smell. After a few more steps, they saw
the source of the nasty scent: a dead and partly decomposed deer with maggots
crawling in the messy flesh. “Yuck!” Emma exclaimed, while Olivia appeared
largely unaffected by the scene. Emma’s stomach turned and her face was
screwed in disgust while she jerked her head away from the dead deer. When
Bailey started to put his snout in the exposed intestines, Emma almost threw up
and forced their dog to keep away from the dead animal and follow them along
the trail. Upon their return to the parking lot, Emma thoroughly cleaned Bailey
before letting him into the car for the drive home.

As exemplified in this vignette, disgust is characterized by intense negative

feelings (e.g., aversion) related to a stimulus and an overwhelming urge to
avoid or escape the stimulus. Disgust-evoking stimuli may also include objects
or people that have been in contact with a disgust elicitor (e.g., Bailey’s snout).
In the case that someone is unable to avoid a disgusting stimulus, they typically
respond with immediate attempts to distance themselves from the stimulus
(e.g., wipe off the substance from their skin or clothing) and/or reinstate a
sense of cleanliness (e.g., wash, purge the disgusting item that was consumed).

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-005
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
81
82 de Jong and Borg

This type of response resembles washing compulsions that are characteristic of

a subgroup of patients with obsessive-compulsive disorder (OCD), but it can
also be observed in the context of individuals with small animal phobia (e.g.,
wiping hands after contacting a stimulus during exposure-based treatment) or
in patients with posttraumatic stress disorder (PTSD; e.g., wash or neutralize
thoughts after recalling a sexual assault).
The reflexive tendency to avoid contact with disgusting stimuli also mani-
fests through the characteristic facial expression of disgust (as in the opening
vignette). People typically wrinkle up their nose, close their eyes, and raise
their upper lip, while turning their head away from the source of disgust—
even if only engaging with disgust stimuli within the context of guided men-
tal imagery (e.g., de Jong, Peters, & Vanderhallen, 2002). This highly salient
and ingrained facial response not only helps prevent physical contact and
(oral) incorporation of disgusting stimuli, but also carries important signal
value. For instance, it has been argued that the facial display of disgust is an
efficient way to promote the avoidance of hazardous pathogens (e.g., de Jong,
2013; Rozin & Fallon, 1987). Germane to this, there is experimental evidence
showing that parents intensify their spontaneous facial and vocal disgust
responses when disgust elicitors are presented in the presence of their (young)
children (Oaten, Stevenson, Wagland, Case, & Repacholi, 2014; Stevenson,
Oaten, Case, Repacholi, & Wagland, 2010). These findings seem to indicate
that parents attempt to exploit this feature of their disgust response as a
means to socialize their children and to teach them to avoid potentially harm-
ful stimuli or behavior. Regardless of the parents’ intentions, empirical evi-
dence points to social referencing as a powerful way to render originally
neutral stimuli disgusting (Askew, Çakır, Põldsam, & Reynolds, 2014; Gerull
& Rapee, 2002). Thus, parental disgust responses are probably an important
factor in the acquisition of disgust for particular stimuli and behaviors (Davey,
Forster, & Mayhew, 1993; de Jong, 2013).
Irrespective of how we acquire disgust, people vary greatly in their habit-
ual responsiveness to potential disgust elicitors, as was evidenced by Emma
and Olivia’s differential responding to the dead deer in the opening vignette.
Some people are relatively easily disgusted by all kinds of stimuli, whereas
others show a relatively high threshold for experiencing disgust (e.g.,
Olatunji, Sawchuk, de Jong, & Lohr, 2007; W. J. M. van Overveld, de Jong,
Peters, Cavanagh, & Davey, 2006). In addition, the concrete stimuli and
conditions that elicit disgust are highly variable and show large cross-cultural
variation (e.g., Elwood & Olatunji, 2009). Nevertheless, the whole range of
disgusting stimuli seems to cluster in three coherent domains (Tybur, Lieberman,
& Griskevicius, 2009; Tybur, Lieberman, Kurzban, & DeScioli, 2013): pathogen
disgust (e.g., blood, ulcers, saliva), moral disgust (e.g., rape, misuse), and
“sexual” disgust (e.g., an unappealing colleague making unwanted sexual
advances). Although each form of disgust may be relevant to fear and anxiety
problems, this chapter focuses mainly on pathogen disgust.
Pathogen disgust—the most prototypical type of disgust—concerns stimuli
such as spoiled food, body products, and deformed body parts. These core
 Disgust Sensitivity 83

disgust elicitors share common features in that they are all associated with an
increased risk of the transmission of infectious diseases. There is broad con-
sensus that this type of disgust can be seen as a defensive mechanism that has
evolved to protect the organism from contamination by pathogens and toxins
that are invisible to the naked eye but are nevertheless omnipresent in the
environment and pose a serious threat to our survival (Curtis, de Barra, &
Aunger, 2011). Thus, disgust responses to potentially contaminating stimuli
can be conceptualized as a natural and adaptive “first line of defense” designed
to protect humans from infectious agents (Curtis et al., 2011; Oaten, Stevenson,
& Case, 2009). Consistent with such a disease-avoidance conceptualization,
(pathogen) disgust is typically focused on the intersection between the body
and the environment and concentrates on the skin and body apertures (Rozin,
Nemeroff, Horowitz, Gordon, & Voet, 1995).
Although the functional account of disgust implies disgust has evolved as
a disease avoidance mechanism, such an account does not imply that the
experience of disgust is always elicited by concerns about the possibility of
contracting a dangerous infectious disease. Disgusting stimuli are inherently
disgusting, and it is inherent to disgusting stimuli to elicit a strong urge to
distance oneself from these stimuli. Therefore, simply providing information
indicating that the disgust elicitor is in fact harmless is typically ineffective in
modifying evaluations of disgust. To illustrate this point, imagine that you
are at a restaurant about to take a sip of soup. Before you can lift out a
spoon’s worth of soup, the waiter drops three cockroaches in your bowl.
What feelings emerge upon the prospect of consuming that soup? What if
the waiter explains that these cockroaches have been sterilized and thus
carry no harmful bacteria; would you swallow the soup? For people who
find cockroaches disgusting, knowing that the cockroaches are not contam-
inated typically fails to outweigh the urge to reject the soup (which makes
perfect sense from the perspective that disgusting stimuli—such as the
cockroaches in this example—can be disgusting regardless of their alleged
contaminating properties).

CONCEPTUAL IMPLICATIONS

Disgust-based responding has several features that may help explain how dis-
gust might be involved in fear and anxiety (disorders). This section first
addresses the “laws” that guide individuals’ disgust responding and discusses
how insight in these laws may contribute to our understanding of how dis-
gust might contribute to the persistence of fearful preoccupations. The second
section explains how disgust and fear may be related and why disgust-based
concerns may sometimes give rise to extreme fear. The third section high-
lights that disgust may not only be elicited by external but also by internal
stimuli such as particular images or memories, and it addresses how such
“mental disgust” may relate to clinical anxiety.
84 de Jong and Borg

The “Laws” of Disgust

The perspective that pathogen disgust evolved to protect humans from disease-
inflicting stimuli that cannot be seen or otherwise detected may partially
explain why disgust is geared toward a better safe than sorry heuristic. In case
of life or death, it seems wise to play it safe. This adaptive conservatism may
also have shaped the two major laws that guide our disgust responding and
may therefore be critical for understanding how disgust contributes to the
persistence of clinical anxiety, as discussed next.
The first law is known as the law of similarity. According to this law, a new
stimulus may elicit disgust if it shares some salient features with an already
disgusting stimulus. As an example, macaroni may elicit disgust simply because
it physically resembles maggots, and people may avoid delicious chocolate just
because it is presented in the form of dog feces (Rozin & Fallon, 1987). The law
of similarity makes sense from a functional perspective, as it may be the shared
features between the “already” and “newly” disgusting stimuli that are criti-
cally involved in the transmission of pathogens. However, as its shadow side,
this law also promotes the rejection of many “innocent” stimuli and sets the
stage for (over)generalization of disgust. The latter may be especially problem-
atic for those with an already low habitual threshold for experiencing disgust.
The second law is known as the law of contagion, understood as once in contact
always in contact. This is reflected in the common finding that a disgusting stim-
ulus (e.g., a spider) can render a perfectly good food item inedible by only brief
contact (e.g., Mulkens, de Jong, & Merckelbach, 1996). This second disgust-
related “law” also makes sense from a survival perspective. Yet, if for whatever
reason “innocent” stimuli have unjustly acquired the status of being conta-
gious, this law will hamper correction. Thus, as an undesirable side effect, this
striking feature of disgusting stimuli may contribute further not only to disgust
generalization but also to the persistence of the acquired disgust.

Response Overlap Between Disgust and Fear

Most emotions are functionally linked to well-defined motivational goals and

corresponding patterns of action tendencies (Frijda, 2006). In the context of
pathogen disgust, the ultimate goal of avoiding disease and contamination
mirrors the harm-avoidance goal that is associated with fear or anxiety. Yet
whereas a state of fear–anxiety makes individuals prone to be vigilant for
harm in order to quickly escape a perceived threat (e.g., Lavy, van den Hout,
& Arntz, 1993), disgust is typically restricted to eliciting the urge to keep suf-
ficient distance from disgust elicitors to prevent physical contact (e.g., keep a
distance from a dirty diaper or decaying animal, as described in the opening
vignette). This makes sense from the perspective that most disgust-elicitors
are immobile, inanimate stimuli (e.g., spoiled food, human waste, decaying
meat) without the ability to show self-initiated approach behavior. Thus, the
prototypical disgust-induced avoidance tendencies usually suffice to prevent
physical contact with disgust elicitors.
 Disgust Sensitivity 85

Yet particular conditions heighten the probability of unwanted physical

contact with disgust elicitors. For example, if a school field trip involves wild-
land excursions, stepping in mud or animal droppings may be likely (e.g.,
Bixler, Carlisle, Hammitt, & Floyd, 1994; Bixler & Floyd, 1999). As another
example, someone flying on a cross-country flight may expect to need to use
the public toilet at some point during the journey. Especially for those with a
low threshold for experiencing disgust, these types of (prospective) condi-
tions may elicit fear or anticipatory anxiety fueled by the prospect of contact-
ing disgusting stimuli.
The perceived probability of unwanted physical contact may also be inflated
when the object of disgust can initiate approach behaviors, such as an animal
that can freely move (de Jong, Vorage, & van den Hout, 2000). This may be
especially the case for animals that can readily enter our private living space
such as spiders, mice, and insects. Although individuals’ aversion to these ani-
mals may be entirely constituted by disgust-related preoccupations, fear may
nevertheless be the dominant emotion that people experience and express
upon confrontation with such “disgusting” stimuli (e.g., de Jong & Muris,
2002). People may also dread medical procedures when they anticipate that
these appointments will involve uncontrollable disgusting procedures or close
physical contact with disgusting stimuli (e.g., Reynolds, Consedine, Pizarro, &
Bissett, 2013). In a similar vein, the prospect of intimate sexual behaviors may
elicit fear in people who consider sex and sexual products as highly disgust-
ing (e.g., Borg, de Jong, & Schultz, 2010). All in all, if common disgust-based
avoidance responses do not suffice to avoid contact with a source of disgust,
fear seems to become the dominant emotion to promote a timely escape from
disgusting cues.
Another clinically relevant distinction between the experience of fear and
disgust is the relative rate of decline during prolonged exposure to a disorder-
relevant stimulus (e.g., a “dirty” bedpan within the context of contamination
fear). Specifically, research has shown that although subjective feelings of dis-
gust decline after some time, the rate of decline in disgust was slower relative
to that of anxiety (e.g., Olatunji, Wolitzky-Taylor, Willems, Lohr, & Armstrong,
2009). The apparent refractoriness of disgust may be explained by the relative
difficulty to refute the presence of threats that cannot be detected by the
naked eye. In line with this, some have argued that disgust may not decline
until an individual has gathered several concrete pieces of evidence through
personal experience that a stimulus is in fact safe (Bosman, Borg, & de Jong,
2016; de Jong, 2013). Therefore, clinicians and patients should both keep in
mind that although disgust may take longer to subside than fear–anxiety,
repeated and prolonged physical exposure to aversive stimuli in order to
reduce disgust is nevertheless a critical component of treatment.

Disgusting Mental Stimuli

The strong urge to avoid sources of disgust may relate not only to external
stimuli but also to internal stimuli such as autobiographical memories. To the
86 de Jong and Borg

extent that the activation of particular memories elicits disgust (e.g., Emma’s
memory about coming across a dead deer with maggots crawling in the messy
flesh), people are inclined to avoid the retrieval of these specific memories. If
such a memory might be triggered by an external cue (e.g., a picture of a deer),
the accompanying emotion of disgust might elicit a strong urge to immediately
escape and downregulate disgust by resorting to the global level representa-
tion (e.g., “I once saw a dead deer” instead of “I once saw a deer carcass with
maggots crawling out of it”; cf. Williams et al., 2007). Although the avoidance
of and escape from disgusting memories may effectively eliminate the experi-
ence of disgust and other distressing emotions, disgust-based avoidance never-
theless obstructs any correction of maladaptive appraisals, thereby contributing
to the maintenance of dysfunctional representations or symptoms of clinical
anxiety.

ASSESSMENT

When it comes to the assessment of disgust, it is important to differentiate

between the concrete disgust response upon confrontation with a particular
stimulus or condition (i.e., state disgust) and the more habitual inclination to
experience disgust that represents a more general individual characteristic
(i.e., trait disgust). In the following section, we describe instruments and
measures that can be used to assess both trait and state disgust responding.

Trait Disgust

Several questionnaire measures have been developed to assess individual

differences in habitual disgust responsivity. The following sections critically
discuss the pros and cons of the most prominent measures of trait disgust, with
a separate section devoted to measures adapted to younger age groups.

Disgust Scale—Revised
The 25-item revised version of the Disgust Scale (DS; Haidt, McCauley, &
Rozin, 1994) and the further revision with improved scoring format (DS–R;
Olatunji, Williams, et al., 2007; M. van Overveld, de Jong, Peters, & Schouten,
2011) are currently the most widely used measures of individual differences in
individuals’ propensity to experience disgust. Psychometric analyses showed
that the range of disgust elicitors represented in the DS–R cluster in three
coherent categories (e.g., Olatunji, Williams, et al., 2007; M. van Overveld
et al., 2011): Core, Animal Reminder, and Contamination Related. The DS and
DS–R have been used in numerous studies examining the relationship between
heightened disgust propensity and symptoms of clinical anxiety. These studies
showed that Core and Contamination disgust propensity were related to
symptoms of obsessive-compulsive disorders (e.g., Olatunji, Williams, et al.,
2007), whereas symptoms of blood-injury phobia were more closely related
to Animal Reminder disgust propensity (e.g., de Jong & Merckelbach, 1998).
 Disgust Sensitivity 87

Although both Core and Animal Reminder scores seem to reflect pathogen
disgust, these findings suggest that both subtypes of disgust propensity are
differentially involved in anxiety related pathology. Thus, elevated disgust
propensity for specific types of pathogen disgust may relate to specific types
of fears.
Although the DS–R is widely used, it has also some important limitations
worth considering. First, half of the questionnaire consists of statements that
refer to avoidance of particular stimuli or behaviors that do not explicitly refer
to disgust as the underlying driving force. For example, “I might be willing to
try eating monkey meat, under some circumstances,” or “It would bother me
to see a rat run across my path in a park.” Although these items may pick up
on disgust-induced avoidance, other types of concerns may also drive partic-
ipant responses. Second, there seems to be conceptual overlap with various
measures of anxiety symptoms. For example, items such as “I never let any
part of my body touch the toilet seat in a public washroom” may artificially
inflate the relationship between disgust propensity and fear of contamina-
tion. Similar concerns apply to blood injury phobia or small animal fears.

Three Domain Disgust Scale

Items of the Three Domain Disgust Scale (TDDS; Tybur et al., 2009) assess three
theory-derived domains of disgust mentioned earlier in this chapter: pathogen,
moral, and sexual disgust. Independent psychometric studies confirmed the
proposed three-factor structure of the TDDS (Olatunji et al., 2012). In further
support of its validity, other research showed that the pathogen dimension
was associated with self-reported OCD symptoms (Olatunji, Ebesutani, & Kim,
2015). One limitation of the TDDS is that it does not differentiate between var-
ious types of pathogen-relevant elicitors. On the other hand, a strength is that
the TDDS is not restricted to pathogen disgust; it also assesses sexual and moral
disgust. This provides the opportunity to test whether the three domains of
disgust might be differentially related to various anxiety-related disorders.
As one illustration of such research, van Delft, Finkenauer, Tybur, and Lamers-
Winkelman (2016) found evidence that heightened sexual disgust propensity
(in mothers) was specifically associated with heightened risk for mothers of
sexually abused children to develop PTSD (i.e., secondary victimization). As
a second drawback, the TDDS (like the DS–R) suffers from conceptual over-
lap with indices of anxiety psychopathology by including items that are
close to those measuring animal phobia or OCD (e.g., “Seeing a cockroach
run across the floor” and “Shaking hands with a stranger who has sweaty
palms,” respectively).

Disgust Propensity and Sensitivity Scale

The Disgust Propensity and Sensitivity Scale (DPSS; W. J. M. van Overveld et al.,
2006) was developed to address certain limitations of the DS–R and TDDS. To
overcome the problem of conceptual overlap between measures of anxiety psy-
chopathology and disgust propensity, the DPSS measures disgust propen-
sity irrespective of particular elicitors. In addition, the DPSS assesses not only
88 de Jong and Borg

individual differences in the inclination to experience disgust (i.e., disgust

propensity) but also in the appraisal of experiencing disgust (i.e., disgust sen-
sitivity). This distinction is an important and clinically useful one in light of
research indicating that clinical anxiety is related not only to how easily people
are disgusted but also to how unpleasant the experience of disgust is perceived to
be (e.g., W. J. M. van Overveld et al., 2006). Since its initial validation, the DPSS
has been revised based on accumulated psychometric research (DPSS–R;
Fergus & Valentiner, 2009). The current 12-item DPSS-R has been shown to
be a parsimonious and psychometrically sound measure with predictive valid-
ity for actual avoidance behavior (e.g., M. van Overveld, de Jong, & Peters,
2010) and symptoms of psychopathology (e.g., Engelhard, Olatunji, & de Jong,
2011). Although the scale was developed as a two-factor measure, there is
evidence that a three-factor model provides a better fit with the data (Goetz,
Cougle, & Lee, 2013). This third domain seems to reflect ruminative and
self-focused disgust and shows a specific association with a measure of obses-
sional symptoms.

Measures for Youth

The common versions of the DS–R, TDDS, and DPSS–R are not suitable for
younger age groups. For assessing (pathogen) disgust in youth, burgeoning
work supports using the 30-item Disgust Emotion Scale for Children (Muris
et al., 2012), which reliably differentiates five relevant domains of pathogen
disgust (animals, injections and blood draws, mutilation and death, rotting
foods, and odors). In addition, the 14-item Child Disgust Scale (Viar-Paxton
et al., 2015) has been developed as a child-oriented equivalent of the DS–R.
Although the Child Disgust Scale showed adequate psychometric properties,
it suffers from the same conceptual problem as the original DS–R in that
the majority of the items do not explicitly refer to disgust as the underlying
driving force.

State Disgust

To evaluate how disgust might be involved in fear and anxiety, it is necessary

to consider individual differences in trait disgust and in people’s responses to
concrete disgust elicitors. The following sections evaluate explicit and implicit
measures of state disgust that have (also) been used within the context of
phobic fears and anxiety disorders.

Self-Report
An obvious and particularly direct way of assessing disgust is to ask individuals
to report their feelings of disgust on a Visual Analogue Scale (Aitken, 1969)
ranging from 0 (absolutely no disgust) to 100 (extreme disgust). This can be done
upon actual confrontation with the disgusting stimulus (e.g., Rozin et al., 1995;
M. van Overveld et al., 2010), as well as in response to recalling a disgust-
eliciting memory or imagining contacting a disgusting stimulus (e.g., de Jong,
Andrea, & Muris, 1997; Engelhard et al., 2011). Of course, there might be a
 Disgust Sensitivity 89

discrepancy between the level of disgust experienced during mere visual expo-
sure to the stimulus and the intensity of the disgust response during (the pros-
pect of) physical contact with the stimulus (e.g., Borg & de Jong, 2012).
Following actual or imagined physical contact with the source of disgust, it may
also be relevant to ask participants or patients to rate their urge to wash or
cleanse themselves as a measure of disgust responding (e.g., Badour, Feldner,
Babson, Blumenthal, & Dutton, 2013; Fairbrother, Newth, & Rachman, 2005).

Implicit Assessment
It has been argued that it is important to differentiate between automatic and
deliberate affective associations (e.g., Gawronski & Bodenhausen, 2006), as
some people may be hesitant to report their true level of disgust in response to
a particular stimulus (e.g., sexual intercourse) because of self-presentational
concerns or other considerations. Accordingly, several experts have developed
indirect performance measures to tap into the automatic affective associations
(for a review, see Roefs et al., 2011), although their use might be more feasible
in research relative to clinical settings.
A prominent example of implicit assessment is a modification of the Implicit
Association Test (Greenwald, McGhee, & Schwartz, 1998; see also Bar-Anan
& Nosek, 2014; Borg et al., 2010; Huijding & de Jong, 2007; Teachman, Gregg,
& Woody, 2001). The Implicit Association Test is essentially a sorting task,
wherein respondents are thought to correctly categorize disgusting target words
presented on a screen more quickly when required to pair disgust-relevant
stimuli (e.g., the words spider and nasty) than when required to pair disgust-
eliciting stimuli with neutral or positive words (e.g., spider and good). However,
the Implicit Association Test is not without its critics (for a compelling analysis
of its limitations in measuring automatic associations, see Fiedler, Messner, &
Bluemke, 2006), and it generally lacks sufficient sensitivity to be used as a
measure of individual differences.
An alternative approach to implicit assessment of disgust is a reaction-time
based approach-avoidance task (e.g., Najmi, Kuckertz, & Amir, 2010). In the
typical approach-avoidance task, the potential source of disgust is a task-
irrelevant feature, and participants are instructed to push or pull a joystick
(analogue to approaching or avoiding, respectively) as quickly as possible on
the basis of some feature of the visual stimulus. However, as already noted
with regard to self-report measures above, this behavioral avoidance may not
be uniquely driven by disgust-induced avoidance. These types of concerns
also apply to paradigms that use eye movements and fixations as an index of
disgust responding (e.g., Armstrong, McClenahan, Kittle, & Olatunji, 2014;
Mason & Richardson, 2010), in that although people may typically look away
from disgusting cues, looking away does not necessarily imply disgust.

Facial Expression
As mentioned earlier, disgust is associated with a salient and characteristic
facial expression. Thus, merely observing people’s face during a clinical inter-
view or treatment session when patients discuss or contact potential disgust
90 de Jong and Borg

elicitors may provide relevant insight to the degree of an individual’s disgust

level. The intensity of the disgust expression can also be quantified in the
context of more controlled exposure to disgust-related stimuli. For example,
programs such as FaceReader (2014) can quantify disgust (and other expres-
sions) on the basis of facial recordings. (For a validation of FaceReader, see
Lewinski, den Uyl, & Butler, 2014.) However, such facial expression analysis
technology may not be practical in routine clinical settings.
Another strategy that has been used to index the facial expression of dis-
gust is the measurement of facial EMG (e.g., de Jong et al., 2002; W. J. M. van
Overveld, de Jong, & Peters, 2009; Vrana, 1993). Specifically, the m. levator
labii superioris alesque nasii that is responsible for the nose wrinkle seems rele-
vant in the context of the specific expression of disgust when confronted with
pathogen disgust elicitors. There is some evidence that the m. levator anguli oris
is involved in responding to moral transgressions (i.e., moral disgust). Con-
traction of this muscle results in rising of the upper lip; the resulting facial
expression seems more closely related to social rejection than to the rejection
of bad food (see also Rozin, Lowery, & Ebert, 1994). Although this assessment
has its own limitations regarding specificity, it nevertheless carries the advan-
tage of being able to detect subtle disgust responses that go unnoticed by the
human eye.

CLINICAL IMPLICATIONS

Disgust-based mechanisms are relevant to many fear- and anxiety-related

symptoms and disorders (e.g., Olatunji, Armstrong, & Elwood, 2017; Woody
& Teachman, 2000). We next discuss in more detail how disgust-based mech-
anisms may play a role in the development, expression, and persistence of
specific concerns.

Specific Phobias

Most of the initial research on the role of disgust in clinical anxiety and fear
predominantly focussed on animal fears (e.g., spider phobia). Matchett and
Davey (1991) were the first to propose that small animal phobias may be
explained from a disease avoidance perspective, in which disgust plays a cen-
tral role. They argued that although people with spider phobia often report
concerns about spider-related physical harm (e.g., the spider will bite me;
Arntz, Lavy, van den Berg, & van Rijsoort, 1993) and respond fearfully to
spiders in vivo, these individuals also exhibit patterns of disgust responding.
For example, the finding that spider fearful individuals rejected food items
that a spider contacted implicated disgust in the experience of spider aversion
(de Jong et al., 1997; Mulkens et al., 1996). These types of observations
sparked further consideration of how disgust may be involved in specific pho-
bias. Subsequent research indeed showed that the contagious properties of a
spider (i.e., an index of subjective disgust) and the perceived probability of
 Disgust Sensitivity 91

involuntary physical contact were strong predictors of spider fear, whereas

perceptions of the spider’s ability to cause physical harm added little explan-
atory value (de Jong & Muris, 2002). Together, these findings corroborate the
notion that spider phobia reflects a fear of physical contact with a disgusting
stimulus.

Blood, Injection, and Injury Phobias

Heightened disgust appears to be the dominant emotion when people with

blood, injection, and injury (BII) fears are exposed to blood-related stimuli
(Page, 1994; Tolin, Lohr, Sawchuk, & Lee, 1997). Moreover, people with blood
phobia generally exhibit heightened trait disgust sensitivity (e.g., M. van
Overveld et al., 2010), thus exacerbating their disgust-related avoidance and
responding. Research on individual differences in trait disgust propensity
systematically found that BII fears are associated with scores on the Animal
Reminder subscale of the DS(–R), but not the Core disgust subscale (e.g., de
Jong & Merckelbach, 1998; Olatunji, Sawchuk, de Jong, & Lohr, 2006). In other
words, BII fears seem to reflect an inclination to respond with disgust to
body-related pathogen-disgust-relevant stimuli in particular.
For some people with BII phobia, fear is predominantly focused on injec-
tions and related medical procedures. Fear of injections appears to be driven by
two components: one related to features of uncontrollability regarding the
medical procedure and a second component related to disgust (envelope viola-
tion and blood). Of course, some people may fear the pain or harm associated
with an injection, which can overshadow concerns about envelope violation
and/or blood (e.g., Trijsburg et al., 1996). The persistence of BII phobia may
thus be promoted by biased judgments about the uncontrollability of the med-
ical procedure and its consequences, as well as by inflated disgust responding.

Obsessive-Compulsive Disorder

There is consistent evidence that people with greater contamination fear and
washing compulsions show a generally enhanced responsivity to potential dis-
gust elicitors and score higher on measures assessing contamination-related
disgust (e.g., Olatunji, Sawchuk, Lohr, & de Jong, 2004; Olatunji, Williams,
et al., 2007). Perhaps unsurprisingly, available research indicates that sources
of disgust that carry a high threat of contagion are most strongly linked to
contamination fears as observed in individuals with OCD. There is also evi-
dence that patients with OCD are especially sensitive to the mere prospect
of contamination. The creative “contagious pencil” experiment (see Tolin,
Worhunsky, & Maltby, 2004) is a striking illustration of how the disgusting
quality of particular contamination-relevant stimuli can be persistently trans-
ferred to other stimuli among patients with OCD, which may result in a highly
invalidating over-generalization of disgust elicitors. In this experiment, partic-
ipants were first asked to identify “the most contaminated object in this
building.” Most participants selected objects such as a toilet or garbage can.
92 de Jong and Borg

Then a brand new pencil was unpacked and thoroughly brushed along “the
most contaminated object.” Subsequently, participants were asked to indicate
the contaminating properties of the pencil. Next, a second pencil was unpacked
and thoroughly brushed along the “contaminated” (first) pencil; again, partic-
ipants then rated the pencil’s contaminating properties. This procedure of
unpacking and thoroughly brushing new pencils against the most recently
“contaminated” pencil was repeated several times. For participants without
OCD, contamination ratings gradually declined during this repeated proce-
dure and were about zero from the seventh pencil onwards. In contrast,
ratings provided by participants with OCD showed a tendency to stabilize;
even after 12 pencils, these participants still reported contamination ratings
well above 50 on a 100-point scale. This heightened perceived probability of
contamination (“once in contact always in contact”) may thus help explain
the development and persistence of generalized disgust-induced avoidance
in contamination-based OCD.
One crucial question is why patients with OCD maintain their position that
even “innocent” disgusting stimuli should be avoided. One possible explana-
tion is that people with OCD use their feelings of disgust as information. Indeed,
it has been shown that individuals with fear of contamination are inclined to
infer contamination or physical threat (illness) on the basis of their subjective
disgust response (i.e., “if I feel disgust, it must be contagious”; Verwoerd,
de Jong, Wessel, & van Hout, 2013). Thus, people with contamination-related
OCD not only more rapidly experience disgust, but are also more inclined to
use these feelings of disgust as evidence for the threat value of the disgust elic-
itor. Such tendency to avoid potential contamination on the basis of disgust-
based emotional reasoning may serve to confirm and reinforce mistaken
disgust-related catastrophic beliefs (see Chapter 2). It might therefore be import-
ant for clinicians to assess for whether disgust and disgust-based reasoning
should be incorporated into a contamination-fearful patient’s case conceptu-
alization and treatment plan.

Posttraumatic Stress Disorder

There is increasing appreciation for the potential role of disgust in PTSD (for
a review, see Badour & Feldner, 2018). Pointing to the relevance of disgust in
the development and persistence of PTSD, Foy, Sipprelle, Rueger, and Carroll
(1984) previously described that persistent feelings of disgust were quite com-
mon among Vietnam veterans and showed predictive value for the develop-
ment of PTSD. More recent research indicates that disgust is the primary
emotion for approximately 10% of patients with PTSD (Power & Fyvie, 2013).
Many traumatic events, including combat experiences and sexual assault, share
features that may elicit disgust. Indeed, people with combat-related trauma
experiences report peritraumatic disgust in addition to peritraumatic fear (e.g.,
Engelhard et al., 2011). Similar findings have been reported for women who
developed PTSD following sexual assault (e.g., Badour et al., 2013).
It seems reasonable to assume that people with stronger disgust propensity
would be at risk for experiencing elevated peritraumatic disgust. Indeed, the
 Disgust Sensitivity 93

level of retrospectively rated peritraumatic disgust following combat experi-

ences in Afghanistan was higher in soldiers with higher scores on the DS–R
Animal Reminder subscale (Engelhard et al., 2011). Interestingly, the rela-
tionship between the strength of peritraumatic disgust and the level of PTSD
symptomatology was moderated by disgust sensitivity as indexed by the
DPSS–R. Specifically, the relationship between peritraumatic disgust and
PTSD symptoms were stronger among those with greater disgust sensitivity.
To the extent that activating a specific trauma memory elicits disgust, people
are typically inclined to avoid all cues that may elicit this memory. The urge
to avoid these types of disgust-eliciting memories would be especially strong
in people with high disgust sensitivity because of their particularly negative
appreciation of the experience of disgust. Thus, high disgust sensitivity may
promote disgust-based avoidance of specific (trauma) memories, thereby
obstructing any correction of maladaptive appraisals and associated distress.
More generally, urges to avoid traumatic memories that elicit disgust may not
only contribute to the persistence of PTSD, but also hamper the efficacy of
exposure-based PTSD treatments. Thus, clinicians should consider incorpo-
rating strategies that target PTSD-related disgust (e.g., “conceptual reorienta-
tion”; see Jung & Steil, 2013; Rozin & Fallon, 1987).

CONCLUSION

There is increasing evidence that disgust-based mechanisms are important to

the development, maintenance, and treatment of clinical anxiety. Paradoxi-
cally, effective disgust-motivated avoidance may also obscure the relevance of
disgust-based underpinnings of anxiety- and fear-related disorders, because
such clinically significant disgust may only be recognized to the extent that
people are exposed to disgust-evoking stimuli that they habitually avoid. That
disgust evolved as a mechanism to prevent contamination by invisible stimuli
may not only help explain why disgust is relatively resistant to disconfirma-
tory evidence, but also why many individuals engage in emotional reasoning
and other types of dysfunctional attributional processes that sustain the dis-
gust responses (e.g., Verwoerd, van Hout, & de Jong, 2016). All in all, there is
ample evidence that disgust (and disgust-based mechanisms) should be incor-
porated into cognitive behavioral conceptualizations of clinical anxiety and
related disorders. Doing so may not only help to improve our understanding
of the processes involved in the persistence of fear and anxiety problems but
also highlight promising directions for future research that could improve
currently available treatment options.

REFERENCES
Aitken, R. C. B. (1969). Measurement of feeling using visual analogue scales. Proceed-
ings of the Royal Society of Medicine, 62, 989–993.
Armstrong, T., McClenahan, L., Kittle, J., & Olatunji, B. O. (2014). Don’t look now!
Oculomotor avoidance as a conditioned disgust response. Emotion, 14, 95–104.
http://dx.doi.org/10.1037/a0034558
94 de Jong and Borg

Arntz, A., Lavy, E., van den Berg, G., & van Rijsoort, S. (1993). Negative beliefs of
spider phobics: A psychometric evaluation of the Spider Phobia Beliefs Question-
naire. Advances in Behaviour Research and Therapy, 15, 257–277. http://dx.doi.org/
10.1016/0146-6402(93)90012-Q
Askew, C., Çakır, K., Põldsam, L., & Reynolds, G. (2014). The effect of disgust and fear
modeling on children’s disgust and fear for animals. Journal of Abnormal Psychology,
123, 566–577. http://dx.doi.org/10.1037/a0037228
Badour, C. L., & Feldner, M. T. (2018). The role of disgust in posttraumatic stress: A critical
review of the empirical literature. Journal of Experimental Psychopathology, 3, 1–26.
Badour, C. L., Feldner, M. T., Babson, K. A., Blumenthal, H., & Dutton, C. E. (2013).
Disgust, mental contamination, and posttraumatic stress: Unique relations follow-
ing sexual versus non-sexual assault. Journal of Anxiety Disorders, 27, 155–162.
http://dx.doi.org/10.1016/j.janxdis.2012.11.002
Bar-Anan, Y., & Nosek, B. A. (2014). A comparative investigation of seven indirect atti-
tude measures. Behavior Research Methods, 46, 668–688. http://dx.doi.org/10.3758/
s13428-013-0410-6
Bixler, R. D., Carlisle, C. L., Hammitt, W. E., & Floyd, M. F. (1994). Observed fears and dis­
comforts among urban students on field trips to wildland areas. The Journal of Environ-
mental Education, 26, 24–33. http://dx.doi.org/10.1080/00958964.1994.9941430
Bixler, R. D., & Floyd, M. F. (1999). Hands on or hands off? Disgust sensitivity and
preference for environmental education activities. The Journal of Environmental
Education, 30, 4–11. http://dx.doi.org/10.1080/00958969909601871
Borg, C., & de Jong, P. J. (2012). Feelings of disgust and disgust-induced avoidance
weaken following induced sexual arousal in women. PLoS One, 7, e44111. http://
dx.doi.org/10.1371/journal.pone.0044111
Borg, C., de Jong, P. J., & Schultz, W. W. (2010). Vaginismus and dyspareunia: Auto-
matic vs. deliberate disgust responsivity. Journal of Sexual Medicine, 7, 2149–2157.
http://dx.doi.org/10.1111/j.1743-6109.2010.01800.x
Bosman, R. C., Borg, C., & de Jong, P. J. (2016). Optimizing extinction of conditioned
disgust. PLoS One, 11, e0148626. http://dx.doi.org/10.1371/journal.pone.0148626
Curtis, V., de Barra, M., & Aunger, R. (2011). Disgust as an adaptive system for disease
avoidance behaviour. Philosophical Transactions of the Royal Society of London: Series B.
Biological Sciences, 366, 389–401. http://dx.doi.org/10.1098/rstb.2010.0117
Davey, G. C. L., Forster, L., & Mayhew, G. (1993). Familial resemblances in disgust
sensitivity and animal phobias. Behaviour Research and Therapy, 31, 41–50. http://
dx.doi.org/10.1016/0005-7967(93)90041-R
de Jong, P. J. (2013). Learning mechanisms in the acquisition of disgust. In D. Hermans,
B. Rimé & B. Mesquita (Eds.), Changing emotions (pp. 74–80). London, England: Psy-
chology Press.
de Jong, P. J., Andrea, H., & Muris, P. (1997). Spider phobia in children: Disgust and
fear before and after treatment. Behaviour Research and Therapy, 35, 559–562. http://
dx.doi.org/10.1016/S0005-7967(97)00002-8
de Jong, P. J., & Merckelbach, H. (1998). Blood-injection-injury phobia and fear of spi-
ders: Domain specific individual differences in disgust sensitivity. Personality and Indi-
vidual Differences, 24, 153–158. http://dx.doi.org/10.1016/S0191-8869(97)00178-5
de Jong, P. J., & Muris, P. (2002). Spider phobia: Interaction of disgust and perceived
likelihood of involuntary physical contact. Journal of Anxiety Disorders, 16, 51–65.
http://dx.doi.org/10.1016/S0887-6185(01)00089-5
de Jong, P. J., Peters, M., & Vanderhallen, I. (2002). Disgust and disgust sensitivity in
spider phobia: Facial EMG in response to spider and oral disgust imagery. Journal of
Anxiety Disorders, 16, 477–493. http://dx.doi.org/10.1016/S0887-6185(02)00167-6
de Jong, P. J., Vorage, I., & van den Hout, M. A. (2000). Counterconditioning in the
treatment of spider phobia: Effects on disgust, fear and valence. Behaviour Research
and Therapy, 38, 1055–1069. http://dx.doi.org/10.1016/S0005-7967(99)00135-7
 Disgust Sensitivity 95

Elwood, L. S., & Olatunji, B. O. (2009). A cross-cultural perspective on disgust. In

B. Olatunji & D. McKay (Eds.), Disgust and its disorders: Theory, assessment, and treat-
ment (pp. 99–122). Washington, DC: American Psychological Association. http://
dx.doi.org/10.1037/11856-005
Engelhard, I. M., Olatunji, B. O., & de Jong, P. J. (2011). Disgust and the development
of posttraumatic stress among soldiers deployed to Afghanistan. Journal of Anxiety
Disorders, 25, 58–63. http://dx.doi.org/10.1016/j.janxdis.2010.08.003
FaceReader (Version 6.0) [Computer software]. (2014). Wageningen, the Netherlands:
Noldus Information Technology B.V.
Fairbrother, N., Newth, S. J., & Rachman, S. (2005). Mental pollution: Feelings of dirt-
iness without physical contact. Behaviour Research and Therapy, 43, 121–130. http://
dx.doi.org/10.1016/j.brat.2003.12.005
Fergus, T. A., & Valentiner, D. P. (2009). The Disgust Propensity and Sensitivity Scale–
Revised: An examination of a reduced-item version. Journal of Anxiety Disorders, 23,
703–710. http://dx.doi.org/10.1016/j.janxdis.2009.02.009
Fiedler, K., Messner, C., & Bluemke, M. (2006). Unresolved problems with the “I,” the
“A,” and the “T”: A logical and psychometric critique of the Implicit Association Test
(IAT). European Review of Social Psychology, 17, 74–147. http://dx.doi.org/10.1080/
10463280600681248
Foy, D. W., Sipprelle, R. C., Rueger, D. B., & Carroll, E. M. (1984). Etiology of post­
traumatic stress disorder in Vietnam veterans: Analysis of premilitary, military, and
combat exposure influences. Journal of Consulting and Clinical Psychology, 52, 79–87.
http://dx.doi.org/10.1037/0022-006X.52.1.79
Frijda, N. H. (2006). The laws of emotion. Mahwah, NJ: Erlbaum.
Gawronski, B., & Bodenhausen, G. V. (2006). Associative and propositional processes
in evaluation: An integrative review of implicit and explicit attitude change. Psycho-
logical Bulletin, 132, 692–731. http://dx.doi.org/10.1037/0033-2909.132.5.692
Gerull, F. C., & Rapee, R. M. (2002). Mother knows best: Effects of maternal modelling
on the acquisition of fear and avoidance behaviour in toddlers. Behaviour Research
and Therapy, 40, 279–287. http://dx.doi.org/10.1016/S0005-7967(01)00013-4
Goetz, A. R., Cougle, J. R., & Lee, H. J. (2013). Revisiting the factor structure of the
12-item Disgust Propensity and Sensitivity Scale—Revised: Evidence for a third
component. Personality and Individual Differences, 55, 579–584. http://dx.doi.org/
10.1016/j.paid.2013.04.029
Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measuring individual dif-
ferences in implicit cognition: The implicit association test. Journal of Personality and
Social Psychology, 74, 1464–1480. http://dx.doi.org/10.1037/0022-3514.74.6.1464
Haidt, J., McCauley, C., & Rozin, P. (1994). Individual differences in sensitivity to dis-
gust: A scale sampling seven domains of disgust elicitors. Personality and Individual
Differences, 16, 701–713. http://dx.doi.org/10.1016/0191-8869(94)90212-7
Huijding, J., & de Jong, P. J. (2007). Beyond fear and disgust: The role of (automatic)
contamination-related associations in spider phobia. Journal of Behavior Therapy and
Experimental Psychiatry, 38, 200–211. http://dx.doi.org/10.1016/j.jbtep.2006.10.009
Jung, K., & Steil, R. (2013). A randomized controlled trial on cognitive restructuring
and imagery modification to reduce the feeling of being contaminated in adult sur-
vivors of childhood sexual abuse suffering from posttraumatic stress disorder. Psy-
chotherapy and Psychosomatics, 82, 213–220. http://dx.doi.org/10.1159/000348450
Lavy, E., van den Hout, M., & Arntz, A. (1993). Attentional bias and facilitated escape:
A pictorial test. Advances in Behaviour Research and Therapy, 15, 279–289. http://
dx.doi.org/10.1016/0146-6402(93)90013-R
Lewinski, P., den Uyl, T. M., & Butler, C. (2014). Automated facial coding: Validation of
basic emotions and FACS AUs in FaceReader. Journal of Neuroscience, Psychology, and
Economics, 7, 227–236. http://dx.doi.org/10.1037/npe0000028
96 de Jong and Borg

Mason, E. C., & Richardson, R. (2010). Looking beyond fear: The extinction of other
emotions implicated in anxiety disorders. Journal of Anxiety Disorders, 24, 63–70.
http://dx.doi.org/10.1016/j.janxdis.2009.08.007
Matchett, G., & Davey, G. C. L. (1991). A test of a disease-avoidance model of animal
phobias. Behaviour Research and Therapy, 29, 91–94. http://dx.doi.org/10.1016/
S0005-7967(09)80011-9
Mulkens, S. A., de Jong, P. J., & Merckelbach, H. (1996). Disgust and spider phobia.
Journal of Abnormal Psychology, 105, 464–468. http://dx.doi.org/10.1037/0021-843X.
105.3.464
Muris, P., Huijding, J., Mayer, B., Langkamp, M., Reyhan, E., & Olatunji, B. (2012).
Assessment of disgust sensitivity in children with an age-downward version of the
Disgust Emotion Scale. Behavior Therapy, 43, 876–886. http://dx.doi.org/10.1016/
j.beth.2012.03.002
Najmi, S., Kuckertz, J. M., & Amir, N. (2010). Automatic avoidance tendencies in indi-
viduals with contamination-related obsessive-compulsive symptoms. Behaviour
Research and Therapy, 48, 1058–1062. http://dx.doi.org/10.1016/j.brat.2010.06.007
Oaten, M., Stevenson, R. J., & Case, T. I. (2009). Disgust as a disease-avoidance mech-
anism. Psychological Bulletin, 135, 303–321. http://dx.doi.org/10.1037/a0014823
Oaten, M., Stevenson, R. J., Wagland, P., Case, T. I., & Repacholi, B. M. (2014). Parent–
child transmission of disgust and hand hygiene: The role of vocalizations, gestures
and other parental responses. The Psychological Record, 64, 803–811. http://dx.doi.org/
10.1007/s40732-014-0044-9
Olatunji, B. O., Adams, T., Ciesielski, B., David, B., Sarawgi, S., & Broman-Fulks, J.
(2012). The Three Domains of Disgust Scale: Factor structure, psychometric proper-
ties, and conceptual limitations. Assessment, 19, 205–225. http://dx.doi.org/10.1177/
1073191111432881
Olatunji, B. O., Armstrong, T., & Elwood, L. (2017). Is disgust proneness associated
with anxiety and related disorders? A qualitative review and meta-analysis of group
comparison and correlational studies. Perspectives on Psychological Science, 12, 613–648.
http://dx.doi.org/10.1177/1745691616688879
Olatunji, B. O., Ebesutani, C., & Kim, E. H. (2015). Examination of a bifactor model of the
Three Domains of Disgust Scale: Specificity in relation to obsessive-compulsive symp-
toms. Psychological Assessment, 27, 102–113. http://dx.doi.org/10.1037/pas0000039
Olatunji, B. O., Sawchuk, C. N., de Jong, P. J., & Lohr, J. M. (2006). The structural rela-
tion between disgust sensitivity and blood–injection–injury fears: A cross-cultural
comparison of US and Dutch data. Journal of Behavior Therapy and Experimental Psychi-
atry, 37, 16–29. http://dx.doi.org/10.1016/j.jbtep.2005.09.002
Olatunji, B. O., Sawchuk, C. N., de Jong, P. J., & Lohr, J. M. (2007). Disgust sensitivity
and anxiety disorder symptoms: Psychometric properties of the disgust emotion scale.
Journal of Psychopathology and Behavioral Assessment, 29, 115–124. http://dx.doi.org/
10.1007/s10862-006-9027-8
Olatunji, B. O., Sawchuk, C. N., Lohr, J. M., & de Jong, P. J. (2004). Disgust domains
in the prediction of contamination fear. Behaviour Research and Therapy, 42, 93–104.
http://dx.doi.org/10.1016/S0005-7967(03)00102-5
Olatunji, B. O., Williams, N. L., Tolin, D. F., Abramowitz, J. S., Sawchuk, C. N., Lohr,
J. M., & Elwood, L. S. (2007). The Disgust Scale: Item analysis, factor structure, and
suggestions for refinement. Psychological Assessment, 19, 281–297. http://dx.doi.org/
10.1037/1040-3590.19.3.281
Olatunji, B. O., Wolitzky-Taylor, K. B., Willems, J., Lohr, J. M., & Armstrong, T. (2009).
Differential habituation of fear and disgust during repeated exposure to threat-relevant
stimuli in contamination-based OCD: An analogue study. Journal of Anxiety Disorders,
23, 118–123. http://dx.doi.org/10.1016/j.janxdis.2008.04.006
Page, A. C. (1994). Blood-injury phobia. Clinical Psychology Review, 14, 443–461. http://
dx.doi.org/10.1016/0272-7358(94)90036-1
 Disgust Sensitivity 97

Power, M. J., & Fyvie, C. (2013). The role of emotion in PTSD: Two preliminary studies.
Behavioural and Cognitive Psychotherapy, 41, 162–172. http://dx.doi.org/10.1017/
S1352465812000148
Reynolds, L. M., Consedine, N. S., Pizarro, D. A., & Bissett, I. P. (2013). Disgust and
behavioral avoidance in colorectal cancer screening and treatment: A systematic
review and research agenda. Cancer Nursing, 36, 122–130. http://dx.doi.org/10.1097/
NCC.0b013e31826a4b1b
Roefs, A., Huijding, J., Smulders, F. T. Y., MacLeod, C. M., de Jong, P. J., Wiers, R. W.,
& Jansen, A. T. M. (2011). Implicit measures of association in psychopathology
research. Psychological Bulletin, 137, 149–193. http://dx.doi.org/10.1037/a0021729
Rozin, P., & Fallon, A. E. (1987). A perspective on disgust. Psychological Review, 94,
23–41. http://dx.doi.org/10.1037/0033-295X.94.1.23
Rozin, P., Lowery, L., & Ebert, R. (1994). Varieties of disgust faces and the structure of
disgust. Journal of Personality and Social Psychology, 66, 870–881. http://dx.doi.org/
10.1037/0022-3514.66.5.870
Rozin, P., Nemeroff, C., Horowitz, M., Gordon, B., & Voet, W. (1995). The borders of
the self: Contamination sensitivity and potency of the body apertures and other
body parts. Journal of Research in Personality, 29, 318–340. http://dx.doi.org/10.1006/
jrpe.1995.1019
Stevenson, R. J., Oaten, M. J., Case, T. I., Repacholi, B. M., & Wagland, P. (2010). Chil-
dren’s response to adult disgust elicitors: Development and acquisition. Developmental
Psychology, 46, 165–177. http://dx.doi.org/10.1037/a0016692
Teachman, B. A., Gregg, A. P., & Woody, S. R. (2001). Implicit associations for fear-
relevant stimuli among individuals with snake and spider fears. Journal of Abnormal
Psychology, 110, 226–235. http://dx.doi.org/10.1037/0021-843X.110.2.226
Tolin, D. F., Lohr, J. M., Sawchuk, C. N., & Lee, T. C. (1997). Disgust and disgust sensi-
tivity in blood-injection-injury and spider phobia. Behaviour Research and Therapy,
35, 949–953. http://dx.doi.org/10.1016/S0005-7967(97)00048-X
Tolin, D. F., Worhunsky, P., & Maltby, N. (2004). Sympathetic magic in contamination-
related OCD. Journal of Behavior Therapy and Experimental Psychiatry, 35, 193–205.
http://dx.doi.org/10.1016/j.jbtep.2004.04.009
Trijsburg, R. W., Jelicic, M., van den Broek, W. W., Plekker, A. E. M., Verheij, R., &
Passchier, J. (1996). Exposure and participant modelling in a case of injection
phobia. Psychotherapy and Psychosomatics, 65, 57–61. http://dx.doi.org/10.1159/
000289033
Tybur, J. M., Lieberman, D., & Griskevicius, V. (2009). Microbes, mating, and morality:
Individual differences in three functional domains of disgust. Journal of Personality
and Social Psychology, 97, 103–122. http://dx.doi.org/10.1037/a0015474
Tybur, J. M., Lieberman, D., Kurzban, R., & DeScioli, P. (2013). Disgust: Evolved function
and structure. Psychological Review, 120, 65–84. http://dx.doi.org/10.1037/a0030778
van Delft, I., Finkenauer, C., Tybur, J. M., & Lamers-Winkelman, F. (2016). Disgusted
by sexual abuse: Exploring the association between disgust sensitivity and post­
traumatic stress symptoms among mothers of sexually abused children. Journal of
Traumatic Stress, 29, 237–244. http://dx.doi.org/10.1002/jts.22099
van Overveld, W. J. M., de Jong, P. J., & Peters, M. L. (2009). Digestive and cardio­
vascular responses to core and animal-reminder disgust. Biological Psychology, 80,
149–157. http://dx.doi.org/10.1016/j.biopsycho.2008.08.002
van Overveld, M., de Jong, P. J., & Peters, M. L. (2010). The Disgust Propensity and Sen-
sitivity Scale—Revised: Its predictive value for avoidance behavior. Personality and
Individual Differences, 49, 706–711. http://dx.doi.org/10.1016/j.paid.2010.06.008
van Overveld, W. J. M., de Jong, P. J., Peters, M. L., Cavanagh, K., & Davey, G. C. L.
(2006). Disgust propensity and disgust sensitivity: Separate constructs that are differ-
entially related to specific fears. Personality and Individual Differences, 41, 1241–1252.
http://dx.doi.org/10.1016/j.paid.2006.04.021
98 de Jong and Borg

van Overveld, M., de Jong, P. J., Peters, M. L., & Schouten, E. (2011). The Disgust
Scale–R: A valid and reliable index to investigate separate disgust domains? Personality
and Individual Differences, 51, 325–330. http://dx.doi.org/10.1016/j.paid.2011.03.023
Verwoerd, J., de Jong, P. J., Wessel, I., & van Hout, W. J. P. J. (2013). “If I feel dis-
gusted, I must be getting ill”: Emotional reasoning in the context of contamination
fear. Behaviour Research and Therapy, 51, 122–127. http://dx.doi.org/10.1016/
j.brat.2012.11.005
Verwoerd, J., van Hout, W. J. P. J., & de Jong, P. J. (2016). Disgust- and anxiety-based
emotional reasoning in non-clinical fear of vomiting. Journal of Behavior Therapy and
Experimental Psychiatry, 50, 83–89. http://dx.doi.org/10.1016/j.jbtep.2015.05.009
Viar-Paxton, M. A., Ebesutani, C., Kim, E. H., Ollendick, T., Young, J., & Olatunji, B. O.
(2015). Development and initial validation of the Child Disgust Scale. Psychological
Assessment, 27, 1082–1096. http://dx.doi.org/10.1037/a0038925
Vrana, S. R. (1993). The psychophysiology of disgust: Differentiating negative emo-
tional contexts with facial EMG. Psychophysiology, 30, 279–286. http://dx.doi.org/
10.1111/j.1469-8986.1993.tb03354.x
Williams, J. M., Barnhofer, T., Crane, C., Herman, D., Raes, F., Watkins, E., & Dalgleish, T.
(2007). Autobiographical memory specificity and emotional disorder. Psychological
Bulletin, 133, 122–148. http://dx.doi.org/10.1037/0033-2909.133.1.122
Woody, S. R., & Teachman, B. A. (2000). Intersection of disgust and fear: Normative
and pathological views. Clinical Psychology: Science and Practice, 7, 291–311. http://
dx.doi.org/10.1093/clipsy.7.3.291
6
Distress Intolerance
Caitlin A. Stamatis, Stephanie E. Hudiburgh, and Kiara R. Timpano

Irma was a business student who hoped to get a job as a marketing consultant
upon finishing her degree. Although she was genuinely interested in her major,
she found her classes extremely distressing, in part because of the required
presentations. Irma worried that others would evaluate her negatively, but more
specifically, she felt incapable of handling the “intolerable and unmanageable”
stress associated with speaking to a group. Irma disliked the physical sensations
that accompanied public speaking, but these did not bother her as much as the
idea of having to endure strong negative emotions. Irma noted that while she
generally disliked feeling upset or stressed, this tendency was particularly pro-
nounced for public speaking. To cope, Irma offered to do all of the preparatory
work for group presentations, leaving the public speaking to her classmates
despite positive feedback from her peers and instructors on her performance.
Though Irma’s role during presentations was limited, she would spend the entire
class helplessly focused on how awful she felt, finding the experience over-
whelming and unbearable. Irma would express shame that presentations caused
her so much distress and anxiety. Eventually, she changed her major to account-
ing, which was less of an interest to her but did not involve public speaking. This
gave her an immediate sense of relief; however, when Irma thinks about the
business major she dropped, she experiences significant guilt and regret.1

Irma’s cognitions, emotions, and behaviors highlight the impact of distress

intolerance on the evaluation of negative emotional states and subsequent
reactions to experiencing distressing situations (Schmidt, Mitchell, Keough, &
Riccardi, 2011). Distress intolerance is an individual difference factor that

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-006
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
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100 Stamatis, Hudiburgh, and Timpano

varies dimensionally across the population (Schmidt et al., 2011). Notably, an

individual’s perceived and actual ability to tolerate stressors may not align
(Bernstein, Marshall, & Zvolensky, 2011). Distress intolerance can also vary
according to emotional domain (Geisser, Robinson, & Pickren, 1992; Simons
& Gaher, 2005) and across situations, which reflects the multifaceted nature of
this cognitive risk factor. Whereas the content and nature of distress may vary
across disorders and individuals, the process of having difficulty tolerating dis-
tress may signal a transdiagnostic vulnerability for psychopathology.
Irma’s distress intolerance influences (a) her anticipatory beliefs in her ability
to tolerate a stressor and her prediction of how distressing it will be, (b) her
experience of distress, and (c) her coping behaviors surrounding the event (Simons
& Gaher, 2005). Illustrating the anticipatory aspect of distress intolerance,
Irma’s anxiety prior to the presentation is associated with negative beliefs about
herself (e.g., “I can’t handle public speaking”) and the future (e.g., “I will
freeze and forget what to say”). Irma envisions herself doing poorly at the
presentation, and she expects to be unable to navigate the negative emotions
sparked by the experience. Her anticipatory beliefs influence her real-time
appraisals of the situation as threatening and unbearable. Individuals with low
distress tolerance may allocate greater attentional resources to negative emo-
tional states (Schmidt et al., 2011), which in Irma’s case includes her stress
level, anxious thoughts, and physical sensations. By directing focus to the most
distressing parts of the stressful event, this attentional bias contributes to Irma’s
appraisal of the situation as overwhelming.
Distress intolerance also foments maladaptive behaviors that maintain psycho­
pathology. Irma’s focus on her experience of distress in the moment prevents
her from allocating resources towards effective coping strategies. Because Irma
believes she is helpless to manage the distress experienced, she perceives her-
self as powerless to change her situation. This perception, in turn, makes her
seek immediate relief from distress by resorting to safety behaviors (e.g., having
classmates complete the speaking portion of presentations; see Chapter 2) or
avoidance (e.g., enrolling in classes that do not require public speaking). Impor-
tantly, Irma’s fear of negative evaluation, which serves as the foundation for
her public speaking fears, is exacerbated by her distress intolerance. Whereas
someone with similar levels of social anxiety but higher levels of distress toler-
ance may be able to respond to public speaking with a “tough it out” attitude,
Irma’s distress intolerance magnifies her negative evaluation fears. As a result,
Irma is more likely to resort to poor coping skills—including avoidance and
safety behaviors—to help navigate public speaking.

CONCEPTUAL IMPLICATIONS

Cognitive Behavior Model of Distress Intolerance

Although there is no single, overarching model of distress intolerance

(Zvolensky, Vujanovic, Bernstein, & Leyro, 2010), scientific evidence points
 Distress Intolerance 101

to several frameworks for understanding this construct. Some researchers

nest distress intolerance under the umbrella of emotional intolerance (Leyro,
Zvolensky, & Bernstein, 2010), along with other cognitive factors, including
avoidance, anxiety sensitivity, and persistence (Zvolensky, Leyro, Bernstein,
& Vujanovic, 2011). These hierarchical models highlight the multifaceted
nature of distress intolerance (Bardeen, Fergus, & Orcutt, 2013; Simons &
Gaher, 2005): uncertainty, ambiguity, frustration, and physical discomfort all
capture distinct elements of the more general notion of distress (Bernstein,
Zvolensky, Vujanovic, & Moos, 2009; Schmidt et al., 2011).
Conceptualizations of distress intolerance draw heavily from cognitive
behavior models of emotion (Leyro et al., 2010). These models contend that
thoughts, feelings, and behaviors influence one another in a bidirectional man-
ner (Beck, 2011). Distress intolerance is also conceptually related to experien-
tial avoidance (see Chapter 7, this handbook), though these processes are not
entirely overlapping. Some researchers have posited that distress intolerance
relates to information processing biases, such as an attentional bias for negative
stimuli (Simons & Gaher, 2005; see also Chapter 12, this handbook). Relatedly,
regulating negative emotion seems to be especially difficult for distress intoler-
ant individuals with poor attentional control, which could reflect difficulty dis-
engaging attention from a negative stimulus (Bardeen, Tull, Dixon-Gordon,
Stevens, & Gratz, 2015). Furthermore, distress intolerance may be linked with
negatively biased perceptions of one’s ability to tolerate distress and regulate
negative emotional responses, which could in turn lead to avoidance of stress-
ful situations (Blalock & Joiner, 2000). The reward value of escaping or avoid-
ing a negative situation, in turn, reinforces beliefs underlying perceived distress
intolerance, strengthening these pathways over time (see Figure 6.1).

Role of Appraisals
Cognitive appraisals are central to the anticipation, experience, and conse-
quences of distress. Individuals with high distress intolerance may catastroph-
ize negative emotion and believe themselves incapable of tolerating a negative
emotional state, which is a catalyst for behavioral avoidance or escape (Schmidt
et al., 2011). In addition, individuals with distress intolerance harbor negative
judgments about their own feelings of distress (Simons & Gaher, 2005), which
can produce feelings of shame and inadequacy, as in Irma’s case.
While general cognitive appraisals contribute to distress intolerance, dis-
tress intolerance also interacts with disorder-specific cognitive appraisals to
influence risk for psychopathology. In the context of Irma’s social anxiety
symptoms, distress intolerance acts synergistically with her core fear of nega-
tive evaluation, thereby magnifying the social anxiety-fueled dread she feels
during presentations. A similar example could apply in the case of a distress
intolerant patient who experiences depressive symptoms, which are kindled
by the core belief that he is weak and helpless. His distress intolerance inter-
acts with his depressive cognitions, such that he appraises negative emotions
as entirely overwhelming. He believes he is powerless to tolerate or change
his situation, which fosters disengagement and social withdrawal. In short,
 102 Stamatis, Hudiburgh, and Timpano
FIGURE 6.1. Cognitive Behavior Model of Distress Intolerance

Cognitions
• Appraisal of stressor/situation: “This is
terrible.”
+ Stressor • Perceived ability to tolerate situation: “I can’t
handle this.”
• Reward value of escaping or avoiding: “I need
to get away from this to feel better.”

Distress Avoid
intolerance
reinforcer

Emotions
Behaviors • Anxiety
reinforc • Escape
• Fear
er • Avoidance
Relief • Negative urgency
 Distress Intolerance 103

this patient’s distress intolerance reinforces his perceived helplessness, and

with it, the severity of his depression.

Role of Avoidance, Safety Behaviors, and Negative Reinforcement

By interacting with psychological vulnerabilities and information-processing
biases, distress intolerance increases the risk that a person will engage in avoid-
ance and safety behaviors (see Chapter 2). These maladaptive behaviors repre-
sent the strongest maintaining factors for anxiety disorders (Borkovec, 1979), as
they incur the unintended consequence of bolstering an individual’s perception
that they are unable to handle experiences of distress (Trafton & Gifford, 2011).
Over time, the avoidance–relief pathway is strengthened through negative
reinforcement (as shown in Figure 6.1), which is likely to increase functional
impairment and hinder recovery.
The reader may note that in spite of participating in presentations, Irma’s
fears failed to subside after accumulated positive experiences, ultimately lead-
ing her to change her major. The link between the Irma’s distress intolerance
and reliance on classmates as a “safety net” highlights the role of the reward
learning framework. Individuals with distress intolerance display a seemingly
impulsive tendency to opt for an immediate reward (i.e., relief from negative
emotion; Trafton & Gifford, 2011). Conversely, tolerating distress involves
inhibiting a response to an immediate negative reinforcement opportunity (i.e.,
withstanding distress). A person’s willingness to “tough it out” in the short
term—for instance, working through anxiety to give a presentation—may stem
from the recognition of an associated long-term reward, such as earning a good
grade in school.

ASSESSMENT

A number of self-report and behavioral measures capture distress intolerance.

Self-report measures of this construct generally ask individuals to reflect on
their perceived ability to endure distress, whereas behavioral measures evaluate
the degree to which they persist toward a goal while completing physically or
cognitively aversive tasks (Leyro et al., 2010). There exists considerable hetero-
geneity within each method of assessment, and no one measure has been iden-
tified or adopted as the gold standard (McHugh & Otto, 2012). The diversity of
measures under the umbrella of distress intolerance reflects the many subfacets
included under the higher order construct (Bardeen et al., 2013); some mea-
sures only focus on one particular lower order factor (e.g., physical discomfort),
whereas others focus on negative emotions more broadly.

Self-Report Measures

The Distress Tolerance Scale (DTS; Simons & Gaher, 2005) is one of the most
frequently used self-report measures of distress intolerance. The DTS broadly
examines an individual’s perceived capacity to handle negative emotions
104 Stamatis, Hudiburgh, and Timpano

(e.g., “I’ll do anything to avoid feeling distressed.”). This 15-item measure has
demonstrated good internal consistency (α = .82), as well as convergent, dis-
criminant, and criterion validity (Simons & Gaher, 2005). The Frustration–
Discomfort Scale (Harrington, 2005), similarly reflects intolerance of broadly
defined unpleasant emotional experiences (e.g., “I can’t stand doing things that
involve a lot of hassle”), while placing a slightly greater emphasis on frustration.
Its subscales exhibit good internal consistency, with alpha coefficients ranging
from .84 to .88, and acceptable divergent and predictive validity (Harrington,
2005, 2006). The Distress Intolerance Index (DII; McHugh & Otto, 2012) com-
bines these two measures in a short 10-item questionnaire, displaying excellent
internal consistency in both nonclinical (α = .91) and clinical samples (α = .92).
Higher scores on these measures have been linked with anxiety, obsessive-
compulsive (OC), and trauma symptoms (Cougle, Timpano, Fitch, & Hawkins,
2011; Harrington, 2006; Macatee, Capron, Guthrie, Schmidt, & Cougle, 2015;
Vinci, Mota, Berenz, & Connolly, 2016).
There are also numerous questionnaires that assess tolerance of specific types
of distress, including tolerance of ambiguity, uncertainty, and physical discomfort.
The Multiple Stimulus Types Ambiguity Tolerance-I (McLain, 1993) and the
Tolerance of Ambiguity Scale-12 (Herman, Stevens, Bird, Mendenhall, &
Oddou, 2010) have been used to assess perceived tolerance of ambiguous
situations. Both demonstrate adequate psychometric properties (α = .86 and
.73, respectively; Herman et al., 2010; McLain, 1993). Similarly, measures of
the intolerance of uncertainty explore unwillingness to tolerate the possibility
of future negative outcomes, even if these are unlikely to occur (see Chap-
ter 3, this handbook). The Discomfort Intolerance Scale (Schmidt, Richey, &
Fitzpatrick, 2006), on the other hand, evaluates the perceived inability to
withstand unpleasant physical sensations or pain (e.g., “I take extreme mea-
sures to avoid feeling physically uncomfortable”). This brief five-item measure
demonstrates acceptable internal (α = .70) and test–retest reliability, as well
convergent and discriminant validity (Schmidt et al., 2006). Finally, measures
of anxiety sensitivity (see Chapter 4, this handbook) capture fear of anxiety-
related symptoms (i.e., fear of fear). Higher scores on many of these measures
have also been associated with greater levels of psychological symptoms
(Buckner, Keough, & Schmidt, 2007; Buhr & Dugas, 2006; Holaway, Heimberg,
& Coles, 2006; Taylor, Koch, & McNally, 1992).

Behavioral Measures

Behavioral measures involving physical or cognitive tasks have been developed

to capture, in real time, an individual’s willingness to persist despite experienc-
ing distress. Of note, most of these tasks do not address distress intolerance in
the same manner or even focus on the same form of distress; however, they all
presume to capture behavioral intolerance by assessing the length of time a par-
ticipant persists in a given distressing task (Leyro et al., 2010). These measures
have been linked to panic (Marshall et al., 2008), smoking cessation (Abrantes
 Distress Intolerance 105

et al., 2008), OC symptoms (Cougle, Timpano, Sarawgi, Smith, & Fitch, 2013),
and general mood and anxiety psychopathology (Bernstein et al., 2011).
Distress intolerance tasks currently used in research utilize a range of phys-
ical and cognitive stimuli. Some physical distress intolerance tasks involve
thermal stressors: for example, in the cold pressor task, an individual is asked
to submerge a hand in ice water for as long as possible (Leyro et al., 2010).
Other physical intolerance tasks involve intentionally eliciting signs of physio-
logical arousal discomfort through breath-holding, hyperventilation, or the
inhalation of carbon dioxide–enriched air (see Brown, Lejuez, Kahler, & Strong,
2002). Cognitive distress intolerance includes the Paced Auditory Serial Addi-
tion Test (PASAT; Gronwall & Sampson, 1974) and the mirror tracing per-
sistence task (MTPT; Matthews & Stoney, 1988). The PASAT involves presenting
single-digit numbers one after another while the participant is asked to con-
tinuously add together the last two digits given, while the MTPT requires the
participant to trace a complex figure as if viewed in a mirror. Another cognitive
measure, the anagram persistence task (Eisenberger & Leonard, 1980; Quinn,
Brandon, & Copeland, 1996), asks participants to solve anagrams of varying
difficulty, with time invested in challenging or unanswerable items used as a
measure of distress tolerance (Leyro et al., 2010).
An adaptation of the Willingness to Pay scale (WTP-DI; McHugh, Hearon,
Halperin, & Otto, 2011) combines elements of both behavioral and self-report
instruments of distress intolerance. When completing the WTP-DI, an indi-
vidual first undergoes a distressing task. Afterward, the individual is asked
how much he or she would be willing to pay (expressed as a percentage of
monthly income) never to reexperience the distress of the task, with willing-
ness to pay greater amounts assumed to reflect distress intolerance (McHugh,
Hearon, et al., 2011).

Assessment in a Clinical Context

The wide variety of instruments focused on distress intolerance provides cli-

nicians with many ways to approach assessment. At the same time, it raises
questions about the construct validity of distress intolerance and whether
these measures truly reflect a single underlying construct. Ratings on self-
report questionnaires often diverge from performance on behavioral tasks
of distress intolerance (Ameral, Palm Reed, Cameron, & Armstrong, 2014;
Glassman et al., 2016; McHugh, Daughters, et al., 2011). Performance (i.e.,
task persistence) on behavioral tasks has often not been linked to clinical
features, even when distress tolerance in the same participants predicted symp-
toms (Bernstein et al., 2011; Hasan, Babson, Banducci, & Bonn-Miller, 2015)
This may indicate that perceived distress intolerance is a stronger predictor
of psychopathology. Measures such as the WTP-DI, which consists of both
behavioral and self-report components, may help clarify this point in future
research (McHugh, Hearon, et al., 2011).
Given the wide range of measures available for assessing distress intoler-
ance, it might be difficult for the clinician to determine the best assessment
106 Stamatis, Hudiburgh, and Timpano

tool for a given case, both in terms of feasibility of use and content. Behav-
ioral measures—with the notable exception of the WTP-DI—are almost cer-
tainly impractical in a clinical setting. With regard to self-report measures,
clinicians may choose to assess the more general construct of distress intoler-
ance or, rather, select a measure to better understand the specific type of dis-
tress the patient perceives as intolerable. Transdiagnostic measures of distress
tolerance, such as the DII, could provide a good starting place for assessing the
level of distress intolerance (McHugh & Otto, 2011). Clinicians may also sim-
ply ask patients about their perceived tolerance of whatever negative emotion
is being experienced. The clinician’s observation can also be a valuable tool in
assessing distress intolerance, so long as distress intolerance is considered sep-
arately from other core fears.

CLINICAL IMPLICATIONS

Distress intolerance impacts a range of behaviors and emotion regulation

processes (Simons & Gaher, 2005). Due to the ubiquity of distress intolerance
across psychopathology (Dugas, Gosselin, & Ladouceur, 2001; Keough, Riccardi,
Timpano, Mitchell, & Schmidt, 2010; Leyro et al., 2010; Timpano, Buckner,
Richey, Murphy, & Schmidt, 2009), clinicians must be able to recognize and
address patients’ difficulties in tolerating negative emotion. Distress intoler-
ance will manifest differently depending on a patient’s primary symptoms.
With anxiety disorders, distress intolerance may elicit an unwillingness to
complete exposures. Thus, clinicians should be aware of ways in which dis-
tress intolerance may be impacting treatment progress and patient recovery,
as well as how to increase willingness to withstand negative emotion in the
face of distress intolerance. Below, we elaborate on specific considerations
for anxiety-related disorders.

Implications for Fear-Based Conditions

Within general treatment seeking samples (Allan, Macatee, Norr, Raines, &
Schmidt, 2015; Michel, Rowa, Young, & McCabe, 2016) and youth (Banducci,
Lejuez, Dougherty, & MacPherson, 2017; Cummings et al., 2013; Wolitzky-
Taylor et al., 2015), distress intolerance predicts general or composite mea-
sures of anxiety and fear. Additional studies have examined this relationship
in the context of specific types of anxiety, including social anxiety, worry, and
panic. Research indicates that distress intolerance is an important cognitive
factor for all anxiety presentations (Keough et al., 2010; Kraemer, Luberto, &
McLeish, 2013; Norr et al., 2013). However, the relationship between distress
intolerance and perseverative thinking, as captured specifically by measures
of worry, appears to be most robust and specific (Macatee et al., 2015).
Across all fear-based conditions, distress intolerance can influence how
symptoms are expressed and exacerbated. First, distress intolerance interacts
with other risk factors for anxiety. For example, research suggests that as
 Distress Intolerance 107

distress intolerance increases, anxiety sensitivity (i.e., the fear of anxiety-

related physical sensations) is likely to increase in tandem (Schmidt et al.,
2011). Similarly, individuals with experiences of childhood emotional abuse,
and who also endorse distress intolerance, report the highest levels of anxiety
and distress (Banducci et al., 2017).
A second pathway by which distress tolerance could help maintain anxiety
symptoms is by fostering overly negative appraisals of a stressor and associated
negative emotions (Simons & Gaher, 2005). This scenario was highlighted in
Irma’s case example. Distress intolerance made Irma experience her fear of
negative evaluation as overwhelming and uncontrollable, which was com-
pounded by a heightened attentional focus on her negative emotional state.
Similarly, for a patient with panic disorder, distress intolerance might magnify
the patient’s focus on negative somatic sensations (Schmidt et al., 2011), also
increasing the likelihood of interpreting sensations such as a racing heartbeat
or feeling of faintness as threatening or dangerous.
The final pathway involves the likelihood that patients—regardless of
diagnosis—will resort to unhelpful coping (Daughters et al., 2009; Korte,
Unruh, Oglesby, & Schmidt, 2015). By relying on subtle safety aids (e.g., anti-
anxiety medication “just in case”) or behaviors (e.g., sitting near an exit), or
falling back on avoidance, anxious patients with distress intolerance are at
greater risk for maintaining anxiety symptoms. They are also more suscepti-
ble to relapsing following treatment gains when faced with threatening stim-
uli (Powers, Smits, & Telch, 2004).

Implications for Obsessive-Compulsive Spectrum Conditions

Research associates distress intolerance with the global severity of OC symp-

toms in people with and without full-fledged obsessive-compulsive disorder
(OCD; Macatee, Capron, Schmidt, & Cougle, 2013). This suggests that distress
intolerance is of clinical utility regardless of a patient’s OC symptom severity.
Additional research suggests that distress intolerance is more specifically linked
with obsessions (Hezel, Riemann, & McNally, 2012), particularly those charac-
terized as repugnant (e.g., sexual, religious, or aggressive intrusive thoughts;
Cougle et al., 2013; Macatee et al., 2013). Notably, despite exhibiting emo-
tional distress intolerance, individuals with OCD seem to display greater toler-
ance for physical pain (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007),
underscoring the idea that withstanding emotional and physical distress may
not go hand in hand. With respect to other OC spectrum conditions, distress
intolerance has also been associated with hoarding symptoms (Timpano et al.,
2009; Timpano, Shaw, Cougle, & Fitch, 2014); no research has addressed con-
nections to body dysmorphic disorder, tic disorders, or trichotillomania.
Distress intolerance may influence OC spectrum symptoms via several
pathways. The first is by magnifying the intensity of obsessions, which patients
already appraise as unacceptable and threatening. Patients with distress intol-
erance may pay even greater attention to obsessive thoughts and appraise
them as more negative and uncontrollable. These patients feel incapable of
108 Stamatis, Hudiburgh, and Timpano

tolerating not only the distress associated with the obsessions, but also the
distress of not performing a ritual—which functions to momentarily relieve
anxiety due to an obsession—in response. The exacerbation of obsessions seen
with distress intolerance is important to the course of OC symptoms, as distress
intolerance predicts increased obsessions over time (Cougle et al., 2011).
A second way that distress intolerance contributes to the development and
maintenance of OC symptoms is in interaction with negative urgency (i.e.,
the need to respond immediately to negative emotion). Distress intolerance
may work in tandem with negative urgency, leading to difficulty inhibiting an
immediate response to a negative reinforcement opportunity. In OCD, the
immediate reward is relief from obsessions obtained through rituals. Thus,
distress intolerance and high negative urgency are a “one-two punch” that
renders irresistible the need to eradicate negative emotions through com-
pulsions, suppression, or other neutralizing acts (Cougle et al., 2011; Macatee
et al., 2013). Each time patients yield to a compulsive urge, however, they
contribute to increasing the frequency and severity of obsessions, maintain-
ing the disorder.
Research connecting OC symptoms and distress intolerance points to a
number of clinical implications. Given that intolerance of negative emotion
predicts increases in obsessions (Cougle et al., 2011), it is essential to assess
for distress intolerance in patients at high risk of OCD, or who display sub­
clinical symptoms. By learning to bolster distress tolerance through accep-
tance and commitment therapy or dialectical behavior therapy, a patient could
conceivably weaken the link between obsessions (thoughts) and compulsions
(behaviors). In early stages of OCD, increasing distress tolerance may arrest
symptom progression; in treatment, it may augment exposure efficacy; and in
recovery, it may help prevent relapse.

Implications for Trauma-Related Conditions

Only a fraction of people exposed to trauma develop chronic, trauma-related

symptoms (Hezel et al., 2012). Moreover, while one person could develop
posttraumatic stress disorder (PTSD) after one trauma event, another may
endure several severe traumatic stressors without long-term repercussions
(Johnson & Thompson, 2008). Distress intolerance may be one factor to help
explain these holes in the dose-response theory of trauma and PTSD (Ozer &
Weiss, 2004).
Research links distress intolerance with risk for developing PTSD symp-
toms after trauma exposure. The severity of PTSD symptoms relates to both
self-reported (Vujanovic, Rathnayaka, Amador, & Schmitz, 2016) and behav-
iorally measured (Vujanovic, Dutcher, & Berenz, 2017) distress intolerance,
particularly when coupled with intense negative emotion (Vujanovic et al.,
2013). Distress intolerance predicts greater avoidance of trauma triggers and
emotions, increased involuntary trauma reexperiencing, and nervous system
hyperarousal (Vujanovic, Bernstein, & Litz, 2011). The link between distress
 Distress Intolerance 109

intolerance and PTSD remains robust when researchers account for variables
known to relate to PTSD, such as number of traumas, neuroticism, sex, and sub-
stance use (Marshall-Berenz, Vujanovic, Bonn-Miller, Bernstein, & Zvolensky,
2010; Vujanovic, Bonn-Miller, Potter, Marshall, & Zvolensky, 2011).
Distress intolerance stands to amplify the posttraumatic stress response at
various stages in the development of PTSD symptoms and may also contribute
to the maintenance of the disorder. Individuals with distress intolerance dis-
play greater reactivity during a traumatic event, as well as an attentional bias
toward trauma-related threats after the experience, which magnifies the emo-
tional toll of coping with trauma (Marshall-Berenz et al., 2010). Distress intol-
erance may also influence the manner in which a traumatic memory is formed.
Research suggests that shallow encoding of the trauma in memory may engen-
der risk for PTSD, as this could influence both the unwanted reexperiencing of
the trauma and poor intentional recall of the trauma seen in PTSD (Ehlers &
Clark, 2000). Given their greater unwillingness to withstand negative emotion,
distress intolerant individuals could be more susceptible to processing and
storing information in a manner that increases PTSD risk. Moreover, distress
intolerance might increase as a result of trauma exposure (Foa & Kozak, 1986),
which could further exacerbate or maintain PTSD.
Clinically, distress intolerance contributes to high-risk behaviors in patients
with PTSD. Perceiving their ability to cope with trauma-related distress as
low (Ehlers & Clark, 2000), distress intolerant patients may turn to marijuana
(Potter, Vujanovic, Marshall-Berenz, Bernstein, & Bonn-Miller, 2011) and
alcohol (Vujanovic, Marshall-Berenz, & Zvolensky, 2011) to cope with PTSD
symptoms and negative affect. For these reasons, as well as the cognitive and
emotional burden of constantly attempting to overregulate negative emotion
(Vujanovic, Bernstein, et al., 2011), distress intolerance complicates trauma treat-
ment. Distress intolerant patients may display minimal symptom improve-
ment, which likely reflects reliance on safety behaviors or other avoidance
during exposures. Thus, the efficacy of exposures may depend on increasing
willingness to approach feared situations. Underscoring this idea, studies
suggest that successful treatment of PTSD with exposure therapy hinges on
reductions in perceived distress (Bluett, Zoellner, & Feeny, 2014), which
likely correspond to increases in distress tolerance.

CONCLUSION

Defined as the inability to withstand a negative emotional state, distress intol-

erance is a type of poor emotion regulation that appears to influence a range
of psychopathological symptoms. Though traditionally linked to borderline
personality disorder, distress intolerance has been empirically connected to
anxiety, OC, and trauma-related disorders, as well as symptoms of depressive,
alcohol/substance use, and eating disorders. Across these syndromes, distress
intolerance can influence a person’s appraisal of a stressful stimulus, perceived
110 Stamatis, Hudiburgh, and Timpano

ability to tolerate resulting distress, and behavioral coping response. Though

distress intolerance in itself may present a risk factor for psychopathology, it
also works synergistically with other cognitive and emotional tolerance factors
to increase risk for psychopathology.
In this chapter, and in line with the majority of research on the topic, we
have focused our discussion on distress intolerance as a predictor of psycho­
pathology; however, tolerance of distress is not unilaterally desirable. In fact,
distress awareness is key to survival and general functioning, as healthy distress
tolerance involves awareness of one’s own emotions, urges, and sensations
(Lynch & Mizon, 2011). Nevertheless, distress intolerance remains a promising
avenue for continued research on models of psychopathology, as well as an
emerging treatment target in cognitive behavior therapy for a variety of
psycho­logical conditions, as well as other empirically supported therapies—
namely, acceptance and commitment therapy and dialectical behavior therapy.

REFERENCES
Abrantes, A. M., Strong, D. R., Lejuez, C. W., Kahler, C. W., Carpenter, L. L., Price,
L. H., . . . Brown, R. A. (2008). The role of negative affect in risk for early lapse
among low distress tolerance smokers. Addictive Behaviors, 33, 1394–1401. http://
dx.doi.org/10.1016/j.addbeh.2008.06.018
Allan, N. P., Macatee, R. J., Norr, A. M., Raines, A. M., & Schmidt, N. B. (2015). Rela-
tions between common and specific factors of anxiety sensitivity and distress toler-
ance and fear, distress, and alcohol and substance use disorders. Journal of Anxiety
Disorders, 33, 81–89. http://dx.doi.org/10.1016/j.janxdis.2015.05.002
Ameral, V., Palm Reed, K. M., Cameron, A., & Armstrong, J. L. (2014). What are mea-
sures of distress tolerance really capturing? A mixed methods analysis. Psychology of
Consciousness, 1, 357–369. http://dx.doi.org/10.1037/cns0000024
Banducci, A. N., Lejuez, C. W., Dougherty, L. R., & MacPherson, L. (2017). A prospec-
tive examination of the relations between emotional abuse and anxiety: Modera-
tion by distress tolerance. Prevention Science, 18, 20–30. http://dx.doi.org/10.1007/
s11121-016-0691-y
Bardeen, J. R., Fergus, T. A., & Orcutt, H. K. (2013). Testing a hierarchical model of
distress tolerance. Journal of Psychopathology and Behavioral Assessment, 35, 495–505.
http://dx.doi.org/10.1007/s10862-013-9359-0
Bardeen, J. R., Tull, M. T., Dixon-Gordon, K. L., Stevens, E. N., & Gratz, K. L. (2015).
Attentional control as a moderator of the relationship between difficulties accessing
effective emotion regulation strategies and distress tolerance. Journal of Psychopathology
and Behavioral Assessment, 37, 79–84. http://dx.doi.org/10.1007/s10862-014-9433-2
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. New York, NY: Guilford
Press.
Bernstein, A., Marshall, E. C., & Zvolensky, M. J. (2011). Multi-method evaluation of
distress tolerance measures and construct(s): Concurrent relations to mood and
anxiety psychopathology and quality of life. Journal of Experimental Psychopathology,
2, 386–399. http://dx.doi.org/10.5127/jep.006610
Bernstein, A., Zvolensky, M. J., Vujanovic, A. A., & Moos, R. (2009). Integrating anxi-
ety sensitivity, distress tolerance, and discomfort intolerance: A hierarchical model
of affect sensitivity and tolerance. Behavior Therapy, 40, 291–301. http://dx.doi.org/
10.1016/j.beth.2008.08.001
Blalock, J. A., & Joiner, T. E., Jr. (2000). Interaction of cognitive avoidance coping and
stress in predicting depression/anxiety. Cognitive Therapy and Research, 24, 47–65.
http://dx.doi.org/10.1023/A:1005450908245
 Distress Intolerance 111

Bluett, E. J., Zoellner, L. A., & Feeny, N. C. (2014). Does change in distress matter?
Mechanisms of change in prolonged exposure for PTSD. Journal of Behavior Therapy
and Experimental Psychiatry, 45, 97–104. http://dx.doi.org/10.1016/j.jbtep.2013.09.003
Borkovec, T. D. (1979). Extensions of two-factor theory: Cognitive avoidance and
autonomic perception. In N. Birbaumer & H. D. Kimmel (Eds.), Biofeedback and
self-regulation (pp. 139–148). Hillsdale, NJ: Erlbaum.
Brown, R. A., Lejuez, C. W., Kahler, C. W., & Strong, D. R. (2002). Distress tolerance
and duration of past smoking cessation attempts. Journal of Abnormal Psychology,
111, 180–185. http://dx.doi.org/10.1037/0021-843X.111.1.180
Buckner, J. D., Keough, M. E., & Schmidt, N. B. (2007). Problematic alcohol and
cannabis use among young adults: The roles of depression and discomfort and
distress tolerance. Addictive Behaviors, 32, 1957–1963. http://dx.doi.org/10.1016/
j.addbeh.2006.12.019
Buhr, K., & Dugas, M. J. (2006). Investigating the construct validity of intolerance of
uncertainty and its unique relationship with worry. Journal of Anxiety Disorders, 20,
222–236. http://dx.doi.org/10.1016/j.janxdis.2004.12.004
Cougle, J. R., Timpano, K. R., Fitch, K. E., & Hawkins, K. A. (2011). Distress tolerance
and obsessions: An integrative analysis. Depression and Anxiety, 28, 906–914. http://
dx.doi.org/10.1002/da.20846
Cougle, J. R., Timpano, K. R., Sarawgi, S., Smith, C. M., & Fitch, K. E. (2013). A multi-
modal investigation of the roles of distress tolerance and emotional reactivity in
obsessive-compulsive symptoms. Anxiety, Stress, and Coping: An International Journal,
26, 478–492. http://dx.doi.org/10.1080/10615806.2012.697156
Cummings, J. R., Bornovalova, M. A., Ojanen, T., Hunt, E., MacPherson, L., & Lejuez, C.
(2013). Time doesn’t change everything: The longitudinal course of distress toler-
ance and its relationship with externalizing and internalizing symptoms during early
adolescence. Journal of Abnormal Child Psychology, 41, 735–748. http://dx.doi.org/
10.1007/s10802-012-9704-x
Daughters, S. B., Reynolds, E. K., MacPherson, L., Kahler, C. W., Danielson, C. K.,
Zvolensky, M., & Lejuez, C. W. (2009). Distress tolerance and early adolescent
externalizing and internalizing symptoms: The moderating role of gender and
ethnicity. Behaviour Research and Therapy, 47, 198–205. http://dx.doi.org/10.1016/
j.brat.2008.12.001
Dugas, M. J., Gosselin, P., & Ladouceur, R. (2001). Intolerance of uncertainty and worry:
Investigating specificity in a nonclinical sample. Cognitive Therapy and Research, 25,
551–558. http://dx.doi.org/10.1023/A:1005553414688
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress dis­
order. Behaviour Research and Therapy, 38, 319–345. http://dx.doi.org/10.1016/
S0005-7967(99)00123-0
Eisenberger, R., & Leonard, J. M. (1980). Effects of conceptual task difficulty on gener-
alized persistence. The American Journal of Psychology, 93, 285–298. http://dx.doi.org/
10.2307/1422233
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to cor-
rective information. Psychological Bulletin, 99, 20–35. http://dx.doi.org/10.1037/
0033-2909.99.1.20
Geisser, M. E., Robinson, M. E., & Pickren, W. E. (1992). Differences in cognitive coping
strategies among pain-sensitive and pain-tolerant individuals on the cold-pressor
test. Behavior Therapy, 23, 31–41. http://dx.doi.org/10.1016/S0005-7894(05)80306-5
Glassman, L. H., Martin, L. M., Bradley, L. E., Ibrahim, A., Goldstein, S. P., Forman,
E. M., & Herbert, J. D. (2016). A brief report on the assessment of distress toler-
ance: Are we measuring the same construct? Journal of Rational-Emotive & Cognitive-
Behavior Therapy, 34, 87–99. http://dx.doi.org/10.1007/s10942-015-0224-9
Gronwall, D. M., & Sampson, H. (1974). The psychological effects of concussion. Oxford,
England: Auckland University Press.
112 Stamatis, Hudiburgh, and Timpano

Harrington, N. (2005). The Frustration Discomfort Scale: Development and psycho-

metric properties. Clinical Psychology & Psychotherapy, 12, 374–387. http://dx.doi.org/
10.1002/cpp.465
Harrington, N. (2006). Frustration intolerance beliefs: Their relationship with depres-
sion, anxiety, and anger, in a clinical population. Cognitive Therapy and Research, 30,
699–709. http://dx.doi.org/10.1007/s10608-006-9061-6
Hasan, N. S., Babson, K. A., Banducci, A. N., & Bonn-Miller, M. O. (2015). The pro-
spective effects of perceived and laboratory indices of distress tolerance on cannabis
use following a self-guided quit attempt. Psychology of Addictive Behaviors, 29, 933–940.
http://dx.doi.org/10.1037/adb0000132
Herman, J. L., Stevens, M. J., Bird, A., Mendenhall, M., & Oddou, G. (2010). The
Tolerance for Ambiguity Scale: Towards a more refined measure for international
management research. International Journal of Intercultural Relations, 34, 58–65.
http://dx.doi.org/10.1016/j.ijintrel.2009.09.004
Hezel, D. M., Riemann, B. C., & McNally, R. J. (2012). Emotional distress and pain tol-
erance in obsessive–compulsive disorder. Journal of Behavior Therapy and Experimen-
tal Psychiatry, 43, 981–987. http://dx.doi.org/10.1016/j.jbtep.2012.03.005
Holaway, R. M., Heimberg, R. G., & Coles, M. E. (2006). A comparison of intolerance
of uncertainty in analogue obsessive-compulsive disorder and generalized anxiety
disorder. Journal of Anxiety Disorders, 20, 158–174. http://dx.doi.org/10.1016/
j.janxdis.2005.01.002
Johnson, H., & Thompson, A. (2008). The development and maintenance of post-
traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and tor-
ture: A review. Clinical Psychology Review, 28, 36–47. http://dx.doi.org/10.1016/
j.cpr.2007.01.017
Keough, M. E., Riccardi, C. J., Timpano, K. R., Mitchell, M. A., & Schmidt, N. B. (2010).
Anxiety symptomatology: The association with distress tolerance and anxiety sensi-
tivity. Behavior Therapy, 41, 567–574. http://dx.doi.org/10.1016/j.beth.2010.04.002
Korte, K. J., Unruh, A. S., Oglesby, M. E., & Schmidt, N. B. (2015). Safety aid use and
social anxiety symptoms: The mediating role of perceived control. Psychiatry
Research, 228, 510–515. http://dx.doi.org/10.1016/j.psychres.2015.06.006
Kraemer, K. M., Luberto, C. M., & McLeish, A. C. (2013). The moderating role of dis­
tress tolerance in the association between anxiety sensitivity physical concerns and
panic and PTSD-related re-experiencing symptoms. Anxiety, Stress, and Coping: An
Inter­national Journal, 26, 330–342. http://dx.doi.org/10.1080/10615806.2012.693604
Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psycho-
pathological symptoms and disorders: A review of the empirical literature among
adults. Psychological Bulletin, 136, 576–600. http://dx.doi.org/10.1037/a0019712
Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics
and functions of non-suicidal self-injury in a community sample of adolescents. Psy-
chological Medicine, 37, 1183–1192. http://dx.doi.org/10.1017/S003329170700027X
Lynch, T. R., & Mizon, G. A. (2011). Distress overtolerance and distress intolerance: A
behavioral perspective. In M. Zvolensky, A. Bernstein, & A. A. Vujanovic (Eds.),
Distress tolerance: Theory, research, and clinical applications (pp. 552–79). New York, NY:
Guilford Press.
Macatee, R. J., Capron, D. W., Guthrie, W., Schmidt, N. B., & Cougle, J. R. (2015). Dis-
tress tolerance and pathological worry: Tests of incremental and prospective relation-
ships. Behavior Therapy, 46, 449–462. http://dx.doi.org/10.1016/j.beth.2015.03.003
Macatee, R. J., Capron, D. W., Schmidt, N. B., & Cougle, J. R. (2013). An examination of
low distress tolerance and life stressors as factors underlying obsessions. Journal of Psy-
chiatric Research, 47, 1462–1468. http://dx.doi.org/10.1016/j.jpsychires.2013.06.019
Marshall, E. C., Zvolensky, M. J., Vujanovic, A. A., Gregor, K., Gibson, L. E., & Leyro,
T. M. (2008). Panic reactivity to voluntary hyperventilation challenge predicts dis-
tress tolerance to bodily sensations among daily cigarette smokers. Experimental and
Clinical Psychopharmacology, 16, 313–321. http://dx.doi.org/10.1037/a0012752
 Distress Intolerance 113

Marshall-Berenz, E. C., Vujanovic, A. A., Bonn-Miller, M. O., Bernstein, A., &

Zvolensky, M. J. (2010). Multimethod study of distress tolerance and PTSD symp-
tom severity in a trauma-exposed community sample. Journal of Traumatic Stress, 23,
623–630. http://dx.doi.org/10.1002/jts.20568
Matthews, K. A., & Stoney, C. M. (1988). Influences of sex and age on cardiovascular
responses during stress. Psychosomatic Medicine, 50, 46–56. http://dx.doi.org/10.1097/
00006842-198801000-00006
McHugh, R. K., Daughters, S. B., Lejuez, C. W., Murray, H. W., Hearon, B. A., Gorka,
S. M., & Otto, M. W. (2011). Shared variance among self-report and behavioral
measures of distress intolerance. Cognitive Therapy and Research, 35, 266–275. http://
dx.doi.org/10.1007/s10608-010-9295-1
McHugh, R. K., Hearon, B. A., Halperin, D. M., & Otto, M. W. (2011). A novel method
for assessing distress intolerance: Adaptation of a measure of willingness to pay. Jour-
nal of Behavior Therapy and Experimental Psychiatry, 42, 440–446. http://dx.doi.org/
10.1016/j.jbtep.2011.04.003
McHugh, R. K., & Otto, M. W. (2011). Domain-general and domain-specific strategies for
the assessment of distress intolerance. Psychology of Addictive Behaviors, 25, 745–749.
http://dx.doi.org/10.1037/a0025094
McHugh, R. K., & Otto, M. W. (2012). Refining the measurement of distress intoler-
ance. Behavior Therapy, 43, 641–651. http://dx.doi.org/10.1016/j.beth.2011.12.001
McLain, D. L. (1993). The MSTAT-I: A new measure of an individual’s tolerance for
ambiguity. Educational and Psychological Measurement, 53, 183–189. http://dx.doi.org/
10.1177/0013164493053001020
Michel, N. M., Rowa, K., Young, L., & McCabe, R. E. (2016). Emotional distress tolerance
across anxiety disorders. Journal of Anxiety Disorders, 40, 94–103. http://dx.doi.org/
10.1016/j.janxdis.2016.04.009
Norr, A. M., Oglesby, M. E., Capron, D. W., Raines, A. M., Korte, K. J., & Schmidt,
N. B. (2013). Evaluating the unique contribution of intolerance of uncertainty rel-
ative to other cognitive vulnerability factors in anxiety psychopathology. Journal of
Affective Disorders, 151, 136–142. http://dx.doi.org/10.1016/j.jad.2013.05.063
Ozer, E. J., & Weiss, D. S. (2004). Who develops posttraumatic stress disorder? Cur-
rent Directions in Psychological Science, 13, 169–172. http://dx.doi.org/10.1111/
j.0963-7214.2004.00300.x
Potter, C. M., Vujanovic, A. A., Marshall-Berenz, E. C., Bernstein, A., & Bonn-Miller,
M. O. (2011). Posttraumatic stress and marijuana use coping motives: The mediating
role of distress tolerance. Journal of Anxiety Disorders, 25, 437–443. http://dx.doi.org/
10.1016/j.janxdis.2010.11.007
Powers, M. B., Smits, J. A., & Telch, M. J. (2004). Disentangling the effects of safety-
behavior utilization and safety-behavior availability during exposure-based treat-
ment: A placebo-controlled trial. Journal of Consulting and Clinical Psychology, 72,
448–454. http://dx.doi.org/10.1037/0022-006X.72.3.448
Quinn, E. P., Brandon, T. H., & Copeland, A. L. (1996). Is task persistence related to
smoking and substance abuse? The application of learned industriousness theory
to addictive behaviors. Experimental and Clinical Psychopharmacology, 4, 186–190.
http://dx.doi.org/10.1037/1064-1297.4.2.186
Schmidt, N., Mitchell, M., Keough, M., & Riccardi, C. (2011). Anxiety and its disorders.
In M. Zvolensky, A. Bernstein, & A. A. Vujanovic (Eds.), Distress tolerance: Theory,
research, and clinical applications (pp. 105–125). New York, NY: Guilford Press.
Schmidt, N. B., Richey, J. A., & Fitzpatrick, K. K. (2006). Discomfort intolerance: Devel-
opment of a construct and measure relevant to panic disorder. Journal of Anxiety
Disorders, 20, 263–280. http://dx.doi.org/10.1016/j.janxdis.2005.02.002
Simons, J. S., & Gaher, R. M. (2005). The Distress Tolerance Scale: Development and
validation of a self-report measure. Motivation and Emotion, 29, 83–102. http://
dx.doi.org/10.1007/s11031-005-7955-3
114 Stamatis, Hudiburgh, and Timpano

Taylor, S., Koch, W. J., & McNally, R. J. (1992). How does anxiety sensitivity vary across
the anxiety disorders? Journal of Anxiety Disorders, 6, 249–259. http://dx.doi.org/
10.1016/0887-6185(92)90037-8
Timpano, K. R., Buckner, J. D., Richey, J. A., Murphy, D. L., & Schmidt, N. B. (2009).
Exploration of anxiety sensitivity and distress tolerance as vulnerability factors for
hoarding behaviors. Depression and Anxiety, 26, 343–353. http://dx.doi.org/10.1002/
da.20469
Timpano, K. R., Shaw, A. M., Cougle, J. R., & Fitch, K. E. (2014). A multifaceted
assessment of emotional tolerance and intensity in hoarding. Behavior Therapy, 45,
690–699. http://dx.doi.org/10.1016/j.beth.2014.04.002
Trafton, J. A., & Gifford, E. V. (2011). Biological bases of distress tolerance. In
M. Zvolensky, A. Bernstein, & A. A. Vujanovic (Eds.), Distress tolerance: Theory,
research, and clinical applications (pp. 80–104). New York, NY: Guilford Press.
Vinci, C., Mota, N., Berenz, E., & Connolly, K. (2016). Examination of the relationship
between PTSD and distress tolerance in a sample of male veterans with comorbid
substance use disorders. Military Psychology, 28, 104–114. http://dx.doi.org/10.1037/
mil0000100
Vujanovic, A. A., Bernstein, A., & Litz, B. (2011). Traumatic stress. In M. Zvolensky, A.
Bernstein, & A. A. Vujanovic (Eds.), Distress tolerance: Theory, research, and clinical
applications (pp. 126–148). New York, NY: Guilford Press.
Vujanovic, A. A., Bonn-Miller, M. O., Potter, C. M., Marshall, E. C., & Zvolensky, M. J.
(2011). An evaluation of the relation between distress tolerance and posttraumatic
stress within a trauma-exposed sample. Journal of Psychopathology and Behavioral
Assessment, 33, 129–135. http://dx.doi.org/10.1007/s10862-010-9209-2
Vujanovic, A. A., Dutcher, C. D., & Berenz, E. C. (2017). Multimodal examination of
distress tolerance and posttraumatic stress disorder symptoms in acute-care psychi-
atric inpatients. Journal of Anxiety Disorders, 48, 45–53. http://dx.doi.org/10.1016/
j.janxdis.2016.08.005
Vujanovic, A. A., Hart, A. S., Potter, C. M., Berenz, E. C., Niles, B., & Bernstein, A.
(2013). Main and interactive effects of distress tolerance and negative affect inten-
sity in relation to PTSD Symptoms among trauma-exposed adults. Journal of Psy­
chopathology and Behavioral Assessment, 35, 235–243. http://dx.doi.org/10.1007/
s10862-012-9325-2
Vujanovic, A. A., Marshall-Berenz, E. C., & Zvolensky, M. J. (2011). Posttraumatic
stress and alcohol use motives: A test of the incremental and mediating role of dis-
tress tolerance. Journal of Cognitive Psychotherapy, 25, 130–141. http://dx.doi.org/
10.1891/0889-8391.25.2.130
Vujanovic, A. A., Rathnayaka, N., Amador, C. D., & Schmitz, J. M. (2016). Distress tol-
erance: Associations with posttraumatic stress disorder symptoms among trauma-
exposed, cocaine-dependent adults. Behavior Modification, 40, 120–143. http://
dx.doi.org/10.1177/0145445515621490
Wolitzky-Taylor, K., Guillot, C. R., Pang, R. D., Kirkpatrick, M. G., Zvolensky, M. J.,
Buckner, J. D., & Leventhal, A. M. (2015). Examination of anxiety sensitivity and
distress tolerance as transdiagnostic mechanisms linking multiple anxiety patholo-
gies to alcohol use problems in adolescents. Alcoholism: Clinical and Experimental
Research, 39, 532–539. http://dx.doi.org/10.1111/acer.12638
Zvolensky, M. J., Leyro, T. M., Bernstein, A., & Vujanovic, A. A. (2011). Historical
perspectives, theory, and measurement of distress tolerance. In M. Zvolensky,
A. Bernstein, & A. A. Vujanovic (Eds.), Distress tolerance: Theory, research, and clinical
applications (pp. 3–27). New York, NY: Guilford Press.
Zvolensky, M. J., Vujanovic, A. A., Bernstein, A., & Leyro, T. (2010). Distress tolerance:
Theory, measurement, and relations to psychopathology. Current Directions in Psycho-
logical Science, 19, 406–410. http://dx.doi.org/10.1177/0963721410388642
7
Experiential Avoidance
Sarah A. Hayes-Skelton and Elizabeth H. Eustis

May is a 30-year-old Asian American cisgender woman who identifies as queer.

She currently works at a local hospital, but she dreams of becoming involved in
LGBTQ+ advocacy work in her community. There is a local group that is often
looking for volunteers to work with LGBTQ+ youth in the community, but May
hasn’t been able to participate yet because of the distress about her anxiety.
Recently, she again attempted to attend an event with this LGBTQ+ outreach
group. She felt anxious walking there and had thoughts like “What if no one talks
to me?” and “My family wouldn’t be supportive of this.” These thoughts were
followed by an increased heart rate and sweaty palms. May desperately wanted
to make these thoughts and physical sensations go away. She tried to make them
stop, but they only seemed to become more intense the more she fought them.
She tried to make her mind go blank, with no luck. In fact, she started feeling
more upset and even started remembering past times when she experienced
intense anxiety. When she was growing up, members of May’s immediate family
conveyed messages to her that emotions were “bad” and should not be
expressed. These messages were consistent with her family’s cultural background
and did not seem to cause her parents (who immigrated to the United States
from China) distress, but May now finds that when she feels a strong emotion,
like anxiety, it makes her very uncomfortable, and she tries to get rid of it imme-
diately. In her attempt to attend the event, she thought: “If only I wasn’t anxious,
I could go to the meeting and be how I want to be. What’s wrong with me that I
can’t even get myself to go to a simple meeting?” Instead, she turned around and
went home to escape the distress she was experiencing.1

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-007
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
115
116 Hayes-Skelton and Eustis

If we examine May’s cycle of anxiety, we can see that it is not just her
experiences of anxiety that cause her distress and constrict her behavior;
rather, her attempts to control her internal experiences (e.g., thoughts, emo-
tions, physiological sensations, memories) seem to exacerbate her distress
and further limit her behavior, while also making her feel like she cannot
change her life until her anxiety goes away. In May’s desperate attempt to
make her anxious thoughts and physical sensations stop, she likely notices
the ways that she is unable to do so, making her more upset with herself and
leading her to feel more out of control, and thus further increasing her anxiety.
For May, it is the additional anxiety, anger, and frustration at not being able
to stop her anxiety that ultimately contributes to her avoiding the event. It is
this unwillingness to remain in contact with distressing internal experiences
along with the attempts to control or avoid these experiences regardless of
consequences that is referred to as experiential avoidance (EA; Hayes, Wilson,
Gifford, Follette, & Strosahl, 1996).
Of note, avoidance of distressing internal experiences can be an effective
emotion regulation strategy when used flexibly and with intention. In fact,
there are times when we all choose to avoid distressing internal experiences
(e.g., workplace, performance situations, situations in which it may be cultur-
ally inconsistent to express emotions). However, when EA becomes habitual,
rigid, and automatic, it tends to cause significant distress and impairment in
people’s lives. This habitual use of EA is more common among those with
clinical levels of anxiety across a range of clinical presentations of anxiety, as
discussed later in this chapter.
There is ongoing discussion about how to best define, measure, and refer
to EA. Often EA is referred to through its opposing process—acceptance, or
allowing internal experiences to come and go without trying to change them.
For example, if a treatment increases acceptance, it decreases EA. Some in the
field have begun to use the term psychological inflexibility in place of EA (Bond
et al., 2011). Psychological inflexibility, which is a broad construct, typically
refers to the six processes that contribute to psychopathology in the accep-
tance and commitment therapy model (see Chapter 18). In addition to EA,
the other five processes include (a) cognitive fusion2 or seeing thoughts as
the truth or facts; (b) dominance of conceptualized past and future or focus-
ing attention on the past or future instead of the present; (c) attachment to
the conceptualized self or the labels that we have of ourselves; (d) lack of
values clarity or difficulty recognizing what is important or fulfilling in life;
and (e) unworkable action or behaviors, including impulsive, reactive, or
habitual responses (Hayes, Strosahl, & Wilson, 2012). Psychological flexibility
typically refers to processes that are in opposition to psychological inflexibil-
ity. Therefore, there is currently some inconsistency in the usage of the
terms EA, acceptance, and psychological inflexibility/psychological flexibil-
ity (see Bond et al., 2011; Hayes et al., 2012).

2
Fusion refers to the process of believing that a thought is an accurate depiction of
reality.
 Experiential Avoidance 117

CONCEPTUAL IMPLICATIONS

An Acceptance-Based Behavioral Model of Anxiety

According to an acceptance-based behavioral model of anxiety (Roemer &

Orsillo, 2014), anxiety is characterized by a fused, narrowed, reactive, and
judgmental relationship with internal experiences along with the strong
desire to not have the anxious experiences (EA), which only serves to
increase the problematic relationship with the anxious experiences. As a
result of this cycle of EA and the fused, judgmental relationship with inter-
nal experiences, it is natural to then avoid future situations and limit expe-
riences that will increase anxiety. In other words, anxiety is maintained by
(a) a problematic fused relationship with internal experiences, (b) EA, and
(c) behavioral constriction and avoidance. For May, her beliefs that anxiety
is “bad” and that it makes one “weak” may lead her to a fused identification
with those experiences in which she identifies anxiety, and therefore her-
self, as bad and weak, which can contribute to engaging in EA rigidly.
When anxiety is experienced as a negative indication of self-worth, it is
only natural to want to avoid the internal experiences that have become signs
of anxiety. However, when individuals try to push away the internal experi-
ences that fuel anxiety, they are often unable to do so, which only serves to
increase the fusion and self-judgment about their inability to rid themselves
of anxiety.
We can see how May’s strong desire to make her mind go blank paradoxi-
cally results in her anxiety becoming stronger. This is likely because her
inability to make her anxiety go away makes her more judgmental and reac-
tive to her thoughts about not being able to go to the event because of her
anxiety. She may say to herself things like “What is wrong with me that
I can’t even go to this event? I just need to force myself to not be anxious.”
However, these thoughts likely lead to more physiological arousal, which
likely makes the thoughts more fused and judgmental, continuing the cycle
of EA and the problematic relationship with her internal experiences. For
example, she may experience thoughts such as, “Look at me, I can’t even
make my own body calm down, how could I ever think that I could be
a leader.” As a result, May avoids going to the event, which reduces her
anxiety; however, it also leads to additional negative thoughts about her
inability to control her anxiety. As can be seen in this example, the cycle of
anxiety is fueled not by the anxious experiences themselves, but by May’s
efforts to deny and avoid the anxiety, which ultimately fail, making her feel
worse about herself, and increasing her anxiety further.
While this model was originally developed specifically for generalized
anxiety disorder, it is broadly applicable to anxiety in general and is consis-
tent with a transdiagnostic approach to anxiety. Following are further
descriptions of how negative, judgmental thoughts, failed attempts at sup-
pression of anxiety, and the consequences of avoidance further strengthen
and maintain EA.
118 Hayes-Skelton and Eustis

Role of Negative, Judgmental Thoughts

Anxiety is an adaptive response to a potentially dangerous situation. There-

fore, it is natural to experience physiological sensations in response to an
actual or anticipated anxiety-provoking situation, such as the increased
heart rate and sweaty palms that May experienced when thinking about
attending the advocacy event. While these responses are often adaptive, they
can become problematic when the individual rigidly reacts to them with
judgment. It is not the thoughts, feelings, or sensations that are problematic,
but the response to them that exacerbates anxiety. In other words, these
entangled (Germer, 2005), “hooked” (Chodron, 2007), or fused (Herzberg
et al., 2012) relationships with our experiences lead to stronger desires to
engage in EA.
Similarly, EA can develop from labeling emotional experiences as “nega-
tive” or “bad,” which can understandably lead people to try to avoid their
internal experiences. We are socialized in societies that often model and
praise the suppression of emotions (e.g., children being told to stop crying), of
course this varies based on familial culture. Given our use of language (see
relational frame theory; Hayes et al., 2012), if we label certain experiences as
“bad,” even thinking about the experience can cause distress and lead to EA.
However, it is also important to acknowledge that this avoidance is only prob-
lematic if it causes the individual significant distress and/or has behavioral
consequences. Therefore, for some individuals across diverse cultures, sup-
pression of emotions can also be adaptive in certain contexts.

Role of Failed Suppression and Control

One of the challenges around trying to control anxiety is that often our
attempts at control work and are helpful, at least in the short term. However,
once someone begins trying to control internal experiences and is unable to
do so, a vicious loop can develop in which the inability to control internal
experiences is judged as “bad.” For example, May looks at other people in her
community and other people who identified as queer and looks up to their
ability to work for change, but she also uses this information to criticize her-
self even further by thinking, “What’s wrong with me that I can’t get over my
anxiety while other people can?” In this way, her response is making the
anxiety stronger and therefore also increasing the desire to engage in EA.
It is common for people to try many different ways to control their anxiety,
even when they are not successful. Some common examples are attempts to
clear the mind and not think of anything, as well as to limit behavior that
may cause anxiety (e.g., not engaging in social interactions, not applying for
jobs). One of the challenges with trying to limit behavior in this way is that
there is always some possibility that a situation may cause anxiety or some-
thing stressful may occur (e.g., “what if”), so it is possible to fear and attempt
to avoid any and all situations. We know from the thought suppression liter-
ature (Purdon, 1999; Wegner, Schneider, Carter, & White, 1987) that the
 Experiential Avoidance 119

more effort one makes to push away an internal experience, the stronger it
returns (see Campbell-Sills, Barlow, Brown, & Hofmann, 2006; Roemer &
Borkovec, 1994). People may also use a range of substances (e.g., alcohol) or
risky behaviors (e.g., self-harm, risky sex) to try to avoid their internal expe-
riences and shift their attention to something else. While these strategies may
feel effective in the short term, they tend to have long-term consequences.

Consequences of Avoidance

EA can have many consequences, including increased distress and behavioral

consequences. When situations are perceived as leading to troubling internal
experiences and subsequent EA, then it is only natural that individuals will
avoid those situations. Individuals with anxiety often constrict their lives in
an effort to avoid these experiences. In the case of May, we see that she des-
perately wants to be involved in her community; however, she has been
unable to attend events and thinks she must control her anxiety before she
can become more involved. Given that she may not master this level of con-
trol over her anxiety, she will likely never get involved unless and until she is
willing to accept that she will have some anxiety, at least in the beginning.
Rigid use of EA can also negatively impact relationships, given that people
may spend a significant amount of time trying to control their internal expe-
riences and/or distract from them, which makes it difficult to engage in the
present moment and with the people around them. For example, May often
finds herself caught up in trying to feel less anxious while eating dinner with
her family. This often means that she misses part of the conversation and
seems distracted. When her family members ask her if she is okay, she feels
bad and is not sure what to say. Her anxiety increases as her family’s reactions
cause her to increase her judgments about her own anxiety and, thus, her
desire to avoid and suppress her anxiety, continuing the EA loop.

ASSESSMENT

Because EA is habitual and can feel automatic, some patients may be unaware
of their use of EA and how it contributes to and maintains their anxiety.
Instead, patients may describe their anxiety as the “problem” and may identify
that everything would be better if only they could get rid of their anxiety. To
assess EA, we recommend that clinicians discuss and assess for EA during the
clinical interview and throughout sessions, incorporate experiential practices
in session, and use self-report measures.

Clinical Interview

Experiential avoidance can be assessed in multiple ways, including through

the clinical interview. Right from the beginning, patients often express EA in
120 Hayes-Skelton and Eustis

response to questions about why they are seeking treatment (e.g., “I just
want to make my anxiety go away,” “I want a magic pill so I never have to
feel anxious ever again”). Similarly, when asking about what they are avoid-
ing, patients with heightened EA may describe behavioral avoidance due to
their anxiety. For example, patients high in EA often use anxiety as an expla-
nation for why they did not do something that is important to them (e.g.,
“I can’t do X because it will make me anxious”). In these conversations, it is
helpful to assess whether it is the avoidance of anxiety (EA) that is the direct
cause of the behavioral avoidance or if there are other factors also impacting
behavior.
Patients who are engaging in EA may be less aware of their emotions and
other internal experiences and may have a harder time identifying emotions,
thoughts, and physiological sensations. Therefore, it may be helpful to ask
questions like

• What happens when you start to feel anxious?

• What thoughts, emotions, action urges do you notice next? Do you try to
make sensations go away? What happens when you try to do that?
• Are there things you don’t do because doing them would make you feel
anxious? What are those things?

Assessment of EA occurs both during an initial assessment and throughout

treatment, as it can take a while for patients and therapists to recognize the
ways that EA is influencing anxiety. Often EA comes up in the context of
discussing suppression and asking the patient about their own experiences
with attempts to control (e.g., “What happens when you try to control or
avoid your anxiety?”). Asking questions like this can help therapists under-
stand the specific ways that EA may be influencing anxiety.
It is always important to consider the patient’s cultural background and how
different aspects of identity may influence the messages they have received
about emotions, and how they respond to their emotions. While much
research has demonstrated negative mental health outcomes related to EA
in the United States and Europe, some research conducted in China has
demonstrated that EA was not significantly associated with mental health con-
sequences (Soto, Perez, Kim, Lee, & Minnick, 2011), suggesting that cultural
context needs to be considered. Clinicians can ask about the patient’s cultural
background and the messages they received about emotions growing up from
family members, friends, and their broader cultural communities. Clinicians
can also ask the patient whether they feel like their use of EA is helpful. If some-
one thinks that it is not harmful, the therapist should further consider the
possibility that, in the patient’s specific context, EA may not be problematic.
Patients from diverse cultural backgrounds may also report that their family
members (or others with the same background) seem to use EA without nega-
tive consequences, but that they experience consequences with their own use of
EA. This can be a challenge for patients and add another layer of self-judgment
as they attempt to navigate different cultural messages about emotions and
make decisions about what is helpful for them in different contexts.
 Experiential Avoidance 121

Experiential Practices

There are also a number of experiential practices that can be used either as an
intervention or as an assessment. As an assessment, these exercises can be
particularly helpful to further illustrate what is meant by EA, which can be a
difficult construct to explain. These exercises can be useful as another method
for having patients talk about their experiences with EA and to illustrate the
problems with trying to control or suppress internal experiences. The classical
example is Wegner’s white bear exercise (Wegner et al., 1987), in which one
is asked to think about anything as long as it is not a white bear. However, the
majority of people do end up thinking about white bears despite efforts to
suppress this thought. This exercise, or a similar one (e.g., don’t think of jelly
donuts, don’t think of chocolate cake), demonstrates how attempts to control
often fail and actually make the occurrence of the thought (or other internal
experience) stronger. Similarly, the metaphor of “tug of war with a monster”
(Hayes et al., 2012, p. 276) can be another way to demonstrate how letting go
of EA (accepting anxiety) can be an alternate option. This metaphor is partic-
ularly helpful to show that if we are constantly trying to avoid our internal
experiences, we cannot be engaged in the present moment. By asking patients
to describe in what ways they are playing tug of war with their anxiety, the
therapist can further assess what EA looks like for that specific patient.

Self-Report Measures

As noted previously, it may be hard for some patients who engage in EA to

describe their attempts to control their internal experiences, and so it can be
helpful to use validated self-report measures in assessing EA. Historically, EA
has most often been measured by some version of the Acceptance and Action
Questionnaire (AAQ; Bond et al., 2011; Hayes et al., 2004). The original 22-item
AAQ can be scored multiple ways (single-factor 16-item version, two-factor
16-item version, and single-factor 9-item version).3 In response to concerns
about the internal consistency and language of the original version of the
AAQ (Bond et al., 2011; Gámez et al., 2011, 2014; Schmalz & Murrell, 2010),
the AAQ-II4 (Bond et al., 2011) and several other self-report measures were
developed. Please see Table 7.1 for a list of these measures.
Across these self-report measures, some examine EA as a single construct/
factor (e.g., nine-item version of the AAQ), while others examine a multi­
dimensional construct (e.g., the Multidimensional Experiential Avoidance
Questionnaire and the two-factor 16-item version of the AAQ). Most of these
measures are available online or in publications. Some of these measures,

3
Some have begun to refer to the AAQ and the AAQ-II as measures of psychological
flexibility. As previously mentioned, there is ongoing discussion in the field as to how
best define, measure, and differentiate EA and psychological inflexibility.
4
Some research has found the AAQ-II to be more closely associated with general
distress (Wolgast, 2014) or neuroticism and negative affect (Rochefort, Baldwin, &
Chmielewski, 2018) versus acceptance.
122 Hayes-Skelton and Eustis

TABLE 7.1. Self-Report Measures of Experiential Avoidance

Measure Items Source
Acceptance and Action Questionnaire 22a Hayes et al., 2004
Acceptance and Action Questionnaire-2 7 Bond et al., 2011
Social Anxiety—Acceptance and Action 19 MacKenzie and Kocovski, 2010
Questionnaire
Multidimensional Experiential Avoidance 62 Gámez, Chmielewski, Kotov,
Questionnaire Ruggero, and Watson, 2011
The Brief Experiential Avoidance Questionnaire 15 Gámez et al., 2014
The Avoidance and Fusion Questionnaire 17 Schmalz and Murrell, 2010
Note. aDifferent versions of scoring use either 16 or 9 of the 22 items; therefore, items for a specific
version could be selected to decrease the total number of items.

including the AAQ and AAQ-II, have been translated and validated in differ-
ent languages, including Spanish (Barraca Mairal, 2004; Ruiz et al., 2013). A
social anxiety-specific version of the AAQ has also been developed (MacKenzie
& Kocovski, 2010).

CLINICAL IMPLICATIONS

Experiential avoidance is a transdiagnostic process that appears to contribute

to the development and maintenance of anxiety across a range of clinical
presentations (Spinhoven, Drost, de Rooij, van Hemert, & Penninx, 2014).
Next, we present some ways that EA surfaces across fear- and anxiety-related
contexts.

Fear of Negative Evaluations

An individual’s fears and concerns about others’ judgments and evaluations

are central to both social anxiety and body dysmorphic disorder. These fears
can be triggered by actual or imagined social situations where the individual
believes that they are being observed and evaluated. Models of social anxiety
(see Clark & Wells, 1995; Herbert & Cardaciotto, 2005; Rapee & Heimberg,
1997) highlight how individuals with this problem believe there is a per­
formance standard that they are not living up to, and that others are eval­
uating them negatively for this failure. This is coupled with a negative
relationship with internal experiences, where these individuals believe
these negatively biased thoughts to be true and judges themselves for not
being able to perform differently in the situation, drawing their attention
away from the actual situation to focus on negative internal signs of failure
rather than external signs of success (see Chapter 12), which then increases
anxiety and experiential avoidance. This results in increased behavioral
avoidance and reduced opportunities for new learning that social situa-
tions may not be dangerous (see Chapter 2). In fact, research has shown that
 Experiential Avoidance 123

those diagnosed with social anxiety disorder exhibit more EA compared to

those without a diagnosis (Kashdan et al., 2013).
People with fears of negative evaluations, such as May, often become
anxious at the idea that others are noticing and/or judging them. Often these
social anxiety-related fears include concerns about appearing anxious in front
of others due to beliefs that others will judge them for their anxiety or will see
their anxiety as a sign that they are incompetent. For example, given May’s
childhood history of learning that others believe that anxiety is bad, she likely
fears the judgments that will come from others who may notice that she is
anxious. Given the nature of these fears, individuals with fears of negative
evaluations are particularly invested in engaging in EA to avoid appearing
anxious to others. In fact, there is some evidence that individuals with social
anxiety try to suppress their emotions more than others do (Kashdan &
Steger, 2006). However, the failed attempts to control their anxiety, coupled
with an over interpretation of how anxious they are appearing to others,
continues the cycle of anxiety.

Worry

Worry is the cognitive process of future-focused, negative, and often wide-

ranging repeated thought that often leads to anxiety. While worry is most
commonly associated with generalized anxiety disorder, it is a transdiagnostic
process that can occur across anxiety disorders and is also common in those
without diagnosed anxiety (see Chapter 8). Research on the function of worry
shows that worry serves as a distraction from more emotional topics (Borkovec
& Roemer, 1995). From this perspective, worry serves the function of helping
the individual avoid other distressing stimuli and emotions by damping down
physiological arousal. In other words, worry can serve as an EA strategy. It
functions to help individuals avoid the underlying distress. Research has sup-
ported this by showing that excessive worry is associated with EA (Buhr &
Dugas, 2012).
In the case of May, there are many situations that may trigger her worry,
such as the anticipation of going to a volunteer event, considering what her
family and friends may think of her for her involvement in the LGBTQ+ com-
munity, and overheard comments about judging others for expressing their
emotions. These are clearly distressing thoughts to her, particularly as worry
tends to focus on catastrophic outcomes. For example, she may be worried
that her family will disown her or that all of her friends will leave her (with-
out evidence that this will be the case). Given that these catastrophic thoughts
are highly distressing, May will naturally want to avoid the distress. This EA
may include her trying to stop her worry spirals by willing her mind to go
blank. However, we rarely are successful in willing our thoughts to slow
down, and only end up making them stronger, thus providing evidence that
the catastrophic events may occur. Similarly, May’s worry may be covering up
other emotions (e.g., sadness, grief, anger) that she is trying to suppress, as
worry itself can be a form of emotional suppression. It may be that May is
124 Hayes-Skelton and Eustis

feeling sad and angry with herself that she has been unable to engage with
the community in the way she wants. These emotions may be more difficult
for May to express than anxiety and worry are.

Fear of Somatic Cues

Fears of somatic cues occur across a range of clinical presentations of anxiety

(see Chapter 4). These fears can involve concerns that the physical sensa-
tions mean impending death or the presence of a disease such as cancer or
multiple sclerosis; or they can be feared because of the discomfort associated
with the sensations when they occur—in that escape will not be possible; or
they can be feared because of the embarrassment that comes from others
noticing the physical manifestations (e.g., sweating, trembling). In these ways,
when these internal sensations, emotions, and situations that trigger somatic
responses are perceived as threatening, there is a nonacceptance of these
sensations and emotions and a strong desire to change them. Under­lying these
fears is often a sense that this physiological arousal is outside of one’s control
and is unpredictable.
For example, in panic attacks, the fears are often related to the feeling that
panic sensations are coming out of the blue and that the individual is not able
to predict them. In fact, panic disorder is characterized by fear of panic, rather
than actually having a panic attack. Similarly, agoraphobia is often triggered
by the inability to escape the crowd, the elevator, or the movie theater—in
other words, not being in control of the situation. When we feel out of con-
trol, it is natural to want to exert control over whatever we can. Therefore,
there is a natural attempt to try to control the physical sensations, thus engag-
ing in EA. Sometimes these attempts at controlling physical sensations are
successful. For example, sometimes taking slow breaths does slow down heart
rate; however, particularly as anxiety gets high, we are not able to fully con-
trol these sensations. Research has shown that those with a history of uncued
panic attacks report more EA than those without this history (Tull & Roemer,
2007). Similarly, those with clinical levels of health anxiety report more
EA than those with lower levels of health anxiety (Wheaton, Berman, &
Abramowitz, 2010). This may be partially related to the association between
anxiety sensitivity and EA. There is a growing body of research on the associ-
ation between EA and anxiety sensitivity, or the tendency to respond fear-
fully to physical sensations due to the belief that these sensations could have
harmful consequences (Reiss, Peterson, Gursky, & McNally, 1986). While a
full review of this literature is beyond the scope of this chapter; there seems
to be evidence that EA and anxiety sensitivity are overlapping, yet distinct
constructs (see Kämpfe et al., 2012).
In the case of May, we see that she is particularly focused on her increased
heart rate and that this increased heart rate means that something is wrong.
This is coupled with her belief that she should be able to reduce her heart
rate. However, as she tries to reduce her heart rate, through willing herself to
calm down, she may be unsuccessful, which provides more evidence that
 Experiential Avoidance 125

there is something wrong, which may then increase, rather than decrease her
heart rate. In this way, May’s attempts at EA paradoxically increase the
somatic cues that she is trying to avoid. While this is not what is described in
May’s case, it is easy to see how this cycle of noticing somatic cues, trying to
suppress or avoid them, but paradoxically increasing them could easily lead
to a panic attack. She may then become hypervigilant to even slight increases
in heart rate, trying to avoid anything that may increase her heart rate, fur-
ther leading to avoidance of emotions, thoughts, or situations that would lead
to an increase in heart rate.

Fear of the Significance or Meaning of Thoughts

Some individuals fear the significance or the meaning of having a particular

thought. These fears are related to the obsessions often seen in those
diagnosed with obsessive-compulsive disorder (OCD) and the worry seen in
generalized anxiety disorder. Obsessions are recurring, intrusive, distressing,
unwanted thoughts, images, or impulses that come in to one’s mind. Simi-
larly, worry may function to distract individuals away from fear associated
with the content or meaning of the underlying thought or other internal
experience (Borkovec & Roemer, 1995). Similarly, individuals with both OCD
and generalized anxiety disorder often engage in a process where the individual
believes that having a thought about an event makes the event more likely to
happen (Thompson-Hollands, Farchione, & Barlow, 2013). This is referred to
as thought–action fusion. This thought–action fusion likely increases the distress
of the thought and the motivation to avoid the thought. In response to these
unwanted thoughts, images, or impulses, individuals may respond with a
particular behavior (e.g., compulsive ritual, avoidance) or with worry to pre-
vent a feared consequence or to reduce anxiety. These behaviors may take the
form of a mental ritual, assurance seeking, repeating words or behaviors, dis-
traction through worry, or avoiding things that trigger the thoughts. In this
way, Eifert and Forsyth (2005) suggested that these compulsive behaviors are
an attempt at EA. In other words, in an attempt to avoid the anxiety and not
experience the distress associated with the obsessional beliefs, compulsions
may function to avoid or correct for the feared consequence. For example,
if an individual has an intrusive thought about their child being hurt while
lying in bed at night and they go to check on their child to make sure nothing
is wrong, the reassurance-seeking through checking may be an attempt to
control and reduce the distress caused by the obsessive thought. Similarly, an
individual may engage in EA through worry rather than facing the fear that
their negative thoughts are a sign that they will not be able to cope with what
is coming.
However, it is important to note that the research is mixed regarding the
role of EA in fears of the significance or meaning of thoughts. For example,
studies have shown a relationship between EA and symptoms of generalized
anxiety disorder (Lee, Orsillo, Roemer, & Allen, 2010; Roemer, Salters, Raffa,
& Orsillo, 2005); however, several studies have failed to show a relation
126 Hayes-Skelton and Eustis

between EA and obsessive-compulsive symptom severity, although there is

some understanding that this could be due to measurement issues (see
Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010). Interestingly,
more recent research has found associations between EA and some aspects of
obsessive-compulsive symptoms. For example, EA has been shown to predict
obsessional symptoms but not other obsessive-compulsive symptoms (Blakey,
Jacoby, Reuman, & Abramowitz, 2016). Similarly, EA has been correlated
with the unacceptability of thoughts, responsibility for harm, and a desire for
symmetry, but not with contamination-based fears (Wetterneck, Steinberg, &
Hart, 2014).

Fear of Traumatic Events

Following exposure to a potentially traumatic event or learning about a

potentially traumatic event happening to a loved one, many individuals
develop strong physiological arousal and fear at reminders of the traumatic
event. For some individuals, the reexperiencing aspects of the trauma, avoid-
ance of situations and cues that remind them of the trauma, emotional numb-
ing, and hyperarousal continue and may warrant a diagnosis of posttraumatic
stress disorder (PTSD). When there is a traumatic event, it is natural to want
to avoid and push away the terror and pain. However, these efforts to avoid
and suppress often contribute to the reexperiencing and avoidance character-
istic of PTSD. In fact, there is research evidence that the more one is prone to
use EA as a coping strategy prior to a traumatic event the more likely one is
to develop posttraumatic stress symptomology (Kumpula, Orcutt, Bardeen, &
Varkovitzky, 2011).
Additionally, peritraumatic dissociation may serve an EA function in that
peritraumatic dissociation serves to avoid and regulate aspects of the trauma
experience in an attempt to cope with the experience (see Wagner & Linehan,
1998). By dissociating and removing oneself psychologically from the trauma,
the individual is reducing the immediate anxiety and fear of the experience.
Like other instances of EA, this initial avoidance may be effective in the short
term; however, symptoms often are reexperienced at a later date. In these
ways, using EA as a coping strategy following a traumatic event likely con-
tributes to the psychological distress associated with the trauma. For example,
if an individual is in a traumatic car accident, they may attempt to suppress
any emotions about the accident, which may be helpful in the short term.
However, if they continue to try to suppress the emotions, it may contribute
to an ongoing cycle of EA where the emotional experience may paradoxically
strengthen, thus further increasing their avoidance and other symptoms.

Contextual Stressors

Many individuals face stressors on a regular basis due to discrimination and

marginalization based on race, ethnicity, sexual orientation, gender identity
and expression, immigration status, religion, class, and disability status. These
 Experiential Avoidance 127

chronic experiences of discrimination and marginalization may lead to a

battle fatigue that includes increased anxiety and worry as well as physical
health consequences. While the effect of discrimination on anxiety is multi-
faceted, EA can be part of this pattern. For example, in the face of chronic
experiences of marginalization, it is natural to have strong emotions that we
then want to suppress or avoid. Additionally, individuals with a minority sta-
tus are often subtly (or not so subtly) told to suppress, ignore, or doubt aspects
of their experience. This is particularly true of microaggressions where indi-
viduals are often told that their emotions and fear in response to these expe-
riences is unjustified and that they should ignore it. Similarly, the individual
also often criticizes themselves for being distressed, saying that they should
just be able to cope with it because “it wasn’t a big deal.” In these ways, the
individual is employing EA in the face of these experiences. In some situa-
tions, it is adaptive to control and suppress our emotional responses; however,
as we have discussed above, denying, suppressing, and trying to avoid the
emotion associated with these experiences likely increases anxiety and worry
in the future. In fact, recent research has found EA to moderate the relations
between past year frequency of discrimination and depressive symptoms, and
stress appraisal of discrimination and symptoms of anxiety (Martinez, Eustis,
Arbid, Graham-LoPresti, & Roemer, 2018), indicating that experiences with
discrimination combined with high levels of EA may increase mental health
symptoms, and that EA may be an important target to consider in treatment.
In the case of May, we are aware that she has multiple marginalized
identities (her identity as Asian-American and as queer). Given these identi-
ties, she likely experiences both racial and sexual orientation microaggres-
sions. This may be an added burden that gets in the way of May engaging in
events. For example, if she believes that she will experience microaggressions
related to race if she attends the LGBTQ+ advocacy group and that these
experiences will lead her to experience additional emotions, including
increased anxiety, then she will likely avoid attending such events. Similarly,
denying that her experiences of discrimination and marginalization have an
impact on her may make her even more reactive to her internal experiences,
further exacerbating her desire to engage in EA, and therefore further perpet-
uating her cycle of anxiety.

Procrastination

Procrastination is often a concern of patients presenting with clinical and non­

clinical anxiety. Procrastination is often a presenting concern for many work-
ing in a college counseling setting, and procrastination can occur along with
other anxiety disorders, particularly generalized anxiety disorder and social
anxiety disorder, making it difficult to move forward on necessary tasks (e.g.,
job applications, scheduling doctor’s appointments, making phone calls
required for work). While there are currently multiple theories regarding the
function of procrastination, there is growing evidence that procrastination is
128 Hayes-Skelton and Eustis

related to task-related anxieties (Fritzsche, Young, & Hickson, 2003) and

fears of failure (Beck, Koons, & Milgrim, 2000). From this perspective, pro-
crastination may be serving an EA function as the delaying of a task allows
individuals to avoid the anxiety and fears that arise as they approach the
task. In trying to approach a task, they may experience anxiety related to
their fears of not being able to complete the task along with fears about what
it would mean to not complete the task. Sometimes this may be coupled
with the sense that they have to be less anxious before they can approach
the task. As a result, they may put off the task until they are feeling less
anxious about it. However, the longer they put off the task, the more pres-
sure there is to complete the task and the harder it is to even approach it. In
this way, procrastination is serving an avoidant function, as engaging in pro-
crastination is avoiding the short-term discomfort and anxiety that arise
when thinking about the task. In fact, research has shown that the closely
related construct of psychological inflexibility was associated with procrasti-
nation and predicted procrastination over and above trait anxiety (Glick,
Millstein, & Orsillo, 2014).

CONCLUSION

Experiential avoidance, or the unwillingness to remain in contact with distress-

ing internal experiences along with the attempts to control or avoid distressing
internal experiences, has been associated with a range of psychopathological
symptoms across a range of clinical presentations of anxiety and fear. These
attempts to control internal experiences (e.g., thoughts, emotions, physiolog-
ical sensations, memories) can exacerbate distress and limit behavior. The
flexible use of EA can be adaptive in certain contexts; it is when EA becomes
habitual, rigid, and/or automatic that it can lead to significant distress and/or
impairment in people’s lives. This chapter positioned EA within an acceptance-
based behavioral model of anxiety with a particular focus on how EA is
strengthened and maintained through negative and judgmental thoughts,
failed attempts at suppression of anxiety, and the consequences of avoidance.
EA has been linked with fear of negative evaluations, worry, fear of somatic
cues, fear of the significance or meaning of thoughts, fear of traumatic events,
contextual stressors, and procrastination. This chapter used the term “experi-
ential avoidance” throughout; however, some in the field are moving to the
broader term of “psychological inflexibility.” EA is often referred to, particu-
larly in the treatment literature, through its opposing process of psychological
flexibility or acceptance, the process of allowing internal experiences to
come and go without trying to change them. EA is a promising construct for
research on transdiagnostic models of anxiety, and it appears to be an import-
ant construct to target in treatment. However, more research is needed to
fully understand the role that EA plays in maintaining distress, so that treat-
ment can better target and reduce the impact of EA on patients’ lives.
 Experiential Avoidance 129

REFERENCES
Abramowitz, J. S., Lackey, G. R., & Wheaton, M. G. (2009). Obsessive–compulsive
symptoms: The contribution of obsessional beliefs and experiential avoidance. Jour-
nal of Anxiety Disorders, 23, 160–166. http://dx.doi.org/10.1016/j.janxdis.2008.06.003
Barraca Mairal, J. (2004). Spanish adaptation of the Acceptance and Action Question-
naire (AAQ). International Journal of Psychology & Psychological Therapy, 4, 505–515.
Retrieved from https://www.ijpsy.com/volumen4/num3/97/spanish-adaptation-
of-the-acceptance-and-EN.pdf
Beck, B. L., Koons, S. R., & Milgrim, D. L. (2000). Correlates and consequences of behav-
ioral procrastination: The effects of academic procrastination, self-consciousness,
self-esteem and self-handicapping. Journal of Social Behavior and Personality, 15, 3–13.
Blakey, S. M., Jacoby, R. J., Reuman, L., & Abramowitz, J. S. (2016). The relative
contributions of experiential avoidance and distress tolerance to OC symptoms.
Behavioural and Cognitive Psychotherapy, 44, 460–471. http://dx.doi.org/10.1017/
S1352465815000703
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., . . .
Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance
and Action Questionnaire-II: A revised measure of psychological inflexibility and
experiential avoidance. Behavior Therapy, 42, 676–688. http://dx.doi.org/10.1016/
j.beth.2011.03.007
Borkovec, T. D., & Roemer, L. (1995). Perceived functions of worry among generalized
anxiety disorder subjects: Distraction from more emotionally distressing topics?
Journal of Behavior Therapy and Experimental Psychiatry, 26, 25–30. http://dx.doi.org/
10.1016/0005-7916(94)00064-S
Buhr, K., & Dugas, M. J. (2012). Fear of emotions, experiential avoidance, and intoler-
ance of uncertainty in worry and generalized anxiety disorder. International Journal
of Cognitive Therapy, 5, 1–17. http://dx.doi.org/10.1521/ijct.2012.5.1.1
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of
suppression and acceptance on emotional responses of individuals with anxiety and
mood disorders. Behaviour Research and Therapy, 44, 1251–1263. http://dx.doi.org/
10.1016/j.brat.2005.10.001
Chodron, P. (2007). Practicing peace in times of war. Boston, MA: Shambhala.
Clark, D. M., & Wells, A. A. (1995). A cognitive model of social phobia. In R. G. Heimberg,
M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment,
and treatment (pp. 69–93). New York, NY: Guilford Press.
Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders:
A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior
change strategies. Oakland, CA: New Harbinger.
Fritzsche, B. A., Young, B. R., & Hickson, K. C. (2003). Individual differences in aca-
demic procrastination tendency and writing success. Personality and Individual Differ-
ences, 35, 1549–1557. http://dx.doi.org/10.1016/S0191-8869(02)00369-0
Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., Suzuki, N., & Watson, D. (2014).
The brief experiential avoidance questionnaire: Development and initial validation.
Psychological Assessment, 26, 35–45. http://dx.doi.org/10.1037/a0034473
Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., & Watson, D. (2011). Develop-
ment of a measure of experiential avoidance: The Multidimensional Experiential
Avoidance Questionnaire. Psychological Assessment, 23, 692–713. http://dx.doi.org/
10.1037/a0023242
Germer, C. K. (2005). Anxiety disorders: Befriending fear. In C. K. Germer, R. D. Siegel, &
P. R. Fulton (Eds.), Mindfulness and psychotherapy (1st ed.), (pp. 152–172). New York,
NY: Guilford Press.
Glick, D. M., Millstein, D. J., & Orsillo, S. M. (2014). A preliminary investigation of the
role of psychological inflexibility in academic procrastination. Journal of Contextual
Behavioral Science, 3, 81–88. http://dx.doi.org/10.1016/j.jcbs.2014.04.002
130 Hayes-Skelton and Eustis

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy:
The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., . . .
McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a
working model. The Psychological Record, 54, 553–578. http://dx.doi.org/10.1007/
BF03395492
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Exper-
imental avoidance and behavioral disorders: A functional dimensional approach to
diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.
http://dx.doi.org/10.1037/0022-006X.64.6.1152
Herbert, J. D., & Cardaciotto, L. A. (2005). An acceptance and mindfulness-based per-
spective on social anxiety disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance
and mindfulness-based approaches to anxiety (pp. 189–212). New York, NY: Springer.
http://dx.doi.org/10.1007/0-387-25989-9_8
Herzberg, K. N., Sheppard, S. C., Forsyth, J. P., Credé, M., Earleywine, M., & Eifert,
G. H. (2012). The Believability of Anxious Feelings and Thoughts Questionnaire
(BAFT): A psychometric evaluation of cognitive fusion in a nonclinical and highly
anxious community sample. Psychological Assessment, 24, 877–891. http://dx.doi.org/
10.1037/a0027782
Kämpfe, C. K., Gloster, A. T., Wittchen, H.-U., Helbig-Lang, S., Lang, T., Gerlach, A. L., . . .
Deckert, J. (2012). Experiential avoidance and anxiety sensitivity in patients with
panic disorder and agoraphobia: Do both constructs measure the same? Inter­
national Journal of Clinical and Health Psychology, 12, 5–22. Retrieved from https://
www.redalyc.org/html/337/33723707001/
Kashdan, T. B., Farmer, A. S., Adams, L. M., Ferssizidis, P., McKnight, P. E., & Nezlek,
J. B. (2013). Distinguishing healthy adults from people with social anxiety disorder:
Evidence for the value of experiential avoidance and positive emotions in everyday
social interactions. Journal of Abnormal Psychology, 122, 645–655. http://dx.doi.org/
10.1037/a0032733
Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety.
An experience-sampling assessment of positive emotions, positive events, and
emotion suppression. Psychological Science, 17, 120–128. http://dx.doi.org/10.1111/
j.1467-9280.2006.01674.x
Kumpula, M. J., Orcutt, H. K., Bardeen, J. R., & Varkovitzky, R. L. (2011). Peritraumatic
dissociation and experiential avoidance as prospective predictors of posttraumatic
stress symptoms. Journal of Abnormal Psychology, 120, 617–627. http://dx.doi.org/
10.1037/a0023927
Lee, J. K., Orsillo, S. M., Roemer, L., & Allen, L. B. (2010). Distress and avoidance in gen-
eralized anxiety disorder: Exploring the relationships with intolerance of uncertainty
and worry. Cognitive Behaviour Therapy, 39, 126–136. http://dx.doi.org/10.1080/
16506070902966918
MacKenzie, M. B., & Kocovski, N. L. (2010). Self-reported acceptance of social anxiety
symptoms: Development and validation of the Social Anxiety—Acceptance and
Action Questionnaire. International Journal of Behavioral Consultation and Therapy, 6,
214–232. http://dx.doi.org/10.1037/h0100909
Manos, R. C., Cahill, S. P., Wetterneck, C. T., Conelea, C. A., Ross, A. R., & Riemann,
B. C. (2010). The impact of experiential avoidance and obsessive beliefs on obsessive–
compulsive symptoms in a severe clinical sample. Journal of Anxiety Disorders, 24,
700–708. http://dx.doi.org/10.1016/j.janxdis.2010.05.001
Martinez, J. H., Eustis, E. H., Arbid, N., Graham-LoPresti, J. R., & Roemer, L. (2018).
Impact of experiential avoidance in the relation between racial discrimination and negative
mental health outcomes. Manuscript in preparation.
Purdon, C. (1999). Thought suppression and psychopathology. Behaviour Research and
Therapy, 37, 1029–1054. http://dx.doi.org/10.1016/S0005-7967(98)00200-9
 Experiential Avoidance 131

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in

social phobia. Behaviour Research and Therapy, 35, 741–756. http://dx.doi.org/
10.1016/S0005-7967(97)00022-3
Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (1986). Anxiety sensitivity,
anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy,
24, 1–8. http://dx.doi.org/10.1016/0005-7967(86)90143-9
Rochefort, C., Baldwin, A. S., & Chmielewski, M. (2018). Experiential avoidance: An
examination of the construct validity of the AAQ-II and MEAQ. Behavior Therapy,
49, 435–449. http://dx.doi.org/10.1016/j.beth.2017.08.008
Roemer, L., & Borkovec, T. D. (1994). Effects of suppressing thoughts about emotional
material. Journal of Abnormal Psychology, 103, 467–474. http://dx.doi.org/10.1037/
0021-843X.103.3.467
Roemer, L., & Orsillo, S. M. (2014). An acceptance-based behavioral therapy for general-
ized anxiety disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders,
5th Edition: A step-by-step treatment manual (pp. 206–236). New York, NY: Guilford Press.
Roemer, L., Salters, K., Raffa, S. D., & Orsillo, S. M. (2005). Fear and avoidance of
internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive
Therapy and Research, 29, 71–88. http://dx.doi.org/10.1007/s10608-005-1650-2
Ruiz, F. J., Langer Herrera, A. I., Luciano, C., Cangas, A. J., & Beltrán, I. (2013). Mea-
suring experiential avoidance and psychological inflexibility: The Spanish version
of the Acceptance and Action Questionnaire - II. Psicothema, 25, 123–129. Retrieved
from http://www.psicothema.com/english/psicothema.asp?id=4090
Schmalz, J. E., & Murrell, A. R. (2010). Measuring experiential avoidance in adults:
The Avoidance and Fusion Questionnaire. International Journal of Behavioral Consul-
tation and Therapy, 6, 198–213. http://dx.doi.org/10.1037/h0100908
Soto, J. A., Perez, C. R., Kim, Y.-H., Lee, E. A., & Minnick, M. R. (2011). Is expressive
suppression always associated with poorer psychological functioning? A cross-
cultural comparison between European Americans and Hong Kong Chinese. Emo-
tion, 11, 1450–1455. http://dx.doi.org/10.1037/a0023340
Spinhoven, P., Drost, J., de Rooij, M., van Hemert, A. M., & Penninx, B. W. (2014).
A longitudinal study of experiential avoidance in emotional disorders. Behavior
Therapy, 45, 840–850. http://dx.doi.org/10.1016/j.beth.2014.07.001
Thompson-Hollands, J., Farchione, T. J., & Barlow, D. H. (2013). Thought-action
fusion across anxiety disorder diagnoses: Specificity and treatment effects. The
Journal of Nervous and Mental Disease, 201, 407–413. http://dx.doi.org/10.1097/
NMD.0b013e31828e102c
Tull, M. T., & Roemer, L. (2007). Emotion regulation difficulties associated with the
experience of uncued panic attacks: Evidence of experiential avoidance, emotional
nonacceptance, and decreased emotional clarity. Behavior Therapy, 38, 378–391.
http://dx.doi.org/10.1016/j.beth.2006.10.006
Wagner, A. W., & Linehan, M. M. (1998). Dissociative behavior. In V. M. Follette, J. I.
Ruzek, & F. R. Abueg (Eds.), Cognitive-behavioral therapies for trauma (pp. 191–225).
New York, NY: Guilford Press.
Wegner, D. M., Schneider, D. J., Carter, S. R., III, & White, T. L. (1987). Paradoxical
effects of thought suppression. Journal of Personality and Social Psychology, 53, 5–13.
http://dx.doi.org/10.1037/0022-3514.53.1.5
Wetterneck, C. T., Steinberg, D. S., & Hart, J. (2014). Experiential avoidance in symptom
dimensions of OCD. Bulletin of the Menninger Clinic, 78, 253–269. http://dx.doi.org/
10.1521/bumc.2014.78.3.253
Wheaton, M. G., Berman, N. C., & Abramowitz, J. S. (2010). The contribution of experi-
ential avoidance and anxiety sensitivity in the prediction of health anxiety. Journal of
Cognitive Psychotherapy, 24, 229–239. http://dx.doi.org/10.1891/0889-8391.24.3.229
Wolgast, M. (2014). What does the Acceptance and Action Questionnaire (AAQ-II)
really measure? Behavior Therapy, 45, 831–839. http://dx.doi.org/10.1016/
j.beth.2014.07.002
8
Worry and Rumination
Thane M. Erickson, Michelle G. Newman, and Jamie L. Tingey

Maria, a 28-year-old Latina American woman, presents with somatic symp-

toms of anxiety (e.g., muscle tension, headaches, gastrointestinal disturbance)
and intermittent depression. Despite her initial emphasis on somatic con-
cerns, assessment reveals diffuse distress about many domains. Specifically,
she reports perseverative thoughts about whether her part-time online busi-
ness will fail. Maria also spends hours worrying about the adequacy of educa-
tion for her two elementary school-age children and her own competence as
a parent, given her own developmental history of neglect. Moreover, she rou-
tinely questions her balance of work and parenting. In her marriage, she rumi-
nates about whether she had found the right husband, given their personality
differences. At her worst, she feels unable to stop thinking about such issues,
wondering if it makes her physically ill. Maria’s chronic preoccupation with
these domains feeds symptoms of anxiety and irritability, occasional panic
attacks, shame, and at times, suicidal ideation. She copes with negative emo-
tions by alternating between avoiding direct problem-solving (e.g., completing
taxes for her business, seeking help) and perfectionistic overcommitment.
Expecting that others would not support her, she chronically takes care of
others’ needs but avoids disclosing her needs to her husband or friends. This
leads to resentment punctuated by occasional angry complaints—followed by
apologetic, passive behavior. Although Maria possesses the important strengths
of resilience and determination, she reports a recurring sense of a life spinning
out of control.1

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-008
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
133
134 Erickson, Newman, and Tingey

Examination of Maria’s presentation suggests that perseverative negative

thoughts occupy a central place in her life. Worry—traditionally conceptual-
ized as the verbal–linguistic, future-oriented anticipation of potential threats
(Borkovec, Robinson, Pruzinsky, & DePree, 1983)—represents a pervasive
process for her. She spends hours daily mired in thoughts about whether
negative outcomes will occur in her family and work, contributing to anxiety,
other negative emotions, and somatic symptoms. In addition, in line with the
fact that some patients succumb to negative thinking about negative thinking
or its consequences (i.e., metaworry; Wells, 2006), Maria worries that worry
itself may pose a risk for her mental and physical health.
Maria also suffers from chronic rumination, originally defined as persever-
ative thinking about one’s problems and associated feelings (Nolen-Hoeksema,
1991). It often entails attempts to make sense of past failures to meet goals by
repeatedly asking oneself mental questions unlikely to be solvable by such
mentation (e.g., “Why did that happen to me?” “What’s wrong with me?” “Why
can’t I fix this?”). As with worry, preservative negative thoughts typify rumina-
tion. Maria incessantly questions her past decisions about marriage, parenting,
and work—dwelling on events, their consequences, and concomitant feelings.
Such rumination invariably elicits dysphoria and, at worst, suicidal ideation.
In this chapter, we consider the role that worry and rumination play as
trans­diagnostic maintenance factors for anxiety. We discuss conceptual models
of (a) how these processes may promote distress, (b) relevant assessment
methods, and (c) clinical application to a range of symptoms.

CONCEPTUAL IMPLICATIONS

Initial conceptual models of worry and rumination implied specificity to par-

ticular psychological disorders. Namely, excessive and uncontrollable worry
represents the cardinal symptom of generalized anxiety disorder (GAD;
American Psychiatric Association, 2013), and many conceptual models posit
a unique role for worry in the cause and maintenance of generalized anxiety.
However, worry functions as a continuous dimension rather than a process
circumscribed to GAD (Ruscio, Borkovec, & Ruscio, 2001). Similarly, empiri-
cal approaches to rumination historically conceptualized it as a cognitive pro-
cess that perpetuates depressive symptoms (e.g., Nolen-Hoeksema, 2000).
However, measures of worry and rumination exhibit consistently strong pos-
itive correlations (e.g., McEvoy, Mahoney, & Moulds, 2010), and both worry
(Startup & Erickson, 2006) and rumination (e.g., Fresco, Frankel, Mennin,
Turk, & Heimberg, 2002) have been linked to a broad range of symptoms.
Furthermore, as we discuss below (see Assessment), it remains unclear to
what extent most measures of worry and rumination show specificity to the
theorized constructs. Szkodny and Newman (2017) argued that unique asso-
ciations of worry and rumination to respective syndromal symptoms represent
method variance, warranting caution against making claims of specificity.
 Worry and Rumination 135

Nonetheless, the strong correlation of worry and rumination, as well as their

underlying dimensions (Szkodny & Newman, 2017), supports conceptualiz-
ing them as overlapping transdiagnostic processes of repetitive negative
thinking (RNT) that transcend diagnostic categories, meriting consideration
of how such mechanisms may contribute to emotional difficulties.
We note the existence of other species of repetitive negative thoughts,
such as obsessions (a core feature of obsessive-compulsive disorder [OCD])
and intrusive trauma memories in the context of posttraumatic stress. Obses-
sions represent intrusive, unwanted negative thoughts (e.g., about contami-
nation, asymmetry, doubt, morally “inappropriate” content) that cause distress
and concomitant urges toward neutralizing them by other thoughts or behav-
iors (e.g., compulsions). Intrusive trauma memories reflect unwanted recol-
lections of traumatic events. Like worry and rumination, these cognitions
feature persistent negative content and cause distress. However, relative to
obsessions, worry may involve more verbal (rather than imagery-based) con-
tent, more ego-syntonic features (i.e., less discordant with ideal self; Szkodny
& Newman, 2017), and less ease of neutralization (Langlois, Freeston, &
Ladouceur, 2000). Rumination appears to involve more dwelling on the past
relative to obsessions (Szkodny & Newman, 2017), and longer duration, less
sensory experience, and more shame relative to intrusive trauma memories
(Speckens, Hackmann, Ehlers, & Cuthbert, 2007). Obsessions and intrusive
memories seem to constitute cognitions to which individuals react, whereas
worry and rumination have been conceptualized as ways of coping that may
perpetuate distress.
Although research must further clarify the shared and unique functions of
all types of RNT, our emphasis on anxiety maintenance factors limits our focus
to worry and rumination, for which there exist more established theories and
research on this role. Next, we suggest that worry and rumination entail neg-
ative, perseverative thinking that may contribute to psychopathology by direct
activation of negative emotional and physiological states, serving strategic
functions, impairing problem-solving, and disrupting interpersonal support.

Negative Valence and Promotion of Unpleasant Emotional

and Physiological States

An obvious shared feature of worry and rumination lies in their shared nega-
tive affective valence. Although individuals may ruminate about positive
experiences, typically rumination involves brooding about negative experi-
ences, and worry centers on potential occurrence of stressful events (Borkovec
et al., 1983). Worry and rumination may not be identical, given that experi-
mental engagement in rumination elicited sadness, whereas worry elicited
anxious mood (e.g., McLaughlin, Borkovec, & Sibrava, 2007). Theoretically,
temporal focus discriminates worry (on future threats) from rumination (about
past failures; Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008). Expecting the
worst (future-oriented) did uniquely predict higher GAD but not depressive
136 Erickson, Newman, and Tingey

symptoms, although extant worry and rumination measures may not consis-
tently differ on temporal focus (Szkodny & Newman, 2017); nonetheless, they
jointly emphasize negative content.
Aside from the shared descriptive feature of negative valence, conceptual
models posit that worry and rumination foster negative emotion as well as
unpleasant physiological activation. For instance, higher self-reported worry
predicted negative emotion in naturalistic contexts (e.g., Crouch, Lewis,
Erickson, & Newman, 2017) and heightened sympathetic nervous system
activation (e.g., Pieper, Brosschot, van der Leeden, & Thayer, 2010). Further-
more, experimental worry inductions elicited negative emotions (e.g., Llera &
Newman, 2010) as well as higher sympathetic and lower parasympathetic
nervous system responses compared with baseline and relaxation (e.g., Llera
& Newman, 2010, 2014). Similarly, self-reported rumination prospectively
predicted onset of depressive disorders and prolongation of episodes (e.g.,
Nolen-Hoeksema, 2000). Focusing on causes, meanings, and consequences
of feelings caused dysphoric mood states (e.g., Nolen-Hoeksema & Morrow,
1993), and chronic ruminators experienced greater amygdala reactivity to
unpleasant stimuli (Ray et al., 2005).
For Maria, worry and rumination feed her proneness toward distress.
Worrying about her online business and her children’s education serves to
intensify anxiety, somatic activation (e.g., muscle tension, gastrointestinal
disturbance), and dysphoria. Similarly, ruminating about her choice of spouse
and the intractability of work–life balance only exacerbates her negative
moods. Thus, worry and rumination directly contribute to her negative emo-
tional experiences.

Perseverative Cognition and Prolongation of Negative Thoughts

Perseverative self-focused cognition typifies both worry and rumination.

Interestingly, the etymology of each term implies repetition: cows ruminate by
repeatedly chewing and regurgitating grass, whereas a dog may worry a bone
by incessant gnawing. Indeed, some experts have conceptualized worry and
rumination as facets of a higher order process of perseverative or repetitive
negative thinking (Ehring & Watkins, 2008; Segerstrom et al., 2012) with
transdiagnostic relevance (Arditte, Shaw, & Timpano, 2016). Repetitive atten-
tional focus on negative content may generate and amplify negative mood
states, as patients often find it subjectively difficult to disengage from the
process. Individuals may experience worry as “uncontrollable” not only in
GAD but also beyond this diagnosis. Analogously, individuals who ruminate
find it difficult to inhibit negative emotional information (e.g., Joormann,
2006). On one hand, individuals may possess metacognitive beliefs that wor-
rying is interminable or dangerous (Wells, 2006), implying ego-dystonic fea-
tures. Conversely, they often possess positive beliefs about RNT, implying
ego-syntonic features that might facilitate perseveration. For instance, they
may believe that worry facilitates problem-solving, helps them prepare for the
 Worry and Rumination 137

worst, and means that they care (e.g., Hebert, Dugas, Tulloch, & Holowka,
2014) or that worry helps them avoid further shifts into negative moods
(Newman & Llera, 2011). Some people believe that rumination confers insight
about disappointments (Watkins & Baracaia, 2002) and thus helps them to
prevent or even solve problems (Papageorgiou & Wells, 2001).
Maria chronically perseverates about her family and work. In line with the
foregoing discussion of metacognition, Maria believes that she is unable to
terminate RNT, and worries about concomitant health risks. However, she
states that she has “always been a worrier” and describes RNT as a “comfort-
able” and familiar way of coping, suggesting ego-syntonic features of perse-
veration, despite the fact that it promotes ongoing distress.

Worry and Rumination Serve Cognitive–Affective Functions

Some theories posit that rumination and worry differ in the psychological
functions that they serve. For instance, worry, as a verbal–linguistic process,
has been theorized to help individuals avoid negative imagery and thereby
avoid negative emotional experience (e.g., Borkovec, Alcaine, & Behar, 2004),
or perhaps to avoid or reduce uncertainty (Koerner & Dugas, 2006). How-
ever, the preponderance of evidence suggests that worry promotes—not avoids—
negative emotion (Newman, Llera, Erickson, Przeworski, & Castonguay, 2013).
The contrast avoidance model acknowledges but modifies previous theories,
suggesting that individuals prone to chronic worry are acutely sensitive to
negative emotional contrasts (sharp shifts from neutral or positive moods into
negative ones). Second, patients with GAD may worry deliberately in order
to maintain negative mood and thereby avoid further increase of negative
emotion (not avoiding negative emotion per se). This may reduce a specific
form of uncertainty: whether one will experience unexpected mood shifts.
Experimental (Llera & Newman, 2010, 2014) and longitudinal studies (Crouch
et al., 2017) support the model, and contrast avoidance in worry is germane
to GAD and transdiagnostically (Llera & Newman, 2017).
In contrast, although individuals may believe that they ruminate to gain
insight into past disappointments, rumination may keep them mentally occu-
pied, thereby avoiding having to engage with tasks they find aversive. Moreover,
when people ruminate, they mentally compile evidence that their situations
are hopeless, increasing certainty that problem-solving efforts are pointless,
justifying passivity, avoidance of action, and giving up goals (Nolen-Hoeksema
et al., 2008). Individuals may worry when feeling uncertain about future
threats but shift to rumination when feeling more certain about uncontrolla-
bility or hopelessness regarding stressors.
Although unique functions of worry and rumination remain possible, they
similarly involve generation of a negative state. However, because most wor-
ries or postevent concerns rarely come true, when the feared event does not
occur, repetitive thinking is negatively reinforced, interfering with extinction.
Both cognitive processes serve an “evidentiary” function; they presume a
138 Erickson, Newman, and Tingey

cognitive need to experience subjective certainty about the self or one’s out-
comes related to stressors. Predicting and understanding threats, though dif-
fering in temporal focus, both serve a motive for cognitive consistency, even
if such consistency comes at an emotional price (e.g., when individuals grav-
itate toward negative feedback because it fits self-perceptions; Swann & Read,
1981). Patients may find it less aversive to engage in RNT that increases cer-
tainty of negative outcomes than to live out their values without certainty
about the self or future. This characterization fits Maria, in that she endorses
finding it easier to retreat into mental rumination than to actually face her fears
about her marriage and parenting. Additionally, further assessment revealed a
fear of negative emotional contrasts (“I can’t stand it when I’m having a good
day and then my kids act up and upset me”) and use of worry to avoid negative
contrasts (“I expect the worst so I am not surprised when bad things happen”).
Her procrastination about completing taxes, hesitancy to seek or disclose the
need for help, and perfectionistic overcommitment also represent negatively
reinforced avoidance strategies.

Worry and Rumination Impair Problem-Solving

Worry and rumination may also perpetuate distress by interfering with problem-
solving. Rather than taking direct action, repetitive engagement in negative
thinking monopolizes cognitive resources and keeps individuals from taking
constructive action to improve their lives. Indeed, worry has been linked to
impaired confidence in problem-solving (e.g., Dugas, Letarte, Rhéaume,
Freeston, & Ladouceur, 1995), rumination inductions reduced confidence
and generation of solutions (Lyubomirsky, Tucker, Caldwell, & Berg, 1999),
and chronic rumination predicted avoidance of acting on health problems
(Lyubomirsky, Kasri, Chang, & Chung, 2006). In Maria’s life, worry and rumi-
nation preempt direct problem-solving in work and family challenges. She
believes that prolonged thinking about her problems constitutes taking action,
promoting withdrawal and inaction rather than curiosity and approach behav-
ior. Moreover, like many chronic worriers, she may believe that if she worries
or ruminates enough, it may prepare her to problem solve or help her arrive
at an ideal solution, despite evidence to the contrary in her life.

Negative Impact on Interpersonal Processes

Moreover, individuals who habitually worry and ruminate tend to experience

interpersonal problems that may further maintain distress and symptoms
(Newman & Erickson, 2010; Nolen-Hoeksema et al., 2008). For instance,
chronic worry correlated with self-reported affiliative or “warm” interpersonal
traits, daily behavior, and interpersonal problems (e.g., being overly nurturant;
Erickson et al., 2016), and rumination has similarly predicted self-perceptions
of excessively warm or dependent traits (e.g., Nolen-Hoeksema & Jackson,
2001). Such individuals may believe that perseverative thinking represents
friendly concern (“I only worry because I care so much”). Nevertheless, worry
 Worry and Rumination 139

and rumination may translate into maladaptive interpersonal impacts on

others. Worry was associated with misjudging one’s interpersonal impact on
interactions with confederates (Erickson & Newman, 2007) and significant
others (Erickson et al., 2016). In turn, problematic interpersonal goals pre-
dicted increases in worry over time (e.g., Erickson et al., 2018). Similarly,
rumination has predicted conflict and diminished support from others (e.g.,
Nolen-Hoeksema & Davis, 1999). Individuals may coruminate (ruminate aloud
with others), providing an aversive social experience for others (Stone,
Hankin, Gibb, & Abela, 2011). Thus, RNT may unintentionally contribute to
erosion of social support, causing further distress.
Maria illustrates these processes in that she worries about others, prompt-
ing an interpersonal style of anxious caregiving that is endearing at times, but
inflexible. Negative thinking takes the place of straightforward “owning of”
and disclosing her emotional needs, eventually giving way to resentful out-
bursts. However, even then, ensuing feelings of shame motivate retreat into
passivity and worry instead of a healthy balancing of her and others’ needs.
In summary, worry and rumination reflect transdiagnostic cognitive mech-
anisms that maintain dysfunction. They directly increase negative emotion
and a sense of being “stuck” in negative thoughts. Indirectly, they feed psy-
chopathology by thwarting problem-solving and adaptive social behavior.

ASSESSMENT

Self-Report Inventories

Over the past 3 decades, a bevy of relevant self-report measures has emerged.
We briefly note some of them here (see Table 8.1), as well as reasons for cau-
tion about them. With regard to worry, the Penn State Worry Questionnaire
(Meyer, Miller, Metzger, & Borkovec, 1990) is the most widely used measure
(Startup & Erickson, 2006), and brief versions exist (e.g., Berle et al., 2011),
as well as versions for older adults (Hopko et al., 2003) and youth (Chorpita,
Tracey, Brown, Collica, & Barlow, 1997). Other measures assess worry domains
(Tallis, Davey, & Bond, 1994) and reasons for worry (Hebert et al., 2014).
Related instruments assess metacognitive beliefs about worry (Cartwright-
Hatton & Wells, 1997) and worrying to avoid negative emotional contrasts
(Llera & Newman, 2017).
Other measures were designed to target rumination. The Ruminative
Response Scale of the Response Styles Questionnaire (Nolen-Hoeksema &
Morrow, 1991) is used widely, and a subsequent version reduced item over-
lap with depression (Treynor, Gonzalez, & Nolen-Hoeksema, 2003). Other
measures assess anger rumination (Sukhodolsky, Golub, & Cromwell, 2001),
“postevent processing” about embarrassing interactions (particularly relevant
to social anxiety; McEvoy & Kingsep, 2006), and positive beliefs about rumi-
nation (Papageorgiou & Wells, 2001).
Assessment of general RNT provides another alternative. Highlighting shared
phenomena may sometimes streamline assessment and intervention when
TABLE 8.1. Selected Self-Report Measures of Repetitive Negative Thinking
Constructs putatively assessed,
Measure number of items Reference
Penn State Worry Pathological worry; 16 items Meyer et al. (1990)
Questionnaire

Brief Measure of Pathological worry; 8 items Gladstone et al.

Worry Severity (2005)

Worry Domains Content-specific worry domains Tallis et al. (1994)

Questionnaire (i.e., relationships, lack of
confidence, aimless future,
financial issues, and work);
25 items

Why Worry-II Reasons for worrying (5 subscales); Hebert et al. (2014)

25 items

Contrast-Avoidance Worrying to avoid negative Llera and Newman

Questionnaire- emotional contrast, create (2017)
Worry negative emotion, facilitate
positive contrasts; 30 items

Meta-Cognitions Positive and negative beliefs about Wells and Cartwright-

Questionnaire worry; 30 items Hatton (2004)

Ruminative Response Brooding/rumination; 22 items Nolen-Hoeksema and

Scale Morrow (1991)

Rumination-Reflection Rumination and reflection; 24 items Trapnell and Campbell

Questionnaire (1999)

Rumination on Rumination when feeling “sad, Conway, Csank, Holm,

Sadness Scale down, or blue”; 13 items and Blake (2000)

Anger Rumination Rumination on angry moods, anger- Sukhodolsky et al.

Scale provoking memories, causes and (2001)
consequences of anger states;
19 items

Positive Beliefs About Beliefs about the benefits of Papageorgiou and

Rumination Scale rumination; 9 items Wells (2001)

Post-Event Processing Repetitive negative thinking McEvoy and Kingsep

Questionnaire- following a distressing event; (2006)
Revised 14 items

Repetitive Thinking Repetitive negative thinking McEvoy et al. (2010)

Questionnaire (disorder-specific content removed);
27 items (plus 4 “absence of
repetitive thinking” items)

Perseverative Repetitive negative thinking, Ehring et al. (2011)

Thinking independent of content; 15 items
Questionnaire

Perseverative Lack of controllability, preparing for Szkodny and Newman

Cognitions the future, expecting the worst, (2017)
Questionnaire searching for causes/meaning,
dwelling on the past, and thinking
discordant with ideal self;
45 items
Note. All measures pertain to some form of repetitive negative thinking. However, with the exception of
the Perseverative Cognitions Questionnaire, it remains unclear whether measures provide valid measures
specifically of worry and rumination per se given concerns noted in the Assessment section in the text.
 Worry and Rumination 141

the clinical focus is generalized perseveration rather than a specific species of

negative thought. For instance, Ehring et al. (2011) and McEvoy et al. (2010)
developed measures of perseverative negative thinking. Alternatively, this
approach may sometimes lack specificity in patients endorsing only particular
types of RNT (e.g., only dwelling on the past but not worrying about the
future), given the possibility that worry or rumination may differentially pro-
mote anxiety and depression (Yang et al., 2014).
However, we caution practitioners that the self-report measures of these
constructs may not necessarily assess the theorized constructs in an unambig-
uous fashion, for several reasons outlined by Szkodny and Newman (2017).
First, differences between worry and rumination may be confounded with
item content (e.g., focusing on perceived uncontrollability of the thoughts vs.
causes and consequences of thoughts). Second, measures may use terms
indiscriminately (e.g., measures of worry, rumination, and obsessions incor-
porate the term worry). Third, laypersons may not interpret items in line
with theorized constructs (e.g., patients often refer to past-oriented repetitive
thoughts as worry). Last, measures of worry and rumination have often been
confounded with symptoms of putatively relevant diagnoses (e.g., worry with
GAD, rumination with depression). Therefore, Szkodny and Newman (2017)
developed a measure of the dimensions thought to comprise and differentiate
worry, rumination, and obsessions, finding evidence for factors including lack
of controllability, preparing for the future, expecting the worst, searching for causes/
meaning, dwelling on the past, and thinking discordant with the ideal self (i.e.,
ego-dystonic thoughts). Some findings diverged from theoretical formula-
tions. For instance, both worry and rumination measures correlated with
expecting the worst and dwelling on the past, suggesting that temporal dis-
tinctions are not captured by traditional measures. Thus, we suggest the clin-
ical utility of directly assessing patients on the aforementioned six dimensions
in order to differentiate the features of a patient’s negative thinking. Never-
theless, the fact that traditional measures of worry and rumination correlated
with all of the aforementioned factors bolsters our contention that they (albeit
imperfectly) assess shared variance in RNT.

Clinical Interview

In addition to self-report questionnaires, there exist structured interviews

that assess components of worry and ruminative processes (Chan, Davey, &
Brewin, 2013; Francis & Dugas, 2004). Interview methods provide rich qual-
itative data about the content of worry and rumination. Outside of these
structured procedures, clinicians are encouraged to inquire directly about con-
tent domains (“What areas do you worry about uncontrollably most often?”),
beliefs about worry and rumination (e.g., “What do you see as benefits of
worry?” “What might happen if you were not ruminating about this issue?”
“What do you see as risks of continued worry?”). For patients whose worries
or ruminations are not sufficiently concrete and specific, the classic “down-
ward arrow” strategy provides a useful way to help patients elucidate their
142 Erickson, Newman, and Tingey

core fears and concerns (“If you make mistakes as a parent, what would that
mean about you or your future?”). However, the aforementioned measure-
ment concerns apply here as well, so clinicians are encouraged to directly
inquire about the six domains underlying maladaptive repetitive thinking
(Szkodny & Newman, 2017). For instance, clinicians may glean a wealth of
information by directly inquiring about domains such as preparing for the
future (“When you get stuck in your thoughts, to what extent are you trying
to ready yourself for possible future misfortune?”) versus dwelling on the
past (“How much do these thoughts center upon past disappointments?”).
In-person clarification may often provide unambiguous information relative
to traditional self-reports of worry and rumination.

CLINICAL IMPLICATIONS

Given the transdiagnostic nature of worry and rumination as mechanisms

maintaining psychopathology, we now discuss ways they may apply in the
context of specific transdiagnostic symptom domains, providing clinical
examples for each (see Table 8.2). Because other chapters in Part II of this
handbook address transdiagnostic treatment mechanisms, we do not incorpo-
rate those here.

Generalized Anxiety

Worry, of course, occurs at high levels in GAD (Startup & Erickson, 2006). No
cognitive content typifies all individuals prone to general anxiety, but they
may experience a broad range of worries not subsumed within more narrow
domains of psychopathology (e.g., fear of evaluation in social anxiety). Such
individuals may endorse uncontrollable worry related to topics from the mun-
dane and concrete (e.g., safety, sexuality, finances), to the existential (calling
and purpose) and macrolevel (e.g., geopolitical climate). Worries about inter-
personal concerns are often paramount (Roemer, Molina, & Borkovec, 1997).
In parallel, patients may ruminate in these domains when they perceive their
own inability to reach relevant desired goals.
For instance, one middle-aged, female patient worried chronically and per-
severatively not only about her self-efficacy as an accountant (“What if I can’t
keep up with my task list?”), but also race relations in the country (“What if
people grow even more polarized, leading to another civil war?”). She reported
that on one hand, staying worried conferred a sense of predictability (“It feels
safer to anticipate threats than to be caught off guard.”) and identity (“If I
wasn’t worried about my job performance, I’d be getting lazy.”). Thus, worry
was negatively reinforced by a sense of avoiding being surprised by unex-
pected difficulties at work or in the news. After a challenging work day or viral
news story, her rumination seemed ego-syntonic as a way to make sense of
and validate the importance of the experiences. On the other hand, worry
clearly induced fear and rumination perpetuated negative moods.
 Worry and Rumination 143

TABLE 8.2. Examples of Worries and Ruminative Thoughts Across Common

Symptom Types
Worry Rumination
Generalized anxiety
What if I lose my job and never find a Why can’t I prevent bad things when
new one? I’m in a good mood?
What if my worrying leads to heart What’s wrong with people, with
disease? (metaworry) everyone who voted that way?

Negative social evaluation

How will I recover if I embarrass myself I wish I knew what she thinks of me
by crying? after that failed date.
What if he notices me sweating and How come I can’t ever come off like I have
thinks I’m incompetent? it together?

Somatic concerns
What if this bruise creates a dangerous Why can’t I go for long without
blood clot? needing medical tests?
I wonder—could I die as a result of this I’m doomed to these panic attacks no
fever? matter what I do.

Trauma-related concerns
How will I handle it if I never feel safe There must be something about me
ever again? that attracts abusive men.
What if someone else tries to attack me? Why do illegal aliens keep attacking so
many people?

Obsessive-compulsive spectrum
What if blasphemous thoughts mean How come I can’t get those unlucky
that I really hate God? numbers out of my head?
What if there are traces of unseen Why doesn’t everyone just apply hand
chemicals on my hands? sanitizer all winter?

Agoraphobic concerns
What if I get too far from my house There must be a reason why I can’t
and can’t handle it? ever ride subways or trains.
Where will I go for help if I get Why does my boyfriend put up with
nauseated during the concert? having to drive me around?

Phobic anxiety
What if I encounter a dog while My brain must be broken, because
running? I can’t handle tight spaces.
How would I be able to handle it if Why did I have to move to a state with
spiders nest in my house? hurricanes?

Anger
What if she still thinks she can talk Why didn’t that cyclist stay home and
down to me? off my roads?
What if he has no intention of ever I’ll bet that child meant to disobey just
apologizing? to spite me.

Depression
What if I’m forgettable to people? Why can’t I ever feel joy in my life
anymore?
How will I get out of bed when I have I should figure out why I’m such a
no energy at all? failure.
144 Erickson, Newman, and Tingey

Furthermore, the patient’s worry and rumination, although perceived by

her as a way to manage stressors, actually interfered with more adaptive cop-
ing and problem-solving. Remaining occupied with cognitive processing
made it impossible to engage in self-care activities such as a relaxation or
prayer (which she found aversive due to fear of being caught off guard by a
threat if she “let her guard down”). Moreover, her ceaseless mental activity
sapped her energy, feeding procrastination at work. Worry about race rela-
tions took the place of actually engaging in local service opportunities in her
community. Interpersonally, a tendency to worry aloud and coruminate
alienated her friends. She believed that she was sharing herself, but they
experienced it as excessive, self-focused preoccupation and inattention to
their needs.

Negative Social Evaluation

Individuals suffering from social anxiety endorse high levels of both worry
(Startup & Erickson, 2006) and postevent rumination (McEvoy & Kingsep,
2006). Quintessentially, these perseverative cognitions center upon fear of
social evaluation. Relevant worries feature anxious anticipation of threats to
the “social self” (e.g., “What if they notice me and I start to stutter?” “What if
my coworkers notice mistakes in my email messages?” “Others might hear
me going to the bathroom while I’m in the stall”). Rumination and postevent
processing also apply to such foci (e.g., “Why did she watch me so closely, and
what does it mean that she took notes on her clipboard?” “I can’t believe I
blushed during my presentation. The audience probably thought I was a
weakling”). Analogously, those with body dysmorphia spectrum symptoms
often engage in perseverate thinking about whether others notice their imag-
ined or real physical flaws (e.g., “What if people notice the scars on my neck?”
“They probably noticed my nose; why does that bother me so much?!”). Sim-
ilarly, those with body image concerns and disordered eating may worry and
ruminate about others’ perceptions of their bodies (“Will they notice that I
gained weight?” “Why am I so fat?” “They must have thought I was lazy and
weak for not maintaining my figure since high school”). In individualistic
cultural contexts, perseverative cognitions often center upon interpretations
of social evaluative threats toward the self, whereas in collectivistic contexts,
worry and rumination may also encapsulate concerns about impact on others
(e.g., “What if my poor performance brings shame on my family?” “I really
hope that my body odor didn’t offend other people!”).
Worry and rumination may maintain distress related to social evaluation
fears. A socially anxious 40-year-old man, for instance, worried incessantly
about whether coworkers noticed him sweating while leading team meetings
at work (“What if they notice me getting ‘pitted out?’ They might think I’m
incompetent and too afraid to hold a leadership role”). Such worry led to
excessive striving to avoid displays of sweating. He limited his own presenta-
tions in meetings, took hourly trips to the bathroom to mop his brow and
 Worry and Rumination 145

armpits, and changed his shirt whenever sweat was evident (followed by
rumination about others noticing him sweating). In the short term, this exces-
sive processing seemed to legitimate his struggles, but ultimately perpetuated
his belief that sweating equals incompetence, and led him to distance himself
from others. This kept him from learning a more humble, realistic perspective
that no one cared if he sweated as long as he was genuine, supportive, and
responsible.

Somatic Concerns

Heightened perseveration about somatic concerns occurs in, but also tran-
scends, discrete diagnostic categories. In those with fear of somatic arousal
and interoceptive cues (e.g., panic disorder, agoraphobia), worries pertain to
catastrophic sequelae of unexpected somatic arousal (e.g., “What if my heart
starts racing and I can’t stop it?” “What if I get so anxious that I go crazy and
lose my mind?”), as do ruminative episodes (“This must mean a nervous
breakdown! Why am I falling apart?”). For patients with fear of illness, perse-
verative cognition centers instead upon imagined or real somatic symptoms
as heralds of serious negative health consequences (e.g., “What if I’m dying?”
“That lump could mean cancer.” “I might have a rare disease that won’t be
caught until it’s too late!”). Similarly, worry and rumination perpetuate dis-
tress in individuals with blood injection-injury phobia (“What if I see my own
blood when getting work done at the dentist, and then pass out?” “I bet my
fear of needles goes back to all those cavities I had filled as a child”). Some
body dysmorphia concerns cannot be explained fully by social evaluation
fears (e.g., “Something is really wrong with my skin. Why do I still have acne
as an adult? What if it never goes away?”) as with other body image concerns
(“What if I’m destined for obesity? My family history probably means that”).
For illustrative purposes, consider the case of a woman who presented
with panic disorder (involving fear of interoceptive cues of somatic arousal),
agoraphobia, and illness anxiety. She endorsed chronic worry about not only
future uncued panic attacks in which she might experience somatic activa-
tion (namely, heart palpitations, shakiness, and sensations of “smothering”),
but also fear of a variety of maladies including heart attacks and multiple
sclerosis. Worries served to keep her vigilant for signs of unexplained somatic
activation or symptoms such as headaches, minor epidermal spots, and con-
centration difficulties. These worries promoted behavioral changes including
reduced sexual intimacy with her partner, avoidance of places where escape
would be difficult (e.g., sitting near the exit at cinemas and cafés), and
repeated medical “checking” (reviewing symptom lists on medical Internet
sites, excessive reassurance seeking from physicians). Moreover, worry led to
requiring her boyfriend to accompany her while driving. Despite his initial
willingness to provide comfort, excessive reliance upon him contributed to
his increasing annoyance with her. In turn, the patient ruminated about the
meaning of her anxiety and worried about the future of the relationship.
146 Erickson, Newman, and Tingey

Trauma-Related Concerns

Research on trauma survivors reveals proneness to both perseverative “what

if?” (i.e., worry) and “why?” thoughts (rumination); such thoughts represent
both ways of responding to intrusive trauma memories and also further activate
them (Michael, Halligan, Clark, & Ehlers, 2007). Individuals with persistent
posttraumatic symptoms may worry about the risk of future threats (“What if I
am the victim of another assault?”), the frequency and meaning of reexperienc-
ing symptoms (“What if I can’t stop thinking about the attack?” “What if I can
never drive a car again without feeling agitated?”), and hyperarousal symptoms
themselves (“Will I never be able to sleep well again?”). Similarly, they may
engage in self-focused ruminative cognition about the self—including whether
the self is vulnerable, fragile, and to blame for the trauma—as well as about
others and the world (“This means that no one can be trusted.” “Why is the
world so dangerous?”).
A man who survived a traumatic motor vehicle accident in which he was
dragged under a car worried both about not being able to drive again and
possibly suffering another accident when he did drive. He also worried that
the physical injuries and recovery period would lead to lost work productiv-
ity. When this feared outcome occurred, he ruminated about why he had
allowed injury to impact his success at work. Worry maintained his anxiety
and hypervigilance, focusing his attention on overestimated odds of future
accidents. Rumination contributed to dysphoric mood and anhedonia both
directly and by taking the place of more active problem-solving. He searched
online excessively about legal and physical aspects of car accidents, but he
would quickly become overwhelmed and resort to aimless web surfing and
self-isolation rather than practicing physical therapy activities and seeking
social support, illustrating how worry and rumination perpetuated his prob-
lems associated with aftereffects of trauma.

Obsessive-Compulsive Spectrum

Measures of obsessions, worries, and rumination correlate positively (Exner,

Martin, & Rief, 2009), and obsessions and worries bear similarities in their
perseverative nature, negative valence, and temporal focus on potential
future threats. However, obsessional thoughts may be somewhat more
ego-dystonic and intrusive (Langlois et al., 2000; Szkodny & Newman, 2017),
and typically occur in the context of OCD. Worries and rumination may per-
tain to content domains typical of OCD. For instance, individuals preoccupied
with contamination may not only experience obsessional intrusive thoughts
that they have been sullied by contact with germs, but may also worry about
the possible consequences of contact (“What if those germs make me vio-
lently ill?”) and ruminate about the ubiquity of microbes and disease. Simi-
larly, one may worry and ruminate about lack of symmetry (“What if my
books get out of order?” “I will never convince my spouse to put them back
the right way”) or superstitions (“What if the number 6 occurs in my pay-
check?” “Why is it so hard not to step on cracks, pleasing the devil?”).
 Worry and Rumination 147

For patients with “pure” obsessions (i.e., typically intrusive sexual, aggres-
sive, or blasphemous thoughts), worries (including metaworries) often center
on potential threatening meanings of the fact that one experiences intrusive
thoughts. For instance, those with intrusive thoughts about violating their
own sexual standards may worry that their deepest fear is true (e.g., “What
if—deep down—I really do want to molest children?”), or even that allowing
themselves to encounter related stimuli or thoughts might prove their fears
true. Those plagued by fears of aggression or blasphemy similar worry in these
domains (“What if my true self is violent and could appear at any time?”
“What if I actually hate God even though I say I don’t?”). Those preoccupied
with moral scrupulosity can find themselves perseverating on whether they
can avoid perceived sins. Rumination about the inability to gain complete cer-
tainty about these issues can also generate further distress and dysphoria (e.g.,
“Why can’t I settle for certain whether my spouse truly loves me?” “Maybe I
really am a monster after all”). Worry and rumination in these contexts serve
a function of mental striving to gain predictability or certainty, although they
ultimately perpetuate distress and undercut acceptance and action.

CONCLUSION

Worry and rumination are perseverative negative forms of thinking that

maintain psychopathology by promoting distress, creating negative states to
avoid other perceived threats, and disrupting problem-solving and interper-
sonal functioning. We encourage clinicians to assess worry and rumination
before, during, and after interventions for not only general anxiety and
depression, but the full spectrum of symptom dimensions. Transdiagnostic
mechanisms of change such as cognitive restructuring, exposure (facilitating
extinction and habituation), mindfulness interventions, and lifestyle changes
serve as front-line interventions to target worry and/or rumination. Future
research must confirm unique features (e.g., relative focus on future threats
versus past failures) and functions (preventing unexpected mood shifts ver-
sus seeking certainty or meaning in failures), as well as the differential effec-
tiveness of interventions depending on patients’ type of RNT. In the meantime,
however, clinicians can confidently take advantage of the strong evidence for
the importance of identifying and treating worry and rumination in the ser-
vice of improving the lives of our patients.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Washington, DC: American Psychiatric Association.
Arditte, K., Shaw, A., & Timpano, K. (2016). Repetitive negative thinking: A trans­
diagnostic correlate of affective disorders. Journal of Social and Clinical Psychology, 35,
181–201. http://dx.doi.org/10.1521/jscp.2016.35.3.181
Berle, D., Starcevic, V., Moses, K., Hannan, A., Milicevic, D., & Sammut, P. (2011). Pre-
liminary validation of an ultra-brief version of the Penn State Worry Questionnaire.
Clinical Psychology & Psychotherapy, 18, 339–346. http://dx.doi.org/10.1002/cpp.724
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry
and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, D. S. Mennin,
148 Erickson, Newman, and Tingey

R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder:

Advances in research and practice (pp. 77–108). New York, NY: Guilford Press.
Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983). Preliminary explo-
ration of worry: Some characteristics and processes. Behaviour Research and Therapy,
21, 9–16. http://dx.doi.org/10.1016/0005-7967(83)90121-3
Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The
Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11,
279–296. http://dx.doi.org/10.1016/S0887-6185(97)00011-X
Chan, J. C., Davey, G. C., & Brewin, C. R. (2013). Understanding depressive rumina-
tion from a mood-as-input perspective: Effects of stop-rule manipulation. Behaviour
Research and Therapy, 51, 300–306. http://dx.doi.org/10.1016/j.brat.2013.02.007
Chorpita, B. F., Tracey, S. A., Brown, T. A., Collica, T. J., & Barlow, D. H. (1997). Assess-
ment of worry in children and adolescents: An adaptation of the Penn State Worry
Questionnaire. Behaviour Research and Therapy, 35, 569–581. http://dx.doi.org/
10.1016/S0005-7967(96)00116-7
Conway, M., Csank, P. A., Holm, S. L., & Blake, C. K. (2000). On assessing individual
differences in rumination on sadness. Journal of Personality Assessment, 75, 404–425.
http://dx.doi.org/10.1207/S15327752JPA7503_04
Crouch, T. A., Lewis, J. A., Erickson, T. M., & Newman, M. G. (2017). Prospective
investigation of the contrast avoidance model of generalized anxiety and worry.
Behavior Therapy, 48, 544–556. http://dx.doi.org/10.1016/j.beth.2016.10.001
Dugas, M. J., Letarte, H., Rhéaume, J., Freeston, M. H., & Ladouceur, R. (1995). Worry
and problem solving: Evidence of a specific relationship. Cognitive Therapy and Research,
19, 109–120. http://dx.doi.org/10.1007/BF02229679
Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a transdiagnostic
process. International Journal of Cognitive Therapy, 1, 192–205. http://dx.doi.org/
10.1521/ijct.2008.1.3.192
Ehring, T., Zetsche, U., Weidacker, K., Wahl, K., Schönfeld, S., & Ehlers, A. (2011). The
Perseverative Thinking Questionnaire (PTQ): Validation of a content-independent
measure of repetitive negative thinking. Journal of Behavior Therapy and Experimen-
tal Psychiatry, 42, 225–232. http://dx.doi.org/10.1016/j.jbtep.2010.12.003
Erickson, T. M., Granillo, M. T., Crocker, J., Abelson, J. L., Reas, H. E., & Quach, C. M.
(2018). Compassionate and self-image goals as interpersonal maintenance factors
in clinical depression and anxiety. Journal of Clinical Psychology, 74, 608–625. http://
dx.doi.org/10.1002/jclp.22524
Erickson, T. M., & Newman, M. G. (2007). Interpersonal and emotional processes in
generalized anxiety disorder analogues during social interaction tasks. Behavior
Therapy, 38, 364–377. http://dx.doi.org/10.1016/j.beth.2006.10.005
Erickson, T. M., Newman, M. G., Siebert, E. C., Carlile, J. A., Scarsella, G. M., & Abelson,
J. L. (2016). Does worrying mean caring too much? Interpersonal prototypicality of
dimensional worry controlling for social anxiety and depressive symptoms. Behavior
Therapy, 47, 14–28. http://dx.doi.org/10.1016/j.beth.2015.08.003
Exner, C., Martin, V., & Rief, W. (2009). Self-focused ruminations and memory deficits
in obsessive–compulsive disorder. Cognitive Therapy and Research, 33, 163–174. http://
dx.doi.org/10.1007/s10608-007-9162-x
Francis, K., & Dugas, M. J. (2004). Assessing positive beliefs about worry: Validation
of a structured interview. Personality and Individual Differences, 37, 405–415. http://
dx.doi.org/10.1016/j.paid.2003.09.012
Fresco, D. M., Frankel, A. N., Mennin, D. S., Turk, C. L., & Heimberg, R. G. (2002). Dis-
tinct and overlapping features of rumination and worry: The relationship of cogni-
tive production to negative affective states. Cognitive Therapy and Research, 26,
179–188. http://dx.doi.org/10.1023/A:1014517718949
Gladstone, G. L., Parker, G. B., Mitchell, P. B., Malhi, G. S., Wilhelm, K. A., & Austin, M. P.
(2005). A Brief Measure of Worry Severity (BMWS): Personality and clinical cor-
 Worry and Rumination 149

relates of severe worriers. Journal of Anxiety Disorders, 19, 877–892. http://dx.doi.org/

10.1016/j.janxdis.2004.11.003
Hebert, E. A., Dugas, M. J., Tulloch, T. G., & Holowka, D. W. (2014). Positive beliefs
about worry: A psychometric evaluation of the Why Worry-II. Personality and Indi-
vidual Differences, 56, 3–8. http://dx.doi.org/10.1016/j.paid.2013.08.009
Hopko, D. R., Reas, D. L., Beck, J. G., Stanley, M. A., Wetherell, J. L., Loebach, J., . . .
Averill, P. M. (2003). Assessing worry in older adults: Confirmatory factor analysis
of the Penn State Worry Questionnaire and psychometric properties of an abbre-
viated model. Psychological Assessment, 15, 173–183. http://dx.doi.org/10.1037/
1040-3590.15.2.173
Joormann, J. (2006). Differential effects of rumination and dysphoria on the inhibition
of irrelevant emotional material: Evidence from a negative priming task. Cognitive
Therapy and Research, 30, 149–160. http://dx.doi.org/10.1007/s10608-006-9035-8
Koerner, N., & Dugas, M. J. (2006). A cognitive model of generalized anxiety disorder:
The role of intolerance of uncertainty. In G. L. Davey, & A. Wells (Eds.), Worry and
its psychological disorders: Theory, assessment and treatment (pp. 201–216). Hoboken, NJ:
Wiley. http://dx.doi.org/10.1002/9780470713143.ch12
Langlois, F., Freeston, M. H., & Ladouceur, R. (2000). Differences and similarities
between obsessive intrusive thoughts and worry in a non-clinical population:
Study 1. Behaviour Research and Therapy, 38, 157–173. http://dx.doi.org/10.1016/
S0005-7967(99)00027-3
Llera, S. J., & Newman, M. G. (2010). Effects of worry on physiological and subjective
reactivity to emotional stimuli in generalized anxiety disorder and nonanxious
control participants. Emotion, 10, 640–650. http://dx.doi.org/10.1037/a0019351
Llera, S. J., & Newman, M. G. (2014). Rethinking the role of worry in generalized
anxiety disorder: Evidence supporting a model of emotional contrast avoidance.
Behavior Therapy, 45, 283–299. http://dx.doi.org/10.1016/j.beth.2013.12.011
Llera, S. J., & Newman, M. G. (2017). Development and validation of two measures of
emotional contrast avoidance: The contrast avoidance questionnaires. Journal of
Anxiety Disorders, 49, 114–127. http://dx.doi.org/10.1016/j.janxdis.2017.04.008
Lyubomirsky, S., Kasri, F., Chang, O., & Chung, I. (2006). Ruminative response styles
and delay of seeking diagnosis for breast cancer symptoms. Journal of Social and
Clinical Psychology, 25, 276–304. http://dx.doi.org/10.1521/jscp.2006.25.3.276
Lyubomirsky, S., Tucker, K. L., Caldwell, N. D., & Berg, K. (1999). Why ruminators are
poor problem solvers: Clues from the phenomenology of dysphoric rumination.
Journal of Personality and Social Psychology, 77, 1041–1060. http://dx.doi.org/10.1037/
0022-3514.77.5.1041
McEvoy, P. M., & Kingsep, P. (2006). The post-event processing questionnaire in a
clinical sample with social phobia. Behaviour Research and Therapy, 44, 1689–1697.
http://dx.doi.org/10.1016/j.brat.2005.12.005
McEvoy, P. M., Mahoney, A. E., & Moulds, M. L. (2010). Are worry, rumination, and
post-event processing one and the same? Development of the repetitive thinking
questionnaire. Journal of Anxiety Disorders, 24, 509–519. http://dx.doi.org/10.1016/
j.janxdis.2010.03.008
McLaughlin, K. A., Borkovec, T. D., & Sibrava, N. J. (2007). The effects of worry and
rumination on affect states and cognitive activity. Behavior Therapy, 38, 23–38. http://
dx.doi.org/10.1016/j.beth.2006.03.003
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and
validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy,
28, 487–495. http://dx.doi.org/10.1016/0005-7967(90)90135-6
Michael, T., Halligan, S. L., Clark, D. M., & Ehlers, A. (2007). Rumination in post­
traumatic stress disorder. Depression and Anxiety, 24, 307–317. http://dx.doi.org/
10.1002/da.20228
150 Erickson, Newman, and Tingey

Newman, M. G., & Erickson, T. M. (2010). Generalized anxiety disorder. In J. G. Beck

(Ed.), Interpersonal processes in the anxiety disorders: Implications for understanding
psychopathology and treatment (pp. 235–259). Washington, DC: American Psycholog-
ical Association. http://dx.doi.org/10.1037/12084-009
Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in gen-
eralized anxiety disorder: A review and synthesis of research supporting a contrast
avoidance model of worry. Clinical Psychology Review, 31, 371–382. http://dx.doi.org/
10.1016/j.cpr.2011.01.008
Newman, M. G., Llera, S. J., Erickson, T. M., Przeworski, A., & Castonguay, L. G. (2013).
Worry and generalized anxiety disorder: A review and theoretical synthesis of evi-
dence on nature, etiology, mechanisms, and treatment. Annual Review of Clinical Psy-
chology, 9, 275–297. http://dx.doi.org/10.1146/annurev-clinpsy-050212-185544
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of
depressive episodes. Journal of Abnormal Psychology, 100, 569–582. http://dx.doi.org/
10.1037/0021-843X.100.4.569
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed
anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504–511. http://
dx.doi.org/10.1037/0021-843X.109.3.504
Nolen-Hoeksema, S., & Davis, C. G. (1999). “Thanks for sharing that”: Ruminators and
their social support networks. Journal of Personality and Social Psychology, 77, 801–814.
http://dx.doi.org/10.1037/0022-3514.77.4.801
Nolen-Hoeksema, S., & Jackson, B. (2001). Mediators of the gender difference in
rumination. Psychology of Women Quarterly, 25, 37–47. http://dx.doi.org/10.1111/
1471-6402.00005
Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and post-
traumatic stress symptoms after a natural disaster: The 1989 Loma Prieta Earth-
quake. Journal of Personality and Social Psychology, 61, 115–121. http://dx.doi.org/
10.1037/0022-3514.61.1.115
Nolen-Hoeksema, S., & Morrow, J. (1993). Effects of rumination and distraction
on naturally occurring depressed mood. Cognition and Emotion, 7, 561–570. http://
dx.doi.org/10.1080/02699939308409206
Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumina­
tion. Perspectives on Psychological Science, 3, 400–424. http://dx.doi.org/10.1111/
j.1745-6924.2008.00088.x
Papageorgiou, C., & Wells, A. (2001). Positive beliefs about depressive rumination:
Development and preliminary validation of a self-report scale. Behavior Therapy, 32,
13–26. http://dx.doi.org/10.1016/S0005-7894(01)80041-1
Pieper, S., Brosschot, J. F., van der Leeden, R., & Thayer, J. F. (2010). Prolonged cardiac
effects of momentary assessed stressful events and worry episodes. Psychosomatic
Medicine, 72, 570–577. http://dx.doi.org/10.1097/PSY.0b013e3181dbc0e9
Ray, R. D., Ochsner, K. N., Cooper, J. C., Robertson, E. R., Gabrieli, J. D., & Gross, J. J.
(2005). Individual differences in trait rumination and the neural systems support-
ing cognitive reappraisal. Cognitive, Affective & Behavioral Neuroscience, 5, 156–168.
http://dx.doi.org/10.3758/CABN.5.2.156
Roemer, L., Molina, S., & Borkovec, T. D. (1997). An investigation of worry content
among generally anxious individuals. Journal of Nervous and Mental Disease, 185,
314–319. http://dx.doi.org/10.1097/00005053-199705000-00005
Ruscio, A. M., Borkovec, T. D., & Ruscio, J. (2001). A taxometric investigation of the
latent structure of worry. Journal of Abnormal Psychology, 110, 413–422. http://
dx.doi.org/10.1037/0021-843X.110.3.413
Segerstrom, S. C., Stanton, A. L., Flynn, S. M., Roach, A. R., Testa, J. J., & Hardy, J. K.
(2012). Episodic repetitive thought: Dimensions, correlates, and consequences. Anxiety,
Stress, and Coping, 25, 3–21. http://dx.doi.org/10.1080/10615806.2011.608126
 Worry and Rumination 151

Speckens, A. E., Hackmann, A., Ehlers, A., & Cuthbert, B. (2007). Imagery special issue:
Intrusive images and memories of earlier adverse events in patients with obsessive
compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 38,
411–422. http://dx.doi.org/10.1016/j.jbtep.2007.09.004
Startup, H. M., & Erickson, T. M. (2006). The Penn State Worry Questionnaire (PSWQ).
In G. L. Davey & A. Wells (Eds.), Worry and its psychological disorders: Theory, assess-
ment and treatment (pp. 101–119). Hoboken, NJ: Wiley. http://dx.doi.org/10.1002/
9780470713143.ch7
Stone, L. B., Hankin, B. L., Gibb, B. E., & Abela, J. R. (2011). Co-rumination predicts
the onset of depressive disorders during adolescence. Journal of Abnormal Psychol-
ogy, 120, 752–757. http://dx.doi.org/10.1037/a0023384
Sukhodolsky, D. G., Golub, A., & Cromwell, E. N. (2001). Development and validation
of the anger rumination scale. Personality and Individual Differences, 31, 689–700.
http://dx.doi.org/10.1016/S0191-8869(00)00171-9
Swann, W. B., & Read, S. J. (1981). Acquiring self-knowledge: The search for feedback
that fits. Journal of Personality and Social Psychology, 41, 1119–1128. http://dx.doi.org/
10.1037/0022-3514.41.6.1119
Szkodny, L., & Newman, M. (2017). Delineating characteristics of maladaptive repeti-
tive thought: Development and preliminary validation of the Perseverative Cogni-
tions Questionnaire. Assessment. Advance online publication. http://dx.doi.org/
10.1177/1073191117698753
Tallis, F., Davey, G. L., & Bond, A. (1994). The Worry Domains Questionnaire. In G. L.
Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment and treatment
(pp. 285–297). Oxford, England: John Wiley & Sons.
Trapnell, P. D., & Campbell, J. D. (1999). Private self-consciousness and the five-factor
model of personality: Distinguishing rumination from reflection. Journal of Personal-
ity and Social Psychology, 76, 284–304. http://dx.doi.org/10.1037/0022-3514.76.2.284
Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A
psychometric analysis. Cognitive Therapy and Research, 27, 247–259. http://dx.doi.org/
10.1023/A:1023910315561
Watkins, E., & Baracaia, S. (2002). Rumination and social problem-solving in depres-
sion. Behaviour Research and Therapy, 40, 1179–1189. http://dx.doi.org/10.1016/
S0005-7967(01)00098-5
Wells, A. (2006). The anxious thoughts inventory and related measures of metacogni-
tion and worry. In G. L. Davey & A. Wells (Eds.), Worry and its psychological disorders:
Theory, assessment and treatment (pp. 121–136). Hoboken, NJ: Wiley. http://dx.doi.org/
10.1002/9780470713143.ch8
Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions ques-
tionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42, 385–396.
http://dx.doi.org/10.1016/S0005-7967(03)00147-5
Yang, M.-J., Kim, B.-N., Lee, E.-H., Lee, D., Yu, B.-H., Jeon, H. J., & Kim, J.-H. (2014).
Diagnostic utility of worry and rumination: A comparison between generalized
anxiety disorder and major depressive disorder. Psychiatry and Clinical Neurosciences,
68, 712–720. http://dx.doi.org/10.1111/pcn.12193
9
Perfectionism
Ariella P. Lenton-Brym and Martin M. Antony

Agnes started a competitive master’s degree program and was struggling to

adjust to its demands. Last year, she aimed to not only earn top grades but
also publish several manuscripts, conduct an independent research study, and
take on a student mentoring position. Agnes felt that it was absolutely neces-
sary to achieve these goals; however, each time she met one, she discounted
its importance and “raised the bar” for success. For example, after publishing
a manuscript, Agnes felt that she took too long to complete it and worried that
she should be producing more articles and publishing them in more presti-
gious journals. Despite her academic success, Agnes also worried about class
performance. After giving presentations, she ruminated and harshly criticized
herself for minor mistakes, telling herself that she ruined the presentation
because she stumbled over a few words. She also worried about her super­
visor’s expectations, believing that he expected her work to be perfect. As a
result, she felt overwhelmed about her master’s thesis and repeatedly delayed
working on it. She started to fall behind schedule and felt like a failure.1

Many people set high standards for their own performance—doing so may
help them to maintain goal-focused attention and provide motivation when
obstacles to their success arise. However, as seen in the case of Agnes, issues
begin when people (a) set standards that are impossibly high, (b) rigidly
pursue those standards even when they cause harm to the self, and (c) feel
dissatisfied even after the standards are seemingly met. Together, these ten-
dencies reflect what is sometimes referred to as clinical perfectionism, although

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-009
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
153
154 Lenton-Brym and Antony

there is disagreement in the literature about how best to define this construct.
This section provides a brief overview of extant definitions.

Unidimensional Versus Multidimensional Definitions

Early definitions reflect a unidimensional understanding of perfectionism.

Burns (1980) defined perfectionism as the tendency to hold unrealistically
high standards, strive toward them unremittingly, and estimate one’s worth
based solely on achievement. In the 1990s, however, researchers recognized
that (a) individuals with perfectionism expressed concerns spanning various
domains, and (b) interpersonal features of perfectionism were not being
captured by unidimensional definitions (Frost, Marten, Lahart, & Rosenblate,
1990; Hewitt & Flett, 1991). Frost et al. (1990) proposed six dimensions of
perfectionism: personal standards, organization, concern over mistakes, doubts
about actions, parental expectations, and parental criticism. Hewitt and Flett
(1991) proposed three dimensions: self-oriented perfectionism (i.e., setting
high standards for oneself), other-oriented perfectionism (i.e., holding others to
perfectionistic standards), and socially prescribed perfectionism (i.e., believing
that others have unrealistic standards for us). Research supporting the multi-
dimensional approach has shown that different dimensions relate differentially
to various forms of psychopathology and maladaptive personality traits. Not
all studies, however, support the multidimensional view, and some research
groups have argued that certain dimensions of perfectionism reflect correlates
of the construct rather than features of perfectionism itself (e.g., Shafran,
Cooper, & Fairburn, 2002; Stöber, 1998).

Adaptive Versus Maladaptive Perfectionism

Factor analytic research suggests a distinction between adaptive and mal-

adaptive perfectionism (Bieling, Israeli, & Antony, 2004; Cox, Enns, & Clara,
2002; Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). Despite some variation
in terminology and specific study findings, adaptive perfectionism is consistently
thought to include self-oriented perfectionism and positive striving, whereas
maladaptive perfectionism consistently comprises concern over mistakes, doubts
about actions, and socially prescribed perfectionism (Dunkley, Blankstein,
Masheb, & Grilo, 2006). Of these two forms of perfectionism, the maladaptive
type is more strongly related to anxiety and depression (e.g., Dunkley et al.,
2006; Stoeber & Otto, 2006). Adaptive perfectionism, in contrast, is either
unrelated or inversely related to psychological distress (Antony, Purdon,
Huta, & Swinson, 1998; Chang, Watkins, & Banks, 2004; Enns & Cox, 1999)
and is associated with positive outcomes including feelings of pride, self-
compassion, and optimism (Fedewa, Burns, & Gomez, 2005; Lizmore, Dunn,
& Causgrove Dunn, 2017), problem-focused coping (Dunkley, Blankstein,
Halsall, Williams, & Winkworth, 2000), reduced self-defeating behavior
 Perfectionism 155

(Bieling, Israeli, Smith, & Antony, 2003), and greater task-focused attention
(Rhéaume et al., 2000).
Some have criticized this dichotomous model of perfectionism on the
grounds that it (a) equates adaptive perfectionism with conscientiousness
and (b) overstates the adaptiveness of perfectionism (Flett & Hewitt, 2006).
Indeed, some components of adaptive perfectionism are associated with low
self-satisfaction (e.g., Enns, Cox, Sareen, & Freeman, 2001; Mor, Day, Flett,
& Hewitt, 1995), eating disorders (e.g., Castro-Fornieles et al., 2007), self-
punitiveness, depression (Hull, Lehn, & Tedlie, 1991), and suicidality (Smith
et al., 2018). Thus, Gaudreau and Thompson (2010) proposed that personal
striving (adaptive) and evaluative concerns (maladaptive) reflect coexisting
dimensions of perfectionism, rather than opposite sides of the same coin.
Research on this model suggests that elevated tendencies toward both
dimensions are more adaptive than elevated evaluative concerns alone.

Cognitive Behavior Definition of Perfectionism

Shafran et al. (2002) proposed an alternative to the multidimensional

approach previously described. These authors emphasized the setting of high
standards and the belief that one’s self-worth is contingent on attainment of
such standards. Standards need only be demanding for the individual (i.e., not
necessarily objectively demanding), and perfectionism may be restricted to
specific domains of life that hold personal relevance for the individual. In
this model, the core psychopathology of perfectionism is thought to catalyze
various maladaptive processes, including adopting all-or-nothing indications
of success (e.g., “If I mispronounce one word, I have failed”), exercising strin-
gent self-control, and critically evaluating one’s own performance in a biased
manner (i.e., by assigning more weight to indications of failure than to indi-
cations of success). This conceptualization reflects a trade-off in the difficult
task of defining perfectionism: by providing a streamlined definition, Shafran
et al. did not capture the maladaptive standards that perfectionistic individuals
may hold for others, which may be important information to garner in a clinical
setting where such standards may give rise to interpersonal problems.

Perfectionism as a Transdiagnostic Process

Evidence also supports the conceptualization of perfectionism as a trans­

diagnostic process; perfectionism serves as a risk factor or maintaining
mechanism of various psychological disorders, and therapeutic interventions
aimed at reducing perfectionism have been shown to reduce psychopathology
across these disorders (see Egan, Wade, & Shafran, 2011, for a review). The
transdiagnostic approach is also thought to help explain the comorbidity of
psychological disorders by recognizing the existence of shared maintaining
mechanisms, such as perfectionism, that are common among them (Harvey,
Watkins, Mansell, & Shafran, 2004).
156 Lenton-Brym and Antony

Perfectionism in Obsessive-Compulsive Personality Disorder

Perfectionism is a core feature of obsessive-compulsive personality disorder

(OCPD), although in this context perfectionism differs from that described
thus far. Individuals with OCPD tend to be preoccupied with details, rules,
and organization, often to the extent that it interferes with task completion
(American Psychiatric Association, 2013). Perfectionism in this context allows
individuals with OCPD to gain a sense of control, which as discussed later
is also an important process in understanding perfectionism in obsessive-
compulsive disorder (OCD).

CONCEPTUAL IMPLICATIONS

Perfectionism, in its various forms, is associated with correlates of anxious

psychopathology, such as stress, avoidant coping, and social factors (Burgess &
DiBartolo, 2016; Dunkley et al., 2000). Moreover, perfectionistic beliefs appear
to play a role in generating anxiety. In this section, we provide an overview
of how anxious psychopathology is maintained by problem perfectionism.

Stress

Cognitive approaches to understanding psychological stress (e.g., Lazarus

& Folkman, 1984) purport that when people are confronted with stressors,
they make appraisals about whether those stressors are relevant or threat-
ening to their well-being, and simultaneously evaluate their ability to cope
(Dunkley et al., 2000). In turn, these appraisals dictate the extent to which
stressors negatively influence the individual. Individuals high in maladaptive
perfectionism tend to interpret challenging situations as having high stakes
for their personal well-being, as even minor mistakes are taken as indica-
tions of personal failure (Burgess & DiBartolo, 2016). Consequently, indi-
viduals with elevated perfectionism may have a low threshold for perceiving
life events as highly stressful. Returning to the case of Agnes, while class
presentations are nerve-wracking for many students, Agnes experienced
more intense stress in anticipation of her presentation precisely because it
was a particularly high stakes scenario; her self-evaluation was contingent
on its success.
Ample research has supported the mediating role of stress in the relationship
between maladaptive perfectionism and various indicators of psychological
maladjustment, including increased suicide ideation, negative affect, and
depressive symptoms, as well as reduced positive affect and life satisfaction
(Ashby, Noble, & Gnilka, 2012; Chang et al., 2004). With respect to anxiety in
particular, Dunkley et al. (2000) found that the frequency and duration with
which participants experienced daily stressors (“hassles”) mediated the relation-
ship between maladaptive perfectionism and anxious (as well as depressive)
symptoms.
 Perfectionism 157

Coping

When faced with challenges, individuals with maladaptive perfectionism

tend to display a “helplessness orientation,” exhibiting a tendency to give up
or avoid the situation and feel inadequate as a result (Flett, Russo, & Hewitt,
1994). Specifically, socially prescribed perfectionism is associated with
increased reliance on maladaptive emotion-focused coping (Hewitt, Flett,
& Endler, 1995), lower ratings of problem-solving self-efficacy, reduced use
of constructive coping techniques, and greater use of negative coping tech-
niques (Flett et al., 1994). Maladaptive perfectionism is also associated with
the tendency to procrastinate, which may be seen as a form of avoidant
coping through which one evades imperfect performance or potential failure
(Frost et al., 1990).
Several studies have found that avoidant coping mediates the relationship
between maladaptive perfectionism and anxiety (e.g., Weiner & Carton, 2012).
Avoidant coping, involving denial and behavioral disengagement, has been
shown to exacerbate anxiety both directly and indirectly by increasing stress
(Dunkley et al., 2000). The case of Agnes demonstrates how this process
plays out: Each time she tried to work on her thesis, Agnes quickly felt over-
whelmed and began thinking that she was not smart enough to produce a
result that would meet her supervisor’s standards. Instead of devoting energy
to the task at hand, Agnes felt stressed and shut down her computer. Later,
she felt anxious that she was falling behind schedule, and told herself that she
was a failure.

Perception of Reduced Social Support and Social Feedback

Interpersonal models of psychopathology suggest that the presence of social

support positively influences psychological well-being, whereas the absence
of social support has deleterious psychological consequences. Social support
may improve well-being by offering positive experiences in people’s lives,
as well as by bolstering the perception that one is able to cope when faced
with stress. Despite some inconsistent findings (e.g., Zhou, Zhu, Zhang, & Cai,
2013), several studies have shown that maladaptive perfectionism is associ-
ated with the tendency to feel lonely and believe that one has reduced social
support. The reasons for this are not entirely clear. One suggestion is that
individuals with elevated perfectionism are so focused on achieving high
standards that they have difficulty maintaining interpersonal relationships
(Chang, Sanna, Chang, & Bodem, 2008). No studies, however, have found
an association between self-oriented perfectionism (which involves setting
high standards) and perceived social support. Alternatively, some individuals
may have unreasonably high standards for their peers (i.e., other-oriented
perfectionism), and as a result feel perpetually dissatisfied with the level of
support provided by interpersonal relationships. Regardless of the mechanism
by which perfectionism gives rise to the perception of reduced social support,
feelings of loneliness and the belief that one will not have sufficient support
158 Lenton-Brym and Antony

in times of stress have been shown to perpetuate symptoms of anxiety,

depression, and psychosocial impairment (Dunkley et al., 2000; Chang et al.,
2008; Sherry, Law, Hewitt, Flett, & Besser, 2008).
In addition to the perception of reduced social support, receiving negative
social feedback is also associated with increased symptoms of anxiety and
depression. Importantly, socially prescribed perfectionism is associated with
more frequent negative social interactions (Flett, Hewitt, Garshowitz, &
Martin, 1997), and studies have shown that negative social feedback and inter-
personal rumination (i.e., the extent to which people reflect on perceived
social transgressions) mediate the relationship between socially prescribed
perfectionism and social anxiety (Nepon, Flett, Hewitt, & Molnar, 2011).

Cognitive Factors

Maladaptive perfectionism is associated with cognitive factors that give rise

to and maintain anxiety. For example, when feeling down, individuals with
elevated socially prescribed and self-oriented perfectionism tend to (a) adopt
a ruminative response style characterized by focusing on one’s own sadness,
(b) criticize oneself, and (c) compare one’s situation to an unachieved standard
(Treynor, Gonzalez, & Nolen-Hoeksema, 2003). This response style in turn
contributes to and maintains generalized anxiety, anxious arousal, depres-
sion, and feelings of hopelessness (O’Connor, O’Connor, & Marshall, 2007).
Research has also shown that core beliefs that reflect perfectionistic striving
(e.g., “My work should be flawless”) are highly susceptible to negative,
self-relevant automatic thoughts (e.g., “I’m a failure”), and that the experience
of these negative automatic thoughts contributes to symptoms of anxiety and
depression (Pirbaglou et al., 2013). In Agnes’s case, as she considered her desire
to produce a perfect master’s thesis, her thoughts quickly became negative.
She worried she would let down her supervisor and that her peers would
produce better work than she could, which led to feelings of anxiety and
sadness.

ASSESSMENT

Clinical Interviews

Guidelines for Interviewing

Egan, Wade, Shafran, and Antony (2014) provided an overview of core areas
to assess during a clinical interview, including the triggers for an individual’s
perfectionistic thoughts, behavioral and cognitive features as described earlier
(e.g., rigidly held demands on oneself and others, extreme standards), physio-
logical responses, environmental factors that contribute to one’s perfectionistic
tendencies, and domains of perfectionism (e.g., work, relationships). They also
recommend assessing the impact of perfectionism (e.g., distress, impairment),
and the development and course of the problem.
 Perfectionism 159

Clinical Perfectionism Examination

The Clinical Perfectionism Examination (Riley, Lee, Cooper, Fairburn, &
Shafran, 2007) is a 12-item semistructured interview designed to assess
clinical perfectionism severity. Initial findings suggest good test–retest reli-
ability, interrater reliability, and internal consistency. It has also demonstrated
adequate convergent validity, correlating moderately with self-report scales
described below.

Self-Report Measures

Clinicians may choose from numerous self-report tools that have been designed
to assess perfectionism and related constructs (for a review, see Egan et al.,
2014). This section describes two commonly used multidimensional perfec-
tionism scales, as well as an additional measure that may be particularly useful
for measuring perfectionism in clinical settings.

Multidimensional Perfectionism Scale

The Multidimensional Perfectionism Scale (FMPS; Frost et al., 1990) is a
35-item scale that is widely used to measure perfectionism along six dimen-
sions: concern over mistakes (e.g., “I should be upset if I make a mistake”),
doubts about actions (e.g., “Even when I do something very carefully, I often
feel that it is not quite right”), personal standards (e.g., “I have extremely
high goals”), parental expectations (e.g., “My parents have expected excel-
lence from me”), parental criticism (e.g., “As a child, I was punished for doing
things less than perfectly”), and organization (“Neatness is very important to
me”). Items are scored on a 5-point Likert scale, allowing the calculation of
subtotals for each dimension as well as a total for the whole scale (excluding
organization, which correlates weakly with the other dimensions). However,
because the subscales seem to measure different constructs, the total score for
all subscales is unlikely to be meaningful. The FMPS subscales have generally
demonstrated good-to-excellent reliability and good concurrent validity, cor-
relating with other measures of perfectionism (Frost et al., 1990). A limitation
is that the FMPS was developed on an all-female sample of undergraduate
students, and follow-up studies on more diverse samples have questioned the
original factorial structure (e.g., Cox et al., 2002; Purdon, Antony, & Swinson,
1999; Stöber, 1998).

Hewitt and Flett Multidimensional Perfectionism Scale

The Hewitt and Flett Multidimensional Perfectionism Scale (HMPS; Hewitt &
Flett, 1991) consists of 45 items measuring three subscales: (a) self-oriented
perfectionism, (b) other-oriented perfectionism, and (c) socially prescribed
perfectionism. The three trait dimensions have adequate to good internal
consistency and temporal stability. Established associations between the
HMPS subscales and clinician ratings, as well as correlations between the
subscales and theoretically similar constructs, provide evidence of concurrent
160 Lenton-Brym and Antony

validity (Hewitt & Flett, 1991; Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991).
Two shorter, 15-item versions of the HMPS have also demonstrated similar
psychometric characteristics (Cox et al., 2002; Hewitt, Habke, Lee-Baggley,
Sherry, & Flett, 2008).

Clinical Perfectionism Questionnaire

The Clinical Perfectionism Questionnaire (CPQ) was designed to measure the
unidimensional construct of clinical perfectionism proposed in Shafran et al.’s
(2002) cognitive behavior model. Its 12 items assess cognitive, behavioral,
and affective components of goals striving and the consequences of failure to
meet one’s goals (Riley et al., 2007), and there is one open-ended question in
which participants describe the domains of life in which they set high stan-
dards. The CPQ is particularly applicable to clinical settings because it asks
about patients’ experiences only over the past month, so it can be used to assess
change over the course of treatment. Despite its intention to measure a uni-
dimensional construct, studies suggest that the CPQ has two factors, capturing
perfectionistic strivings and perfectionistic concerns (Dickie, Surgenor, Wilson,
& McDowall, 2012; Stoeber & Damian, 2014). These dimensions broadly map
onto the adaptive versus maladaptive perfectionism distinction discussed pre-
viously. Evidence for the internal consistency of the CPQ has been adequate
to good in studies with large sample sizes, and the scale correlates with other
measures of perfectionism and negative affect, demonstrating convergent
validity (e.g., Chang & Sanna, 2012).

Measuring Specific Domains of Perfectionism

Self-report measures also exist for measuring perfectionism in the contexts of

specific relationships, including romantic relationships, parenting, and families,
as well as in specific domains, including body image and sports performance.
Various measures also exist for the assessment of perfectionism in children
and adolescents (see Egan et al., 2014, for a comprehensive overview of
self-report measures).

CLINICAL IMPLICATIONS

Social Anxiety Disorder

The core fears in social anxiety disorder (SAD; i.e., fears of negative evalu-
ation by others) overlap with interpersonal dimensions of perfectionism
such as perfectionistic concerns about failing to meet others’ expectations.
Unsurprisingly, there is an association between maladaptive perfectionism
and social anxiety (Juster et al., 1996), and individuals with SAD score higher
on some features of maladaptive perfectionism than those with OCD, panic
disorder (PD), and nonclinical volunteers (e.g., Antony et al., 1998). In
contrast, social anxiety is unrelated to features of adaptive perfectionism,
 Perfectionism 161

including personal standards and self-oriented perfectionism (Antony et al.,

1998; Nepon et al., 2011; Santanello & Gardner, 2007). Moreover, social anxiety
longitudinally predicts increases in self-critical perfectionism (but not the
converse), shedding light on the directionality of the relationship (Gautreau,
Sherry, Mushquash, & Stewart, 2015).

Standards
Individuals with SAD who are high in perfectionism hold themselves to
unrealistic standards for social performance (Juster et al., 1996). For example,
beliefs that one must be funny, speak eloquently, and appear relaxed in social
settings might lead to avoidant and overcompensatory behaviors that maintain
social anxiety (Egan et al., 2014). Not all research findings, however, support
this idea, and some even suggest lower self-standards among socially anxious
individuals (e.g., Wallace & Alden, 1997). Thus, perhaps socially anxious indi-
viduals do not set high standards for their own social performance, but do tend
to believe that they fail to meet others’ expectations of them and feel personally
inadequate as a result.

Perfectionistic Self-Presentation
Flett and Hewitt (2014) emphasized the importance of perfectionistic self-
presentation (PSP; Hewitt et al., 2003) in social anxiety. PSP can be distin-
guished from dimensions of trait perfectionism in that it involves a drive to
appear, rather than be, perfect. Someone with social anxiety and perfectionism
might take considerable effort to present oneself as perfect and may try to
cover up or not mention their mistakes to others. One way that socially
anxious individuals express PSP is by hiding the effort that it takes to achieve
their perfectionistic ideals (Flett, Nepon, Hewitt, Molnar, & Zhao, 2016). For
example, after giving a successful presentation, one might tell their classmates
that they barely practiced, despite hours of rehearsal the night before.

Perfectionistic Cognitions
We have seen that perfectionism is associated with negative automatic thoughts
and rumination about perceived failures and the need to be perfect. Flett and
Hewitt (2014) proposed that perfectionistic automatic thoughts contribute to
social anxiety in part by exacerbating negative views of the self and making it
more likely that socially anxious individuals will perceive deficits in their own
social behavior. They also proposed that such individuals tend to ruminate
about past social blunders and worry about anticipated future ones. This
tendency to engage in postevent and anticipatory processing is reflected in
widely accepted cognitive behavior models of social anxiety disorder (e.g., Clark
& Wells, 1995), and it follows that these tendencies would be exacerbated
in socially anxious individuals with perfectionism given that perfectionism
involves preoccupation with mistakes. This cognitive preoccupation is thought
to undermine the ability to perform well in social situations—both by diverting
attention from relevant social cues and by reducing confidence in the ability
to perform well.
162 Lenton-Brym and Antony

Obsessive-Compulsive Disorder

The importance of perfectionism in understanding OCD has long been recog-

nized in theoretical and clinical descriptions of the disorder (Frost & Steketee,
1997). Perfectionism has been recognized as one of three primary domains of
cognitions in OCD (Obsessive Compulsive Cognitions Working Group, 2005)
and has been described as a risk factor for the development of OCD (Rasmussen
& Eisen, 1989).

Control and Harm Avoidance

Individuals with OCD tend to experience a reduced sense of control over their
thoughts and environment, as well as an increased desire to control situations
(Moulding & Kyrios, 2007). This pattern has been associated with negative
psychological outcomes, including anxiety. Some authors have described
perfectionism as a means through which individuals with OCD attain their
desired level of control in order to reduce the risk of perceived harm, a pro-
cess that may be especially relevant to contamination obsessions and cleaning
compulsions (Frost & Steketee, 2002; Moulding & Kyrios, 2007). Specifically,
individuals who experience such obsessions commonly believe that germs or
other infectious substances will cause them serious harm and often describe
feelings of lack of control over further contamination that might arise there-
after (e.g., believing that the contamination will spread across their body or
be transmitted to other people; Rachman, 2004). By compulsively sanitizing
one’s hands after touching any potentially contaminated surface until a perfect
sense of cleanliness is achieved, an individual might feel that he or she has
exerted control by reducing the risk of harm that the environment posed.

Incompleteness and Not-Just-Right Obsessions

Some individuals with OCD perform compulsive rituals in response to “not
just right experiences” (NJREs), during which they experience dissatisfaction
or discomfort with their current state, coupled with the sense that their
actions, environments, or perceptions are incomplete or imperfect (Coles,
Frost, Heimberg, & Rhéaume, 2003; Summerfeldt, Kloosterman, Antony, &
Swinson, 2014). NJREs reflect a unique form of “sensation-based” or “sensory”
perfectionism, wherein perceived mismatches between one’s perceptual input
and expectations are experienced as distressing (Pitman, 1987). Moreover,
the prolonged experience of aversive sensory experiences in this context
might lead to perfectionistic cognitions. For example, someone continually
bothered by the sensation that things are not just right might, over time,
come to believe that there “must be a perfect way to do things” (Summerfeldt
et al., 2014).

Completing Compulsions Perfectly

Individuals with OCD who are high in perfectionism often set strict rules
for how they must complete compulsive rituals (Egan et al., 2014). Take, for
example, a woman who fears that a fire will start if she does not check the
 Perfectionism 163

appliances in her kitchen before leaving the house. To reduce this anxiety-
provoking thought, she has a highly ritualized routine that involves checking
the stove followed by the oven, and then moving to the living room to check
the iron, and finally to the bathroom to check hair appliances. This routine
must be completed three times, in this specific order, before she feels confident
that all appliances are off and she will not be responsible for starting a fire.
If her routine is interrupted, she must restart the ritual from the beginning, as
it must be completed “perfectly” in order for it to be effective.

Panic Disorder and Agoraphobia

Individuals with PD report elevated perfectionism in the form of concerns about

mistakes, doubts about actions, parental criticism, and personal standards
(e.g., Antony et al., 1998). Interestingly, individuals with PD with agoraphobia
score higher than individuals with PD without agoraphobia on several of these
factors, suggesting that perfectionism may be an important feature in under-
standing the onset and maintenance of agoraphobia among individuals with PD
(Iketani et al., 2002).
Individuals with PD sometimes hold the belief that they must remain in
control of their emotional experiences at all times (Egan et al., 2014); con-
sequently, if they experience any symptoms of anxiety, they may believe that
they have failed at meeting this standard. Such high standards for emotional
control may interact with the catastrophic misinterpretations of arousal-related
body sensations that are common in PD, perhaps leading to perceiving such
sensations as indications of weakness and the inability to stay in control. These
thoughts might further reinforce the perfectionistic belief that it is necessary
to maintain complete emotional control at all times (Egan et al., 2014).
Perfectionism may also manifest in PD and agoraphobia in the tendency to
avoid situations in which experiencing panic is possible. For example, indi-
viduals with agoraphobia often report that they would be less inclined to
avoid feared situations (e.g., taking public transportation, being in a crowded
place) if they could be guaranteed that they would not panic. Iketani et al.
(2002) suggested that the requirement that one must be firmly convinced
that one will not panic in order to enter a given situation can be seen as a
perfectionistic tendency. Presumably, this perfectionistic belief may perpetuate
anxiety by encouraging or justifying avoidant behaviors.

Generalized Anxiety Disorder

The role of perfectionism in generalized anxiety disorder (GAD) has received

relatively little attention, although worry, the key feature of GAD, has been
shown to be associated with some aspects of perfectionism (e.g., Santanello
& Gardner, 2007). Intolerance of uncertainty, another important feature of
GAD, is also correlated with self-oriented perfectionism and socially prescribed
perfectionism (Buhr & Dugas, 2006). Moreover, one study showed that among
a sample of individuals seeking treatment for perfectionism, concern over
164 Lenton-Brym and Antony

mistakes and personal standards predicted pathological worry in individuals

with GAD, and doubts about actions was associated with having a GAD diag-
nosis (Handley, Egan, Kane, & Rees, 2014).
Santanello and Gardner (2007) found that maladaptive perfectionism leads
people to avoid uncomfortable internal experiences (e.g., bodily sensations and
negative emotions) by trying to suppress these experiences or avoid events
that might give rise to them, a phenomenon known as experiential avoidance
(Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; also see Chapter 7 of this
handbook). Experiential avoidance, in turn, has been shown to exacerbate
worry (Roemer, Salters, Raffa, & Orsillo, 2005; Santanello & Gardner, 2007).
Individuals who worry also demonstrate elevated “evidence requirements”
(Stöber & Joormann, 2001; Tallis, Eysenck, & Mathews, 1991), requiring
greater certainty about the correctness of their decisions before acting on
them—a tendency that may be exacerbated by perfectionism, including con-
cern over mistakes and doubts about actions (Stöber & Joormann, 2001).
Finally, while some research supports an association between worry and per-
sonal standards, Stöber and Joormann (2001) found that worriers report
lower personal standards when faced with stress. Accordingly, more work is
needed to understand the role of personal standards perfectionism in GAD.

CONCLUSION

Perfectionism is a transdiagnostic phenomenon observed across a range of

psychological conditions, most notably among individuals with clinical anxiety.
We have provided an overview of this phenomenon, its assessment, and a
discussion of how perfectionism serves as a maintenance factor in various
forms of clinical anxiety. Perfectionism is a multifaceted construct that inter-
acts with anxiety in different ways, often depending on the particular presen-
tation of anxiety, or anxiety disorder. It is our aim that this chapter will help
clinicians recognize when their patients’ anxiety is exacerbated by perfection-
istic behaviors or beliefs, so that these tendencies can be addressed as part of
an integrated treatment plan.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Antony, M. M., Purdon, C. L., Huta, V., & Swinson, R. P. (1998). Dimensions of
perfectionism across the anxiety disorders. Behaviour Research and Therapy, 36,
1143–1154. http://dx.doi.org/10.1016/S0005-7967(98)00083-7
Ashby, J. S., Noble, C. L., & Gnilka, P. B. (2012). Multidimensional perfectionism,
depression, and satisfaction with life: Differences among perfectionists and tests of a
stress-mediation model. Journal of College Counseling, 15, 130–143. http://dx.doi.org/
10.1002/j.2161-1882.2012.00011.x
Bieling, P. J., Israeli, A. L., & Antony, M. M. (2004). Is perfectionism good, bad, or
both? Examining models of the perfectionism construct. Personality and Individual
Differences, 36, 1373–1385. http://dx.doi.org/10.1016/S0191-8869(03)00235-6
 Perfectionism 165

Bieling, P. J., Israeli, A., Smith, J., & Antony, M. M. (2003). Making the grade: The
behavioural consequences of perfectionism in the classroom. Personality and Indi-
vidual Differences, 35, 163–178. http://dx.doi.org/10.1016/S0191-8869(02)00173-3
Buhr, K., & Dugas, M. J. (2006). Investigating the construct validity of intolerance of
uncertainty and its unique relationship with worry. Journal of Anxiety Disorders, 20,
222–236. http://dx.doi.org/10.1016/j.janxdis.2004.12.004
Burgess, A. M., & DiBartolo, P. M. (2016). Anxiety and perfectionism: Relationships,
mechanisms, and conditions. In F. M. Sirois & D. S. Molnar (Eds.), Perfectionism,
health, and well-being (pp. 177–203). New York, NY: Springer. http://dx.doi.org/
10.1007/978-3-319-18582-8_8
Burns, D. D. (1980). The perfectionist’s script for self-defeat. Psychology Today, 14,
34–52.
Castro-Fornieles, J., Gual, P., Lahortiga, F., Gila, A., Casulà, V., Fuhrmann, C., . . . Toro, J.
(2007). Self-oriented perfectionism in eating disorders. International Journal of
Eating Disorders, 40, 562–568. http://dx.doi.org/10.1002/eat.20393
Chang, E. C., & Sanna, L. J. (2012). Evidence for the validity of the Clinical Per­
fectionism Questionnaire in a nonclinical population: More than just negative
affectivity. Journal of Personality Assessment, 94, 102–108. http://dx.doi.org/10.1080/
00223891.2011.627962
Chang, E. C., Sanna, L. J., Chang, R., & Bodem, M. R. (2008). A preliminary look at
loneliness as a moderator of the link between perfectionism and depressive and
anxious symptoms in college students: Does being lonely make perfectionistic
strivings more distressing? Behaviour Research and Therapy, 46, 877–886. http://
dx.doi.org/10.1016/j.brat.2008.03.012
Chang, E. C., Watkins, A., & Banks, K. H. (2004). How adaptive and maladaptive
perfectionism relate to positive and negative psychological functioning: Testing a
stress-mediation model in Black and White female college students. Journal of
Counseling Psychology, 51, 93–102. http://dx.doi.org/10.1037/0022-0167.51.1.93
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg,
M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis,
assessment, and treatment (pp. 69–93). New York, NY: Guilford Press.
Coles, M. E., Frost, R. O., Heimberg, R. G., & Rhéaume, J. (2003). “Not just right
experiences”: Perfectionism, obsessive–compulsive features and general psycho­
pathology. Behaviour Research and Therapy, 41, 681–700. http://dx.doi.org/10.1016/
S0005-7967(02)00044-X
Cox, B. J., Enns, M. W., & Clara, I. P. (2002). The multidimensional structure of perfec-
tionism in clinically distressed and college student samples. Psychological Assessment,
14, 365–373. http://dx.doi.org/10.1037/1040-3590.14.3.365
Dickie, L., Surgenor, L. J., Wilson, M., & McDowall, J. (2012). The structure and
reliability of the Clinical Perfectionism Questionnaire. Personality and Individual
Differences, 52, 865–869. http://dx.doi.org/10.1016/j.paid.2012.02.003
Dunkley, D. M., Blankstein, K. R., Halsall, J., Williams, M., & Winkworth, G. (2000).
The relation between perfectionism and distress: Hassles, coping, and perceived
social support as mediators and moderators. Journal of Counseling Psychology, 47,
437–453. http://dx.doi.org/10.1037/0022-0167.47.4.437
Dunkley, D. M., Blankstein, K. R., Masheb, R. M., & Grilo, C. M. (2006). Personal
standards and evaluative concerns dimensions of “clinical” perfectionism: A reply
to Shafran et al. (2002, 2003) and Hewitt et al. (2003). Behaviour Research and
Therapy, 44, 63–84. http://dx.doi.org/10.1016/j.brat.2004.12.004
Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process:
A clinical review. Clinical Psychology Review, 31, 203–212. http://dx.doi.org/10.1016/
j.cpr.2010.04.009
Egan, S. J., Wade, T. D., Shafran, R., & Antony, M. M. (2014). Cognitive-behavioral treat-
ment of perfectionism. New York, NY: Guilford Press.
166 Lenton-Brym and Antony

Enns, M. W., & Cox, B. J. (1999). Perfectionism and depression symptom severity in
major depressive disorder. Behaviour Research and Therapy, 37, 783–794. http://
dx.doi.org/10.1016/S0005-7967(98)00188-0
Enns, M. W., Cox, B. J., Sareen, J., & Freeman, P. (2001). Adaptive and maladaptive
perfectionism in medical students: A longitudinal investigation. Medical Education,
35, 1034–1042. http://dx.doi.org/10.1111/j.1365-2923.2001.01044.x
Fedewa, B. A., Burns, L. R., & Gomez, A. A. (2005). Positive and negative perfection-
ism and the shame/guilt distinction: Adaptive and maladaptive characteristics.
Personality and Individual Differences, 38, 1609–1619. http://dx.doi.org/10.1016/
j.paid.2004.09.026
Flett, G. L., & Hewitt, P. L. (2006). Positive versus negative perfectionism in psycho­
pathology: A comment on Slade and Owens’s dual process model. Behavior Modifi-
cation, 30, 472–495. http://dx.doi.org/10.1177/0145445506288026
Flett, G. L., & Hewitt, P. L. (2014). Perfectionism and perfectionistic self-presentation
in social anxiety: Implications for assessment and treatment. In S. G. Hofmann &
P. M. DiBartolo (Eds.), Social anxiety: Clinical, developmental, and social perspectives
(3rd ed., pp. 159–187). Amsterdam, The Netherlands: Elsevier. http://dx.doi.org/
10.1016/B978-0-12-394427-6.00007-8
Flett, G. L., Hewitt, P. L., Garshowitz, M., & Martin, T. R. (1997). Personality, negative
social interactions, and depressive symptoms. Canadian Journal of Behavioural
Science/Revue canadienne des sciences du comportemen, 29, 28–37. http://dx.doi.org/
10.1037/0008-400X.29.1.28
Flett, G. L., Nepon, T., Hewitt, P. L., Molnar, D. S., & Zhao, W. (2016). Projecting
perfection by hiding effort: Supplementing the perfectionistic self-presentation
scale with a brief self-presentation measure. Self and Identity, 15, 245–261. http://
dx.doi.org/10.1080/15298868.2015.1119188
Flett, G. L., Russo, F. A., & Hewitt, P. L. (1994). Dimensions of perfectionism and
constructive thinking as a coping response. Journal of Rational–Emotive & Cognitive–
Behavior Therapy, 12, 163–179. http://dx.doi.org/10.1007/BF02354594
Frost, R. O., Heimberg, R. G., Holt, C. S., Mattia, J. I., & Neubauer, A. L. (1993).
A comparison of two measures of perfectionism. Personality and Individual Differ-
ences, 14, 119–126. http://dx.doi.org/10.1016/0191-8869(93)90181-2
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfec-
tionism. Cognitive Therapy and Research, 14, 449–468. http://dx.doi.org/10.1007/
BF01172967
Frost, R. O., & Steketee, G. (1997). Perfectionism in obsessive–compulsive disorder
patients. Behaviour Research and Therapy, 35, 291–296. http://dx.doi.org/10.1016/
S0005-7967(96)00108-8
Frost, R. O., & Steketee, G. (Eds.). (2002). Cognitive approaches to obsessions and compulsions:
Theory, assessment, and treatment. Oxford, England: Elsevier.
Gaudreau, P., & Thompson, A. (2010). Testing a 2 × 2 model of dispositional perfection-
ism. Personality and Individual Differences, 48, 532–537. http://dx.doi.org/10.1016/
j.paid.2009.11.031
Gautreau, C. M., Sherry, S. B., Mushquash, A. R., & Stewart, S. H. (2015). Is self-critical
perfectionism an antecedent of or a consequence of social anxiety, or both?
A 12-month, three-wave longitudinal study. Personality and Individual Differences,
82, 125–130. http://dx.doi.org/10.1016/j.paid.2015.03.005
Handley, A. K., Egan, S. J., Kane, R. T., & Rees, C. S. (2014). The relationships between
perfectionism, pathological worry and generalised anxiety disorder. BMC Psychiatry,
14, 98. http://dx.doi.org/10.1186/1471-244X-14-98
Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural pro-
cesses across psychological disorders: A transdiagnostic approach to research and treatment.
Oxford, England: Oxford University Press. http://dx.doi.org/10.1093/med:psych/
9780198528883.001.0001
 Perfectionism 167

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Exper-
imental avoidance and behavioral disorders: A functional dimensional approach to
diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.
http://dx.doi.org/10.1037/0022-006X.64.6.1152
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts:
Conceptualization, assessment, and association with psychopathology. Journal of
Personality and Social Psychology, 60, 456–470. http://dx.doi.org/10.1037/0022-
3514.60.3.456
Hewitt, P. L., Flett, G. L., & Endler, N. S. (1995). Perfectionism, coping, and depression
symptomatology in a clinical sample. Clinical Psychology & Psychotherapy, 2, 47–58.
http://dx.doi.org/10.1002/cpp.5640020105
Hewitt, P. L., Flett, G. L., Sherry, S. B., Habke, M., Parkin, M., Lam, R. W., . . . Stein,
M. B. (2003). The interpersonal expression of perfection: Perfectionistic self-
presentation and psychological distress. Journal of Personality and Social Psychology,
84, 1303–1325. http://dx.doi.org/10.1037/0022-3514.84.6.1303
Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. F. (1991). The Multi­
dimensional Perfectionism Scale: Reliability, validity, and psychometric properties
in psychiatric samples. Psychological Assessment: A Journal of Consulting and Clinical
Psychology, 3, 464–468. http://dx.doi.org/10.1037/1040-3590.3.3.464
Hewitt, P. L., Habke, A. M., Lee-Baggley, D. L., Sherry, S. B., & Flett, G. L. (2008). The
impact of perfectionistic self-presentation on the cognitive, affective, and physio-
logical experience of a clinical interview. Psychiatry: Interpersonal and Biological
Processes, 71, 93–122. http://dx.doi.org/10.1521/psyc.2008.71.2.93
Hull, J. G., Lehn, D. A., & Tedlie, J. C. (1991). A general approach to testing multifaceted
personality constructs. Journal of Personality and Social Psychology, 61, 932–945.
http://dx.doi.org/10.1037/0022-3514.61.6.932
Iketani, T., Kiriike, N., Stein, M. B., Nagao, K., Nagata, T., Minamikawa, N., . . .
Fukuhara, H. (2002). Relationship between perfectionism and agoraphobia in patients
with panic disorder. Cognitive Behaviour Therapy, 31, 119–128. http://dx.doi.org/
10.1080/165060702320337997
Juster, H. R., Heimberg, R. G., Frost, R. O., Holt, C. S., Mattia, J. I., & Faccenda, K.
(1996). Social phobia and perfectionism. Personality and Individual Differences, 21,
403–410. http://dx.doi.org/10.1016/0191-8869(96)00075-X
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY:
Springer.
Lizmore, M. R., Dunn, J. G. H., & Causgrove Dunn, J. (2017). Perfectionistic strivings,
perfectionistic concerns, and reactions to poor personal performances among inter-
collegiate athletes. Psychology of Sport and Exercise, 33, 75–84. http://dx.doi.org/
10.1016/j.psychsport.2017.07.010
Mor, S., Day, H. I., Flett, G. L., & Hewitt, P. L. (1995). Perfectionism, control, and
components of performance anxiety in professional artists. Cognitive Therapy and
Research, 19, 207–225. http://dx.doi.org/10.1007/BF02229695
Moulding, R., & Kyrios, M. (2007). Desire for control, sense of control and obsessive–
compulsive symptoms. Cognitive Therapy and Research, 31, 759–772. http://dx.doi.org/
10.1007/s10608-006-9086-x
Nepon, T., Flett, G. L., Hewitt, P. L., & Molnar, D. S. (2011). Perfectionism, negative
social feedback, and interpersonal rumination in depression and social anxiety.
Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement,
43, 297–308. http://dx.doi.org/10.1037/a0025032
Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation
of the obsessive belief questionnaire and interpretation of intrusions inventory—
Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy,
43, 1527–1542. http://dx.doi.org/10.1016/j.brat.2004.07.010
168 Lenton-Brym and Antony

O’Connor, D. B., O’Connor, R. C., & Marshall, R. (2007). Perfectionism and psycho­
logical distress: Evidence of the mediating effects of rumination. European Journal of
Personality, 21, 429–452. http://dx.doi.org/10.1002/per.616
Pirbaglou, M., Cribbie, R., Irvine, J., Radhu, N., Vora, K., & Ritvo, P. (2013). Perfectionism,
anxiety, and depressive distress: Evidence for the mediating role of negative automatic
thoughts and anxiety sensitivity. Journal of American College Health, 61, 477–483.
http://dx.doi.org/10.1080/07448481.2013.833932
Pitman, R. K. (1987). Pierre Janet on obsessive–compulsive disorder (1903): Review
and commentary. Archives of General Psychiatry, 44, 226–232. http://dx.doi.org/
10.1001/archpsyc.1987.01800150032005
Purdon, C., Antony, M. M., & Swinson, R. P. (1999). Psychometric properties of
the Frost Multidimensional Perfectionism Scale in a clinical anxiety disorders
sample. Journal of Clinical Psychology, 55, 1271–1286. http://dx.doi.org/10.1002/
(SICI)1097-4679(199910)55:10<1271::AID-JCLP8>3.0.CO;2-A
Rachman, S. (2004). Fear of contamination. Behaviour Research and Therapy, 42,
1227–1255. http://dx.doi.org/10.1016/j.brat.2003.10.009
Rasmussen, S. A., & Eisen, J. L. (1989). Clinical features and phenomenology of obses-
sive compulsive disorder. Psychiatric Annals, 19, 67–73. http://dx.doi.org/10.3928/
0048-5713-19890201-06
Rhéaume, J., Freeston, M. H., Ladouceur, R., Bouchard, C., Gallant, L., Talbot, F., &
Vallières, A. (2000). Functional and dysfunctional perfectionists: Are they different
on compulsive-like behaviors? Behaviour Research and Therapy, 38, 119–128. http://
dx.doi.org/10.1016/S0005-7967(98)00203-4
Riley, C., Lee, M., Cooper, Z., Fairburn, C. G., & Shafran, R. (2007). A randomised con-
trolled trial of cognitive–behaviour therapy for clinical perfectionism: A preliminary
study. Behaviour Research and Therapy, 45, 2221–2231. http://dx.doi.org/10.1016/
j.brat.2006.12.003
Roemer, L., Salters, K., Raffa, S. D., & Orsillo, S. M. (2005). Fear and avoidance of
internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive
Therapy and Research, 29, 71–88. http://dx.doi.org/10.1007/s10608-005-1650-2
Santanello, A. W., & Gardner, F. L. (2007). The role of experiential avoidance in the
relationship between maladaptive perfectionism and worry. Cognitive Therapy and
Research, 31, 319–332. http://dx.doi.org/10.1007/s10608-006-9000-6
Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive-
behavioural analysis. Behaviour Research and Therapy, 40, 773–791. http://dx.doi.org/
10.1016/S0005-7967(01)00059-6
Sherry, S. B., Law, A., Hewitt, P. L., Flett, G. L., & Besser, A. (2008). Social support as a
mediator of the relationship between perfectionism and depression: A preliminary
test of the social disconnection model. Personality and Individual Differences, 45,
339–344. http://dx.doi.org/10.1016/j.paid.2008.05.001
Smith, M. M., Sherry, S. B., Chen, S., Saklofske, D. H., Mushquash, C., Flett, G. L., &
Hewitt, P. L. (2018). The perniciousness of perfectionism: A meta-analytic review of
the perfectionism-suicide relationship. Journal of Personality, 86, 522–542.
Stöber, J. (1998). The Frost Multidimensional Perfectionism Scale revisited: More
perfect with four (instead of six) dimensions. Personality and Individual Differences,
24, 481–491. http://dx.doi.org/10.1016/S0191-8869(97)00207-9
Stöber, J., & Joormann, J. (2001). Worry, procrastination, and perfectionism: Differen-
tiating amount of worry, pathological worry, anxiety, and depression. Cognitive
Therapy and Research, 25, 49–60. http://dx.doi.org/10.1023/A:1026474715384
Stoeber, J., & Damian, L. E. (2014). The Clinical Perfectionism Questionnaire:
Further evidence for two factors capturing perfectionistic strivings and concerns.
Personality and Individual Differences, 61–62, 38–42. http://dx.doi.org/10.1016/
j.paid.2014.01.003
 Perfectionism 169

Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches,

evidence, challenges. Personality and Social Psychology Review, 10, 295–319. http://
dx.doi.org/10.1207/s15327957pspr1004_2
Summerfeldt, L. J., Kloosterman, P. H., Antony, M. M., & Swinson, R. P. (2014).
Examining an obsessive–compulsive core dimensions model: Structural validity
of harm avoidance and incompleteness. Journal of Obsessive–Compulsive and Related
Disorders, 3, 83–94. http://dx.doi.org/10.1016/j.jocrd.2014.01.003
Tallis, F., Eysenck, M., & Mathews, A. (1991). Elevated evidence requirements and
worry. Personality and Individual Differences, 12, 21–27. http://dx.doi.org/10.1016/
0191-8869(91)90128-X
Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered:
A psychometric analysis. Cognitive Therapy and Research, 27, 247–259. http://
dx.doi.org/10.1023/A:1023910315561
Wallace, S. T., & Alden, L. E. (1997). Social phobia and positive social events: The price
of success. Journal of Abnormal Psychology, 106, 416–424. http://dx.doi.org/
10.1037/0021-843X.106.3.416
Weiner, B. A., & Carton, J. S. (2012). Avoidant coping: A mediator of maladaptive
perfectionism and test anxiety. Personality and Individual Differences, 52, 632–636.
http://dx.doi.org/10.1016/j.paid.2011.12.009
Zhou, X., Zhu, H., Zhang, B., & Cai, T. (2013). Perceived social support as moderator
of perfectionism, depression, and anxiety in college students. Social Behavior and
Personality: An International Journal, 41, 1141–1152. http://dx.doi.org/10.2224/
sbp.2013.41.7.1141
10
Metacognition
Adrian Wells and Lora Capobianco

Oscar is a 49-year-old teacher diagnosed with generalized anxiety disorder (GAD)

who reports that he cannot stop worrying and that he has been a worrier all of
his life. He currently worries about terror attacks, his children being involved in
accidents, and his own abilities as a teacher. In the past he has worried about a
range of topics, including his physical health and the status of his romantic rela-
tionships. Oscar believes that all of his excessive worrying means that his mind
is “out of control” and that the worrying will lead to a “mental breakdown.” At
the same time, however, he feels that worrying and analyzing help him solve
problems and prepare him should the worst actually happen. To cope with his
constant worrying, Oscar sometimes tries distracting himself by watching a
movie or TV show or tries to push thoughts out of his mind, but such strategies
rarely bring about relief or do so only temporarily.1

Metacognition refers to cognitive factors that are involved in monitoring, con-

trolling and interpreting one’s own thinking. It is an area of research and theory
that arose originally in the field of educational development (e.g., Flavell, 1979)
and in the psychology of subjective memory (e.g., Nelson & Narens, 1980).
The construct was subsequently formulated as a central causal factor in a
transdiagnostic theory of psychological disorders, the Self-Regulatory Executive
Function model (S-REF; Wells & Matthews, 1994, 1996). Within this frame-
work, metacognition and the regulation of cognitive processes are the foci of
modification in metacognitive therapy (Wells, 2009).

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-010
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
171
172 Wells and Capobianco

Metacognition is divided into three components: (a) knowledge, (b) strate-

gies, and (c) experiences. Knowledge refers to the stored information that
individuals hold about their own cognition and the factors that influence it;
for example, the belief that one has poor short-term memory. In the context
of metacognitive therapy, knowledge is conceptualized as a set of beliefs about
the importance of thinking, and positive and negative metacognitive beliefs
have been distinguished. Positive metacognitive beliefs include the idea that
repetitive negative thinking is helpful; for example, a patient might believe that
mentally analyzing their previous trauma will help them understand and
overcome anxiety. Oscar’s belief that his worrying helps him to solve prob-
lems and prepares him for the worst is another example. In addition to posi-
tive beliefs, negative beliefs have been postulated as central to clinical anxiety
in the metacognitive model, such as the belief that worrying is uncontrollable
or the belief that some thoughts can cause harm, as illustrated by Oscar’s
belief that his worrying indicates that his mind is “out of control” and will
lead to a “mental breakdown.” The belief that thoughts can cause harm is also
observed in obsessive-compulsive disorder (OCD). Positive metacognitive
beliefs are common in the general population, whereas negative metacogni-
tive beliefs are elevated in clinical groups. As Oscar’s case illustrates, positive
and negative metacognitive beliefs can coexist among anxious individuals,
and can further compromise effective self-regulation efforts; for example,
Oscar is conflicted about giving up worry, which leads him to think more in
order to try and worry less, but neither of these methods helps Oscar bring his
thinking processes under control.
Metacognitive strategies are overt and covert behaviors that individuals
use to regulate or alter the status of their own cognition. Clinical anxiety is
characterized by repetitive negative thoughts, and the strategies anxious
individuals use to regulate such thinking are often counterproductive and
paradoxically lead to the maintenance of negative metacognitive beliefs or
to additional negative thinking. Oscar, for example, copes by engaging in
worry, a strategy focused on anticipating that the worst that might happen.
Such a process maintains the analysis of threat, and so the anxiety response
system is continuously primed. Oscar’s use of distraction is another exam-
ple of a metacognitive strategy, as is the strategy of trying to remove nega-
tive thoughts from his mind. A large body of experimental research shows
that trying to suppress thoughts (pushing them out of consciousness) is
counterproductive in that it paradoxically leads to an increase in the
to-be-suppressed thought (Wegner, Schneider, Carter, & White, 1987). In
contrast, metacognitive strategies such as social control (e.g., talking to
friends about thoughts) and distraction from negative thoughts might be
helpful in some situations. For example, distraction may interrupt negative
self-referential processing such as worry and rumination resulting in a pos-
itive effect on mood (Wells & Matthews, 1994). The goal (or function) of
using such strategies (as opposed to its form or topography) determines
whether the strategy is helpful or maladaptive. The use of distraction to
 Metacognition 173

remove a “dangerous” thought, for example, can have a negative overall

effect if it prevents the individual from discovering that thoughts are in fact
not dangerous.
Metacognitive experiences refer to the in-situation appraisal or subjective
feeling associated with the status of cognition. A well-known example is the
“tip-of-the-tongue” effect, where it feels as if an item of information is stored
in memory even though it cannot be currently retrieved. This in-situation
feeling state appears to signal the status of memory. Other experiences, such
as in-the-moment interpretations of cognition, are more relevant to clinical
anxiety. Oscar’s interpretation of his worry as a sign that he is going to have
a mental breakdown provides an example of a metacognitive experience.
This is an example of an experience that has been called worry about worry
(aka metaworry; Wells, 1994). Similarly, someone with obsessions might
interpret an unwanted image of harming a friend as a sign that they are a
sociopath.

CONCEPTUAL IMPLICATIONS

The metacognitive model identifies a pattern of thinking called the cognitive

attentional syndrome (CAS; Wells & Matthews, 1994), which is a transdiag-
nostic thinking style that maintains emotional distress such as clinical anxi-
ety. The CAS consists of increased self-focused attention, repetitive thinking
(e.g., worry or rumination), threat monitoring, and coping behaviors (i.e.,
distraction, punishment, social control) that have paradoxical effects on
self-regulation. Coping strategies such as distraction, punishment (i.e., punish­
ing oneself for having negative thoughts), and social control (e.g., asking
friends if they have similar thoughts) maintain negative processing as they
inhibit self-control by conceding to external factors. While self-focused attention
is not always problematic, it becomes counterproductive for self-regulation
when these states become inflexible. This results in increased internal experi-
ences and greater attentional demands, therefore reducing the ability to select
adaptive processing such as retuning cognition to the external threat-free
environment. Threat monitoring increases attention for potentially threaten-
ing stimuli, which maintains the sense of danger.
A patient with health anxiety, for example, may believe that they are vul-
nerable to a heart attack and therefore will monitor their heart rate, leading
to a constant cycle of monitoring body sensations for potential danger. In
these circumstances, the individual’s scope for adaptive processing and action
is constrained because processing resources and goals are dominated by
threat-related processing. For most individuals, periods of emotion such as
social anxiety or health anxiety are temporary, since cognition is controlled in
a way that leads to the development of a sense of control and responses that
meet self-regulatory goals. However, an important factor contributing to anx-
iety are metacognitive beliefs that give rise to the CAS, which maintains a
current sense of threat.
174 Wells and Capobianco

Metacognitive beliefs can be divided into positive and negative beliefs.

Negative metacognitive beliefs concern the uncontrollability and danger of
worrying or rumination, for example, “I cannot control my worrying.” Alter-
natively, positive metacognitive beliefs concern the usefulness of worrying or
threat monitoring, such as, “If I worry, I’ll be prepared.” In many cases both
sets of metacognitive beliefs exist, creating conflicted self-regulation of repet-
itive negative thinking. For example, health anxious individuals can hold the
positive metacognitive belief that thinking the worst about symptoms will
mean that they do not fail to act on something that could be important. This
leads to constant misinterpretation (worry) about symptoms but also anxiety
about giving up this thinking style. At the same time, such individuals might
believe that worrying can cause damage to the body. Thus, they are anxious
if they continue to worry and if they stop worrying, which generates a conflict
in the regulation of thinking.
A central idea of this approach is that negative thoughts and beliefs (e.g.,
“I’m a failure”) are normal and transitory experiences. Who hasn’t had a neg-
ative thought about appearing foolish or failing, for example? What is more
important than the content of the thought, however, is how the individual
regulates cognition and action in response to such thoughts. When the indi-
vidual engages in extended negative processing (the CAS), it leads to a persis-
tence or spiral of emotion and the likely development of disorder.

The Metacognitive Model

Figure 10.1 depicts a schematic of the role of metacognitive beliefs and the
CAS. This is constructed around the A-M-C framework (Wells, 2009) in
which an antecedent (A) or trigger thought primes metacognitions (M) lead-
ing to extended negative thinking (CAS) resulting in emotional consequences
(C), which in this example is clinical anxiety (or an “anxiety disorder”). The
starting point in modelling clinical anxiety is the individual’s reaction to a
negative thought or belief that is dependent on metacognition. When the
response includes extended negative thinking, attending to threat, and/or
paradoxical coping responses, the sense of danger persists, which is the hall-
mark of clinical anxiety.2 Worrying or ruminating persists in response to the
trigger thought because the individual believes it is uncontrollable and there-
fore invests little effort in interrupting the process. However, the person also
believes that analyzing failures is a way to cope, and this prolongs negative
emotion and maintains the trigger thought for worry. Paradoxical coping
strategies are likely to involve attempts to suppress thoughts of failure,
because the individual believes that thoughts are dangerous, which the ther-
apist should explore further.

2
In Figure 10.1, metacognitive beliefs (knowledge) are represented, but the reader
might be interested to know that other dimensions of metacognition such as executive
control skills and experiences (appraisal of thoughts) have been omitted for simplicity
and the full metacognitive architecture is not displayed.
 Metacognition 175

FIGURE 10.1. A Schematic of the Metacognitive Model of Anxiety Disorder

Based on the A-M-C Framework (Wells, 2009)

A M C
Trigger Thought Metacognitive Control Consequences

METABELIEFS
Worry is uncontrollable.
Thoughts are dangerous.
Analyzing my failures will
help me cope. Anxiety
“What if I fail?” disorder

CAS
Worry
Rumination
Threat monitoring
Ironic coping strategies

CAS = cognitive attentional syndrome.

ASSESSMENT

Research on the metacognitive model has required the development of a

range of assessment and measurement tools, which are listed in Table 10.1.
Some of these have undergone substantial psychometric testing. The gold
standard measure of metacognitive beliefs is the Metacognitions Question-
naire (MCQ). This measure has five subscales: (a) positive beliefs about worry,
(b) negative beliefs concerning uncontrollability and danger, (c) beliefs about
the need to control thoughts, (d) low cognitive confidence, and (e) cognitive
self-consciousness. There are both a 65-item and a shorter 30-item version of
the scale.
Multiple types of metacognitive strategies can be measured with the
Thought Control Questionnaire (TCQ), a 30-item self-report measure assess-
ing the following strategies of thought control: (a) distraction, (b) punishment
(e.g., beating up on oneself for thinking unwanted thoughts), (c) reappraisal
(trying to analyze the unwanted thought), (d) worrying about the thought,
and (e) social control (e.g., speaking with someone else about the thought).
Both the MCQ and TCQ are typically used in research settings and higher
scores on these measures have been shown to predict poorer treatment out-
comes. The MCQ and TCQ have also been adapted for use in children and
adolescents (Bacow, Pincus, Ehrenreich, & Brody, 2009; Cartwright-Hatton
et al., 2004; Gill, Papageorgiou, Gaskell, & Wells, 2013).
A range of metacognitive measures have been developed that are appli-
cable to individual anxiety disorders. The Thought Fusion Instrument,
for example, is used to assess negative metacognitive beliefs in the context
of OCD; whereas the Beliefs About Memory Questionnaire is available to
assess metacognitions relevant to posttraumatic stress disorder (PTSD). The
176 Wells and Capobianco

TABLE 10.1. Measures of Metacognitive Constructs

Measure Description and scoring Psychometric properties
Metacognitions A self-report scale that Cronbach alphas for the
Questionnaire assesses positive beliefs five subscales: PB = .87,
(MCQ-65; about worry (PB), negative UD = .89, CC = .84,
Cartwright- beliefs (uncontrollability/ NC = .74, CSC = .72.
Hatton & Wells, danger; UD), superstition/
1997) punishment/need for
control (NC), cognitive
confidence (CC), cognitive
self-consciousness (CSC).
Metacognitions A shortened version of The scale demonstrates good
Questionnaire the MCQ-65. It has the convergent validity,
(MCQ-30; Wells same five factors and test–retest reliability
& Cartwright- response format. Total and internal consisten-
Hatton, 2004) scores range from cy (Spada, Mohiyeddini,
30 to 120. & Wells, 2008; Wells &
Cartwright-Hatton, 2004;
Yilmaz, Gençöz, & Wells,
2008). Cronbach’s alphas
for the subscales:
CC = 0.93, PB = 0.92,
CSC = 0.92, UD = 0.91,
and NC = 0.72.
Thought Control A self-report measure that Good test–retest reliability
Questionnaire assesses thought control (r = 0.83). Subscales
(Wells & Davies, strategies across five demonstrate acceptable–
1994) subscales: distraction, good internal consistency
worry, thought control, with scores from 0.67 to
punishment, and 0.79 (Reynolds & Wells,
reappraisal. 1999; Wells & Davies,
1994).
CAS-1 (Wells, 2009) A self-report scale that eval- The CAS-1 has demonstrated
uates the weekly extent to good internal consistency
which individuals engage for the overall scale
in worrying, rumination, (Cronbach alpha = .86;
and threat monitoring, use Fergus, Bardeen, &
unhelpful coping strategies, Orcutt, 2012).
and positive and negative
metacognitive beliefs.
Anxious Thoughts A self-report measure that Cronbach alphas for the
Inventory assesses three dimensions subscales: 0.84 (social
(Wells, 1994) of anxious worry: social worry), 0.81 (health worry),
worry, health worry, and and 0.75 (metaworry).
metaworry. The social and
health worry subscales
are content focused, while
the metaworry subscale is
processes focused.
Meta-Worry A self-report measure of the Cronbach coefficients for the
Questionnaire frequency and belief frequency scale were .88
(Wells, 2005) dimensions of metaworry and .95 for the belief scale.
in the danger domain.
 Metacognition 177

TABLE 10.1. (Continued)

Measure Description and scoring Psychometric properties
Beliefs About Evaluates beliefs about The positive belief subscale
Memory trauma memory across had a Cronbach alpha of
Questionnaire two subscales: positive 0.90, and negative beliefs
(Bennett and negative beliefs about subscale had a Cronbach
& Wells, 2010) memory. alpha of 0.70.
Thought Fusion Evaluates negative meta- The scale has one factor that
Instrument (TFI; cognitive beliefs in OCD demonstrates a Cronbach
Wells, Gwilliam, & across three domains: alpha of 0.89 (Gwilliam
Cartwright- thought–event fusion, et al., 2004).
Hatton, 2001) thought–action fusion, and
thought–object fusion.
Beliefs About Evaluates individuals’ posi- Total score Cronbach
Rituals Inventory tive beliefs about rituals alpha = 0.86, subscale
(Wells & McNicol, (typically linked to OCD) alpha range from 0.77
2004) using three subscales: to 0.87 (McNicol & Wells,
behavior and character 2012).
change, guilt and loss of
function, and anxiety.
Note. CAS-1 = Cognitive Attentional Syndrome-1; OCD = obsessive-compulsive disorder.

metacognition-focused clinical interview may be used as a principle means of

determining triggers, metacognitions, and the CAS for purposes of generating
a clinical case formulation. For example, the following series of questions
based on the GAD case formulation interview (Wells, 2009) can be used
across various presentations of clinical anxiety:

1. What was the initial thought that triggered your worrying (was it a “what
if question,” doubt, or image)? [Trigger]
2. What did you then go on to worry about (for how long)? [CAS]
3. How did that make you feel emotionally (anxiety symptoms for example)?
[Consequences]
4. What is the worst that could happen if you continue to worry? [Negative
metabelief]
5. Could you stop worrying if you wanted to? [Uncontrollability metabelief]
6. Is worrying helpful in any way? [Positive metabelief]
7. When you start worrying what do you do to manage your worry/anxiety?
[CAS]
8. Do you ever try to suppress thoughts (get rid of them)? [CAS]
9. Have you ever just decided to leave a trigger thought alone? [Bridge to
therapy]

CLINICAL IMPLICATIONS

From a metacognitive perspective, intervention for clinical anxiety is focused on

modifying how the individual responds to thoughts, specifically by helping them
bring the CAS under adaptive control and then by reducing it. Put another way,
178 Wells and Capobianco

individuals are helped to relate to their thoughts in a new, more adaptive way.
This requires the modification of metacognitive beliefs (e.g., the belief that worry
is uncontrollable and dangerous) and also the development of new, more
healthy, metacognitive strategies. Importantly, this is in contrast to other cogni-
tive therapy techniques that involve analyzing and challenging the validity of
the thoughts themselves (e.g., overestimates of threat), which, from a metacog-
nitive perspective would be conceptualized as extended thinking (the CAS).
As an example, someone with a diagnosis of OCD might be asked, “Are there
any advantages to worrying about harming someone?” rather than “What are
the chances that you will harm someone?” Accordingly, the metacognitive
approach has led to the development of intervention techniques designed to
modify aspects of the metacognitive system. These techniques are described
fully in Wells (2009), and some of the most commonly used techniques are
described briefly within the overview of specific anxiety disorders below.

Generalized Anxiety Disorder

Individuals with GAD use worry in order to anticipate future problems and as
a coping strategy in response to negative thoughts. For example, a trigger
thought might be “What if I get sick and can’t work?” In GAD, such cogni-
tions are dealt with by engaging in extended negative thinking (e.g., worry-
ing). From a metacognitive perspective (Wells, 1995, 1997) there are two
types of worry: Type 1 and Type 2. Type 1 worry is general worry about exter-
nal events, social, and physical health concerns (e.g., “What if my partner has
an accident, how will I cope, what if its serious, what if I can’t cope, how will
I care for the family?”). Here, worry is considered a coping strategy and is
associated with positive metacognitive beliefs such as, “Worrying helps me to
avoid problems in the future” or “Worrying helps me cope.” Although such
positive metacognitive beliefs play a role in GAD, it is the development and
activation of an individual’s negative metacognitive beliefs that is the main
cause of excessive worry as observed in GAD.
Two negative metacognitive beliefs are important in GAD: (a) negative meta-
cognitive beliefs concerning the uncontrollability of worry and (b) negative
metacognitive beliefs concerning the danger or harmfulness of worry (e.g., my
worrying is uncontrollable, worrying will cause me to have a heart attack). An
individual’s negative metacognitive beliefs lead to negative appraisals of worry
and introduce worry about worry (i.e., Type 2 worry) into the worry chain. This
causes greater anxiety and feelings of being unable to cope. Type 2 worry, also
called metaworry (Wells, 1994), increases the sense of immediate danger
because the worry process itself becomes a source of imminent threat. Examples
of metaworry are “I’m losing control, I’m going crazy, what if I crack up?”

Obsessive-Compulsive Disorder

In OCD, the CAS predominantly comprises worry, rumination, covert and overt
rituals, and threat monitoring in order to avoid danger. Threat monitoring is a
 Metacognition 179

coping behavior that involves vigilance for certain thoughts, feelings, or pos-
sible contaminants. Examples include monitoring for “bad” or unwanted
thoughts, scrutinizing the environment for germs or dirt, and being sensitive
for certain feelings or emotions. Other important coping strategies involve
overt and covert rituals that are aimed to prevent harm. Examples of covert
rituals include praying, forming “safe images,” repeating words, or counting.
Overt rituals include washing, checking, repeating actions, tidying, aligning
objects, and avoidance. These processes are conceptualized as key features of
the CAS and driven by the individual’s metacognitive beliefs.
Two domains of metacognitive beliefs that are central in OCD are (a) beliefs
about the significance or importance of thoughts and feelings, also termed
fusion beliefs (Wells, 1997), and (b) metacognitive beliefs about the need to
perform rituals in response to thoughts and impulses. In applying the meta-
cognitive model to OCD (Wells, 1997) there are three types of negative fusion
metabeliefs: thought–event fusion, thought–action fusion, and thought–
object fusion. Thought–event fusion is the belief that having an intrusive
thought or doubt (e.g., “Has the plane crashed?”) can cause an event to occur
(e.g., “thoughts about accidents can make them happen”). Thought–action
fusion is the belief that thoughts or feelings have the power to cause one to
commit unwanted actions (e.g., “having an urge/image of harming someone
will make me do it”). Thought–object fusion is the belief that thoughts, feel-
ings, or memories can be transferred into objects (e.g., “I can infect my books
with thoughts of the Devil”).

Posttraumatic Stress Disorder

The metacognitive model as applied to PTSD (Wells, 2000; Wells & Sembi, 2004)
is based on the assumption that after an individual experiences a traumatic
event, an intrinsic survival objective is to create a metacognitive plan to guide
cognition in the future to avoid potential threat. This process is called the reflex-
ive adaptation process, and normally this process is automatic and occurs unhin-
dered. PTSD, however, is caused when this process is interrupted by the CAS.
The activation of the CAS consists of the features identified earlier plus “gap
filling,” a preoccupation with incomplete memory of the trauma and attempts to
complete it. Additional unhelpful strategies include avoidance of situations or
reminders of the trauma, which are also part of the CAS repertoire. The CAS
maintains a sense of current threat, such that the danger (arousal/survival) pro-
gram continues to run and is inadvertently strengthened. Positive metacognitive
beliefs concern the value of engaging in aspects of the CAS. For instance, gap
filling is driven by the belief that by having a complete memory, the person will
be able to identifying blame or responsibility for negative events or that they will
be able to avoid future threat or recover quickly. Other positive beliefs concern
the use of worry, rumination, threat monitoring, and the need to control nega-
tive thoughts. (e.g., “Worrying about my assault will help me to avoid it happen-
ing again” “If I don’t think about it I will recover”). Negative metacognitive
beliefs concern the meaning of thoughts and feelings. For example some patients
180 Wells and Capobianco

who have reported flashbacks believe that they are a sign of brain damage or of
imminent mental breakdown.

Social Anxiety

A metacognitive approach to social anxiety emphasizes anticipatory process-

ing (i.e., worry), postevent rumination (i.e., analyzing one’s behaviors and
responses after an event), and unhelpful coping strategies as found in the
CAS. In addition, negative metacognitive beliefs concerning uncontrollability
lead socially anxious individuals to continue to worry about themselves (e.g.,
“What if I look like a fool?”).

CONCLUSION

In this chapter, we described the role of metacognition in various presenta-

tions of clinical anxiety. Metacognitive phenomena have been examined
empirically, with findings demonstrating their relevance to the development
and maintenance of clinical anxiety (see Wells, 2009). Moreover, metacogni-
tive therapy, a set of procedures based on metacognitive conceptualizations of
anxiety (and other realms of psychopathology), has also been evaluated in
numerous clinical trials and is demonstrated to be an effective intervention
for anxiety and depression (Normann, van Emmerik, & Morina, 2014). In
fact, research suggests that changes in metacognition are part of the mecha-
nisms of action in other treatment modalities used with clinically anxious
individuals, such as exposure therapy and cognitive restructuring, despite the
fact that these strategies do not explicitly address metacognition (e.g., Fernie,
Murphy, Wells, Nikčevic’, & Spada, 2016; Solem, Håland, Vogel, Hansen, &
Wells, 2009).

REFERENCES
Bacow, T. L., Pincus, D. B., Ehrenreich, J. T., & Brody, L. R. (2009). The metacognitions
questionnaire for children: Development and validation in a clinical sample of children
and adolescents with anxiety disorders. Journal of Anxiety Disorders, 23, 727–736. http://
dx.doi.org/10.1016/j.janxdis.2009.02.013
Bennett, H., & Wells, A. (2010). Metacognition, memory disorganization and rumina-
tion in posttraumatic stress symptoms. Journal of Anxiety Disorders, 24, 318–325.
http://dx.doi.org/10.1016/j.janxdis.2010.01.004
Cartwright-Hatton, S., Mather, A., Illingworth, V., Brocki, J., Harrington, R., &
Wells, A. (2004). Development and preliminary validation of the Meta-cognitions
Questionnaire—Adolescent Version. Journal of Anxiety Disorders, 18, 411–422.
http://dx.doi.org/10.1016/S0887-6185(02)00294-3
Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The
Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11,
279–296. http://dx.doi.org/10.1016/S0887-6185(97)00011-X
Fergus, T. A., Bardeen, J. R., & Orcutt, H. K. (2012). Attentional control moderates the
relationship between activation of the cognitive attentional syndrome and symp-
toms of psychopathology. Personality and Individual Differences, 53, 213–217. http://
dx.doi.org/10.1016/j.paid.2012.03.017
 Metacognition 181

Fernie, B. A., Murphy, G., Wells, A., Nikčevic’, A. V., & Spada, M. M. (2016). Treatment
outcome and metacognitive change in CBT and GET for chronic fatigue syndrome.
Behavioural and Cognitive Psychotherapy, 44, 397–409. http://dx.doi.org/10.1017/
S135246581500017X
Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of cognitive
developmental inquiry. American Psychologist, 34, 906–911. http://dx.doi.org/
10.1037/0003-066X.34.10.906
Gill, A. H., Papageorgiou, C., Gaskell, S. L., & Wells, A. (2013). Development and prelim-
inary validation of the Thought Control Questionnaire for Adolescents (TCQ-A). Cog-
nitive Therapy and Research, 37, 242–255. http://dx.doi.org/10.1007/s10608-012-9465-4
Gwilliam, P., Wells, S., & Cartwright-Hatton, S. (2004). Does metacognition or respon-
sibility predict obsessive–compulsive symptoms: A test of the metacognitive model.
Clinical Psychology and Psychotherapy, 11, 137–144. http://dx.doi.org/10.1002/cpp.402
McNicol, K., & Wells, A. (2012). Metacognition and obsessive–compulsive symptoms:
The contribution of thought–fusion beliefs and beliefs about rituals. International
Journal of Cognitive Therapy, Special Section: Cognitive Vulnerability, Stress, and Symptom
Specificity in Children and Adolescents, 5, 330–340. http://dx.doi.org/10.1521/
ijct.2012.5.3.330
Nelson, T. O., & Narens, L. (1980). A new technique for investigating the feeling of know-
ing. Acta Psychologica, 46, 69–80. http://dx.doi.org/10.1016/0001-6918(80)90060-8
Normann, N., van Emmerik, A. A. P., & Morina, N. (2014). The efficacy of metacogni-
tive therapy for anxiety and depression: A meta-analytic review. Depression and
Anxiety, 31, 402–411. http://dx.doi.org/10.1002/da.22273
Reynolds, M., & Wells, A. (1999). The Thought Control Questionnaire—Psychometric
properties in a clinical sample, and relationships with PTSD and depression. Psycho-
logical Medicine, 29, 1089–1099. http://dx.doi.org/10.1017/S003329179900104X
Solem, S., Håland, A. T., Vogel, P. A., Hansen, B., & Wells, A. (2009). Change in meta-
cognitions predicts outcome in obsessive–compulsive disorder patients undergoing
treatment with exposure and response prevention. Behaviour Research and Therapy,
47, 301–307. http://dx.doi.org/10.1016/j.brat.2009.01.003
Spada, M. M., Mohiyeddini, C., & Wells, A. (2008). Measuring metacognitions associ-
ated with emotional distress: Factor structure and predictive validity of the Meta-
cognitions Questionnaire 30. Personality and Individual Differences, 45, 238–242.
http://dx.doi.org/10.1016/j.paid.2008.04.005
Wegner, D. M., Schneider, D. J., Carter, S. R., III, & White, T. L. (1987). Paradoxical
effects of thought suppression. Journal of Personality and Social Psychology, 53, 5–13.
http://dx.doi.org/10.1037/0022-3514.53.1.5
Wells, A. (1994). A multi-dimensional measure of worry: Development and prelimi-
nary validation of the Anxious Thoughts Inventory. Anxiety, Stress, and Coping: An
International Journal, 6, 289–299. http://dx.doi.org/10.1080/10615809408248803
Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety
disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320. http://dx.doi.org/
10.1017/S1352465800015897
Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual
guide. Chichester, England: Wiley.
Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy.
Chichester, England: Wiley.
Wells, A. (2005). The metacognitive model of GAD: Assessment of meta-worry and
relationship with DSM–IV generalized anxiety disorder. Cognitive Therapy and
Research, 29, 107–121. http://dx.doi.org/10.1007/s10608-005-1652-0
Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York, NY: Guildford
Press.
Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions ques-
tionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42, 385–396.
http://dx.doi.org/10.1016/S0005-7967(03)00147-5
182 Wells and Capobianco

Wells, A., & Davies, M. I. (1994). The Thought Control Questionnaire: A measure of
individual differences in the control of unwanted thoughts. Behaviour Research and
Therapy, 32, 871–878. http://dx.doi.org/10.1016/0005-7967(94)90168-6
Wells, A., Gwilliam, P., & Cartwright-Hatton, S. (2001). The Thought Fusion Instrument
(Unpublished self-report scale). University of Manchester, England.
Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. New York,
NY: Psychology Press/Taylor & Francis.
Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The
S-REF model. Behaviour Research and Therapy, 34, 881–888. http://dx.doi.org/
10.1016/S0005-7967(96)00050-2
Wells, A., & McNicol, K. (2004). The Beliefs about Rituals Inventory (Unpublished self-
report scale). University of Manchester, England.
Wells, A., & Sembi, S. (2004). Metacognitive therapy for PTSD: A core treatment
manual. Cognitive and Behavioral Practice, 11, 365–377. http://dx.doi.org/10.1016/
S1077-7229(04)80053-1
Yilmaz, A. E., Gençöz, T., & Wells, A. (2008). Psychometric characteristics of the Penn
State Worry Questionnaire and Metacognitions Questionnaire-30 and metacogni-
tive predictors of worry and obsessive–compulsive symptoms in a Turkish sample.
Clinical Psychology & Psychotherapy, 15, 424–439. http://dx.doi.org/10.1002/cpp.589
11
Autobiographical
Memory Bias
Mia Romano, Ruofan Ma, Morris Moscovitch,
and David A. Moscovitch

Dev was a cashier who found it very difficult to attend social functions where
he would have to mingle with small groups of people. He was afraid that when
he interacted with people they would notice that he was anxious, sweating,
and blushing. Whenever Dev had an event to attend, he would picture himself
from an observer’s perspective, standing in front of a crowd with a bright red
face like a tomato, with sweat dripping profusely from his chin. When he antic-
ipated attending the social function, he found it very difficult to stop this image
from coming to mind: it was intrusive and anxiety provoking, and he knew that
this image in his mind’s eye was exactly how other people would see him when
he attended the event. Sometimes Dev would avoid the event so that his fears
would not come true, and other times he tried to hide his signs of anxiety by
standing off to the side or not talking much. At first Dev was not sure where
this image had come from despite feeling like it had been with him forever.
When probed to trace the image back, he realized that it had first emerged
when he was in high school. He remembered attending a party where he had
spilled a drink all over his date and everybody had laughed at him. Dev felt very
embarrassed and he turned bright red. He remembered that after this event it
became harder to attend parties and social gatherings, especially because he
was worried that people would notice his blushing and sweating. Even though
there had been times where he did not sweat and blush he always envisioned
the same image, and to Dev, this image represented his incompetence.1

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-011
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
183
184 Romano et al.

In this case example, Dev’s autobiographical memory of a past, socially pain-

ful experience is preferentially retrieved when encountering social situations,
even though he has had previous positive experiences in social gatherings. This
memory comes to him in the form of anxious visual imagery. This image serves
to maintain his feelings of anxiety and avoidance because Dev formulates his
expectations of future social situations on the basis of his past experiences, and
he believes this image to be an accurate representation of how others will see
him in social situations. To protect himself from reliving this negative predic-
tion, Dev uses safety behaviors (e.g., avoiding conversations; see Chapter 2).
These behaviors ease his anxiety in the moment but also “hijack” his attention,
preventing him from devoting attentional resources to the task at hand, and
potentially noticing and later remembering positive aspects of the event that
may help him update the image and his associated network of memories. In
Dev’s case, avoidance reinforces the negative autobiographical memory, which
strengthens his schema (i.e., pervasive mental framework) about the “danger”
of social functions.
Autobiographical memory consists of personally remembered experiences and
information that provide knowledge about the self. Autobiographical memory
consists of two components: (a) recollections of specific episodes or events that
happened at a particular time and place, which can be consciously accessed
and retrieved (i.e., Dev remembers attending a party where he spilled a drink
all over his date, he blushed, and everybody laughed at him) and (b) general
semantic knowledge about the self that is derived from such memories (i.e.,
Dev knows that he always blushes in social situations and this means he is
incompetent). Autobiographical memory is inherent to human functioning. It
enables us to remain oriented in the world, to pursue goals effectively in light of
past problem-solving, and to regulate emotions and self-care (M. Moscovitch,
Cabeza, Winocur, & Nadel, 2016; Williams et al., 2007). Moreover, our ability
to imagine future events and simulate alternative perspectives is facilitated by
having a memory system that can flexibly draw upon and recombine details
of past events (Schacter et al., 2012). The reconstructive nature of autobio­
graphical memory can be adaptive and supportive of healthy functioning, but
it may also be biased (e.g., “sins of memory” described by Schacter, 2001).
For these reasons, it is not surprising that autobiographical memory may
play a key role in maintaining psychopathology. Healthy individuals also
experience and encode threatening information and report negative autobio­
graphical memories of past events. However, for individuals diagnosed with
fear and anxiety disorders, the impact of negative autobiographical memories
appears to be more extreme and plays a greater role in influencing cognition
and behavior. In individuals with anxiety, the emotional significance and
appraisal of particular autobiographical memories, their relationship to their
self-schema, and the extent to which anxiety-related autobiographical memo-
ries come to mind differentiate their autobiographical memory from that of the
general population. It is unlikely that individuals with anxiety have a funda-
mentally biased system, but that normal autobiographical memory processes
maintain clinical fear and anxiety by operating within a system that prioritizes
information relevant to anxiety (see Berntsen, 2012). Although individual
 Autobiographical Memory Bias 185

anxiety disorders share some common elements (e.g., physiological response

elements, escape or avoidance responses), what is prioritized depends on
each individual and the specific pathological elements of their underlying
fear structure (Foa, Huppert, & Cahill, 2006). The result of this experience is
an autobiographical memory system that supports information thematically
relevant to an individual’s fear. A cue that would elicit retrieval of negative
autobiographical memories for one individual may be different for another
individual.

AUTOBIOGRAPHICAL MEMORY INCLUDES EPISODIC

AND SEMANTIC COMPONENTS

Episodic and semantic components of autobiographical memory represent

two pathways to self-knowledge, each of which may contribute to the main-
tenance of clinical fear and anxiety. The process of episodic recollection
encompasses an experiential component termed autonoetic consciousness, which
involves an awareness that the particular event is unique to that individual’s
past experience (Tulving, 1985). As such, episodic memories of specific salient
past events provide a way for people to exist beyond the present moment,
allowing them to perform various self-projections and engage in “mental time
travel” from recollected past to imagined future events (Schacter et al., 2012).
Episodic memories also provide a template for the simulation of personal
goal-directed scenarios and problem-solving in the context of novel situations
(M. Moscovitch, 2012).
In individuals with anxiety, negative or traumatic personal events appear to
be recalled and retrieved (voluntarily or involuntarily) in particularly rich and
vivid episodic detail (e.g., D. A. Moscovitch et al., 2018). Access to rich auto­
biographical details related to anxiety can contribute to biased self-projections
or evoke biased solutions to current and future problems. Specific autobio­
graphical memories can contribute to anxiety by providing exemplar templates
of fear, which are drawn upon and influence how an individual responds in
anticipation of or during anxiety-provoking situations.
Most episodic memories are transformed and assimilated over time into
higher-order autobiographical representations, so that they become more sche-
matic and semantic, encapsulating the central gist of the event or experience
rather than a rich episodic memory representation per se (M. Moscovitch,
2012). Given that semantic memories do not depend on the ability to retrieve
episodic memories of the events that led to the creation of particular schemas
or self-beliefs, the use of semantic information can provide a quick route to
schema-based cognitions and behaviors. In anxiety disorders, relying on nega-
tive schematic information represented in semantic memory can maintain mal-
adaptive core beliefs, which contribute to the inability to access more adaptive,
alternative modes of thinking and behaving (Beck, Emery, & Greenberg, 2005;
D. A. Clark & Beck, 2010). Semantic memory also provides a frame through
which people retrieve, assemble, and interpret relevant episodic details from
186 Romano et al.

memory (D’Argembeau, 2012). For example, Dev has an image of himself

blushing, drawn from a specific episode, which over time has come to rep-
resented an amalgamation of blushing experiences, providing him with
semantic knowledge of the negative self-relevant consequences of attending
anxiety-provoking situations (i.e., he will blush and people will believe he is
incompetent).

THE ORIGIN OF AUTOBIOGRAPHICAL MEMORY BIAS

Although it may be intuitive to assume that problems with fear and anxiety
develop because of an aversive conditioning experience, not all individuals
with anxiety recall such an event. Alternatively, autobiographical memory may
maintain specific fears through other episodic learning experiences, which are
then abstracted and incorporated into the individual’s semantic knowledge
base (e.g., learning that snakes are dangerous during a school class and then
having a parent endorse this belief). Therefore, autobiographical memory may
maintain anxiety by contributing to a sense of knowing that a certain stimulus
is dangerous, without the recollection of a specific episodic experience.
People tend to easily remember information that supports or confirms their
schema. Individuals with anxiety are more attentive to fear-relevant and emo-
tionally salient stimuli in their environment, which increases the likelihood
that such event details are encoded into memory (D. A. Clark & Beck, 2010).
Preferential encoding may then facilitate the storage and retrieval of negative
autobiographical memories, which in turn are maintained by cognitive pro-
cesses that elaborate associative links to negative events in the past, thereby
strengthening memory traces.

AUTOBIOGRAPHICAL MEMORY AND SENSE OF SELF

All individuals have their own memory biases that aim to provide them with a
coherent and stable sense of self over time. Autobiographical memories provide
the raw material from which identity is constructed (e.g., Fitzgerald, 1992) and
a platform to create life stories, continually influencing self-representation
in different contexts. However, the memory-system is limited and not all auto-
biographical memories are retained, nor are memories veridical accounts of
an event.
The self-memory system (SMS) provides a theoretical framework for under-
standing how and why autobiographical memories are retained. According to
the framework, individuals’ sense of self (including self-beliefs and knowl-
edge) is confirmed and supported by their autobiographical memory system,
which comprises their life stories, knowledge relating to lifetime periods,
summaries of extended and repeated events, and episodic details of specific
events (Conway & Pleydell-Pearce, 2000). A central tenet of the model is the
 Autobiographical Memory Bias 187

process of coherence. Coherence acts at encoding and consolidation, retrieval,

and reencoding to shape an individual’s memories—including the accessibility
of memories and content of autobiographical knowledge—in a way that is con-
sistent with their current goals, self-images, and self-beliefs (see Conway, 2005).
For example, Dev might be more likely to encode information during social
situations that supports his self-schema of incompetence (e.g., the “grimace”
on his interaction partner’s face when he slurs his speech, the physiological
sensations that signify his blushing).
The SMS stipulates that autobiographical memories are reconstructed in
accordance with an individual’s current sense of self, or working self, which
organizes and processes the psychological present on the basis of personal goals
and interacts with an individual’s active self-schemas and autobiographical
memory base. This point is particularly relevant to fear and anxiety dis­orders,
as they are often characterized by distorted self-representations that have an
overbearing influence on cognition and behavior. Autobiographical memo-
ries consistent with the anxious self that are continuously drawn upon to
support individuals’ anxious and fearful self-conceptualizations are often
deemed “self-defining.”
Self-defining memories stand out as exemplar memories of experiences and
are affectively intense, repetitive, and vivid (Singer & Salovey, 1993). Because
of the personal significance of these memories, self-defining memories typically
comprise narratives that individuals draw on to inform their sense of identity
and encompass powerful scripts for actions, affect, and outcomes (Conway,
2005). This is particularly true for posttraumatic stress disorder (PTSD), because
traumatic experiences often alter an individual’s self-construct (Sutherland
& Bryant, 2005). Self-defining memories are not restricted to memories that
meet the criterion for a traumatic event according to the Diagnostic and Statistical
Manual of Mental Disorders (fifth ed. [DSM–5]; American Psychiatric Association,
2013) but are also present in the memories of patients diagnosed with other
anxiety and fear-based disorders. Individuals who are socially anxious tend
to report more anxiety-related self-defining memories and endorse traumatic
social experiences as being particularly influential of and consistent with their
views of themselves, others, and the world (e.g., Krans, de Bree, & Bryant,
2014; D. A. Moscovitch et al., 2018); for individuals with agoraphobia and
health anxiety, memories of traumatic situations can also result in negative
appraisals of the self (e.g., Hackmann, Day, & Holmes, 2009; Muse, McManus,
Hackmann, Williams, & Williams, 2010).
One consequence of possessing anxiety-related self-defining memories is
that retrieval of such memories may not only maintain anxious mood states
and negative self-perceptions but also influence the capacity to consider pos-
itive experiences that are contrary to the negative memories (Sutherland &
Bryant, 2005). Moreover, anxious self-defining memories may have undue
influence on an individual’s affective and behavioral responses in the moment
or when anticipating future anxiety-provoking situations. In instances when
an experience is incompatible with an individual’s long-term goals, the control
188 Romano et al.

processes of the working self may act to edit memory content to maintain
long-term self-coherence. For instance, an individual with PTSD saw himself
as a highly skilled and controlled driver; his memory of a traumatic car crash
was distorted such that he believed he could have stopped the event from
happening (Conway, 2005).

THE ROLE OF MENTAL IMAGES

Mental images are mental representations that possess sensory qualities (e.g.,
visual, audio, olfactory), as if “seeing with the mind’s eye or hearing with the
minds ear” (Kosslyn, Ganis, & Thompson, 2001, p. 635). Mental images access
sensory information from memory rather than from direct perception and
as such, can encompass memory fragments, reconstructions, dreams, and
symbols that stand for objects, feelings, or ideas (Horowitz, 1970). Whether
they are spontaneously triggered or deliberately self-generated, mental
images commonly feature in individuals’ internal worlds and may coincide
with memories, thoughts, emotions, and self-representations (Holmes &
Mathews, 2010).
Intrusive imagery is featured specifically in DSM–5 (American Psychiatric
Association, 2013) criteria for PTSD and obsessive-compulsive disorder (OCD)
but is also prevalent in other fear and anxiety disorders. Intrusive images
often originate from a particular autobiographical memory that either coin-
cided with the onset of the disorder or exacerbated the disorder presentation.
The images typically consist of a rich sensory representation of what occurred
in the autobiographical experience, and if not identical in content, tend to be
thematically similar to the memory from which they were derived (for further
information, see Brewin, Gregory, Lipton, & Burgess, 2010; Stopa, 2009).
Although intrusive imagery in fear and anxiety disorders has been linked
to traumatic experiences (e.g., physical or sexual assault or abuse), intrusions
may also originate from less severe experiences (e.g., arguing with significant
others; being teased, criticized, bullied, and humiliated; Çili & Stopa, 2015).
Not all intrusive images arise directly from an adverse experience, however,
and images tend to lie on a continuum ranging from actual episodic memories
to entirely hypothetical situations. Nonetheless, even images that are fantasy-
based still appear to contain memory-related material and to draw on brain
circuitries that correspond with episodic memory (Brewin et al., 2010). It is
likely that recurrent and intrusive images in anxiety disorders may provide
a pathway through which autobiographical memories maintain clinical fear
and anxiety.
The meaning derived from autobiographical memories may be represented
through images (Çili & Stopa, 2015), such that the meaning of the memory
may “live on” in the intrusive image and become part of one’s semantic auto-
biographical knowledge. In clinical anxiety, self-images can represent an
 Autobiographical Memory Bias 189

individual’s feared self or some state to be avoided (e.g., threats to the integ-
rity of self; Stopa, 2009), and it is this self that often takes a front seat in driv-
ing their anxious behavior. Recurrent images can also preserve the belief that
the image is a realistic portrayal of the individual, or a probable outcome that
is likely to occur. In the case example, Dev’s repetitive and intrusive image of
himself blushing in a social situation maintained his belief that he would
always blush in social situations, and that this would mean he was incompe-
tent. Similarly, an intrusive flashback of a traumatic experience in PTSD can
elicit physiological arousal and perceived threat from new situations, which
may increase the likelihood of behavioral avoidance but also avoidance of
emotional processing of the traumatic memory necessary to move on from
the event (Foa & Jaycox, 1999).

THE ROLE OF EMOTION

The impact of emotion on memory for autobiographical events is complex and

involves many different factors. Some of the most important factors are briefly
summarized next.
Emotional arousal experienced during the event and also the affective
valence of the event (i.e., negative or positive affect) may influence the degree
to which the event, or specific event details, are remembered (Holland &
Kensinger, 2010). Physiological arousal boosts consolidation of memory traces
through activation of the amygdala (McGaugh, 2004). This process can func-
tion to narrow memory focus for central information. Patients with PTSD
sometimes report tunnel vision in their traumatic flashbacks, such that the
memory contains a central event (e.g., a gun) without contextual details
(LaBar, 2007). Emotion also influences the perceptual and phenomenological
properties of autobiographical memories, such as the vividness and narrative
details and the extent to which the memory is relived on retrieval. Because
the emotional arousal experienced during the event is encoded into the epi-
sodic memory trace, retrieval of the episodic information reactivates emo-
tional systems and contributes to the feeling of reliving or reexperiencing the
past event (LaBar, 2007). Additionally, emotional arousal may confer mne-
monic benefits because of influence on cognitive factors, such as attentional
focusing and distinctive processing and organization, which allow emotionally
salient features of complex events to be processed relatively automatically and
preferentially retained in memory (Talmi, 2013). For example, when Dev per-
ceives that he is under social threat and his levels of emotional arousal increase,
it may lead to preferential processing of signs of incompetence.
In individuals with anxiety, elaborative cognitive processes (e.g., repeated
rumination, postevent processing) may serve to retrospectively imbed negative
meaning and emotion into an event memory, whereas anticipatory rumination
might facilitate enhanced attention to and encoding of upcoming negative
190 Romano et al.

details prioritized as central to the event. Moreover, repeated rehearsal of a

negative experience via rumination can increase the likelihood that embel-
lished details of that negative experience are encoded as part of the episodic/
autobiographical memory, which may hinder individuals’ ability over time to
distinguish between real memory details and imagined details that feel real but
may have never actually occurred (see Hertel, Brozovich, Joormann, & Gotlib,
2008; M. Moscovitch, 2008). In the case example, Dev remembers that every-
body laughed at him when he spilt his drink; however, this description may
represent an embellishment that has occurred because of Dev’s focus on social
threat within the situation and ruminative processing following the situa-
tion. Although Dev’s anxiety makes him feel certain that everybody noticed,
it is unlikely that this is the case; this embellishment, however, can serve to
perpetuate the overestimation of the probability and cost of future social expe-
riences. Retrieval of past negative experiences can then also prime anxious
individuals to perceive threat from current or future situations, as reflected in
hypervigilance or avoidance to potential threats (Brown et al., 2013), thus
increasing the likelihood that new “threats” will be encoded into the
memory network and may further potentiate the tendency for individuals
to imagine and anticipate negative futures (Sansom-Daly, Bryant, Cohn, &
Wakefield, 2014).

ASSESSMENT

Even in fear-related disorders where a negative event may not have caused
symptom onset, identifying past autobiographical experiences can facilitate
the treatment process. Such memories can provide clinicians with a look-
ing glass into the development of underlying schemas, including negative
core beliefs the individual holds about self, others, and the world, which can
often be derived from such experiences. Understanding the autobiographical
experiences that contribute to patient cognition and behavior not only facil-
itates enhanced empathic attunement toward the patient’s experience but
can also help to identify targets of treatment, such as the conditional rules
and assumptions derived from the past experience(s) that perpetuate mal-
adaptive behavior.
It is the very nature of autobiographical memory that makes biases idio-
syncratic to the individuals who experience them. Many individuals may
spontaneously recall past negative experiences that contribute to their cur-
rent levels of anxiety, which colors their predictions about what will happen
in future feared situations. It is likely that they may also report spontaneous
mental images which fuel the cycle of anxiety. Some individuals can readily
draw links between intrusive images and memories, whereas for others, spe-
cific autobiographical events may be less accessible. In these cases, intrusive
images could provide a gateway to particularly salient autobiographical mem-
ories. Cognitive strategies assessing core beliefs can also provide an avenue for
accessing salient memories that contribute to an individual’s fear. Clinicians
 Autobiographical Memory Bias 191

may ask the following questions: “Where do you think this belief might have
come from?” “Is there a specific mental image or memory that comes to mind
when you think about that?” “Can you access any significant pictures or sen-
sory representations in your mind’s eye, which may or may not be related to
an actual personal event that you experienced in the past?”
Following identification of pertinent autobiographical memories, it is use-
ful for clinicians to guide patients to offer a freely recalled narrative of the
event in as much detail as possible (Thomsen & Brinkmann, 2009). From the
patient’s memory description, it is often possible for the clinician to infer how
the patient appraises the event, in terms of its emotional salience and mean-
ingfulness or to use the patient’s description as a foundation for further ques-
tioning. Understanding the meaning (versus mere content) of the memory is
crucial, as such an understanding will help to guide individualized case con-
ceptualization and treatment.
Although clinical interviewing methods may provide the opportunity to
uncover deeper meaning associated with particular autobiographical memo-
ries, some important facets of the memory description may best be captured
by standardized instruments that aim to distinguish elements of autobio­
graphical memory or the process of memory retrieval. There are a number of
instruments that aim to elucidate the features of autobiographical memory
that may be used in clinical populations (for some examples, see Zlomuzica
et al., 2014). It is important to note that methods of assessing autobiographi-
cal memory can be time intensive, so clinicians are encouraged to use methods
most relevant to their patient.
In their own work, the authors have used the Waterloo Images and Mem-
ories Interview (D. A. Moscovitch, Gavric, Merrifield, Bielak, & Moscovitch,
2011), a structured interview that elicits mental images and episodic memory
narratives related to anxiety provoking social situations. The narratives are
then coded for descriptive detail, and beliefs associated with the auto­
biographical memories are assessed with the Core Beliefs Module. This sup-
plementary module uses the cognitive behavioral “downward arrow” approach
to explore core beliefs associated with the individual’s negative image and
memory (see Reimer & Moscovitch, 2015).
Clinicians may also wish to gain an understanding of the phenomenological
aspects of the memory (e.g., vividness, self-perspective, state of conscious-
ness), how the memory is experienced by the patient (e.g., intrusiveness,
intensity, emotional valence), and how it is appraised (e.g., influence on
beliefs). These features may be targeted by additional coder rating schemes
(e.g., coding disorder-relevant content; Witheridge, Cabral, & Rector, 2010), or
with patient self-report measures (e.g., the centrality of events scale—Berntsen
& Rubin, 2006; the memory characteristics questionnaire—Johnson, Foley,
Suengas, & Raye, 1988). Such supplemental materials can provide important
clues as to the impact particular autobiographical memories have for the patient
and the meaning associated with the memories, which may serve to benefit
treatment beyond an initial assessment.
192 Romano et al.

CLINICAL IMPLICATIONS

As noted previously, autobiographical memory processes are reconstructive.

Although this feature can be advantageous, it can also serve to promote cog-
nitive biases that maintain high levels of fear, worry, and avoidance.

Fear of Animals, Environment, Vomiting, Blood,

Injection or Injury, and Situations

Fear of animals, elements of the natural environment, blood, injection or injury,

specific situations (e.g., planes, elevators), or other fears such as choking or
vomiting are commonly organized under the DSM–5 diagnosis of specific
phobia (American Psychiatric Association, 2013). Autobiographical memories
of aversive experiences with phobic stimuli, engendered by the individual’s
direct experience or learning of others’ experiences, may maintain fear and
anxiety because of avoidance (e.g., the memory of being bitten by a dog as a
child fuels the belief that dogs are dangerous, and one should avoid situations
in which dogs may be encountered to subdue feelings of anxiety and remain
out of harm’s way). Alternatively, remembering a story on the news about
someone dying after being trapped in an elevator instills a fear of elevators (or
enclosed spaces more generally).
Intrusive images are also common and may be triggered by various phobic
cues. For example, in vomiting phobia, negative images may be triggered by
seeing someone who looks unwell or by feelings of nausea (Price, Veale, &
Brewin, 2012). Similarly, individuals with needle phobia might experience
intrusive images related to pain whenever they see a needle or confront a doc-
tor’s waiting room. Images can reflect actual memories of feared experiences in
which they encountered the phobic stimulus directly, experiences that contain
content and emotional meaning related to the phobic stimulus, or “worst-case
scenarios” (e.g., other negative memories of pain for those afraid of needles,
memories of disgust for those afraid of spiders). Recurrent retrieval of aversive
memories or future scenarios coincide with verbal worry and physiological
anxiety sensations that increase an individual’s perception that the feared con-
sequence is likely to occur. In vomit phobia, retrieval of aversive memories
commonly includes images of vomiting but also nauseous sensations, which
strengthens the belief that vomiting inevitably follows nausea (Veale, 2009).

Fear of Negative Self-Exposure and Negative Evaluation

Fear of exposing negative self-attributes for evaluation by critical others may

be perpetuated through increased accessibility of memories relating to events
where the individual appeared foolish, was criticized, or felt embarrassed
or humiliated. In the face of anxiety-provoking cues or following anxiety-
provoking situations, the autobiographical memory system of individuals
with social anxiety tends to favor the recall of “social failures” and negative
information (see Morgan, 2010, for a review).
 Autobiographical Memory Bias 193

Although we all have memories of negative social experiences, individuals

with higher levels of social anxiety and evaluative concerns recall them more
vividly and appraise them as more emotionally meaningful and even trau-
matic. Indeed, they tend to recount past social events with more self-referential
information and higher levels of self-conscious emotions (e.g., Anderson,
Goldin, Kurita, & Gross, 2008), which can maintain the negative impact of the
event. Moreover, the recall of socially stressful events can also elicit avoidance
and hyperarousal responses that are akin to the responses of patients diag-
nosed with PTSD who have experienced events that meet the DSM–5 criteria
for traumatic incidents (American Psychiatric Association, 2013; Erwin,
Heimberg, Marx, & Franklin, 2006).
The content of what is remembered may also differ for people with social
anxiety, such that they recall a greater number of episodic details associated
with negative social experiences (D. A. Moscovitch et al., 2018). Increased
episodic detail may underlie increased vividness and the feeling of reliving
salient negative events when they come to mind, and could provide biased
building blocks for simulating future anxiety-provoking scenarios. Retrieval
of episodic detail may suggest that the event has been encoded in more detail
at the time (as is the case for emotionally laden events) or that particularly
salient details of the event have been rehearsed and elaborated during
repeated rumination and postevent processing, as noted previously.
Cognitive models of social anxiety disorder and body dysmorphic disorder,
in which fear of negative evaluation are paramount, have clearly held that
negative self-imagery is central to the maintenance cycle of the disorder (D. M.
Clark & Wells, 1995; Rapee & Heimberg, 1997; Veale, 2004). Intrusive images
may come to mind when anticipating, entering, or even following social situ-
ations, when worrying about appearance or looking in the mirror or during
ruminative episodes, for example. The images (typically viewed from an
observer perspective) are usually distorted and unrealistic and often depict the
individuals’ fear of what will occur in the situation (e.g., an auditory represen-
tation of themselves stuttering or sounding quiet and awkward, a picture of
people making fun of their perceived flaw, a disproportional focus on a “defec-
tive” feature; Osman, Cooper, Hackmann, & Veale, 2004).
The continuous retrieval of negative images and associated memories
maintains self-focused attention along with a view of what the individual will
look like and feel like in anxiety-provoking situations, and strengthens mal-
adaptive beliefs about their perceived flaw (e.g., a distorted image of an enor-
mous and disfigured nose alongside efficient retrieval of autobiographical
memories of feeling self-conscious while sitting alone during social get-
togethers maintains the belief that one is ugly and abnormal).

Fear of Intrusive Thoughts, Contamination,

and “Not Just Right” Experiences

One way that autobiographical memories maintain fear in OCD is that they
provide a source of internal and external stimuli that evoke obsessional thoughts,
194 Romano et al.

feelings of discomfort and anxiety, and compulsive behavior. A range of dis-

tinct memories can provide a source of mental contamination (Coughtrey,
Shafran, Lee, & Rachman, 2012), including memories associated with moral
violation or betrayal (e.g., prompting the urge to wash in victims of sexual
assault; Fairbrother & Rachman, 2004), memories of criticism (e.g., child-
hood memories of belittlement), or other types of negative memories that
evoke feelings of disgust (e.g., the memory of finding a dead body) or shame.
Coughtrey and colleagues (2012) described one patient with OCD who
reported being unable to use a chair in their home because someone unpleas-
ant had sat on it 10 years previously, illustrating not only the persistence of
autobiographical memories in maintaining anxiety but also suggesting that
associative links in autobiographical memory can proliferate and elaborate
fear. Recurrent retrieval of contamination experiences in neutral contexts
might trigger contamination fears and support the subsequent encoding of
neutral or uncontaminated stimuli as being polluted, which in turn contrib-
utes to the overlap between contact and mental contamination (Coughtrey
et al., 2012).
As in other fear domains, intrusive imagery provides an avenue for the
recurrent retrieval of distressing memories, as such images are often connected
to a disturbing memory and incorporate personally significant past events
(Rachman, 2007). At other times, formative beliefs associated with personally
significant memories are reflected in images that might not obviously link to
the memory at first glance. Speckens, Hackmann, Ehlers, and Cuthbert (2007)
described a patient’s image of herself covered in feces and urine, having wrin-
kles, and looking horrible. On further assessment, the patient reported that
this image meant that she was a bad person and said that she would react to
the image by punishing herself physically, by scratching her body or walking
into things intentionally. The image was associated with feelings of strong guilt
in relation to earlier memories of having treated her mother badly as a child.
Intrusive images and memories can also serve to maintain compulsive
behavior by disrupting the act of compulsions, such that the compulsive behav-
ioral sequence must be restarted. de Silva (1986) reported the case of a patient
who had intrusive images related to past memories of homosexual acts that
were to be cleansed with prayers to God in a certain sequence. However, when-
ever the sequence was interrupted by intrusive images, the patient felt com-
pelled to restart the process from the beginning.
Notably, although obsessional images may reflect a reactivation of a stress
experience or other personally significant event, many images described by
patients with OCD incorporate unusual, unrealistic, and fantasy-based ele-
ments (de Silva, 1986). Elaborative cognitions and images that seem incon-
gruent with reality might be instigated by self-beliefs that underlie the
auto­biographical memory system and reveal something terrible about the
patient’s identity (e.g., “I am immoral,” “I am dangerous,” “I am personally
responsible”; Salkovskis, 1989). Intrusive memories, then, can serve to main-
tain beliefs that form the object of obsessions and compulsions and can also
incite self-doubt relating to the individual’s own character.
 Autobiographical Memory Bias 195

Fear of Somatic Cues and the Consequences of Panic Symptoms

Fear of somatic cues and symptoms, as in panic disorder and agoraphobia, are
often represented in the mind’s eye by anxious imagery linked to specific
autobiographical memories. Imagery in panic disorder can include vivid memo-
ries of previous threatening experiences and sensations (Ottaviani & Beck,
1987). In agoraphobia, images can reflect memories of instances where the
physical integrity of the self was threatened and/or felt vulnerable (e.g., being
stranded alone in a supermarket, being bullied for being small, nearly drown-
ing in the sea) and correspond with feelings of fear, humiliation, intimidation,
vulnerability, and a desire to escape the situation to preserve one’s physical
integrity (Hackmann et al., 2009).
Individuals who have panic attacks are thought to become conditioned to
the unpleasant physical sensations that occur during a panic attack (Goldstein
& Chambless, 1978), and such conditioning can occur even in the absence of
negative cognitions (Bouton, Mineka, & Barlow, 2001). Individuals who have
panic attacks tend to quickly recall autobiographical memories after panic-
related cues (Wenzel & Cochran, 2006), and panic memories are typically vivid,
are emotionally intense, and are perceived as reflecting an accurate portrayal
of the negative event (e.g., O’Toole, Watson, Rosenberg, & Berntsen, 2016).
Some individuals even reproduce panic symptoms when imaging events that
have triggered panic in past (Ottaviani & Beck, 1987). Prioritized access to
memories linked to beliefs related to panic may perpetuate the idea that an
individual cannot cope with the occurrence of a panic attack or associated
negative consequences. Furthermore, access to such memories can impede
patients from understanding the realistic likelihood and consequences of an
attack and maintain their heightened focus on bodily sensations and atten-
tion to threat, which in turn can enhance the likelihood that a panic attack
will actually occur.

Fear of Having or Contracting an Illness

Autobiographical memories related to illness may help to maintain fear of

having or contracting an illness, as in individuals with health anxiety. These
individuals often report intrusive imagery when feeling anxious about their
health, with images typically relating to anticipation of a future illness episode,
including being told that they have contracted a life-threatening illness, suffer-
ing and dying from a life-threatening illness, or the impact of a life-threatening
illness on loved ones (Muse et al., 2010). Readily accessible future imaginings
that are maintained by the autobiographical memory system, including mem-
ories of past health-related experiences, may increase the individual’s percep-
tion that a health problem is more likely to occur (overestimating threat) and
in turn, increase the tendency for health care seeking behavior, reassur-
ance seeking, and/or avoidance. Recurrent memories that encompass illness-
relevant self-beliefs also perpetuate goals of illness avoidance, and represent
states to be avoided (e.g., “if I am ill, it means I am worthless”). Goal-directed
196 Romano et al.

behavior related to avoiding illness can also be maintained via memories of

successful health care and reassurance seeking.

Fear of Traumatic Memories and Posttraumatic Sequelae

PTSD presents an interesting case for autobiographical memory bias, in which

a hallmark symptom of PTSD is the involuntary but intrusive recollection of
the traumatic experience, often in the form of mental images. The memories
are so vivid, emotional, and sensory laden that the individuals experiencing
them report feeling as if they are back in the traumatic situation (Brewin,
Dalgleish, & Joseph, 1996). On the other hand, however, some individuals
may struggle to retrieve details of the event voluntarily and in a coherent
manner, though this is not the case for all individuals (e.g., Rubin, 2011).
Although the experience of flashbacks suggests that some representation
of the traumatic event has been encoded and stored in memory, the inability
to recall particular details suggests that the memories may not always be fully
accessible. It is possible that involuntary reexperiencing of the traumatic
event consists primarily of sensory impressions and physiological sensations,
which are more accessible and directly activated in response to fear stimuli
(Ehlers & Clark, 2000). Intrusive memories often represent stimuli that during
the course of events predicted the onset of the trauma or signaled the onset
of moments when the meaning became more traumatic and serve as warn-
ing signals (e.g., stimuli that if encountered again, would indicate impending
danger and future threat; see Hackmann, Ehlers, Speckens, & Clark, 2004).
In terms of voluntary retrieval of autobiographical memories, individuals
diagnosed with PTSD or acute stress disorder may demonstrate difficulty retriev-
ing specific episodic memories (i.e., overgeneral memory bias), show deficien-
cies in retrieving positive autobiographical memories, and typically retrieve
more trauma-related memories and episodic content relative to individuals
who experience trauma and do not develop PTSD (see Moore & Zoellner,
2007). Deficits in the specific retrieval of past experiences can contribute to the
maintenance of fear, avoidance, and negative outlook and substantiate trauma-
focused self-representations.
The mnemonic representations of how the person behaved during and after
the trauma, his or her appraisals of the trauma, and the presence of PTSD
symptoms can also work to bias the voluntary recall of trauma memories.
Ehlers and Clark (2000) reported the case of an individual who believed her
trauma showed that nobody cared about her and recalled unfriendly responses
of nurses in hospital, but did not recall that several people had tried to help
her after the accident. Such selective retrieval prevents individuals from remem-
bering aspects of the traumatic event that contradict their appraisals and thus
prevents change in the appraisals. On the other hand, inability to remember
all of the details of the trauma can be appraised by individuals in a way that
maintains the sense of current threat; Ehlers and Clark (2000) described that
some individuals concluded that flashbacks of the event or an inability to
access all of the details of their memory meant something was seriously wrong
 Autobiographical Memory Bias 197

with them (e.g., brain damage, insanity, losing control). An inability to remem-
ber the exact nature or order of events can contribute to the erroneous appraisal
of being responsible for the event or the incorrect conclusion that something
even worse must have happened during the trauma.

Fear of Uncertain or Negative Outcomes

Biases in autobiographical memory may also be clinically relevant to patholog-

ical worry associated with fear of uncertainty. To this end, individuals with
generalized anxiety disorder (GAD)—and OCD in some cases—present with
broad worry domains, making it seem unlikely that a single, pivotal episodic
autobiographical memory stands out as a stimulus for their fear (unlike intru-
sive imagery seen in other anxiety disorders). On the other hand, there is also
evidence suggesting that they exhibit prioritized access to anxious negative
memories (Burke & Mathews, 1992). These memories might contribute to
their elaborative worry process and provide biased building blocks for future
prospection, which can then facilitate the unrealistic apprehension of “dis­
astrous” future events, which lead to more worry. Moreover, the propensity to
recall negative past events more efficiently may promote a sense of danger in
the world in general, contributing to insecurity and intolerance of uncertainty.
Autobiographical memory processes implicated in imagining the future
may also perpetuate the worry process in individuals with GAD. Although
these individuals do not report intrusive imagery associated with their fears,
they do demonstrate a looming cognitive style that is characterized by broad
and pervasive generation of mental scenarios that stereotypically represent
potential threats as rapidly unfolding and rising in risk (Riskind & Williams,
2005). Borkovec, Alcaine, and Behar (2004) suggested that worry is a cogni-
tive avoidance strategy that prevents imagining, coping with, and problem-
solving around negative future events. The inability to vividly imagine future
scenarios may hinder their ability to take concrete steps to resolve the worry
(Jing, Madore, & Schacter, 2016), which then perpetuates future worry. More­
over, pathologically rehearsing either past or future scenarios can deepen
associative memory networks, which increases the likelihood of drawing
upon negative past and future scenarios when anxiety is activated.

CONCLUSION

Previous work has shown that recurrent memories and intrusive images of
personal negative experiences can play a key role in the persistence of clinical
fear and anxiety (e.g., Harvey, Watkins, Mansell, & Shafran, 2004). Drawing
from theoretical and applied research in cognitive science, this chapter dem­
onstrated that autobiographical memory biases may extend to the encoding
and storage of particular episodic event details, the appraisal and impact of
negative autobiographical memories, the prospection of future events, and
the extraction of negative schematic meaning from environmental or internal
198 Romano et al.

cues that are perceived as threatening. A major implication of biased auto­

biographical memory is that it can perpetuate negative and distorted self-
representations, which are often paramount across fear and anxiety disorders.
Although distinct from other cognitive processes, such as attention bias
(see Chapter 12) and interpretation bias (see Chapter 20), autobiographical
memory bias is nevertheless related to the constellation of automatic fear-
and anxiety-related cognitive events. The importance of autobiographical
memory bias as a transdiagnostic maintenance process is also highlighted by
the success of established and emerging treatment approaches (e.g., imagi-
nal exposure, imagery rescripting), which are designed to target, modify,
and/or retrain emotional memories and associated memory processes in fear
and anxiety disorders.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Washington, DC: Author.
Anderson, B., Goldin, P. R., Kurita, K., & Gross, J. J. (2008). Self-representation in
social anxiety disorder: Linguistic analysis of autobiographical narratives. Behaviour
Research and Therapy, 46, 1119–1125. http://dx.doi.org/10.1016/j.brat.2008.07.001
Beck, A., Emery, G., & Greenberg, R. (2005). Anxiety disorders and phobias: A cognitive
perspective (15th ed.). Cambridge, MA: Basic Books.
Berntsen, D. (2012). Spontaneous recollections: Involuntary autobiographical memories
are a basic mode of remembering. In D. Berntsen & D. C. Rubin (Eds.), Understanding
autobiographical memory: Theories and approaches (pp. 290–310). Cambridge, England:
Cambridge University Press. http://dx.doi.org/10.1017/CBO9781139021937.021
Berntsen, D., & Rubin, D. C. (2006). The centrality of event scale: A measure of inte-
grating a trauma into one’s identity and its relation to posttraumatic stress disorder
symptoms. Behaviour Research and Therapy, 44, 219–231. http://dx.doi.org/10.1016/
j.brat.2005.01.009
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and
generalized anxiety disorder. In R. Heimberg, C. Turk, & D. Mennin (Eds.), General-
ized anxiety disorder: Advances in research and practice (pp. 77–108). New York, NY:
Guilford Press.
Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory per­
spective on the etiology of panic disorder. Psychological Review, 108, 4–32. http://
dx.doi.org/10.1037/0033-295X.108.1.4
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of post-
traumatic stress disorder. Psychological Review, 103, 670–686. http://dx.doi.org/
10.1037/0033-295X.103.4.670
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in
psychological disorders: Characteristics, neural mechanisms, and treatment impli-
cations. Psychological Review, 117, 210–232. http://dx.doi.org/10.1037/a0018113
Brown, A. D., Root, J. C., Romano, T. A., Chang, L. J., Bryant, R. A., & Hirst, W. (2013).
Overgeneralized autobiographical memory and future thinking in combat veterans
with posttraumatic stress disorder. Journal of Behavior Therapy and Experimental
Psychiatry, 44, 129–134. http://dx.doi.org/10.1016/j.jbtep.2011.11.004
Burke, M., & Mathews, A. (1992). Autobiographical memory and clinical anxiety.
Cognition and Emotion, 6, 23–35. http://dx.doi.org/10.1080/02699939208411056
Çili, S., & Stopa, L. (2015). Intrusive mental imagery in psychological disorders: Is the
self the key to understanding maintenance? Frontiers in Psychiatry, 6, 103. http://
dx.doi.org/10.3389/fpsyt.2015.00103
 Autobiographical Memory Bias 199

Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and prac-
tice. New York, NY: Guilford Press.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg,
M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assess-
ment and treatment (pp. 69–93). New York, NY: Guilford Press.
Conway, M. A. (2005). Memory and the self. Journal of Memory and Language, 53,
594–628. http://dx.doi.org/10.1016/j.jml.2005.08.005
Conway, M. A., & Pleydell-Pearce, C. W. (2000). The construction of autobiographical
memories in the self-memory system. Psychological Review, 107, 261–288. http://
dx.doi.org/10.1037/0033-295X.107.2.261
Coughtrey, A. E., Shafran, R., Lee, M., & Rachman, S. J. (2012). It’s the feeling inside
my head: A qualitative analysis of mental contamination in obsessive-compulsive
disorder. Behavioural and Cognitive Psychotherapy, 40, 163–173. http://dx.doi.org/
10.1017/S1352465811000658
D’Argembeau, A. (2012). Autobiographical memory and future thinking. In D. Berntsen
& D. C. Rubin (Eds.), Understanding autobiographical memory: Theories and approaches
(pp. 311–330). Cambridge, England: Cambridge University Press. http://dx.doi.org/
10.1017/CBO9781139021937.022
de Silva, P. (1986). Obsessional-compulsive imagery. Behaviour Research and Therapy,
24, 333–350. http://dx.doi.org/10.1016/0005-7967(86)90193-2
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress dis­
order. Behaviour Research and Therapy, 38, 319–345. http://dx.doi.org/10.1016/
S0005-7967(99)00123-0
Erwin, B. A., Heimberg, R. G., Marx, B. P., & Franklin, M. E. (2006). Traumatic and
socially stressful life events among persons with social anxiety disorder. Journal of
Anxiety Disorders, 20, 896–914. http://dx.doi.org/10.1016/j.janxdis.2005.05.006
Fairbrother, N., & Rachman, S. (2004). Feelings of mental pollution subsequent to
sexual assault. Behaviour Research and Therapy, 42, 173–189. http://dx.doi.org/10.1016/
S0005-7967(03)00108-6
Fitzgerald, J. M. (1992). Autobiographical memory and conceptualizations of the self.
In M. A. Conway, D. C. Rubin, H. Spinnler, & W. A. Wagenaar (Eds.), Theoretical
perspectives on autobiographical memory (pp. 99–114). Dordrecht, the Netherlands:
Springer. http://dx.doi.org/10.1007/978-94-015-7967-4_6
Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory:
An update. In B. O. Rothbaum (Ed.), The nature and treatment of pathological anxiety
(pp. 3–24). New York, NY: Guilford Press.
Foa, E. B., & Jaycox, L. H. (1999). Cognitive-behavioral theory and treatment of post-
traumatic stress disorder. In I. D. Spiegel (Ed.), Efficacy and cost-effectiveness of psycho-
therapy (pp. 23–61). Washington, DC: American Psychiatric Association.
Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy,
9, 47–59. http://dx.doi.org/10.1016/S0005-7894(78)80053-7
Hackmann, A., Day, S., & Holmes, E. A. (2009). Agoraphobia: Imagery and the threatened
self. In L. Stopa (Ed.), Imagery and the threatened self: Perspectives on mental imagery
and the self in cognitive therapy (pp. 112–136). London, England: Routledge.
Hackmann, A., Ehlers, A., Speckens, A., & Clark, D. M. (2004). Characteristics and con-
tent of intrusive memories in PTSD and their changes with treatment. Journal of
Trauma­tic Stress, 17, 231–240. http://dx.doi.org/10.1023/B:JOTS.0000029266.88369.fd
Harvey, A. G., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural
processes across psychological disorders. Oxford, England: Oxford University Press.
http://dx.doi.org/10.1093/med:psych/9780198528883.001.0001
Hertel, P. T., Brozovich, F., Joormann, J., & Gotlib, I. H. (2008). Biases in interpretation
and memory in generalized social phobia. Journal of Abnormal Psychology, 117, 278–288.
http://dx.doi.org/10.1037/0021-843X.117.2.278
200 Romano et al.

Holland, A. C., & Kensinger, E. A. (2010). Emotion and autobiographical memory.

Physics of Life Reviews, 7, 88–131. http://dx.doi.org/10.1016/j.plrev.2010.01.006
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
dis­orders. Clinical Psychology Review, 30, 349–362. http://dx.doi.org/10.1016/
j.cpr.2010.01.001
Horowitz, M. J. (1970). Image formation and cognition. New York, NY: Appleton-Century
Crofts.
Jing, H. G., Madore, K. P., & Schacter, D. L. (2016). Worrying about the future: An
episodic specificity induction impacts problem solving, reappraisal, and well-being.
Journal of Experimental Psychology: General, 145, 402–418. http://dx.doi.org/10.1037/
xge0000142
Johnson, M. K., Foley, M. A., Suengas, A. G., & Raye, C. L. (1988). Phenomenal
characteristics of memories for perceived and imagined autobiographical events.
Journal of Experimental Psychology: General, 117, 371–376. http://dx.doi.org/10.1037/
0096-3445.117.4.371
Kosslyn, S. M., Ganis, G., & Thompson, W. L. (2001). Neural foundations of imagery.
Nature Reviews Neuroscience, 2, 635–642. http://dx.doi.org/10.1038/35090055
Krans, J., de Bree, J., & Bryant, R. A. (2014). Autobiographical memory bias in social
anxiety. Memory, 22, 890–897. http://dx.doi.org/10.1080/09658211.2013.844261
LaBar, K. S. (2007). Beyond fear: Emotional memory mechanisms in the human brain.
Current Directions in Psychological Science, 16, 173–177. http://dx.doi.org/10.1111/
j.1467-8721.2007.00498.x
McGaugh, J. L. (2004). The amygdala modulates the consolidation of memories of
emotionally arousing experiences. Annual Review of Neuroscience, 27, 1–28. http://
dx.doi.org/10.1146/annurev.neuro.27.070203.144157
Moore, S. A., & Zoellner, L. A. (2007). Overgeneral autobiographical memory and
traumatic events: An evaluative review. Psychological Bulletin, 133, 419–437. http://
dx.doi.org/10.1037/0033-2909.133.3.419
Morgan, J. (2010). Autobiographical memory biases in social anxiety. Clinical Psychol-
ogy Review, 30, 288–297. http://dx.doi.org/10.1016/j.cpr.2009.12.003
Moscovitch, D. A., Gavric, D. L., Merrifield, C., Bielak, T., & Moscovitch, M. (2011).
Retrieval properties of negative vs. positive mental images and autobiographical
memories in social anxiety: Outcomes with a new measure. Behaviour Research and
Therapy, 49, 505–517. http://dx.doi.org/10.1016/j.brat.2011.05.009
Moscovitch, D. A., Vidovic, V., Lenton-Brym, A. P., Dupasquier, J. R., Barber, K. C.,
Hudd, T., . . . Romano, M. (2018). Autobiographical memory retrieval and appraisal
in social anxiety disorder. Behaviour Research and Therapy, 107, 106–116. http://
dx.doi.org/10.1016/j.brat.2018.06.008
Moscovitch, M. (2008). The hippocampus as a “stupid,” domain-specific module: Impli-
cations for theories of recent and remote memory, and of imagination. Canadian
Journal of Experimental Psychology/Revue Canadienne de Psychologie Expérimentale, 62,
62–79. http://dx.doi.org/10.1037/1196-1961.62.1.62
Moscovitch, M. (2012). The contribution of research on autobiographical memory to
past and present theories of memory consolidation. In R. Bernsten & D. C. Rubin
(Eds.), Understanding autobiographical memory: Theories and approaches (pp. 91–113).
Cambridge, England: Cambridge University Press. http://dx.doi.org/10.1017/
CBO9781139021937.009
Moscovitch, M., Cabeza, R., Winocur, G., & Nadel, L. (2016). Episodic memory and
beyond: The hippocampus and neocortex in transformation. Annual Review of Psy-
chology, 67, 105–134. http://dx.doi.org/10.1146/annurev-psych-113011-143733
Muse, K., McManus, F., Hackmann, A., Williams, M., & Williams, M. (2010). Intrusive
imagery in severe health anxiety: Prevalence, nature and links with memories and
maintenance cycles. Behaviour Research and Therapy, 48, 792–798. http://dx.doi.org/
10.1016/j.brat.2010.05.008
 Autobiographical Memory Bias 201

Osman, S., Cooper, M., Hackmann, A., & Veale, D. (2004). Spontaneously occurring
images and early memories in people with body dysmorphic disorder. Memory, 12,
428–436. http://dx.doi.org/10.1080/09658210444000043
O’Toole, M. S., Watson, L. A., Rosenberg, N. K., & Berntsen, D. (2016). Negative auto-
biographical memories in social anxiety disorder: A comparison with panic disorder
and healthy controls. Journal of Behavior Therapy and Experimental Psychiatry, 50,
223–230. http://dx.doi.org/10.1016/j.jbtep.2015.09.008
Ottaviani, R., & Beck, A. T. (1987). Cognitive aspects of panic disorders. Journal of
Anxiety Disorders, 1, 15–28. http://dx.doi.org/10.1016/0887-6185(87)90019-3
Price, K., Veale, D., & Brewin, C. R. (2012). Intrusive imagery in people with a specific
phobia of vomiting. Journal of Behavior Therapy and Experimental Psychiatry, 43,
672–678. http://dx.doi.org/10.1016/j.jbtep.2011.09.007
Rachman, S. (2007). Unwanted intrusive images in obsessive compulsive disorders.
Journal of Behavior Therapy and Experimental Psychiatry, 38, 402–410. http://dx.doi.org/
10.1016/j.jbtep.2007.10.008
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in
social phobia. Behaviour Research and Therapy, 35, 741–756. http://dx.doi.org/10.1016/
S0005-7967(97)00022-3
Reimer, S. G., & Moscovitch, D. A. (2015). The impact of imagery rescripting on
memory appraisals and core beliefs in social anxiety disorder. Behaviour Research
and Therapy, 75, 48–59. http://dx.doi.org/10.1016/j.brat.2015.10.007
Riskind, J. H., & Williams, N. L. (2005). The looming cognitive style and generalized
anxiety disorder: Distinctive danger schemas and cognitive phenomenology. Cogni-
tive Therapy and Research, 29, 7–27. http://dx.doi.org/10.1007/s10608-005-1645-z
Rubin, D. C. (2011). The coherence of memories for trauma: Evidence from post­
traumatic stress disorder. Consciousness and Cognition: An International Journal, 20,
857–865. http://dx.doi.org/10.1016/j.concog.2010.03.018
Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intru-
sive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677–682.
http://dx.doi.org/10.1016/0005-7967(89)90152-6
Sansom-Daly, U. M., Bryant, R. A., Cohn, R. J., & Wakefield, C. E. (2014). Imagining
the future in health anxiety: The impact of rumination on the specificity of illness-
related memory and future thinking. Anxiety, Stress, & Coping: An International Jour-
nal, 27, 587–600. http://dx.doi.org/10.1080/10615806.2014.880111
Schacter, D. L. (2001). The seven sins of memory: How the mind forgets and remembers.
Boston, MA: Houghton Mifflin.
Schacter, D. L., Addis, D. R., Hassabis, D., Martin, V. C., Spreng, R. N., & Szpunar, K. K.
(2012). The future of memory: Remembering, imagining, and the brain. Neuron, 76,
677–694. http://dx.doi.org/10.1016/j.neuron.2012.11.001
Singer, J. A., & Salovey, P. (1993). The remembered self: Emotion and memory in personality.
New York, NY: Free Press.
Speckens, A. E. M., Hackmann, A., Ehlers, A., & Cuthbert, B. (2007). Imagery special
issue: Intrusive images and memories of earlier adverse events in patients with
obsessive-compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry,
38, 411–422. http://dx.doi.org/10.1016/j.jbtep.2007.09.004
Stopa, L. (Ed.). (2009). Imagery and the threatened self: Perspectives on mental imagery and
the self in cognitive therapy. New York, NY: Routledge. http://dx.doi.org/10.4324/
9780203878644
Sutherland, K., & Bryant, R. A. (2005). Self-defining memories in posttraumatic stress
disorder. British Journal of Clinical Psychology, 44, 591–598. http://dx.doi.org/10.1348/
014466505X64081
Talmi, D. (2013). Enhanced emotional memory: Cognitive and neural mechanisms.
Current Directions in Psychological Science, 22, 430–436. http://dx.doi.org/10.1177/
0963721413498893
202 Romano et al.

Thomsen, D. K., & Brinkmann, S. (2009). An interviewer’s guide to autobiographical

memory: Ways to elicit concrete experiences and to avoid pitfalls in interpreting
them. Qualitative Research in Psychology, 6, 294–312. http://dx.doi.org/10.1080/
14780880802396806
Tulving, E. (1985). Memory and consciousness. Canadian Psychology/Psychologie
Canadienne, 26, 1–12. http://dx.doi.org/10.1037/h0080017
Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic dis-
order. Body Image, 1, 113–125. http://dx.doi.org/10.1016/S1740-1445(03)00009-3
Veale, D. (2009). Cognitive behaviour therapy for a specific phobia of vomiting. The Cog-
nitive Behaviour Therapist, 2, 272–288. http://dx.doi.org/10.1017/S1754470X09990080
Wenzel, A., & Cochran, C. K. (2006). Autobiographical memories prompted by auto-
matic thoughts in panic disorder and social phobia. Cognitive Behaviour Therapy, 35,
129–137. http://dx.doi.org/10.1080/16506070600583130
Williams, J. M. G., Barnhofer, T., Crane, C., Herman, D., Raes, F., Watkins, E., &
Dalgleish, T. (2007). Autobiographical memory specificity and emotional disorder.
Psychological Bulletin, 133, 122–148. http://dx.doi.org/10.1037/0033-2909.133.1.122
Witheridge, K. S., Cabral, C. M., & Rector, N. A. (2010). Examining autobiographical
memory content in patients with depression and anxiety disorders. Cognitive Behaviour
Therapy, 39, 302–310. http://dx.doi.org/10.1080/16506073.2010.520730
Zlomuzica, A., Dere, D., Machulska, A., Adolph, D., Dere, E., & Margraf, J. (2014).
Episodic memories in anxiety disorders: Clinical implications. Frontiers in Behavioral
Neuroscience, 8, 131. http://dx.doi.org/10.3389/fnbeh.2014.00131
12
Attention Bias
Omer Azriel and Yair Bar-Haim

Imagine two scenarios. In the first, Arun is hiking through the forest when she
spots a rattlesnake several yards ahead on the trail.1 Arun’s attention prioritizes
processing the snake over nearly all other aspects of the environment. Focusing
on the snake and allocating resources for dealing with its presence is adaptive
and paramount for her survival. Now, imagine a second scenario: Arun is hiking
in the same forest when she spots a tree branch several yards ahead on the
ground. The branch grabs her attention briefly, but her attention system gives
it low priority for further processing; perhaps at a level that fails to reach con-
sciousness. She continues hiking, ignoring the branch altogether. An adaptive
function of her attention system has facilitated detection and further process-
ing of threats and allowed her to filter and ignore less relevant stimuli. Note,
however, that a rattlesnake and a branch reflect extremes that are rather easily
distinguished in relation to threat. Almost anyone would allocate extensive
attentional resources to the former and ignore the latter.

Attention bias is the tendency to prioritize the processing of certain types of

stimuli over others. At any given moment, an individual’s senses can perceive
countless stimuli in the immediate surroundings. Initially, multiple messages
that reach the senses are processed in parallel. However, because of the limited
capacity of the human mind, further detailed processing is possible only for a

All clinical case material has been altered to protect patient confidentiality.
1

http://dx.doi.org/10.1037/0000150-012
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
203
 204 Azriel and Bar-Haim

select subset of stimuli. To reduce the load, a selective filter blocks irrelevant
messages before they reach the processing bottleneck and allows only a limited
number of signals to be more thoroughly processed and used in the control of
behavior. Attention is at the core of these filtering and prioritization processes
(Broadbent, 1958; Duncan, 1980; Treisman, 1969). While attention biases
reflect an ongoing cognitive adaptation associated with the processing of all
aspects of the environment, paying specific attention to potential threats is a
priority for survival and therefore, a primary function of the attention system.
This chapter focuses on threat-related attention bias—the tendency to prioritize the
processing of potential threats over benign stimuli—and its relation to anxiety.
Figure 12.1 shows the individual differences in threat-related attention, espe-
cially when the processed stimulus is ambiguous. What if Arun had spotted a
gecko rather than a snake, encountered a snake locked in a vivarium, saw a
photograph of a snake, or simply read the word snake? Would her attention
system prioritize these stimuli over other more neutral ones? There is ample
evidence to suggest that the human brain still selectively processes and priori-
tizes such low-risk stimuli (e.g., Dijksterhuis & Aarts, 2003; Fox et al., 2000;
Hansen & Hansen, 1988; Öhman, Flykt, & Esteves, 2001). It is with such stimuli,
however, where individual differences emerge; some people consistently
display a threat-related attention bias (Bar-Haim, Lamy, Pergamin, Bakermans-
Kranenburg, & van IJzendoorn, 2007; Mogg & Bradley, 1998). Individuals

FIGURE 12.1. Individual Differences in Attentional Prioritization Are Typically

Revealed in Relation to Minor Threats

High
Stimulus Attentional Prioritization

Low

No threat Minor threat High threat

Threat Level of Stimulus
The solid line depicts a person who would prioritize mild threats more readily compared with a typical
person (depicted with the dashed line). The dotted line depicts no threat prioritization.
 Attention Bias 205

prone to threat-related attention bias have their attention more frequently and
more intensely captured by minor threats and find it difficult to disengage
from such stimuli (Cisler & Koster, 2010; Fox, Russo, Bowles, & Dutton, 2001;
Richards, Benson, Donnelly, & Hadwin, 2014; Yiend, 2010). Extensive research
indicates that threat-related attention bias plays a significant role in the develop-
ment and maintenance of clinical anxiety, which is discussed next.

CONCEPTUAL IMPLICATIONS

Attention Bias and Anxiety

Once a stimulus is appraised as threatening, it takes on negative emotional

significance and becomes a mental priority. This is an automatic part of the
body’s innate danger detection system—the fight-or-flight response—that is
activated whenever a threat is perceived (Beck & Clark, 1997; Davis &
Whalen, 2001; LeDoux, 2009). By scanning the surroundings and being
hypervigilant for danger cues, this mechanism helps individuals determine
how to protect themselves in the event that danger is present. Although this
is often an involuntary process, some individuals adopt a more deliberate
anticipatory strategy of hypervigilance and scanning if they believe such
tactics are necessary to avoid perceived threat. As a result of this attention
bias toward threat, these individuals become exquisitely sensitive to threat-
relevant stimuli, even those that pose little danger. Thus, attention bias main-
tains anxiety by fostering an enhanced perception of the world as dangerous
(Eysenck, 1992), which in turn intensifies threat-related attention bias (Eldar,
Ricon, & Bar-Haim, 2008; Eysenck, 1997; Mathews & MacLeod, 2002).
Numerous studies indicate that individuals with anxiety across a wide
range of clinical and subclinical categories exhibit attention bias toward
threatening information (Armstrong & Olatunji, 2012; Bar-Haim et al., 2007;
Van Bockstaele et al., 2014). Attention bias is typically stronger for disor-
der-congruent stimuli relative to more general threats. Pictures of snakes or
words related to snakes elicit greater attention bias compared with other neg-
ative stimuli among individuals with snake phobia (Wikström, Lundh, West-
erlund, & Högman, 2004); whereas individuals with social anxiety are more
likely to exhibit attention bias when facing words related to social fears rela-
tive to general threat words (e.g., Becker, Rinck, Margraf, & Roth, 2001; for a
review and meta-analysis, see Pergamin-Hight, Naim, Bakermans-Kranen-
burg, van IJzendoorn, & Bar-Haim, 2015). Similarly, individuals with health
anxiety and panic attacks, who are afraid of certain bodily sensations, fearing
that they indicate the presence of a serious medical condition (e.g., heart
attack, cardiac disease, cancer), preferentially attend to even slight fluctua-
tions and perturbations in these internal stimuli (e.g., Asmundson, Sandler,
Wilson, & Walker, 1992). Finally, individuals with obsessional problems dis-
play attention bias toward idiosyncratic stimuli that cue obsessional fear and
compulsive rituals (Foa, Ilai, McCarthy, Shoyer, & Murdock, 1993).
206 Azriel and Bar-Haim

Etiology and Developmental Aspects

Whether threat-related attention bias is innate, acquired, or both is unknown.

Threat-related attention bias is observed among children as young as 5 years
old (Pérez-Edgar et al., 2011; White, Degnan, et al., 2017). This suggests that
early environmental or biological factors are involved in the formation of
threat-related attentional patterns. For example, various studies indicate that
allele variants of the serotonin transporter gene (5-HTTLPR), known to modu­
late synaptic efficacy of serotonin reuptake, is associated with selective atten-
tion to threat. Carriers of the low serotonin transmission genotype tend to
display an enhanced attentional threat bias relative to carriers of the inter-
mediate and high efficacy genotypes (for a review and meta-analysis, see
Pergamin-Hight, Bakermans-Kranenburg, van IJzendoorn, & Bar-Haim, 2012).
Although correlational, such evidence suggests a genetic influence on threat-
related attention deployment with some individuals receiving a slight push
from nature to overattend to minor threats.
Whether innate, acquired, or reflecting transactions among both, elevated
attention bias to threats early in life has the potential to shape a hostile per-
ception of the environment and has a long-term effect on emotional develop-
ment in children. Some children exhibit an early tendency for behavioral
inhibition—a temperament characterized by anxious behaviors, heightened
sensitivity to novelty, and social withdrawal. These children tend to exhibit
anxious behaviors at later ages as well and are at increased risk for developing
anxiety disorders (Biederman et al., 1993, 2001; Chronis-Tuscano et al.,
2009). Attention bias to threats moderates this association, increasing the risk
of young children with early behavioral inhibition to exhibit anxiety-related
behaviors at later childhood and adolescence (Pérez-Edgar et al., 2010, 2011;
White, Degnan, et al., 2017). Threat-related attention bias is likely to con-
tribute to long-term maintenance and aggravation of anxiety in predisposed
children by coloring their environments in danger and threat shades (for further
discussion see Pine, Helfinstein, Bar-Haim, Nelson, & Fox, 2009; White,
Degnan, et al., 2017).

ASSESSMENT

Unlike most concepts in psychopathology, which can be assessed using patient

self-report and clinical interview methods, the measurement of attention bias
in the context of anxiety relies heavily on adaptations form experimental
research and typically uses computerized cognitive tasks. Two types of para-
digms exist: those relying on measures of reaction time (RT) and those apply-
ing eye-tacking paradigms. RT tasks infer attention bias from differences in
the amount of time required for an individual to respond to different types of
stimuli (e.g., threat vs. neutral). Such tasks have been used extensively in
research but are not widely used in clinical settings. They are also limited in
that (a) they capture only indirect and static effects of attention on behavior,
 Attention Bias 207

and (b) derived bias scores have poor psychometric properties (e.g., Evans &
Britton, 2018; McNally, 2019; Price et al., 2015). Eye-tracking tasks, on the
other hand, capture more direct effects of, and provide continuous access to,
dynamic changes in attention. Some of these tasks also possess good psycho-
metric properties (e.g., Lazarov, Abend, & Bar-Haim, 2016; Lazarov, Ben-Zion,
Shamai, Pine, & Bar-Haim, 2018). Some of the typical tasks applied to mea-
sure threat-related attention bias are described next.

Reaction Time-Based Measures

Emotional Stroop Task

The emotional Stroop task is a modified version of the classic color-naming
Stroop task (Stroop, 1935). In this task, either a colored neutral word (e.g.,
data, written in blue [but shown in bold in Figure 12.2a]) or a colored threat-
related word (e.g., dead, written in green [but shown in italics in Figure 12.2a])
are sequentially presented. Participants are asked to indicate as quickly as pos-
sible the color in which each word is written. Threat-related attention bias is
determined by comparing the difference between mean RT with color-name
threat words and mean RT with color-name neutral words. This relation is
thought to represent the extent to which threat stimuli capture attention and
interfere with the otherwise emotionally neutral color-naming task. Variants
of the emotional Stroop task use schematic or real faces displaying threat and
neutral expressions of emotion (e.g., Kolassa & Miltner, 2006; Putman,
Hermans, & van Honk, 2004). In such variants, individuals are instructed to
color-name the background on which the face is superimposed or the color in
which the schematic face is drawn. Applying faces rather than words as stimuli
can be useful when studying populations with differing levels of reading com-
prehension (e.g., children, individuals with reading disabilities, nonnative
readers).

Dot-Probe Task
In the dot-probe task (MacLeod, Mathews, & Tata, 1986), neutral and threat-
related stimuli are presented simultaneously, creating a spatial rivalry for an
individual’s attention. In each trial, threat–neutral pairs are presented for a
brief time followed by a probe (e.g., an x) appearing on the screen at either
the location of the neutral or the threat-related stimulus (see Figure 12.2b).
The individual is asked to respond as quickly and accurately as possible to the
probe, either identifying its location or discriminating its variant (e.g., if the
probe is an arrowhead, the patient should indicate its direction). Attention
bias is calculated as the relation between the mean RT of trials in which the
probe was presented at the location of a threat-related stimulus (i.e., threat
congruent trials) and the mean RT of trials in which the probe was presented
at the location of a neutral stimulus (i.e., threat incongruent trials). When RTs
are consistently faster for trials in which the probe appears at the location of
the threat-relevant stimulus, it is thought to reflect an attention bias toward
208 Azriel and Bar-Haim

FIGURE 12.2. Examples of Typical Trials in Different Attention Bias

Assessment Methods

A. The emotional Stroop task B. The dot probe task

+ +

500 ms
DEAD
DATA
Until DATA
response 500 ms

+
Tim

Until <
ing

500 ms response

DEAD +
Until
response 500 ms
GRAVE

C. The emotional spatial cuing task COUCH

500 ms
<
+
Until
response
1000 ms

100 ms

50 ms

+
^

Until
response
(A) The emotional Stroop task: A trial with a neutral stimulus followed by a trial with a threat stimulus.
Participants are asked to name the text color as fast as possible. (B) The dot-probe task: A trial with
a target appearing at the neutral stimulus location followed by a trial with a target appearing at the
threat stimulus location. Participants are asked to indicate the arrowhead’s direction as fast as
possible. (C) The emotional spatial cueing task: valid-cue trial with a threatening stimulus. Participants
are asked to indicate the arrowhead’s direction as fast as possible.
 Attention Bias 209

FIGURE 12.2. (Continued)

D. Visual search task E. Free viewing task

Until response 6000 ms

Until response
(D) A visual search task. Participants are asked to detect the angry face within the faces array (top
panel). All neutral faces array; participants are asked to indicate whether the array contains an angry
face or not (bottom panel). (E) A free viewing task: Participants are asked to freely watch an array
with equally appearing disgusted and neutral faces. Images IDs: F01NE, F04DI, F04NE, F06DI, F07NE,
F09NE, F12NE, F14NE, F19AN, F19DI, F21NE, F23DI, F27DI, F28NE, F29NE, F30DI, F32NE, M02DI,
M07NE, M08AN, M11NE, M13NE, M14NE, M16NE, M17NE, M18NE, M21NE, M22NE, M23DI, M28NE,
M29NE, M30NE, M34NE, M35NE. All faces images from The Karolinska Directed Emotional Faces
(KDEF) [CD ROM], by E. Lundqvist, D. Flykt, and A. Öhman, 1998, Solna, Sweden: Karolinska Institutet.
Copyright 1998 by Karolinska Institutet. Reprinted with permission.
210 Azriel and Bar-Haim

threat. Meta-analyses indicate a medium size effect of the association between

anxiety and attention bias as measured by the dot-probe task.
The task is easy to administer, takes about 5 to 10 minutes, and can apply
words, faces, or any other relevant stimuli. Yet, it has important drawbacks.
First, it has low internal consistency and test–retest reliability (e.g., Schmukle,
2005; Staugaard, 2009). Second, it cannot distinguish between specific sub-
components of attention (i.e., one cannot determine whether faster responses
to probes appearing at threat locations result from faster engagement with,
or slower disengagement from threat stimuli). Koster, Crombez, Verschuere,
and De Houwer (2004) suggested adding and computing mean RTs to trials
consisting of two neutral stimuli. Faster engagement with threat could
be indexed by faster responses to threat-congruent trials compared with
neutral–neutral trials. Difficulty to disengage attention from threat could be
indexed by slower responses to threat-incongruent trials compared with
neutral–neutral trials.

Emotional Spatial Cuing Task

Based on Posner’s (1980) spatial cuing paradigm, the emotional spatial cuing
task (Fox et al., 2001) includes a brief presentation of either a neutral cue or
a threat cue in each trial. Immediately after this presentation, the individual
responds to a target that appears either at the spatially cued location (valid-cue
condition; see Figure 12.2c) or at the alternative location (invalid-cue condition).
The mean RT on valid-cue trials is subtracted from the mean RT on invalid-
cue trials, with the difference indicating a general threat-related attention
bias. The emotional spatial cueing task also affords a differentiation between
biased attentional engagement and disengagement processes. Performance
differences between threat and neutral trials in the valid-cue condition are
thought to indicate a bias in initial orienting of attention or attentional
engagement. Alternatively, differences in the invalid-cue condition reflect
difficulty to disengage attention from threat-related stimuli.
Studies that have used the emotional spatial cueing task indicate an asso-
ciation between threat-related attention bias and anxiety, with effect sizes
like those found in studies using the emotional Stroop and the dot-probe
tasks (Bar-Haim et al., 2007). Threat-related attention bias in anxiety is also
associated with difficulty disengaging attention from than with faster engage-
ment with threat stimuli (e.g., Amir, Elias, Klumpp, & Przeworski, 2003; Fox
et al., 2001). Importantly, the emotional spatial cuing task involves the pre-
sentation of a single stimulus in each trail, thus not modeling a direct compe-
tition between different stimuli on attention resources, arguably reflecting
low ecological validity (Bar-Haim et al., 2007).

Visual Search Tasks

In visual search tasks (e.g., Öhman, Flykt, & Esteves, 2001; Rinck, Becker,
Kellermann, & Roth, 2003), individuals are presented with arrays of words or
images, and instructed to detect a specific target within each array (e.g., an
angry face among eight neutral faces, a neutral face among eight angry faces;
 Attention Bias 211

see Figure 12.2d, top). Threat-related attention bias is inferred from faster
detection of threat-relevant stimuli within an array of neutral stimuli as com-
pared with the inverse. A variant of this task includes fully neutral arrays
(e.g., eight neutral faces) and instructs the respondent to determine whether a
threat-relevant stimulus (e.g., an angry face) appeared or not (see Figure 12.2d,
bottom). Threat-related attention bias in such designs is calculated as the
difference between the mean time taken to decide that no target appeared
(nontarget trials) and the decision time in trials including an actual threat-
related target. Visual search tasks are not widely used in research and have
produced inconsistent results (e.g., Eastwood et al., 2005; Wieser, Hambach,
& Weymar, 2018).

Eye-Tracking Measures

The most straightforward use of eye-tracking technology for the assessment of

threat-related attention biases is through free-viewing tasks. These tasks present
arrays comprising neutral and threat stimuli (see Figure 12.2e), and individu-
als observe these in any way they like as their gaze is tracked and recorded.
Various indices of threat-related attention bias can then be extracted from the
gaze data. Biased attentional orienting toward threat is typically indexed by
more frequent and/or faster first fixations on threat stimuli relative to neutral
stimuli. A more global measure of attention bias is the relative overall time the
individual visually dwells on threat stimuli relative to neutral stimuli, with
longer time spent on the former compared with the later indicating threat-
related attention bias (for detailed reviews, see Armstrong & Olatunji, 2012;
Richards et al., 2014). Total dwell time measures are typically more consistent
and reliable than first fixation indices (Lazarov et al., 2016, 2018; Waechter,
Nelson, Wright, Hyatt, & Oakman, 2014). A meta-analysis of eye-tracking
studies indicates a significant association between anxiety and attention bias
toward threat using these methods (Armstrong & Olatunji, 2012).

CLINICAL IMPLICATIONS

Most psychosocial interventions for anxiety target top-down conscious

thought processes and rely heavily on helping individuals to think about their
internal models of self, others, and the world; and consciously challenge and
modify maladaptive thoughts and behaviors. However, although efficacious
treatments for anxiety have been available for decades, current first-line
interventions (e.g., cognitive behavior therapy [CBT], pharmacotherapy)
have a 50% to 70% response plateau (Ballenger, 2004; Barlow, Gorman,
Shear, & Woods, 2000; Hofmann & Smits, 2008; McEvoy, 2007), with high
rates of relapse and low rates of remission. These observations have led to a
call for interventions that increase patient access with automated computer-
based procedures, reduce costs, and target novel mechanisms that are not
accessible through traditional therapies (Mohr, Burns, Schueller, Clarke, &
212 Azriel and Bar-Haim

Klinkman, 2013). Three decades of extensive research on threat-related

attention biases provide viable therapeutic targets for answering this call.
Attention bias modification therapy (ABM; Bar-Haim, 2010; MacLeod &
Clarke, 2015), is designed to directly target the mechanism of selective atten-
tion to threat in anxiety. ABM seeks to modify threat-related attention biases
through computerized retraining exercises. The rationale behind ABM ther-
apy is straightforward: If threat-related attention bias plays a causal role in
promoting anxiety, then reduction of threat bias should lead to reduction of
symptoms. This approach departs from traditional CBT as it relies on implicit
training of a cognitive pattern as opposed to effortful induction of changes to
thought and behavior.
The first generation of ABM therapies relied on modified RT-based atten-
tion bias measurement tasks. Although various ABM variants have been
tested, the most robustly studied ABM therapy uses variants of the dot-probe
task. Unlike the classic attention measurement task described previously, in
which threat-neutral pairs are shown briefly on each trial and respondents
are asked to discriminate a following probe that appears with equal proba-
bility at the location of threat and neutral stimuli (see Figure 12.2b), in ABM
variants probe location is systematically manipulated to increase the propor-
tion of probes appearing at the location of the neutral stimulus. It is assumed
that because attending to such contingencies can assist in task performance,
an implicitly learned bias away from threat is gradually being induced with
repetition of many trials. Although large variability exists in the number of
training trials delivered per ABM session, and in the number of sessions in an
ABM treatment protocol, ABM therapy is usually brief. The most commonly
applied protocol delivers 150 to 200 training repetitions per session (lasting
about 10 minutes), in eight twice-weekly sessions. Meta-analyses of random-
ized controlled trials (RCTs) suggest a significant small-to-medium effect size
for ABM therapy in anxiety disorders (Hakamata et al., 2010; Jones & Sharpe,
2017; Linetzky, Pergamin-Hight, Pine, & Bar-Haim, 2015; Lowther & Newman,
2014; Mogoaşe, David, & Koster, 2014).
ABM therapy has also been applied as an adjunct to CBT, with preliminary
results from RCTs suggesting augmentation of overall treatment outcome
(Lazarov, Marom, et al., 2017; Riemann et al., 2013; Shechner et al., 2014;
White, Sequeira, et al., 2017; but see Rapee et al., 2013 for failed augmenta-
tion). Research on how ABM could most effectively be integrated into stan-
dard CBT or pharmacological therapies, however, is still in its early stages. One
option is to apply ABM within standard CBT sessions (e.g., Lazarov, Marom,
et al., 2017; Shechner et al., 2014). Alternatively, ABM could be offered as
homework complementing standard CBT (Rapee et al., 2013). Finally, ABM
could be applied as a separate module sequenced before standard CBT proto-
cols with the hope of enhancing overall treatment gains. Although this latter
approach still lacks evidence in formal RCTs, it is currently being tested in
various trials. The driving hypothesis for such sequenced delivery (ABM
before CBT) is based on the notion that if bottom-up threat-related attention
biases could be attenuated before formal CBT begins, greater therapeutic
 Attention Bias 213

gains and lower dropout rates may be achieved as patients would engage less
with threats at automatic-perceptual levels, therefore facilitating direct and
effortful dealings with their fears in CBT.
Although the first generation of RT-based ABM therapies show promise
and have been extensively studied, researchers and clinicians readily acknowl-
edge that technological advances and better understanding of neurocognitive
mechanisms could be harnessed for the development of even more potent
and engaging ABM therapies. In many respects, one could think of dot-probe-
based ABM as reflecting the very early stage of arcade video games that fea-
tured simple, monochromatic two-dimensional graphics—a far cry from the
level of sophistication of current video games. Similarly, further develop-
ments with novel ABM procedures are likely in the coming years. One
example of a second-generation eye-tracking-based protocol for social anxi-
ety disorder, gaze contingent music reward therapy (GC-MRT), was recently
tested in an RCT for patients with social anxiety disorder (Lazarov, Pine, &
Bar-Haim, 2017).
In a GC-MRT session, the patient is asked to select a music track he or
she would like to listen to during the session. The patient is then asked to
observe matrices of faces comprising threat and neutral expressions (e.g.,
Figure 12.2e) while gaze position is continuously monitored. Importantly, the
selected music is played only when the patient fixates on one of the neutral
faces. The music halts when the patient looks at a threat face. Through this
operant conditioning procedure, the patient’s attentional threat bias is modi-
fied to favor neutral over threat facial expressions. It is expected that these
induced changes in gaze pattern would generalize to real-life social situations
and will eventually lead to meaningful reductions in social anxiety. Indeed, a
preliminary RCT (Lazarov, Pine, & Bar-Haim, 2017) indicates that GC-MRT
yielded greater reductions in social anxiety relative to a control condition on
clinician-rated and self-reported measures, and that therapeutic effects were
maintained at a 3-month follow-up. GC-MRT reduced dwell time on threat,
which partially mediated the observed clinical effects. Relative to first gener-
ation ABMs, this novel ABM protocol appears to be more acceptable for
patients, more potent in changing threat-related attention bias, and yields a
large effect size.

CONCLUSION

Threat-related attention bias refers to the tendency to prioritize the process-

ing of threats over benign or neutral stimuli. When an actual threat is
present, this process is highly adaptive and important to survival. Yet, when
an individual overattends to minor threats, this could lead to viewing the envi-
ronment as overly hostile. This, in turn, increases the frequency, intensity,
and duration of anxiety and fear episodes. Deployment of attention toward
stimuli that pose little threat can also lead to underprocessing of valuable non-
threat information and interfere with daily functioning. For these reasons,
214 Azriel and Bar-Haim

attention bias is a key factor in the development and maintenance of clinical

anxiety. Accordingly, accurate and reliable methods for assessing attention
bias are important. Once detected, aberrant attentional components can be
therapeutically targeted, with the intention of preventing clinical anxiety in
vulnerable individuals or reducing symptoms for those who are clinically
anxious. ABM protocols tested in RCTs have been successful in reducing
anxiety in clinical patients, and it is hoped that conceptual, technological, and
experimental advances will further improve on available assessment methods
and interventions.

REFERENCES
Amir, N., Elias, J., Klumpp, H., & Przeworski, A. (2003). Attentional bias to threat in
social phobia: Facilitated processing of threat or difficulty disengaging attention
from threat? Behaviour Research and Therapy, 41, 1325–1335. http://dx.doi.org/
10.1016/S0005-7967(03)00039-1
Armstrong, T., & Olatunji, B. O. (2012). Eye tracking of attention in the affective disor-
ders: A meta-analytic review and synthesis. Clinical Psychology Review, 32, 704–723.
http://dx.doi.org/10.1016/j.cpr.2012.09.004
Asmundson, G. J., Sandler, L. S., Wilson, K. G., & Walker, J. R. (1992). Selective atten-
tion toward physical threat in patients with panic disorder. Journal of Anxiety Dis­
orders, 6, 295–303. http://dx.doi.org/10.1016/0887-6185(92)90001-N
Ballenger, J. C. (2004). Remission rates in patients with anxiety disorders treated with
paroxetine. The Journal of Clinical Psychiatry, 65, 1696–1707. http://dx.doi.org/
10.4088/JCP.v65n1216
Bar-Haim, Y. (2010). Research review: Attention bias modification (ABM): A novel treat-
ment for anxiety disorders. Journal of Child Psychology and Psychiatry, 51, 859–870.
http://dx.doi.org/10.1111/j.1469-7610.2010.02251.x
Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & van IJzendoorn,
M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals:
A meta-analytic study. Psychological Bulletin, 133, 1–24. http://dx.doi.org/10.1037/
0033-2909.133.1.1
Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral
therapy, imipramine, or their combination for panic disorder: A randomized con-
trolled trial. JAMA, 283, 2529–2536. http://dx.doi.org/10.1001/jama.283.19.2529
Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Auto-
matic and strategic processes. Behaviour Research and Therapy, 35, 49–58. http://
dx.doi.org/10.1016/S0005-7967(96)00069-1
Becker, E. S., Rinck, M., Margraf, J., & Roth, W. T. (2001). The emotional Stroop effect
in anxiety disorders: General emotional or disorder specificity? Journal of Anxiety
Disorders, 15, 147–159. http://dx.doi.org/10.1016/S0887-6185(01)00055-X
Biederman, J., Hirshfeld-Becker, D. R., Rosenbaum, J. F., Hérot, C., Friedman, D.,
Snidman, N., . . . Faraone, S. V. (2001). Further evidence of association between
behavioral inhibition and social anxiety in children. The American Journal of Psychiatry,
158, 1673–1679. http://dx.doi.org/10.1176/appi.ajp.158.10.1673
Biederman, J., Rosenbaum, J. F., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J.,
Hirshfeld, D. R., & Kagan, J. (1993). A 3-year follow-up of children with and with-
out behavioral inhibition. Journal of the American Academy of Child & Adolescent Psychi-
atry, 32, 814–821. http://dx.doi.org/10.1097/00004583-199307000-00016
Broadbent, D. E. (1958). Perception and communication. London, England: Pergamon.
http://dx.doi.org/10.1037/10037-000
Chronis-Tuscano, A., Degnan, K. A., Pine, D. S., Perez-Edgar, K., Henderson, H. A.,
Diaz, Y., . . . Fox, N. A. (2009). Stable early maternal report of behavioral inhibition
 Attention Bias 215

predicts lifetime social anxiety disorder in adolescence. Journal of the American

Academy of Child & Adolescent Psychiatry, 48, 928–935. http://dx.doi.org/10.1097/
CHI.0b013e3181ae09df
Cisler, J. M., & Koster, E. H. W. (2010). Mechanisms of attentional biases towards threat
in anxiety disorder: An integrative review. Clinical Psychology Review, 30, 1–29.
Davis, M., & Whalen, P. J. (2001). The amygdala: Vigilance and emotion. Molecular
Psychiatry, 6, 13–34. http://dx.doi.org/10.1038/sj.mp.4000812
Dijksterhuis, A., & Aarts, H. (2003). On wildebeests and humans: The preferential detec-
tion of negative stimuli. Psychological Science, 14, 14–18. http://dx.doi.org/10.1111/
1467-9280.t01-1-01412
Duncan, J. (1980). The locus of interference in the perception of simultaneous stimuli.
Psychological Review, 87, 272–300. http://dx.doi.org/10.1037/0033-295X.87.3.272
Eastwood, J. D., Smile, D., Oakman, J. M., Farvolden, P., van Ameringen, M., Mancini, C.,
& Merikle, P. M. (2005). Individuals with social phobia are biased to become aware
of negative faces. Visual Cognition, 12, 159–179. http://dx.doi.org/10.1080/
13506280444000175
Eldar, S., Ricon, T., & Bar-Haim, Y. (2008). Plasticity in attention: Implications for stress
response in children. Behaviour Research and Therapy, 46, 450–461. http://dx.doi.org/
10.1016/j.brat.2008.01.012
Evans, T. C., & Britton, J. C. (2018). Improving the psychometric properties of dot-
probe attention measures using response-based computation. Journal of Behavior
Therapy and Experimental Psychiatry, 60, 95–103. http://dx.doi.org/10.1016/
j.jbtep.2018.01.009
Eysenck, M. W. (1992). Anxiety: The cognitive perspective. Hillsdale, NJ: Lawrence Erlbaum.
Eysenck, M. W. (1997). Anxiety and cognition: A unified theory. Hove, England: Psychology
Press.
Foa, E. B., Ilai, D., McCarthy, P. R., Shoyer, B., & Murdock, T. (1993). Information pro-
cessing in obsessive–compulsive disorder. Cognitive Therapy and Research, 17, 173–189.
Fox, E., Lester, V., Russo, R., Bowles, R. J., Pichler, A., & Dutton, K. (2000). Facial
expressions of emotion: Are angry faces detected more efficiently? Cognition and
Emotion, 14, 61–92. http://dx.doi.org/10.1080/026999300378996
Fox, E., Russo, R., Bowles, R., & Dutton, K. (2001). Do threatening stimuli draw or
hold visual attention in subclinical anxiety? Journal of Experimental Psychology:
General, 130, 681–700. http://dx.doi.org/10.1037/0096-3445.130.4.681
Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., . . .
Pine, D. S. (2010). Attention bias modification treatment: A meta-analysis toward
the establishment of novel treatment for anxiety. Biological Psychiatry, 68, 982–990.
http://dx.doi.org/10.1016/j.biopsych.2010.07.021
Hansen, C. H., & Hansen, R. D. (1988). Finding the face in the crowd: An anger superior-
ity effect. Journal of Personality and Social Psychology, 54, 917–924. http://dx.doi.org/
10.1037/0022-3514.54.6.917
Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult
anxiety disorders: A meta-analysis of randomized placebo-controlled trials. The
Journal of Clinical Psychiatry, 69, 621–632. http://dx.doi.org/10.4088/JCP.v69n0415
Jones, E. B., & Sharpe, L. (2017). Cognitive bias modification: A review of meta-
analyses. Journal of Affective Disorders, 223, 175–183. http://dx.doi.org/10.1016/
j.jad.2017.07.034
Kolassa, I. T., & Miltner, W. H. R. (2006). Psychophysiological correlates of face pro-
cessing in social phobia. Brain Research, 1118, 130–141. http://dx.doi.org/10.1016/
j.brainres.2006.08.019
Koster, E. H. W., Crombez, G., Verschuere, B., & De Houwer, J. (2004). Selective attention
to threat in the dot probe paradigm: Differentiating vigilance and difficulty to dis­
engage. Behaviour Research and Therapy, 42, 1183–1192. http://dx.doi.org/10.1016/
j.brat.2003.08.001
216 Azriel and Bar-Haim

Lazarov, A., Abend, R., & Bar-Haim, Y. (2016). Social anxiety is related to increased
dwell time on socially threatening faces. Journal of Affective Disorders, 193, 282–288.
http://dx.doi.org/10.1016/j.jad.2016.01.007
Lazarov, A., Ben-Zion, Z., Shamai, D., Pine, D. S., & Bar-Haim, Y. (2018). Free viewing of
sad and happy faces in depression: A potential target for attention bias modification.
Journal of Affective Disorders, 238, 94–100. http://dx.doi.org/10.1016/j.jad.2018.05.047
Lazarov, A., Marom, S., Yahalom, N., Pine, D. S., Hermesh, H., & Bar-Haim, Y. (2017).
Attention bias modification augments cognitive–behavioral group therapy for social
anxiety disorder: A randomized controlled trial. Psychological Medicine, 48, 2177–2185.
Lazarov, A., Pine, D. S., & Bar-Haim, Y. (2017). Gaze-contingent music reward therapy
for social anxiety disorder: A randomized controlled trial. The American Journal of
Psychiatry, 174, 649–656. http://dx.doi.org/10.1176/appi.ajp.2016.16080894
LeDoux, J. E. (2009). Emotion circuits in the brain. Focus, 7, 274–289. http://dx.doi.org/
10.1176/foc.7.2.foc274
Linetzky, M., Pergamin-Hight, L., Pine, D. S., & Bar-Haim, Y. (2015). Quantitative evalu-
ation of the clinical efficacy of attention bias modification treatment for anxiety dis­
orders. Depression and Anxiety, 32, 383–391. http://dx.doi.org/10.1002/da.22344
Lowther, H., & Newman, E. (2014). Attention bias modification (ABM) as a treatment
for child and adolescent anxiety: A systematic review. Journal of Affective Disorders,
168, 125–135. http://dx.doi.org/10.1016/j.jad.2014.06.051
Lundqvist, D., Flykt, A., & Öhman, A. (1998). The Karolinska directed emotional faces
(KDEF) [CD ROM]. Solna, Sweden: Karolinska Institutet.
MacLeod, C., & Clarke, P. J. F. (2015). The attentional bias modification approach to
anxiety intervention. Clinical Psychological Science, 3, 58–78. http://dx.doi.org/10.1177/
2167702614560749
MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emotional dis­
orders. Journal of Abnormal Psychology, 95, 15–20. http://dx.doi.org/10.1037/
0021-843X.95.1.15
Mathews, A., & MacLeod, C. (2002). Induced processing biases have causal effects
on anxiety. Cognition and Emotion, 16, 331–354. http://dx.doi.org/10.1080/
02699930143000518
McEvoy, P. M. (2007). Effectiveness of cognitive behavioural group therapy for social
phobia in a community clinic: A benchmarking study. Behaviour Research and
Therapy, 45, 3030–3040. http://dx.doi.org/10.1016/j.brat.2007.08.002
McNally, R. J. (2019). Attentional bias for threat: Crisis or opportunity? Clinical Psychol-
ogy Review, 69, 4–13. http://dx.doi.org/10.1016/j.cpr.2018.05.005
Mogg, K., & Bradley, B. P. (1998). A cognitive-motivational analysis of anxiety. Behaviour
Research and Therapy, 36, 809–848. http://dx.doi.org/10.1016/S0005-7967(98)00063-1
Mogoaşe, C., David, D., & Koster, E. H. W. (2014). Clinical efficacy of attentional bias
modification procedures: An updated meta-analysis. Journal of Clinical Psychology,
70, 1133–1157. http://dx.doi.org/10.1002/jclp.22081
Mohr, D. C., Burns, M. N., Schueller, S. M., Clarke, G., & Klinkman, M. (2013). Behav-
ioral intervention technologies: Evidence review and recommendations for future
research in mental health. General Hospital Psychiatry, 35, 332–338. http://dx.doi.org/
10.1016/j.genhosppsych.2013.03.008
Öhman, A., Flykt, A., & Esteves, F. (2001). Emotion drives attention: Detecting the
snake in the grass. Journal of Experimental Psychology: General, 130, 466–478. http://
dx.doi.org/10.1037/0096-3445.130.3.466
Pérez-Edgar, K., Bar-Haim, Y., McDermott, J. M., Chronis-Tuscano, A., Pine, D. S., &
Fox, N. A. (2010). Attention biases to threat and behavioral inhibition in early child-
hood shape adolescent social withdrawal. Emotion, 10, 349–357. http://dx.doi.org/
10.1037/a0018486
 Attention Bias 217

Pérez-Edgar, K., Reeb-Sutherland, B. C., McDermott, J. M., White, L. K., Henderson,

H. A., Degnan, K. A., . . . Fox, N. A. (2011). Attention biases to threat link behavioral
inhibition to social withdrawal over time in very young children. Journal of Abnormal
Child Psychology, 39, 885–895. http://dx.doi.org/10.1007/s10802-011-9495-5
Pergamin-Hight, L., Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., &
Bar-Haim, Y. (2012). Variations in the promoter region of the serotonin transporter
gene and biased attention for emotional information: A meta-analysis. Biological
Psychiatry, 71, 373–379. http://dx.doi.org/10.1016/j.biopsych.2011.10.030
Pergamin-Hight, L., Naim, R., Bakermans-Kranenburg, M. J., van IJzendoorn, M. H.,
& Bar-Haim, Y. (2015). Content specificity of attention bias to threat in anxiety dis-
orders: A meta-analysis. Clinical Psychology Review, 35, 10–18. http://dx.doi.org/
10.1016/j.cpr.2014.10.005
Pine, D. S., Helfinstein, S. M., Bar-Haim, Y., Nelson, E., & Fox, N. A. (2009). Challenges in
developing novel treatments for childhood disorders: Lessons from research on anxiety.
Neuropsychopharmacology, 34, 213–228. http://dx.doi.org/10.1038/npp.2008.113
Posner, M. I. (1980). Orienting of attention. The Quarterly Journal of Experimental
Psychology, 32, 3–25. http://dx.doi.org/10.1080/00335558008248231
Price, R. B., Kuckertz, J. M., Siegle, G. J., Ladouceur, C. D., Silk, J. S., Ryan, N. D., . . .
Amir, N. (2015). Empirical recommendations for improving the stability of the dot-
probe task in clinical research. Psychological Assessment, 27, 365–376. http://dx.doi.org/
10.1037/pas0000036
Putman, P., Hermans, E., & van Honk, J. (2004). Emotional Stroop performance for
masked angry faces: It’s BAS, not BIS. Emotion, 4, 305–311. http://dx.doi.org/
10.1037/1528-3542.4.3.305
Rapee, R. M., MacLeod, C., Carpenter, L., Gaston, J. E., Frei, J., Peters, L., & Baillie, A. J.
(2013). Integrating cognitive bias modification into a standard cognitive behavioural
treatment package for social phobia: A randomized controlled trial. Behaviour Research
and Therapy, 51, 207–215. http://dx.doi.org/10.1016/j.brat.2013.01.005
Richards, H. J., Benson, V., Donnelly, N., & Hadwin, J. A. (2014). Exploring the
function of selective attention and hypervigilance for threat in anxiety. Clinical
Psychology Review, 34, 1–13. http://dx.doi.org/10.1016/j.cpr.2013.10.006
Riemann, B. C., Kuckertz, J. M., Rozenman, M., Weersing, V. R., & Amir, N. (2013).
Augmentation of youth cognitive behavioral and pharmacological interventions
with attention modification: A preliminary investigation. Depression and Anxiety, 30,
822–828. http://dx.doi.org/10.1002/da.22127
Rinck, M., Becker, E. S., Kellermann, J., & Roth, W. T. (2003). Selective attention in
anxiety: Distraction and enhancement in visual search. Depression and Anxiety, 18,
18–28. http://dx.doi.org/10.1002/da.10105
Schmukle, S. C. (2005). Unreliability of the dot probe task. European Journal of Person-
ality, 19, 595–605. http://dx.doi.org/10.1002/per.554
Shechner, T., Rimon-Chakir, A., Britton, J. C., Lotan, D., Apter, A., Bliese, P. D., . . .
Bar-Haim, Y. (2014). Attention bias modification treatment augmenting effects on
cognitive behavioral therapy in children with anxiety: Randomized controlled trial.
Journal of the American Academy of Child & Adolescent Psychiatry, 53, 61–71. http://
dx.doi.org/10.1016/j.jaac.2013.09.016
Staugaard, S. R. (2009). Reliability of two versions of the dot-probe task using photo-
graphic faces. Psychology Science, 51, 339–350.
Stroop, J. R. (1935). Studies of interference in serial verbal reactions. Journal of Experi-
mental Psychology, 18, 643–662.
Treisman, A. M. (1969). Strategies and models of selective attention. Psychological
Review, 76, 282–299. http://dx.doi.org/10.1037/h0027242
Van Bockstaele, B., Verschuere, B., Tibboel, H., De Houwer, J., Crombez, G., & Koster,
E. H. W. (2014). A review of current evidence for the causal impact of attentional
218 Azriel and Bar-Haim

bias on fear and anxiety. Psychological Bulletin, 140, 682–721. http://dx.doi.org/

10.1037/a0034834
Waechter, S., Nelson, A. L., Wright, C., Hyatt, A., & Oakman, J. (2014). Measuring
attentional bias to threat: Reliability of dot probe and eye movement indices. Cognitive
Therapy and Research, 38, 313–333. http://dx.doi.org/10.1007/s10608-013-9588-2
White, L. K., Degnan, K. A., Henderson, H. A., Pérez-Edgar, K., Walker, O. L.,
Shechner, T., . . . Fox, N. A. (2017). Developmental relations among behavioral
inhibition, anxiety, and attention biases to threat and positive information. Child
Development, 88, 141–155. http://dx.doi.org/10.1111/cdev.12696
White, L. K., Sequeira, S., Britton, J. C., Brotman, M. A., Gold, A. L., Berman, E., . . .
Pine, D. S. (2017). Complementary features of attention bias modification therapy
and cognitive-behavioral therapy in pediatric anxiety disorders. The American Jour-
nal of Psychiatry, 174, 775–784. http://dx.doi.org/10.1176/appi.ajp.2017.16070847
Wieser, M. J., Hambach, A., & Weymar, M. (2018). Neurophysiological correlates of
attentional bias for emotional faces in socially anxious individuals: Evidence from a
visual search task and N2pc. Biological Psychology, 132, 192–201. http://dx.doi.org/
10.1016/j.biopsycho.2018.01.004
Wikström, J., Lundh, L. G., Westerlund, J., & Högman, L. (2004). Preattentive bias for
snake words in snake phobia? Behaviour Research and Therapy, 42, 949–970. http://
dx.doi.org/10.1016/j.brat.2003.07.002
Yiend, J. (2010). The effects of emotion on attention: A review of attentional process-
ing of emotional information. Cognition and Emotion, 24, 3–47. http://dx.doi.org/
10.1080/02699930903205698
13
Interpersonal Processes
Jonathan S. Abramowitz and Donald H. Baucom

Jerry is a 53-year-old devoutly religious man with a diagnosis of obsessive-

compulsive disorder (OCD).1 His obsessions focus on thoughts that he has sinned
by having too many “impure thoughts” (e.g., thoughts about sex). He is afraid
God is upset with him and that he will go to hell when he dies. He also engages
in excessive praying rituals when such obsessions come to mind and tries to
avoid stimuli (e.g., anything related to sexuality) that triggers these thoughts.
After his wife, Anna, failed to convince Jerry that his thoughts were not sinful,
she agreed to watch only “wholesome,” family-friendly TV channels, as Jerry
wished. Anna also agreed not to wear clothes Jerry considered “seductive” to
avoid triggering Jerry’s obsessions. Although Anna is frequently frustrated about
what has become the status quo, she is willing to go along with her husband
because she knows that anything different could lead to anxiety and anger.
Anna reports that giving in to (i.e., accommodating) Jerry’s OCD symptoms is
how she shows him that she loves and cares for him.

Although research has typically focused on how clinical anxiety affects the
individual with marked distress and interference in functioning, severe anxiety
can have equally detrimental effects on interpersonal relationships (e.g., part-
ner, spouse, parent, other close relative).2 In turn, relationship difficulties also
influence the trajectory of clinical anxiety. This chapter describes two pri-
mary ways in which this occurs: first, a caregiver may inadvertently maintain

All clinical case material has been altered to protect patient confidentiality.
1

For the purposes of this chapter, we refer to the individual with an anxiety disorder
2

as the patient and those with whom the patient has close interpersonal relationships
as caregiver.
http://dx.doi.org/10.1037/0000150-013
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
219
220 Abramowitz and Baucom

symptoms by “helping” the patient avoid or escape from anxiety (i.e., accommo-
dation); this mechanism is focal to how the couple interacts around the prob-
lem with anxiety. Second, relationship conflict may exacerbate the anxiety;
this mechanism focuses on a broader, more defuse negative atmosphere that
increases anxiety. This chapter also discusses conceptual implications of these
phenomena, before turning to assessment and implications for treatment.
The case example illustrates the process of symptom accommodation.
Accommodation occurs when a caregiver of someone with anxiety modifies
their typical behavior to take part in anxiety-reduction strategies (e.g., by help-
ing with avoidance strategies), to assume daily responsibilities for the patient
(e.g., doing shopping), or to help to resolve problems that have resulted from
the patient’s anxiety symptoms (e.g., contributing money to ease the costs of
anxiety-reduction behavior; Boeding et al., 2013). The accommodation might
occur because of negative consequences that the caretaker experiences if the
caregiver does not engage in accommodation (e.g., the patient becomes furious
or makes threats). It might also occur because the caregiver wants to express
care and concern for the patient by helping to “protect” him or her from feeling
anxious.
Accommodation can be subtle or overt, is often performed with positive
intentions, and is observed in interpersonal relationships that are either dis-
tressed or nondistressed. For example, Anna boasted that she and Jerry rarely
argued about OCD-related issues. Yet, even if there is no obvious arguing,
accommodation is usually accompanied by frustration on the part of the care-
giver, and it creates a relationship “system” that fits with the anxious symp-
toms to perpetuate the vicious cycle that maintains the problem (as discussed
in greater detail following). Table 13.1 shows examples of accommodation

TABLE 13.1. Examples of Accommodation Behaviors in Different

Anxiety Disorders
Anxiety disorder Partner accommodation behaviors
Obsessive- Changing clothes for someone with contamination obsessions;
compulsive answering compulsive requests for reassurance that the door
disorder is locked
Social anxiety Helping to come up with excuses for missing social gatherings;
disorder agreeing to leave a social gathering early because a partner
feels anxious
Panic disorder/ Accompanying a partner on errands out of the house; paying for
agoraphobia visits to the emergency room during panic attacks
Illness anxiety Answering questions about health-related issues; agreeing not to
disorder mention certain feared diseases
Phobias Volunteering to go to higher floors of a building to run errands;
checking the weather and providing constant updates and
reassurance about the probability of thunderstorms
Posttraumatic Agreeing to avoid the place where a partner was raped; agreeing
stress disorder never to discuss a car accident
Separation anxiety Writing notes to the teacher to justify absences for a child afraid of
disorder going to school; allowing an anxious child to sleep in the parents’
bed (or a parent sleeping with the child in the child’s bed)
 Interpersonal Processes 221

behaviors observed with couples and families in which one member has an
anxiety disorder diagnosis.
Studies suggest symptom accommodation is all but ubiquitous when anxi-
ety occurs in the context of a close interpersonal relationship, whether between
romantic partners or a parent and child (e.g., Boeding et al., 2013; Lebowitz
et al., 2013; Norman, Silverman, & Lebowitz, 2015), with as much as 90% to
97% of caregivers reporting engaging in at least some accommodation (e.g.,
Calvocoressi et al., 1999; Thompson-Hollands, Kerns, Pincus, & Comer, 2014).
Moreover, accommodation can be costly regarding time and money, as affected
families might end up depleting their resources while incurring decreased
productivity (e.g., Bodden et al., 2008).
Finally, several studies have identified predictors of accommodation behav-
ior among caregivers. In one study, Amir, Freshman, and Foa (2000) found
that caregivers with greater levels of general anxiety and depression them-
selves engaged in more accommodation. Another found that caregiver levels
of empathy—the capacity for taking another person’s perspective and sharing
a congruent emotional reaction—were positively associated with levels of
accommodation (Caporino et al., 2012). The point correlates to a third reason
that caregivers might engage in accommodation: to avoid or reduce their own
negative emotions. Sensitivity to guilt also appears related to the tendency to
accommodate a patient’s anxiety (Cosentino et al., 2015). Specifically avoid-
ing the guilt of not helping a loved one was a motivating factor for engaging
in symptom accommodation. Finally, the tendency toward greater expressed
emotion (EE)—the extent to which caregivers (and family members in gen-
eral) express critical, hostile (i.e., rejecting), or emotionally overinvolved (or
overprotective) attitudes—is related to higher levels of accommodation (Amir
et al., 2000).

RELATIONSHIP CONFLICT

Relationships in which one individual has clinically severe anxiety are often
characterized by interdependency, unassertiveness, and avoidant communi-
cation patterns that foster stress and conflict (Marcaurelle, Bélanger, Marchand,
Katerelos, & Mainguy, 2005; McCarthy & Shean, 1996). Relatives of patients
with anxiety may also engage in arguments about the seeming illogic of the
anxiety, which elevates the general level of relationship stress. EE is not only
a predictor of accommodation but also of anxious psychopathology and relapse
following successful treatment (Chambless, Bryan, Aiken, Steketee, & Hooley,
2001). Anxiety and relationship distress, however, influence each other in a
recursive manner rather than one exclusively leading to the other. The dis-
agreements that occur when a patient with social anxiety refuses to attend
work parties might further contribute to the patient’s social anxiety, leading
to further disagreements. As another example, consider Joan, a 32-year-old
with panic attacks and agoraphobia who lives with her mother. Joan insists
that her mother be at her beck and call and asks that her mother not leave the
222 Abramowitz and Baucom

house in case Joan begins to experience a panic attack. Yet, the frequent argu-
ments that occur over this situation increase Joan’s physiological arousal,
which often triggers her panic attacks.
Relationship conflict does not have to be focal to the anxiety problem to
increase relationship distress and contribute to the maintenance of anxiety.
Among families, homework, chores, problems with academic or social func-
tioning, finances, and health concerns may serve to increase ambient levels of
stress, leading to increased anxiety. Within romantic partnerships, disagreements
over child care, financial decisions, and in-laws, among others, may have the
same effects. Such disagreements may be fueled by poor problem-solving skills,
a tendency toward hostility and criticism (Marcaurelle et al., 2005), and general
emotional overinvolvement.
In conclusion, it is important to differentiate between two ways that rela-
tionship functioning might maintain or exacerbate anxiety. First, the ways that
caregivers and patients interact around anxiety can involve accommodation,
which can lower the patient’s anxiety in the short term. But by helping the
patient avoid or escape anxiety, the accommodation contributes to mainte-
nance or exacerbation of the anxiety long term through negative reinforce-
ment. In this instance, there is no assumption that there is relationship distress
present; in fact, very loving caregivers might inadvertently accommodate to
the patient’s symptoms. Relationship distress operates in a different manner
by serving as a broad, diffuse, chronic stressor on the patient, which is likely
to exacerbate symptoms, even if the relationship discord is not focal to expe-
riences with anxiety.

CONCEPTUAL IMPLICATIONS

Empirically supported approaches to understanding clinical anxiety and fear

generally stem from Beck’s (1976) cognitive model of emotion, which holds
that strong negative emotions result from certain types of mistaken beliefs.
Anxiety and fear are conceptualized as arising largely from overestimates of
the likelihood and severity of danger and underestimates of an individual’s
ability to cope, which lead to the unwarranted perception of threat. The indi-
vidual then deploys safety behaviors (e.g., avoidance, compulsive rituals, use
of safety cues and behaviors) to control the anxiety and reduce the perceived
threat. As discussed in greater detail in Chapter 2, safety behaviors prevent the
natural disconfirmation of the mistaken cognitions (and extinction of fear)
because they artificially eliminate the perceived threat and a compelling
alternative explanation for why danger did not occur (other than the fact
that threat was low to begin with). As a result, the faulty overestimates of
threat persist. Moreover, because safety behaviors technically “work” as an
immediate (albeit temporary) escape from feelings of anxiety, they are negatively
reinforced and become habitual, leading to the long-term maintenance (and
intensification) of the irrational fear and anxiety.
 Interpersonal Processes 223

Accommodation is conceptualized as a maintaining factor in this process:

Regardless of who performs the safety behavior (or supports and encourages
it), its consequences are the same (i.e., prevention of natural fear extinction).
By accommodating, the caregiver inadvertently perpetuates anxiety symptoms
by preventing the anxious person from learning that their fear-based concerns
are unlikely to materialize, and that anxiety (and fear) itself is harmless and
manageable. For example, consider a mother with obsessional thoughts of
acting on unwanted impulses to molest her newborn infant. Her partner, by
taking over all childcare responsibilities and thereby encouraging avoidance of
the infant, prevents the mother from learning that her intense anxiety over these
obsessions is temporary and harmless, and that she is unlikely to act on these
obsessions. It also prevents the mother from learning how to manage inevitable
unwanted thoughts and uncertainties. From a functional perspective, symptom
accommodation enacted by a caregiver is identical to safety behaviors and avoid-
ance strategies performed by the patient with clinical anxiety.
Accommodation has several additional negative consequences. First, it might
decrease the patient’s motivation to engage in treatment because he or she
might not perceive good reasons to change the status quo—especially if treat-
ment involves facing his or her fears (i.e., exposure therapy). For example, a
woman with fears of bees avoided leaving her home during the spring and
summer when bees are commonly found outside. Her partner handled all the
shopping and errands during this time. Although the woman regretted the
impact of this phobia on her life, she struggled to commit to exposure therapy
(i.e., to going outside and learning that bee stings are relatively rare) partly
because she did not view taking such “risks” as worthwhile, because her
partner’s accommodation had diminished the consequences of the extreme
phobic avoidance to the point that the problem seemed tolerable relative to
confronting her fears.
In some relationships, accommodation becomes the chief way in which
a caregiver expresses warmth, caring, and compassion for the patient. For
example, one man prided himself on the fact that whenever his adult daughter
with panic attacks and health-related anxiety became very anxious and worried,
he would “come to the rescue” by traveling to wherever she was to calm her
down and reassure her that she was going to be fine. This became an impor-
tant way of showing care in their father–daughter relationship. Not only does
such accommodation maintain pathological fear and anxiety in ways that have
been discussed (i.e., by preventing the daughter from learning that fear sub-
sides on its own and is not dangerous), it also begets additional accommodation
as the relationship develops around this sort of caring behavior. Not surpris-
ingly, accommodation is related to more severe anxiety symptoms and poorer
long-term treatment outcome (Calvocoressi et al., 1999). Accommodation might
also carry with it the meaning that “you need me to take care of you” and that
the patient cannot take care of herself or himself. Whether intended or not,
such actions might undermine the sense of self-efficacy of the patient which
can lead to further avoidance and escape from distressing situations.
224 Abramowitz and Baucom

Relationship conflict is also conceptualized as a maintaining factor of clin-

ical anxiety. Research demonstrates the role that increased stress plays in the
exacerbation of anxiety symptoms. Moreover, this relationship is reciprocal,
with increased anxiety and related behavioral patterns often resulting in
more frequent conflicts within the relationship. It is hardly surprising that
relatives living with patients with clinical anxiety often have some negative
feelings about the patient, given the strains anxiety and fear place on family life
and the associated burden on the relatives themselves. Findings from research
with patients with OCD and agoraphobia suggest that EE, and hostility in par-
ticular, is related to clinical anxiety and dropout from treatment (Chambless
& Steketee, 1999). Such hostility might lead to reduced motivation on the
part of the patient. In contrast, when caregivers express dissatisfaction with
disorder-specific aspects of patients’ behavior (e.g., anxiety symptoms) but do
not reject the patients themselves, such comments may have positive motiva-
tional consequences.

ASSESSMENT

There are several approaches to assessing accommodation and other relation-

ship factors that are part of the maintenance of anxiety. This section describes
clinical interviews and other empirically supported measures that practi-
tioners can use to provide an indication of the presence of these factors.

Assessing Symptom–System Fit

An important focus of assessment concerns the symptom–system fit, which refers

to how the environment in which the relationship exists is structured so as
to accommodate anxiety. As previously discussed, accommodation may occur
within seemingly “happy” relationships (i.e., “good” symptom–system fit) or
within conflicted relationships in which the caregiver refuses to accommodate
anxiety symptoms or overtly resents the negative impact these symptoms
have on the relationship (i.e., “poor” symptom–system fit). Exhibit 13.1 is a
list of suggested questions for engaging patient and caregiver in an unstruc-
tured discussion to assess symptom–system fit and identify specific ways in
which the two parties relate concerning anxiety symptoms.
A brief psychological assessment of any caregiver who might become
involved in treatment for anxiety is also suggested for the purpose of noting
(a) whether this individual experiences any psychopathology of his or her
own and (b) what factors might have contributed to the development of an
interpersonal system in which the patient’s anxiety flourishes. For example, a
woman whose first husband died of a heart attack was especially sensitive to
her current husband’s posttraumatic stress disorder (PTSD) symptoms for fear
that they would also lead to a heart attack. She willingly did everything she
could to keep her current husband from becoming even slightly anxious,
thereby contributing to the maintenance of his PTSD symptoms. The woman
 Interpersonal Processes 225

EXHIBIT 13.1

Questions for Assessing Symptom–System Fit

(obtain responses from each party)
• When and how did the caregiver become aware of the patient’s problem with anxiety?
• What effects have anxiety symptoms (fear, avoidance, safety behaviors) had on the
relationship in terms of daily life?
• If there are any patterns that seem to have developed because of the patient’s anxiety
symptoms, what are they?
• How does each person think their relationship might be different if the patient did not
have difficulties with anxiety?
• Is there anyone else who is affected in any way by the patient having problems with
anxiety? (If so, explore who and how.)
• What types of strategies have you tried to use to cope with the patient’s anxiety?
• When the patient is experiencing fear or performing safety behaviors, does it ever lead
to anger or arguments? What happens in these situations?
• Does the caregiver ever tend to help the patient escape from the anxiety, avoid
situations that cause anxiety, or assist with safety behaviors to lower the anxiety?
How well has this worked?
• Describe how the two of you communicate about the anxiety problem.

had to be educated about the short-term effects of anxiety and how these
effects are unlikely to be dangerous.

Family Accommodation Scale and Its Variants

Calvocoressi, Lewis, Harris, and Trufan (1995) pioneered the systematic mea-
surement of family accommodation by developing the 13-item Family Accom-
modation Scale (FAS) as an index of the type and frequency of accommodation
behaviors performed by caregivers (e.g., parents) of children with OCD. The
FAS is administered to the caregiver in a clinician-rated semistructured inter-
view. It consists of two sections. The first section is an OCD-symptom checklist
adapted from the symptom checklist in the Yale–Brown Obsessive-Compulsive
Scale, which is considered the gold standard in assessing the presence and
severity of OCD symptoms in adults (Goodman et al., 1989). This section is
primarily used to (a) assess the caregiver’s awareness of the patient’s OCD symp-
toms and (b) serve as probes when querying about family accommodation in
the second section of the measure. The second section examines the care­
giver’s accommodating behaviors by assessing modifications of routines, pro-
vision of reassurance, facilitation of compulsive rituals, direct participation in
rituals, avoidance of certain situations, modifying the patient’s responsibilities,
and permitting compulsions to happen (e.g., waiting for them, tolerating
disruptions). Relatives are asked to provide the frequency of such accommo-
dating behaviors on a scale from 0 (never) to 4 (everyday). The scores are then
summed to obtain a total score. Not only does the FAS have good internal
226 Abramowitz and Baucom

consistency and strong interrater agreement, but there is also strong evidence
for convergent and discriminant validity.
More recently, Pinto, Van Noppen, and Calvocoressi (2013) created a more
user-friendly self-report version of the FAS for the caregiver to complete. The
language and wording of the items in the new measure were modified to be
more appropriate for nonclinicians, increasing the accuracy of responses
provided by the relatives. The self-report version assesses accommodating
behaviors in the past week and has excellent internal consistency (Cronbach’s
α = .90) and good convergent validity. They also found good agreement between
the self-report and the clinician-related version of the scale.
Lebowitz and colleagues (2013) adapted the parent self-report version of
the FAS for use with other anxiety-related disorders. They reworded the items
and modified the rating scale, finding that this modification has good psycho-
metric properties. Subsequently, Lebowitz, Scharfstein, and Jones (2015), inter-
ested in the convergence of child and parent report of accommodation,
developed a child-report version of the FAS for children with anxiety disorders.
Items were rephrased so that a child could respond about the parents’ accom-
modation behavior. For example, the parent item “How often did you assist
your child in avoiding things that might make him/her more anxious?” was
rephrased to “How often did your parent help you to avoid things that make
you feel anxious?”.

Camberwell Family Interview

The Camberwell Family Interview (Leff & Vaughn, 1985) is a semistructured

clinician-administered tool considered the gold-standard measure of EE. It is
conducted with the patient’s key caregiver(s) (typically a parent or a spouse)
without the patient being present (parents are interviewed separately). The
interview, often used in research on family factors in psychopathology, is more
like a conversation with the caregiver than a formal interview. Its questions
address (a) the onset of the patient’s difficulties, (b) level of tension in the
household, (c) irritability, (d) the patient’s participation in routine household
tasks, and (e) the daily routines of the patient and various family members.
The typical length of the interview is between 1 and 2 hours. Following the
interview, the clinician makes ratings on five scales: criticism, hostility, emo-
tional overinvolvement, warmth, and positive remarks (the first three scales
are most relevant to EE). On the basis of these ratings, caregivers can be clas-
sified as high or low in EE.
Several of these subscales have relevance to the constructs currently under
consideration. Most focal to accommodation is the notion of emotional over-
involvement, which includes several factors like excessive self-sacrifice.
Excessive self-sacrifice involves the caregiver changing his or her own life and
schedule to an extreme degree to take care of the patient, when such changes
are not necessarily needed. In a further refinement of this concept, Fredman,
Baucom, Miklowitz, and Stanton (2008) differentiated between appropriate
 Interpersonal Processes 227

high levels of involvement and excessive high levels of involvement, depending

on the patient’s abilities to care for self and engage in distressing situations.
The subscales of criticism and hostility likely have very different effects and
appear to be some of the most deleterious behaviors that caregivers direct at
patients, often within the context of dissatisfied relationship, more focal to
assessing the effects of distressed relationships on the patient.

Level of Expressed Emotion Scale

The Level of Expressed Emotion (LEE) scale (Cole & Kazarian, 1988) is a 60-item
self-report measure that assesses the emotional environment in the patient’s
most important relationships. There are two forms: The patient version asks
patients to evaluate their relationship with their closest caregiver, and the rel-
ative version requires the caregiver to evaluate his or her relationship with the
patient. All items are rated in a true–false format and both versions of the LEE
include four subscales: intrusiveness, emotional response, attitude toward ill-
ness, and tolerance and expectations. Because the LEE is a self-report mea-
sure, many clinicians find that it is easier to administer and requires less time
to score than the Camberwell Family Interview.

Perceived Criticism

Easier to administer is the Perceived Criticism measure (PC; Hooley & Teasdale,
1989), which is based on the idea that criticism is the most important element
of EE (e.g., Hooley & Teasdale, 1989), and simply asks patients to rate how
critical of them is their caregiver using a 10-point Likert-type scale. In addition,
using the same scale, the PC asks patients how critical of their caregiver are they.
The PC can also be administered to the caregiver using the same rating scales.
This measure provides a very quick assessment of the negative atmosphere that
is created in the relationship. Depending on how the item is phrased, the assess-
ment can provide information about how much criticism there is about the
disorder versus the overall level of criticism in the relationship.

Relationship Adjustment

The above measures target specific aspects of the couple relationship that are
more focal to psychopathology. In addition, the overall tone of the relation-
ship creates an environment that can either add to or alleviate stress that the
patient is experience more broadly, as well as impact whether a caregiver is
motivated to assist in the patient’s treatment. Therefore, an overall measure
of relationship adjustment can serve as a meaningful index of the overall sat-
isfaction that each partner experiences in the relationship.
The 32-item Dyadic Adjustment Scale (Spanier, 1976) is one of the most
widely used measures of relationship adjustment, with good reliability and
validity. Whereas subscales have been devised, the overall summary score
228 Abramowitz and Baucom

provides a simple assessment of relationship satisfaction. Scores can range

from 0 to 151, with higher scores indicating greater relationship satisfaction.
A score below 100 indicates relationship distress.
A more recent measure of relationship satisfaction that has taken advantage
of recent scale development strategies is the Couples Satisfaction Index (Funk
& Rogge, 2007), which demonstrates notable construct validity, is highly cor-
related with longer measures of the same construct, and exists in different
lengths dependent on the needs of the user, including 4-, 8-, 16-, and 32-item
versions.

CLINICAL IMPLICATIONS

In this section, interpersonal phenomena are placed within a clinical frame-

work and how these processes present across different presentations of fear/
anxiety is discussed. Interventions that can be used to mitigate interpersonal
processes that maintain clinical anxiety are also reviewed.

Transdiagnostic Presentation of Accommodation

As discussed previously, symptom accommodation is present transdiagnos-

tically, such that clinicians are bound to encounter examples of it in almost
all anxious patients who live with or depend on one or more caregivers. The
following section describes how such accommodation behavior may manifest
itself across anxiety-related diagnoses to illustrate when, why, and how clini-
cians can assess for such behavior. The treatment of accommodation behavior
is also discussed. Aside from the behaviors described here, there are many
healthy forms of support and caregiving which may or may not have anxiety-
reducing qualities.

Obsessive-Compulsive Disorder
The ubiquity of compulsive rituals and avoidance behaviors in patients with
OCD provides rich opportunities for caregivers to accommodate. As OCD is a
highly heterogeneous condition (e.g., Abramowitz et al., 2010), so are the ways
that accommodation manifests, and clinicians are wise to assess for it care-
fully when working with patients involved in intimate relationships or living
with relatives.
Among patients with contamination obsessions, caregiver accommodation
often involves washing and cleaning rituals (e.g., doing extra loads of laundry)
for the patient or helping the patient avoid feared contaminants. It is not
uncommon for caregivers to change shoes or clothes to help keep their loved
one’s anxiety at bay, avoid contact with certain stimuli (e.g., the mail) before
it has been “decontaminated” by the patient, and avoid going into certain
rooms in the house. For example, a patient may be afraid to leave her room
because of contamination fears, and her parents accommodate this by bringing
 Interpersonal Processes 229

all food (and other requested items) to their daughter’s room and engage in a
lengthy decontamination ritual before entering.
Reassurance about safety might also be given: A patient who is fearful of
rabies may insist her husband come to inspect any dead animal she jogs past
on her morning runs. Other accommodation is more subtle: a mother always
samples her son’s food before he began to eat to reassure him that the food
was safe to eat. Other manifestations of the accommodation of contamination
obsessions include purchasing (or providing funding for) “heavy duty” or
unnecessary cleaning products (e.g., extra strength soaps and detergents) and
supplies (e.g., extra toilet paper). Delaying or cancelling previously scheduled
family events because a patient is performing lengthy cleaning and washing
rituals is another form of accommodation.
Among patients with checking and reassurance-seeking rituals, accommo-
dation typically includes providing reassurance in the form of actual checking
for (or with) the patient (e.g., checking the stove, looking up information on
the Internet) or repeatedly answering questions. Such questions might per-
tain to whether the patient has committed a sin or mistake, whether they have
harmed someone, questions about sexual preference, religious faith, or about
someone’s “true” nature (“Am I a pedophile just because I was thinking about
it?” “Do I have OCD or some other problem?”). Patients might also ask care-
givers whether they have had similar thoughts, feelings, or physical sensa-
tions as the patient. It is important to note that responding once to the honest
asking of such questions would not constitute accommodation; yet, care­givers
often find themselves repeating themselves in response to the same (or very
similar) questions being asked again and again. If the patient already knows
(or could assume) the answer to his or her question, the question is more
likely functioning as a compulsive ritual or attempt to seek reassurance—
a form of accommodation that serves the purpose of temporarily reducing the
patient’s distress.
Patients with obsessions about taboo topics such as sex, violence, or blas-
phemy often engage in avoidance of stimuli that trigger such thoughts and
mandate that their caregivers do the same. Examples include avoiding certain
movies, TV shows, words, places, and people. Caregivers may go to great lengths
to avoid or keep the patient from having to experience such triggers and the
obsessional thoughts they provoke. Patients with taboo obsessions may also
confess their thoughts to loved ones, and listening to such confessions is con-
sidered a form of accommodation.

Social Anxiety Disorder

In the context of social anxiety, accommodation often manifests in the care-
giver speaking for the anxious person. This might involve making phone calls on
behalf of the individual, ordering food in a restaurant, or returning unwanted
items to a store, among others. When the patient is unable to assertively decline
an invitation, the caregiver might volunteer to do so in his or her place or pro-
vide an excuse. Caregivers might also take responsibility for sheltering patients
230 Abramowitz and Baucom

from potential social situations the caregivers anticipate would be difficult for
the patients. In extreme instances, accommodation by parents involves allow-
ing an adult child to live at home and avoid all social interactions (e.g., school,
dating, job interviews, employment). In such instances, the parents might
work to meet many (or all) of the patient’s needs so he or she does not have
to experience distress. Thus, accommodation often takes the form of helping
the patient avoid potentially anxiety-provoking social interactions. In addi-
tion, many caregivers agree to leave social settings when the patient becomes
anxious. At a social gathering, a mere whisper from a patient that “I want to
leave now,” can be enough to terminate the pair’s presence at the event, low-
ering the patient’s anxiety through an escape response.

Panic Disorder, Agoraphobia, and Health/Illness-Related Anxiety

Accommodation for patients with panic attacks and agoraphobia might take
various forms, including acting as a “safe person” and accompanying the
patient on all trips out of the home. The goal of the accommodation is to keep
the anxious individual from having to experience “too much” anxiety on the
basis of the belief that this could have serious negative consequences. Other
caregivers might offer to run errands for the anxious person or, as in social
anxiety, provide cover for the patient to be excused from responsibilities
outside the home. One form of accommodation involves shifting roles and
responsibilities to allow the person with agoraphobia to remain in safe places
close to home. Volunteering to be easily available (e.g., by phone) in case of a
panic attack or other health problem, providing reassurance about health and
illness (e.g., answering questions, helping with researching illnesses), taking
the patient (and paying for) for unnecessary doctor visits or medical tests, and
providing resources (financial or otherwise) for patients who believe they
require special medical care or refuse to leave the home (e.g., to go to work)
are also common accommodation behaviors.

Specific Phobias and Separation Anxiety

For adults and children with phobias, including separation anxiety, caregiver
accommodation involves helping with avoidance and providing reassurance.
Some parents go to great lengths to provide reassurance and/or help their
child not have to confront otherwise age appropriate situations such as going
to school, spending the night at a friend’s house (e.g., by providing excuses),
sleeping in their own room (e.g., sleeping with them, allowing them to sleep
with the caregiver), or meeting new animals (e.g., asking neighbors to con-
ceal their pets). Because specific phobias involve singular stimuli that evoke
fear, caregivers often can find ways to help the patient avoid this specific
aspect of their lives.

Posttraumatic Stress Disorder

Caregivers of those with PTSD accommodate by helping the individuals avoid
triggers or reminders of the traumatic experience. As an example, a caregiver
helped the patient avoid having to go out at night after she had been raped at
 Interpersonal Processes 231

night. The caregiver did this by arranging for all social events to take place
during the day. Other forms of accommodation include providing unnecessary
reassurance of safety, helping with safety cues and behaviors (e.g., installing
extra locks, purchasing weapons for safety), and helping with checking for
safety. Caregivers also try to help the patient avoid triggers by informing other
family members what is acceptable and unacceptable to say. The family might
be told never to talk about war or never to ask about a patient’s experiences as
a firefighter. There are several ways that loved ones attempt to rearrange the
patient’s environment to help them avoid potential triggers or reminders of
the traumatic event.
Just as with other fear and anxiety-based disorders, at times, caregivers
provide ongoing reassurance to patients with PTSD. Some individuals with
PTSD experience great guilt that they were at fault for the trauma, which may
have impacted or killed other individuals. In such instances, family members
might provide repeated reassurance that it was not the patient’s fault. Unfor-
tunately, such reassurance rarely has durable anxiolytic effects and must be
repeated.
One of the most damaging posttraumatic symptoms to relationships is the
emotional numbing that accompanies patients with PTSD. In many instances,
it appears that the patient’s system for experiencing negative and positive
emotions has almost shut down, making it difficult for caregivers to relate to
the patient. Fearing what will happen if the patient experiences emotions or
not knowing what to do, caregivers accommodate in a more passive manner
by going along with the emotional distance. Family members interact with
the patient in a less emotional manner, effectively validating the message that
experiencing emotions might be dangerous. It is difficult for the patient to
process the traumatic event or resume a healthy life if the patient continues
to avoid emotions in their daily life.

Rationale for Targeting Interpersonal Factors in Treatment

There is evidence that relationship functioning impacts treatment outcome in

anxiety-related disorders. Higher levels of family accommodation at baseline
predicted poorer treatment outcome (i.e., greater symptom severity post­
treatment) in a pediatric OCD sample (Garcia et al., 2010). However, greater
decreases in accommodation from pre- to posttest were associated with better
treatment response in symptom severity and impairment (Merlo, Lehmkuhl,
Geffken, & Storch, 2009). Piacentini and colleagues (2011) also found that
improvement in OCD symptoms followed decreases in accommodation behav-
ior. Results such as these, as well as the bidirectional association between
anxiety symptoms and interpersonal functioning suggests that involving
caregivers in treatment will enhance short- and long-term outcomes of inter-
ventions for anxiety disorders—especially cognitive behavior approaches.
The remainder of this chapter describes techniques for involving caregivers
in cognitive behavior therapy for anxiety to address interpersonal mainte-
nance factors, particularly accommodation. Abramowitz, Baucom, Boeding,
232 Abramowitz and Baucom

and colleagues (2013) focused on adult romantic (e.g., married or committed)

couples in which one partner has been diagnosed with an anxiety disorder,
but much of this work is generalizable to other types of close personal rela-
tionships (e.g., parent–child) involving anxious patients of any age. In addition
to accommodation as a specific set of behaviors focal to the disorder, relation-
ship distress can also impact the patient’s functioning as a broad, diffuse
stressor on the patient. Therefore, addressing relationship distress when it is
present is also an important intervention for these couples. However, because
cognitive behavior interventions for addressing relationship distress are well
documented elsewhere (e.g., Epstein & Baucom, 2002), this chapter focuses
on interventions specific to the disorder within a relationship context.

Psychoeducation

Presenting the cognitive behavior conceptual model of anxiety can help reduce
a caregiver’s expressions of resentment and criticism, normalize his or her
experience, and begin to alleviate feelings of guilt and frustration about the
patient’s experiences with anxiety. Similarly, learning about how treatment
operates, and the evidence for its effectiveness, can increase hopefulness and
reduce feelings of helplessness and of being overwhelmed. For example, when
Frank began to understand that his daughter Chelsea’s resistance to spending
time at her grandparents’ home arose from her OCD-related obsessional fears
about the possibility of radon gas in their home, rather than from her dislike
of his parents, Frank was less critical of Chelsea and her behavior. Knowing
that Chelsea would be participating in an effective treatment further increased
his patience.
Many caregivers also find the notion of exposure therapy counterintuitive,
often believing that their role is to help their loved one stay away from anxiety-
provoking situations or alleviate distress if anxiety cannot be avoided. Educa-
tion helps caregivers understand that their role is to help the patient confront
the anxiety, realize that it is not harmful or dangerous, and develop skills for
how to “stick it out” and “get through” the unpleasant feelings and internal
sensations until they dissipate on their own

Caregiver-Assisted Exposure

Once a caregiver understands the principles underlying exposure therapy, he

or she can be taught how to assist with exposure exercises by serving as a
coach. Some treatment outcome studies have indicated that involving close
relatives in this way improves treatment effectiveness for anxiety disorders,
as well as the interpersonal relationship (e.g., Belus, Baucom, & Abramowitz,
2014). However, caregiver-assisted exposure is optimally successful when
conflict and accommodation within the relationship are minimal. By learning
how to play the role of coach, the caregiver provides emotional support to the
patient as he or she completes exposure practices within and outside of the
therapy session. The caregiver is taught to provide gentle, but firm reminders
 Interpersonal Processes 233

not to engage in avoidance or safety behaviors and rituals. Most important,

the caregiver is trained to help the patient implement exposures correctly by
making sure the feared stimulus is confronted in a way that tests fearful pre-
dictions. In the first exposure session, the caregiver and patient are intro-
duced to four phases of confronting a stressor (described following) and how
to communicate with each other at each phase.
An important aspect of this stage of treatment involves teaching the patient
and caregiver two sets of communication skills. The first skill involves sharing
thoughts and feelings, known as emotional expressiveness training, in which
the dyad is taught to discuss with one another how they feel (as opposed to
offering solutions) during exposure while also listening effectively to each
other. This strategy helps the patient to focus on and confront distressing feels
rather than avoiding them. The second skill involves learning how to make
decisions as a team when it comes to planning and implementing exposure
tasks and resisting safety behaviors (Epstein & Baucom, 2002). The actual
process of confronting the fear stimulus—which can be broken down into the
four stages of (a) discussing the exposure task, (b) confronting the feared sit-
uation, (c) dealing with elevated anxiety, and (d) evaluation—is discussed in
further detail elsewhere (e.g., Abramowitz, Baucom, Wheaton, et al., 2013).

Reducing Accommodation

Outside of exposure therapy, clinicians can also intervene with the patient
and caregiver regarding changing accommodation patterns that have become
part of their everyday lives. In such interventions, the therapist begins by
describing accommodation and its deleterious effects, noting that accommo-
dation from the caregiver often is well intended. Next, an activity which has
become hampered by anxiety symptoms is chosen, and the therapist facili-
tates a decision-making discussion regarding ways to handle this situation by
relying on the principle of exposure, rather than relying on avoidance and
safety cues or behaviors. For example, a caregiver might resume shopping at
“contaminated” stores and using the various rooms in the house that had
been off limits because of the patient’s fears of spreading contamination. A
mother might stop speaking up for her son with social anxiety or stop helping
him avoid social interactions. The goal of these interventions is to work
toward a life in which the patient with anxiety (and the caregiver) confronts
the situations and stimuli that he or she has been avoiding and remains in
that situation rather than using safety behaviors. Therefore, exposure becomes
a way of life rather than just a defined exercise as a therapeutic assignment.
As treatment proceeds and exposure is successful, these gains often pro-
vide the patient and caregiver with new opportunities to engage with the
world. Fear-based disorders “shrink” a patient’s world (and perhaps a care­
giver’s world as well), limiting what they can do. Therapeutic gains mean that
there are new opportunities for the patient and for the patient/caregiver
team. To this end, the therapist can initiate a conversation noting that the
patient and caregiver now have many opportunities to engage in life in new
234 Abramowitz and Baucom

ways that were previously hampered by the disorder. What would they like
to do that would make life more rewarding and enriching that they have not
been doing? In approaching treatment gains in this way, therapy is presented
not only as alleviating distress but also as explicitly building opportunities for
a more rewarding life. Such discussions can be helpful because often the pair
develops limited routines in response to the disorder and, over time, stop
thinking about alternative ways of behaving. Helping them make clear deci-
sions about how they want to broaden their lives not only helps improve
their quality of life but also builds exposure into their everyday lives on an
ongoing basis, which can assist in maintenance of therapeutic gains after
treatment is completed.
When discouraging a caregiver from accommodating to the patient’s anxiety
symptoms, it is important to understand what function the accommodation
plays in the interpersonal relationship and address these issues. Accommoda-
tion might have become a major way that a spouse or parent shows care, con-
cern, and love for his or her partner or child. Treatment can have iatrogenic
effects to the extent that accommodation is removed but no replacement
behaviors are offered (e.g., altering the relationship so that the individuals no
longer feel as close to each other or the patient does not feel as loved by the
caregiver). Consequently, it is important to discuss new and adaptive ways the
pair would want to show their love, care, and concern for each other instead
of having this dictated by the anxiety.

CONCLUSION

Although anxiety is typically viewed from the perspective of the individual

with the problem, it exists in a social and interpersonal context. There are a
myriad of ways that caregivers often inadvertently become a part of the anx-
iety process: helping the patient avoid anxiety-provoking situations, becom-
ing safety cues, engaging in safety behaviors and compulsive rituals with
or instead of the patient, and providing frequent reassurance. Whether out of
concern for the patient or resulting from an attempt to avoid arguments about
the problem with anxiety and fear, such behaviors from caregivers can unin-
tentionally serve to maintain the anxiety. There is an almost universal desire
of caregivers to be of assistance; but understandably, they do not typically
come to therapy knowing how to help. Educating both parties about the
treatment of anxiety, helping them understand the roles that each of them
can take to be of assistance, and teaching them to work together as a team
provides the opportunity to use the relationship as an important resource in
the treatment of problems with clinical anxiety. From an interpersonal per-
spective, the fundamental efficacious intervention of exposure therapy remains
the central focus of treatment, but it can be enhanced by an environment that
helps to build a context for generalizing exposure to everyday life on an ongoing
 Interpersonal Processes 235

basis. Research suggests that it is reasonable to expect that with the proper
informed support of a caregiver in the patient’s natural environment, treatment
gains might well be enhanced and maintained more effectively over time.

REFERENCES
Abramowitz, J. S., Baucom, D. H., Boeding, S., Wheaton, M. G., Pukay-Martin, N. D.,
Fabricant, L. E., . . . Fischer, M. S. (2013). Treating obsessive-compulsive disorder in
intimate relationships: A pilot study of couple-based cognitive-behavior therapy.
Behavior Therapy, 44, 395–407. http://dx.doi.org/10.1016/j.beth.2013.02.005
Abramowitz, J. S., Baucom, D. H., Wheaton, M. G., Boeding, S., Fabricant, L. E.,
Paprocki, C., & Fischer, M. S. (2013). Enhancing exposure and response prevention
for OCD: A couple-based approach. Behavior Modification, 37, 189–210. http://
dx.doi.org/10.1177/0145445512444596
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C.,
Losardo, D., . . . Hale, L. R. (2010). Assessment of obsessive-compulsive symptom
dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive
Scale. Psychological Assessment, 22, 180–198. http://dx.doi.org/10.1037/a0018260
Amir, N., Freshman, M., & Foa, E. B. (2000). Family distress and involvement in rela-
tives of obsessive-compulsive disorder patients. Journal of Anxiety Disorders, 14,
209–217. http://dx.doi.org/10.1016/S0887-6185(99)00032-8
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: Inter­
national Universities Press.
Belus, J. M., Baucom, D. H., & Abramowitz, J. S. (2014). The effect of a couple-based
treatment for OCD on intimate partners. Journal of Behavior Therapy and Experimen-
tal Psychiatry, 45, 484–488. http://dx.doi.org/10.1016/j.jbtep.2014.07.001
Bodden, D. H. M., Dirksen, C. D., Bögels, S. M., Nauta, M. H., De Haan, E.,
Ringrose, J., . . . Appelboom-Geerts, K. C. M. M. J. (2008). Costs and cost-effectiveness
of family CBT versus individual CBT in clinically anxious children. Clinical Child Psy-
chology and Psychiatry, 13, 543–564. http://dx.doi.org/10.1177/1359104508090602
Boeding, S. E., Paprocki, C. M., Baucom, D. H., Abramowitz, J. S., Wheaton, M. G.,
Fabricant, L. E., & Fischer, M. S. (2013). Let me check that for you: Symptom accom-
modation in romantic partners of adults with obsessive-compulsive disorder. Behaviour
Research and Therapy, 51, 316–322. http://dx.doi.org/10.1016/j.brat.2013.03.002
Calvocoressi, L., Lewis, B., Harris, M., & Trufan, S. J. (1995). Family accommodation
in obsessive-compulsive disorder. The American Journal of Psychiatry, 152, 441–443.
Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick, J., Fisk, D., Vegso, S. J., . . . Price,
L. H. (1999). Family accommodation of obsessive-compulsive symptoms: Instru-
ment development and assessment of family behavior. Journal of Nervous and Mental
Disease, 187, 636–642. http://dx.doi.org/10.1097/00005053-199910000-00008
Caporino, N. E., Morgan, J., Beckstead, J., Phares, V., Murphy, T. K., & Storch, E. A.
(2012). A structural equation analysis of family accommodation in pediatric
obsessive-compulsive disorder. Journal of Abnormal Child Psychology, 40, 133–143.
http://dx.doi.org/10.1007/s10802-011-9549-8
Chambless, D. L., Bryan, A. D., Aiken, L. S., Steketee, G., & Hooley, J. M. (2001). Pre-
dicting expressed emotion: A study with families of obsessive-compulsive and ago-
raphobic outpatients. Journal of Family Psychology, 15, 225–240. http://dx.doi.org/
10.1037/0893-3200.15.2.225
Chambless, D. L., & Steketee, G. (1999). Expressed emotion and behavior therapy out-
come: A prospective study with obsessive-compulsive and agoraphobic outpatients.
Journal of Consulting and Clinical Psychology, 67, 658–665. http://dx.doi.org/10.1037/
0022-006X.67.5.658
236 Abramowitz and Baucom

Cole, J. D., & Kazarian, S. S. (1988). The Level of Expressed Emotion Scale: A new
measure of expressed emotion. Journal of Clinical Psychology, 44, 392–397. http://
dx.doi.org/10.1002/1097-4679(198805)44:3<392::AID-JCLP2270440313>3.0.CO;2-3
Cosentino, T., Faraci, P., Coda, D., D’Angelo, R., De Pari, L. A., Di Crescenzo, M. R., . . .
Scelza, A. (2015). Family accommodation in obsessive-compulsive disorder: A study
on associated variables. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 12,
128–134.
Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples:
A contextual approach. Washington, DC: American Psychological Association.
Fredman, S. J., Baucom, D. H., Miklowitz, D. J., & Stanton, S. E. (2008). Observed
emotional involvement and overinvolvement in families of patients with bipolar
disorder. Journal of Family Psychology, 22, 71–79. http://dx.doi.org/10.1037/
0893-3200.22.1.71
Funk, J. L., & Rogge, R. D. (2007). Testing the ruler with item response theory: Increas-
ing precision of measurement for relationship satisfaction with the Couples Satis-
faction Index. Journal of Family Psychology, 21, 572–583. http://dx.doi.org/10.1037/
0893-3200.21.4.572
Garcia, A. M., Sapyta, J. J., Moore, P. S., Freeman, J. B., Franklin, M. E., March, J. S.,
& Foa, E. B. (2010). Predictors and moderators of treatment outcome in the Pedi-
atric Obsessive Compulsive Treatment Study (POTS I). Journal of the American Acad-
emy of Child & Adolescent Psychiatry, 49, 1024–1033. http://dx.doi.org/10.1016/
j.jaac.2010.06.013
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L.,
Hill, C. L., . . . Charney, D. S. (1989). The Yale–Brown Obsessive Compulsive
Scale. Archives of General Psychiatry, 46, 1006–1011. http://dx.doi.org/10.1001/
archpsyc.1989.01810110048007
Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depressives:
Expressed emotion, marital distress, and perceived criticism. Journal of Abnormal
Psychology, 98, 229–235.
Lebowitz, E. R., Scharfstein, L., & Jones, J. (2015). Child-report of family accommoda-
tion in pediatric anxiety disorders: Comparison and integration with mother-
report. Child Psychiatry and Human Development, 46, 501–511. http://dx.doi.org/
10.1007/s10578-014-0491-1
Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., . . .
Leckman, J. F. (2013). Family accommodation in pediatric anxiety disorders. Depres-
sion and Anxiety, 30(1), 47–54. http://dx.doi.org/10.1002/da.21998
Leff, J., & Vaughn, C. (1985). Expressed emotion in families: Its significance for mental illness.
New York, NY: Guilford Press.
Marcaurelle, R., Bélanger, C., Marchand, A., Katerelos, T. E., & Mainguy, N. (2005).
Marital predictors of symptom severity in panic disorder with agoraphobia. Journal
of Anxiety Disorders, 19, 211–232.
McCarthy, L., & Shean, G. (1996). Agoraphobia and interpersonal relationships. Jour-
nal of Anxiety Disorders, 10, 477–487.
Merlo, L. J., Lehmkuhl, H. D., Geffken, G. R., & Storch, E. A. (2009). Decreased family
accommodation associated with improved therapy outcome in pediatric obsessive-
compulsive disorder. Journal of Consulting and Clinical Psychology, 77, 355–360. http://
dx.doi.org/10.1037/a0012652
Norman, K. R., Silverman, W. K., & Lebowitz, E. R. (2015). Family accommodation
of child and adolescent anxiety: Mechanisms, assessment, and treatment. Journal of
Child and Adolescent Psychiatric Nursing, 28, 131–140.
Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J. J., &
McCracken, J. (2011). Controlled comparison of family cognitive behavioral ther-
apy and psychoeducation/relaxation training for child obsessive-compulsive dis­
 Interpersonal Processes 237

order. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 1149–1161.
http://dx.doi.org/10.1016/j.jaac.2011.08.003
Pinto, A., Van Noppen, B., & Calvocoressi, L. (2013). Development and preliminary
psychometric evaluation of a self-rated version of the Family Accommodation Scale
for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Dis­
orders, 2, 457–465. http://dx.doi.org/10.1016/j.jocrd.2012.06.001
Spanier, G. (1976). Measuring dyadic adjustment: New scales for assessing the quality
of marriage and similar dyads. Journal of Marriage and the Family, 38, 15–28. http://
dx.doi.org/10.2307/350547
Thompson-Hollands, J., Kerns, C. E., Pincus, D. B., & Comer, J. S. (2014). Parental accom-
modation of child anxiety and related symptoms: Range, impact, and correlates. Jour-
nal of Anxiety Disorders, 28, 765–773. http://dx.doi.org/10.1016/j.janxdis.2014.09.007
II
TREATMENT
MECHANISMS
Introduction to Part II
Why Mechanisms of Change?
Jonathan S. Abramowitz and Shannon M. Blakey

T he field of mental health has reached a point of maturity such that a

multitude of psychological treatments are available for clinical anxiety.
Many of these programs have empirical support and are associated with
desirable emotional, behavioral, cognitive, social, educational, and occupa-
tional outcomes (e.g., Barlow, 2007). Such interventions, usually disseminated
through treatment manuals developed and tested for specific disorders listed
in the Diagnostic and Statistical Manual of Mental Disorders (fifth ed. [DSM–5];
American Psychiatric Association, 2013) and the International Classification of
Diseases (11th ed. [ICD–11]; World Health Organization, 2018), typically include
multiple components. Panic Control Treatment (Craske & Barlow, 2006), for
example, is a program consisting of psychoeducation, cognitive therapy, and
exposure therapy for panic disorder and agoraphobia. Coping Cat (Kendall &
Hedtke, 2006), a cognitive behavior treatment program for anxious youth,
similarly includes psychoeducation, cognitive restructuring, exposure exercises,
somatic management, and problem-solving strategies. Numerous random-
ized controlled trials have been conducted with these and other manualized
psychological treatments and consistently demonstrate that such treatments
work. However, these studies do not necessarily address the mechanisms
of change—why such treatments work. In multicomponent programs, it might
not be clear which components are essential and which are less critical (or
altogether unnecessary) for good outcomes.
The aim of Part II of this handbook is to help clinicians identify empirically
supported mechanisms of change (and the procedures that activate them), as
well as how to match them with the transdiagnostic anxious processes
described in Part I. Drawing from Kazdin and Nock (2003; Kazdin, 2007), we
define treatment mechanisms as the basis for the effectiveness of a treatment—
the processes or reasons demonstrated to be responsible for the changes that
241
242 Why Mechanisms of Change?

occur in therapy. We believe that capitalizing on mechanisms of change to

target psychological maintenance processes (like those discussed in Part I)
affords greater clinical precision than does the use of multicomponent
treatment programs for disorders defined by the DSM–5 and the ICD–11.
The former approach allows the clinician to make the most patient-specific,
evidence-based treatment decisions when the inevitable need to deviate from
disorder-based treatment manuals arises. Critically, we are not advocating for
an “eclectic” approach in which clinicians rely simply on clinical judgment and
choose from assorted theoretical orientations (e.g., behavioral plus psycho­
dynamic). Rather, we argue that following a thorough assessment and case
conceptualization, an effective and efficient clinician will design an optimally
tailored treatment plan using empirically supported procedures activating
mechanisms of change—usually inspired by empirically supported treatment
manuals—to target a patient’s specific anxious processes.
In this introduction, we consider more specifically several reasons that
clinicians are better off focusing on mechanisms of change, rather than rigidly
following disorder-driven manualized treatment programs. We begin, however,
with a brief case example of how early scientifically oriented clinicians derived
empirically informed interventions for fear-based problems.

THE DEVELOPMENT OF AN EMPIRICALLY

SUPPORTED INTERVENTION

Long considered a treatment-refractory condition by those espousing “talk”

therapy (e.g., psychoanalysis), obsessive-compulsive disorder (OCD) was one
of the first problems to be addressed by the behavior therapy movement in
the 1950s and 1960s. Clinicians wishing to apply the principles of learning to
what is now called OCD turned to Richard Solomon’s (e.g., Solomon, Kamin,
& Wynne, 1953) animal model of what was then termed compulsive neurosis.
In this paradigm, dogs were taught to jump over a hurdle when a light was
turned on to avoid an electric shock, which was paired with the light. After
this avoidance response had been learned, the dogs persisted in becoming
visually distressed when the light was illuminated, even after the electrical
power supply to the dogs’ cage had been cut off (i.e., no more shocks were
administered). They continued to “superstitiously” or “ritualistically” jump
over the hurdle to safety even though there was no longer a threat of shock.
Thus, the dogs apparently acquired an obsessive-compulsive habit (jumping
over the hurdle) that was maintained by negative reinforcement (the imme-
diate reduction of emotional distress). The paradigm from Solomon and
colleagues (1953) serves as an animal analogue to OCD in humans, where
compulsive rituals are triggered by fear that is associated with situations or
conditioned stimuli (e.g., toilets, floors, obsessional thoughts) that pose little
or no risk of harm. The fear is then reduced by avoidance and compulsive
rituals (e.g., washing), which are negatively reinforced over time because they
serve as an escape from distress.
 Introduction to Part II 243

Solomon and his colleagues (1953) next attempted to “treat” the dogs’
irrational (“compulsive”) jumping behavior using various techniques, the
most effective of which involved a combination of procedures now referred to
as exposure and response prevention. Solomon and colleagues hypothesized
that exposing the dogs to the conditioned stimulus (turning on the light)
while simultaneously preventing the conditioned escape/avoidance response
(increasing the heights of the hurdle so jumping was not possible) would
eventually result in the extinction of fear. When these procedures were
applied, the dogs first displayed a strong fear response (e.g., running around
the chamber, jumping on the walls, defecating, yelping). Gradually, however,
this behavior subsided as repeated and prolonged exposure and response
prevention produced an extinction of the initial fear. When the height of the
hurdle was lowered after several extinction trials, the dogs no longer felt
compelled to jump when the light was turned on.
Once researchers like Meyer (1966) and Rachman and Hodgson (1980)
recognized the functional parallels between humans with OCD and Solomon
and colleagues’ (1953) dogs, they began studying how systematic exposure
and response prevention could be adapted for the treatment of OCD symptoms
in humans. Patients with OCD with hand washing rituals were seated at a
table with a container of dirt and miscellaneous compost. The experimenter,
after placing his own hands in the mixture, asked the patient to do the same
and explained that he or she would not be permitted to wash his or her
hands for some length of time. When the patient began the procedure, an
increase in anxiety, fear, and urges to wash his or her hands, was observed
(as expected). However, as with the dogs in Solomon and colleagues’ study,
the patients eventually evidenced a reduction in fear and urge to wash with
continued exposure and response prevention, demonstrating therapeutic
extinction (Rachman, De Silva, & Röper, 1976). This procedure was repeated
on sub­sequent days, the theory predicting that after some time, extinction
would be complete and the OCD symptoms would be reduced.
This experimental work serves as the conceptual basis for the use of expo-
sure and response prevention as a tandem of interventions for obsessions and
compulsions—one of the major success stories in the treatment of a set of
symptoms once considered highly complex and unresponsive to psychological
therapies. Indeed, a large body of evidence indicates the efficacy of this approach
to treatment (e.g., Olatunji, Davis, Powers, & Smits, 2013).

OF MANUALS AND MECHANISMS

The takeaway message from this case example for acting (and aspiring) clini-
cians is that in the absence of a treatment manual, the developers of exposure
and response prevention drew from their knowledge of psychological principles
to formulate a conceptualization of the clinical problem. They then applied
experimentally established interventions to activate putative mechanisms of
244 Why Mechanisms of Change?

action. This process of using knowledge of procedures and mechanisms to

modify empirically established psychological processes (such as those described
in the chapters of Part I of this handbook), however, has become a lost art
in the era of the disorder-specific treatment manual. Several reasons that we
believe the former approach is preferable to the latter are discussed next.

One Size Does Not Fit All

Manuals for specific DSM–5 and ICD–11 disorders might be useful in treatment
outcome studies that use carefully selected homogeneous patient samples
with little comorbidity or complexity. Yet in most clinical settings, patients
present with greater complexity, comorbid conditions, and heterogeneity
than a treatment manual can address. Not only are DSM–5 anxiety disorders
highly comorbid with one another (Kessler, Chiu, Demler, & Walters, 2005),
but clinical anxiety and fear are also common complaints outside of these
anxiety disorders (e.g., youth with a learning disability often report significant
testing anxiety). No therapy manual could adequately guide the treatment of
anxiety across the infinite personal variations of the signs and symptoms of fear
and anxiety. When a clinician’s approach is grounded in (a) an understanding
of the patient-specific processes that contribute to clinical anxiety, rather
than simply assigning a diagnosis, and (b) knowledge of the mechanisms that
address these maladaptive cognitive behavior processes, she can operate with-
out the need for or dependence on disorder-based treatment manuals.

Optimize Efficiency

By understanding the mechanisms that account for therapeutic change,

clinicians can better optimize treatment efficiency. “Should I spend more
time using technique A or technique B with this patient?” Without knowing
what is (and what is not) critical for effective treatment, a clinician risks
focusing on superfluous procedures in multicomponent treatment packages,
resulting in a lengthier and costlier course of therapy. The associated oppor-
tunity costs, unfortunately, can be high for patients—especially those with
limited time, finances, and other resources available for treatment. As an
example, eye movement desensitization and reprocessing (EMDR), which
boasts rapid and dramatic reductions in the treatment of posttraumatic stress
disorder (e.g., Shapiro, 1995), consists of exposing a patient to images of his or
her trauma and inducing saccadic eye movements while focusing on sensory,
physiological, and cognitive aspects of anxiety. Yet, studies comparing the
complete EMDR package with EMDR in which the eye movements are
omitted consistently find that the eye movements make no difference and
are not essential to treatment efficacy (e.g., Devilly, Spence, & Rapee, 1998).
The mechanism proposed for why the eye movements work lacks scientific
basis (Hyer & Brandsma, 1997). Thus, the time spent on eye movement
techniques in EMDR would be better used focusing on the other elements
 Introduction to Part II 245

of the therapy (e.g., imaginal exposure) that operate using mechanisms

demonstrated to trigger change processes.

Identify Prognostic Factors

Understanding the mechanisms through which treatment techniques operate

can help clinicians identify factors that should be considered when determining
whether a patient is suitable for treatment (and if so, which specific techniques
are more likely to be effective than others). If the correction of maladaptive
cognitions (i.e., dysfunctional beliefs) via rational discussion is a key mechanism
of change related to clinical anxiety, the clinician might pay particular attention
to a patient’s educational level, attributional style, and logical reasoning skills,
as these will influence whether the patient is a good candidate for a particular
treatment procedure that relies on these abilities (e.g., cognitive restructuring).

Ease Therapist Training

Focusing on ways to capitalize on transdiagnostic mechanisms of change also

affords advantages over a manual-driven approach when it comes to clinical
training. It is easier and more efficient to teach clinicians how to operate from
a single trans­diagnostic conceptual model than it is for clinicians to learn a
multitude of different treatment manuals based on the DSM–5 and ICD–11 for
a variety of psychological conditions. This is especially the case with anxiety
disorders, given that many treatment manuals share core components and
procedures (e.g., in vivo exposure). In turn, clinicians can begin working with
patients with anxiety sooner than they would if they had to be trained in
several manualized treatments. This approach also facilitates dissemination
from a practical and a financial standpoint. Obstacles to mastering the delivery
of psychological treatment include the expenses, time, and great effort required
for sufficient clinical training. After formal graduate training has ended, many
clinicians lack the time or financial ability to pursue supplementary instruction
or supervision (Gray, Elhai, & Schmidt, 2007). Fortunately, these barriers
are attenuated by the transdiagnostic approach and its emphasis on using
empirically derived procedures to target common psychological maintenance
processes.

Overview of Part II

The topics covered in the chapters within this section were chosen on the basis
of empirical support for their likely role as a mechanism of change during treat-
ment for anxiety. Although additional work is needed before these processes
can be definitively labeled mechanisms of change during anxiety treatment
(Kazdin, 2007; Kazdin & Nock, 2003), each process addressed in Part II of this
handbook has a consistent body of research pointing toward its statistically
accounting for reductions in clinical anxiety and a strong conceptual backdrop
for how the process likely explains why reductions in anxiety occurred.
246 Why Mechanisms of Change?

Although there is natural overlap among the change mechanisms (readers

will note conceptual intersection between them), we believe that each change
mechanism is sufficiently unique in how it is implemented and how it
addresses maladaptive anxiety-related processes.
These chapters are not intended to be stand-alone manuals for implemen-
tation strategies that act on each purported mechanism of change. Indeed,
entire volumes have been written on the science and art of the techniques
aimed to capitalize on many of these processes (e.g., Abramowitz, Deacon,
& Whiteside, 2019; Beck, 1976; Hayes, Strosahl, & Wilson, 1999). Rather,
the chapters here are meant to provide a conceptual overview and some basic
instruction so that the reader can develop an understanding of how the
potential mechanism of change can be activated (and assessed) during cogni-
tive behavior treatment for clinical anxiety. Readers interested in seeking
more detailed guidance on the specifics of how to implement therapeutic
interventions should reference other resources devoted to such interventions,
several of which are cited in the chapters that follow.
Each chapter in Part II follows a general format in which the purported
mechanism of change is first defined and described. Next, authors discuss
how to implement interventions that capitalize on this process during treat-
ment for anxiety. Third, each chapter addresses ways to observe and measure
activation of the relevant mechanism in anxiety patients. Each chapter also
contains a brief review of research supporting the efficacy of the hypothesized
mechanism of change. Finally, authors describe contraindications and patient-
specific considerations when using treatment methods that capitalize on each
mechanism of change. Because many readers are accustomed to thinking in
terms of DSM–5 and ICD–11 diagnoses, the mechanisms of change described in
these chapters are also linked back to these classifications. We hope that these
practical chapters will help readers evolve from a focus on multicomponent
treatment manuals for “mental disorders” to a more conceptually oriented
approach in which decisions about how to intervene are made at the level of
mechanisms that change psychological processes.

REFERENCES
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for
anxiety: Principles and practice (2nd ed.). New York, NY: Guilford Press.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Barlow, D. H. (2007). Clinical handbook of psychological disorders: A step-by-step treatment
manual (4th ed.). New York, NY: Guilford Press.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: Inter­
national Universities Press.
Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and panic. Oxford, England:
Oxford University Press.
Devilly, G. J., Spence, S. H., & Rapee, R. M. (1998). Statistical and reliable change
with eye movement desensitization and reprocessing: Treating trauma within a
veteran population. Behavior Therapy, 29, 435–455. http://dx.doi.org/10.1016/
S0005-7894(98)80042-7
 Introduction to Part II 247

Gray, M. J., Elhai, J. D., & Schmidt, L. O. (2007). Trauma professionals’ attitudes toward
and utilization of evidence-based practices. Behavior Modification, 31, 732–748.
http://dx.doi.org/10.1177/0145445507302877
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy:
An experiential approach to behavior change. New York, NY: Guilford Press.
Hyer, L., & Brandsma, J. M. (1997). EMDR minus eye movements equals good
psychotherapy. Journal of Traumatic Stress, 10, 515–522. http://dx.doi.org/10.1002/
jts.2490100314
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy
research. Annual Review of Clinical Psychology, 3, 1–27. http://dx.doi.org/10.1146/
annurev.clinpsy.3.022806.091432
Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of change in child
and adolescent therapy: Methodological issues and research recommendations.
Journal of Child Psychology and Psychiatry, 44, 1116–1129. http://dx.doi.org/10.1111/
1469-7610.00195
Kendall, P. C., & Hedtke, K. A. (2006). Cognitive-behavioral therapy for anxious youth:
Therapist manual (3rd ed.). Ardmore, PA: Workbook.
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity,
and comorbidity of 12-month DSM–IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62, 617–627. http://dx.doi.org/10.1001/
archpsyc.62.6.617
Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour
Research and Therapy, 4, 273–280. http://dx.doi.org/10.1016/0005-7967(66)90023-4
Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. J. (2013). Cognitive-behavioral
therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome
and moderators. Journal of Psychiatric Research, 47, 33–41. http://dx.doi.org/10.1016/
j.jpsychires.2012.08.020
Rachman, S., De Silva, P., & Röper, G. (1976). The spontaneous decay of compulsive
urges. Behaviour Research and Therapy, 14, 445–453. http://dx.doi.org/10.1016/
0005-7967(76)90091-7
Rachman, S. J., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs,
NJ: Prentice-Hall.
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols,
and procedures. New York, NY: Guilford Press.
Solomon, R. L., Kamin, L. J., & Wynne, L. C. (1953). Traumatic avoidance learning:
The outcomes of several extinction procedures with dogs. The Journal of Abnormal
and Social Psychology, 48, 291–302. http://dx.doi.org/10.1037/h0058943
World Health Organization. (2018). International classification of diseases (11th ed.).
Geneva, Switzerland: Author.
14
Habituation
Jessica L. Maples-Keller and Sheila A. M. Rauch

Habituation refers to the natural reduction in anxiety over the course of

exposure therapy as a result of repeated and prolonged confrontation with
feared stimuli. It is considered one mechanism of change within exposure
therapy (e.g., Abramowitz, Deacon, & Whiteside, 2019). Clinical anxiety (e.g.,
anxiety and related disorders as defined in the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) is
characterized by insufficient inhibition of fear in objectively safe situations.
Knowledge of the mechanisms behind fear acquisition and inhibition is vital
for understanding how to best intervene in cases of clinical anxiety. Fear
acquisition can be understood using a Pavlovian fear conditioning model
(Pavlov, 1927) in which an innocuous or neutral stimulus is paired with
an innately aversive unconditioned stimulus, resulting in the previously
neutral stimulus eliciting a conditioned fear response (now a conditioned
stimulus). Fear inhibition is studied via a procedure in which the participant
is repeatedly exposed to a conditioned stimulus in the absence of the aversive
unconditioned stimulus, resulting in a decrease in conditioned fear response.
This is known as fear extinction (e.g., Myers & Davis, 2007), and there is
evidence that such extinction occurs in part because of the process of habit-
uation (the natural decrease in fear responding to a fear-related stimulus

http://dx.doi.org/10.1037/0000150-014
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
249
250 Maples-Keller and Rauch

when such a stimulus is presented in a repeated and/or prolonged manner;

McSweeney & Swindell, 2002).
Early theories of extinction conceptualized this process as representing
unlearning or erasing of previously conditioned fear; however, subsequent
empirical investigation has not fully supported this conceptualization. For
example, conditioned fear responses can return following extinction training
(e.g., Craske & Mystkowski, 2006). A contemporary conceptualization empha-
sizes inhibitory learning, such that the fear association is not “unlearned” but
rather remains intact, and inhibitory associations form in contrast to the con-
ditioned fear association (Myers & Davis, 2007). In other words, the original
fear (i.e., conditioned stimulus) is not erased during extinction but rather
gains a new inhibitory meaning to the individual. It is important to note
that habituation, although highly relevant to extinction, does not provide a
complete explanation for this process, which likely occurs through multiple
mechanisms. This chapter focuses on habituation as a mechanism of change
that occurs during repeated and prolonged exposure therapy (Cooper, Clifton,
& Feeny, 2017). For information related to inhibitory processes in extinction,
see Chapter 15 of this handbook.
Exposure therapy involves repeated confrontation with feared, but objec-
tively safe, situations or stimuli in a systematic and often gradual manner.
This intervention has strong empirical evidence as an effective intervention for
clinically severe fear and anxiety (Deacon & Abramowitz, 2004; Hofmann &
Smits, 2008; Kaczkurkin & Foa, 2015). Exposure therapy is based in part on
emotional processing theory, which conceptualizes the fear structure as a cog-
nitive network of representations of fear stimuli, fear responses, and stimulus-
response meaning (Foa, Huppert, & Cahill, 2006; Foa & Kozak, 1986). The
maladaptive fear structures that underlie clinically severe anxiety differ from
more adaptive fear structures in that they involve excessive response ele-
ments that do not reflect reality. They also contain pathological meaning and
inaccurate or unhelpful interpretations. For example, a survivor of sexual
assault whose assailant was a man with red hair may perceive all red-haired
men as dangerous and experience an excessive fear response whenever she
interacts with any man with red hair. Additionally, she may experience
pathological meaning elements like believing she is to blame for the assault
or the world is unsafe. Exposure therapy involves activating the fear struc-
ture and receiving incompatible information that is subsequently integrated
into the fear structure.
Habituation occurs when the strength of the fear response decreases
over repeated exposure trials, as depicted in Figure 14.1. This decreased fear
response to previously feared objects or situations represents incompatible
information that is incorporated to make the fear structure more adaptive.
Anxiety reduction over repeated exposures may also disconfirm pathological
meaning elements (e.g., experiencing anxiety is dangerous, anxiety will
never decrease) and provide evidence of mastery and competence.
 Habituation 251

FIGURE 14.1. Habituation of Anxiety Over Time During Four Exposure Trials
Using the Same Stimulus

100
Trial 1
90
Anxiety Level (subjective distress)

80 Trial 2
70 Trial 3
60
Trial 4
50
40
30
20
10
0
0 5 10 15 20 25 30 35 40 45 50 60
Time (min)

IMPLEMENTATION

Exposure can occur in different formats depending on the nature and specific
presentations of clinical anxiety and fear, including (a) in vivo exposure,
which entails confronting feared objects or situations (e.g., a spider) in real life;
(b) imaginal exposure, which entails confronting mental stimuli (e.g., unwanted
thoughts, images, memories of traumatic events); (c) interoceptive exposure,
which entails confronting feared internal body sensations (e.g., racing heart,
breathlessness); and (d) virtual reality–based exposure, which entails confront-
ing feared situations and stimuli using an interactive computer generated
environment (e.g., a theatre of war or combat). The type of exposure used
is determined by the patient’s presentation of fear, and many treatment
approaches use multiple types of exposures.

Exposure for Different Presentations of Anxiety

Although the specific stimuli used in exposure necessarily varies across different
presentations of fear and anxiety, the general process of implementing expo-
sure is similar. For specific phobias, which involve excessive fear or anxiety
about a circumscribed object or situation, exposure typically involves direct
exposures to the feared stimulus, often in a gradual manner (e.g., Craske,
Antony, & Barlow, 1997). For example, a child with a phobia of dogs may
begin by confronting a toy dog, then watch a video of an actual dog, and
gradually increase the intensity of exposures until he or she interacts with an
actual dog. In vivo exposure for specific phobia may be conducted across
multiple sessions, or in a single multiple-hour massed session.
252 Maples-Keller and Rauch

When treating panic attacks, which involve fear in response to arousal-

related body sensations, exposure typically involves confrontation with internal
cues via interoceptive exposure. Such cues may be generated through exer-
cises like hyperventilation or spinning in a swivel chair, which provoke sen-
sations like those of a panic attack (e.g., racing heart, shortness of breath,
dizziness; Barlow & Craske, 1994; Clark, 1986). When agoraphobia—the fear
of not being able to escape from a situation in which one experiences panic—
is part of the clinical picture, in vivo exposure to feared stimulations may
be used in addition to interoceptive exposure. In social anxiety—the fear of
embarrassment or scrutiny, often accompanied by fears that others will
react negatively to the observable signs of anxiety (e.g., muscle tension,
sweating)—exposure may involve facing feared social interactions via in
vivo exposure while simultaneously performing interoceptive exposure to
the very bodily sensations that the patient fears might be noticed by others
(e.g., Ledley, Foa, & Huppert, 2005).
Obsessive-compulsive disorder (OCD)—fear provoked by recurrent distress-
ing (obsessional) thoughts and images, often triggered by external stimuli
and repetitive mental or behavioral acts (compulsions)—is addressed using
exposure and response prevention, in which exposures are coupled with the
patient refraining from compulsive rituals (e.g., Foa, Steketee, Grayson,
Turner, & Latimer, 1984). Exposure is often conducted in vivo because obses-
sional fear is typically triggered by objects or situations in the environment
(e.g., toilets) or situations of increased responsibility (e.g., being the last to
leave the house and responsible for locking the door). In addition, exposure for
OCD often necessitates imaginal exposure to the feared obsessional thoughts,
images, and ideas of negative outcomes (e.g., thoughts of becoming ill from
“toilet germs,” images of burglaries because of forgetting to lock the door).
Interventions for severe anxiety related to illness similarly involve in vivo
exposure (e.g., hospitals, reading about diseases) and imaginal exposure (e.g.,
imagining having a serious illness), sometimes accompanied by interoceptive
exposure to bodily sensations that are misinterpreted as indications of ill
health (e.g., headache, sweating, tachycardia).
Finally, posttraumatic stress disorder (PTSD)—fear provoked by memories
of a traumatic event and trauma-related external stimuli—is treated using
in vivo exposure (e.g., feared but safe reminders of the event) and imaginal
exposure (e.g., recounting memories of the trauma itself; Jonas et al., 2013).
If fears of arousal-related body sensations are also part of the clinical picture,
interoceptive exposure may also be appropriate.

Optimizing Habituation During Exposure Therapy

A completed description of how to implement exposure therapy is beyond

the scope of this chapter—there are entire books dedicated to this topic
(e.g., Abramowitz et al., 2019). Accordingly, this section highlights ways to
implement exposure to capitalize on habituation.
 Habituation 253

Information-Gathering and Treatment Rationale

A course of exposure therapy typically begins with an assessment of (a) external
and internal fear cues, (b) the perceived feared consequences of encountering
such cues (e.g., “I will be horribly embarrassed if I speak up in class”), and
(c) the strategies used to reduce anxiety by avoiding and escaping from these
triggers (e.g., safety behaviors). The therapist provides a clear rationale for using
exposure, which helps to motivate the patient to tolerate the initial distress
that typically accompanies exposure exercises until habituation occurs. This
rationale incorporates a clear conceptual model of the anxiety problem, as well
as what it will be like to engage in exposure therapy, including the provocation
and diminution of anxiety during exposure. It can be helpful to use meta-
phors to describe the exposure and habituation process, like asking the patient
to imagine watching the same scary movie several times in a row and asking
him or her how it may feel at the first viewing compared with a fifth (or sub-
sequent) viewing. This provides a straightforward and relatable example of
how habituation to fear-related stimuli occurs over repeated exposures. It is
also important to check for understanding to ensure that the patient has a
solid grasp of why exposure is an effective intervention and how an effective
exposure trial should be conducted. This maximizes the chances of sub­
sequently conducting effective and therapeutic exposures.
In addition, the preparatory stage of exposure introduces the patient to the
importance of reducing (if not eliminating) subtle and not-so-subtle avoidance,
escape strategies, and other safety cues that prevent the natural extinction of
fear (i.e., response prevention). Depending on the nature of the patient’s
anxiety problem and the type of anxiety-reduction strategies he or she uses,
response prevention may take different forms. Individuals with OCD who
engage in compulsive rituals are taught to abstain from such ritualizing, and
individuals with panic attacks who insist a “safe person” accompany them
outside the home are helped to reduce reliance on such caregivers.

Hierarchy Development
Exposure therapy to bring about habituation typically involves constructing a
fear hierarchy—a list of to-be-confronted feared situations and stimuli. The
hierarchy is generated from the information gleaned from the assessment of
fear cues, and this process is a collaborative effort that involves input from the
therapist and the patient. The patient rates how distressing exposure to each
item would be, and then items on the hierarchy are arranged from least to
most distressing. The therapist and then patient then agree on a plan for con-
ducting and repeating the exposures within the hierarchy, usually graduating
from the least to the most fear-provoking.

Implementing Exposure
When deciding on the first exposure for the patient, it can be helpful for the
therapist to consider which item can feasibly be repeated multiple times and
would provide the strongest opportunity for habituation. Exposure often
254 Maples-Keller and Rauch

begins with confronting moderately distressing stimuli on the hierarchy

and gradually working up to more difficult situations. An early successful
experience with anxiety reduction during an exposure can reinforce the treat-
ment rationale and give the patient an experience of mastery and increased
motivation toward completing additional exposures. For example, a child
with a fear of the dark can be helped to confront increasingly less illumi-
nated rooms with the final exposure leaving the child alone in a completely
dark room. Exposures conducted in the session with the therapist’s super-
vision are then repeated by the patient between sessions as “homework”
assignments.
To capitalize on habituation, the patient is instructed to remain in the situ-
ation or to engage with the feared stimulus long enough for him or her to
observe that his or her distress has decreased substantially. To measure habit-
uation over time during the exposure session, the therapist asks the patient to
provide a subjective rating of their current anxiety or distress level (e.g., on a
scale from 0 to 10 or from 0 to 100) before exposure, at various increments
during exposure (e.g., every 5 minutes), and after exposure using the subjec-
tive units of distress scale (SUDS) or an “anxiety thermometer.” This can be
helpful information for titrating the exposure to ensure sufficient fear activation
and for monitoring anxiety reduction across the course of treatment. Two
types of habituation may be observed: anxiety that declines from the beginning
to the end of an individual exposure trial (i.e., within-session habituation)
and anxiety that declines over repeated occasions of exposure and is the basis
of more long-term learning (i.e., between-session habituation). Another con-
sideration is that extinction learning is context dependent (Bouton, 2004);
therefore, after habituation occurs in one context, it can be helpful to conduct
the exposure in different contexts to promote generalization of learning.
For example, during prolonged exposure therapy for PTSD (Foa &
Rothbaum, 1998), the patient should remain in exposure until his or her SUDS
rating decreases to 50% of its peak rating or until the patient has remained
exposed for at least 30 minutes to 45 minutes. However, these are general
guidelines and individual patient experiences during exposures vary. Accord-
ingly, the therapist should note what occurs during exposure and tailor such
guidelines to each specific patient. Some patients require additional time
because of difficulties experiencing habituation, and the therapist may consider
instructing these patients to stay in the exposure for a longer duration of time
(e.g., 60 minutes) or to engage in more frequent exposures (e.g., repetitions of
the trauma narrative).
The relationship between within-session habituation and symptom
reduction is inconsistent in the empirical literature (e.g., van Minnen & Foa,
2006). In fact, recent research suggests that change in SUDS during imaginal
exposure sessions for PTSD is not related to overall treatment response (e.g.,
Sripada & Rauch, 2015); as such, a lack of within-session habituation need not
be concerning and may even represent appropriate emotional engagement
with the exposure. It is recommended that the therapist monitor SUDS ratings
 Habituation 255

within and between sessions, because whether habituation does or does not
occur within session can be a helpful learning experience. For example, if the
patient does experience habituation, the therapist and the patient can reflect
on the fact that when the patient confronted feared stimuli, anxiety decreased.
If habituation does not occur within the session, the therapist can reinforce
new learning, teaching the patient that he or she can be anxious and do it
anyway, is capable of dealing with his or her anxiety, or does not actually lose
control or go crazy when he or she is anxious.
Conversely, between-session habituation has been shown to be a predictor
of treatment response (Gallagher & Resick, 2012; Jaycox, Foa, & Morral, 1998;
Kozak, Foa, & Steketee, 1988; Rauch, Foa, Furr, & Filip, 2004; Sripada &
Rauch, 2015; Telch et al., 2004; van den Hout, van der Molen, Griez, Lousberg,
& Nansen, 1987; van Minnen & Foa, 2006; van Minnen & Hagenaars, 2002),
and monitoring SUDS ratings across exposure sessions is also important. If a
patient is not demonstrating habituation across exposure sessions, the therapist
may consider whether the patient is persisting with individual exposure trials
long enough for anxiety reduction to occur. Additionally, it might be that the
patient is engaging in cognitive or behavioral avoidance during exposures
conducted outside of the session.

Ensuring Proper Engagement With Exposure Stimuli

It is important to monitor the patient’s level of engagement with the fear
stimulus to ensure appropriate activation of fear. Underengagement refers to
too little fear activation during exposure, whereas overengagement refers to too
much fear activation (Hembree, Rauch, & Foa, 2003). Engagement can be
assessed via the patient’s subjective report of fear and anxiety during exposure
(i.e., SUDs ratings), as well as his or her overt behavior (e.g., efforts to avoid
fear). Given the natural tendency to avoid fear-related stimuli, underengage-
ment is more likely to be observed than overengagement. Accordingly, the
therapist can actively encourage emotional engagement as well as structure
exposure trials to optimize the emotional salience of the fear stimulus. For
the patient, this may mean (a) ensuring that the most feared elements of the
hierarchy item are confronted, (b) adding additional fear related stimuli, or
(c) incorporating stimuli from a greater number of sensory modalities (e.g.,
vibrations, smells in virtual reality exposure). In imaginal exposure, this may
include prompting for details that the patient may be omitting because of fear.
It may also include making sure the patient is not engaging in distraction
(Telch et al., 2004).
The patient may use cognitive strategies to avoid or underengage, like
using distraction during in vivo exposure or reminding themselves that a
virtual reality-based exposure is not real. If the patient appears to be expe-
riencing a lack of fear activation, the therapist can query about the patient’s
internal experience and what he or she is saying to himself or herself during
the exposure. The patient may also engage in behavioral avoidance strate-
gies during exposures, including the use of safety behaviors and safety
256 Maples-Keller and Rauch

cues. These are important considerations when maximizing habituation

because safety behaviors and cues undermine activation of the fear response,
impeding the opportunity to experience anxiety reduction across repeated
exposures.
Similarly, it is important that the patients not use other types of “coping
strategies” (e.g., deep breathing, other relaxation techniques) during expo-
sure. Such techniques, although potentially useful for coping with day-to-day
life stress, prevent optimal activation of the fear structure and prevent the
opportunity for habituation. Discussing the problems with using such coping
strategies early in the treatment process can help the therapist anticipate
what coping behaviors to look for that may impact the patient’s emotional
engagement and opportunities to experience habituation.
Although overengagement is a less common phenomenon, it can prevent
habituation and processing of newly learned information. Overengagement
may involve dissociation during the exposure, which attenuates opportuni-
ties for habituation. If dissociation occurs, the therapist can be a supportive
presence while helping the patient stay grounded, such as by asking the patient
to touch their chair or some other object in the room. It might be necessary to
titrate exposures, like incorporating fewer elements of the patient’s fear struc-
ture during an in vivo exposure, or having the patient keep their eyes open
during imaginal exposure. Even with titration, exposure should proceed in a
manner that allows for emotional engagement and conveys the therapist’s
confidence in the patient’s ability to endure temporary anxiety and complete
in the exposure. The therapist’s goal should be to pull back the intensity of the
exposure only as much as is necessary. One suggestion is to try changing one
element at a time; for example, asking a patient with PTSD to open his or her
eyes and look at a spot on the wall while still revisiting a traumatic memory
verbally. If the patient remains overengaged, the therapist might consider
asking the patient to write out a section of the memory instead of recounting
it verbally.

Including Caregivers in Exposure Therapy

For various reasons, it might be beneficial to include a partner, parent, or

other family member in exposure sessions (e.g., if the patient needs assistance
completing exposures outside the therapist’s office). Doing so helps create
an “exposure-based lifestyle” (Cassiday, 2015, p. 95) and acknowledges the
pivotal role played by the family environment in maintaining clinical anxiety,
as well as in reinforcing a therapeutic approach-oriented behavioral style. In
such instances, it is important to review with family members the rationale
for exposure so that they are prepared for tolerating and supporting the
patient’s emotional activation during exposure sessions. Indeed, observing a
child or partner/spouse face their fears and experience high levels of anxiety
and distress—even if temporary and harmless—can be extremely uncomfort-
able for some family members.
 Habituation 257

OUTCOME INDICATORS

Measuring Habituation of Fear

Habituation is measured by several different approaches, including the use of

subjective ratings, psychophysiological measurement, and clinical symptom
tracking. The following section describes how to implement these approaches.

SUDS
A habituation-focused approach toward exposure therapy emphasizes the
level of fear reduction during exposure as an important aspect of clinical
change. As such, the patient’s subjective report of anxiety or distress during
exposures is an important way to assess this process. A common metric, as
described previously, is the SUDS rating, in which the patient rates his or her
moment-to-moment level of anxiety or distress on a scale from 0 to 10 or
from 0 to 100. To assess within-session habituation, the decrease in SUDS
during the exposure trial is considered. To assess between-session habitua-
tion, the decrease in SUDS between therapy sessions is considered. Although
the peak SUDS level within each exposure session is most commonly used,
some authors have suggested focusing on the average SUDS reported across
each session (Bluett, Zoellner, & Feeny, 2014). Some exposure protocols sug-
gest asking the patient for a SUDS rating every 5 minutes during an exposure
(Foa & Rothbaum, 1998) and then obtaining a final rating at the end of the
exposure, whereas other programs vary the interval between SUDS ratings.

Psychophysiological Indices
Habituation can also be measured using physiological indices. Given that the
habituation process involves first activating a fear response, a psychophysio-
logical assessment can be used to obtain objective markers of fear responding
or activation. Common physiological indicators include heart rate and skin
conductance, and these indicators allow for the opportunity to match a more
objective measure with the very subjective self-reported SUDS ratings. An
early investigation assessed heart rate and skin conductance during prolonged
exposure for patients with specific phobia and found evidence that habitua-
tion as assessed using these physiological markers occurred more quickly than
habituation as reported using SUDS (Watson, Gaind, & Marks, 1972). More-
over, habituation as measured by the physiological indices was more strongly
associated with clinical improvement. Recent advances in the assessment of
heart rate and skin conductance allow for real time monitoring and feedback
during all phases of exposure trials. Accordingly, the patient and therapist can
observe skin conductance and heart responses while the patient approaches
feared stimuli (e.g., using a sensor attached to two fingers with an interface
viewed using a tablet or iPad). Such calibration of the patient’s verbal reports
of negative affect can be a therapeutic intervention in itself by helping patients
change maladaptive all-or-none perceptions of negative affect to a more useful
continuum view.
258 Maples-Keller and Rauch

Clinical Symptoms

The impact of exposure therapy and habituation on clinical symptoms can be

measured using standard reliable and valid self-report and clinical interview
measures relevant to the specific fear- or anxiety-related disorder. Physio­
logical assessment has also been used as an outcome for exposure therapy for
anxiety disorders. A recent trial of prolonged exposure for PTSD measured
cortisol reactivity and startle response to fear stimuli immediately before and
after exposure therapy as markers of treatment response (Rothbaum et al.,
2014). Other studies use behavioral approach tests (BATs) to assess the effects
of exposure for specific phobias (e.g., Sloan & Telch, 2002). BATs involve a
series of tasks in which the patient gradually approaches a feared object. The
patient’s score on a BAT is associated with how close he or she can get to the
feared stimulus in question; SUDS and physiological response (e.g., skin con-
ductance, heart rate, galvanic skin response) might also be measured during
these tasks. The use of a BAT can be helpful in monitoring a patient’s progress
in an objective, observable manner as the degree of approach can be compared
from the beginning of treatment to after exposures have been completed.

EMPIRICAL SUPPORT

The association between within-session habituation and treatment response

has not received strong support in the empirical literature, as the former is
often not significantly correlated with treatment outcome (e.g., Baker et al.,
2010; Craske et al., 2008; van Minnen & Foa, 2006). Several studies, how-
ever, suggest that between-session habituation, or a greater reduction in
self-reported distress across exposure trials, is more strongly related to clinical
improvement. This association has been identified across many studies inves-
tigating exposure for PTSD. In a sample of female assault victims receiving
prolonged exposure, analysis of the average distress levels across six exposure
sessions identified a group of patients for whom high initial engagement and
gradual habituation was associated with greater symptom improvement com-
pared with two other groups who did not demonstrate habituation across
exposure sessions (Jaycox et al., 1998). In a sample of female assault survivors
receiving exposure for chronic PTSD, SUDS ratings decreased with repeated
exposure, and greater reductions between the first and last exposure session
were associated with better treatment outcomes (Rauch et al., 2004). This
association between SUDS reduction across exposure sessions and improved
PTSD treatment response was replicated in another sample of female sexual
assault survivors with PTSD (Gallagher & Resick, 2012). In a further study of
trauma survivors, patients who responded to exposure therapy evidenced
greater between-session habituation, and habituation between the first and
second exposure sessions was significantly associated with improved treatment
outcome (van Minnen & Hagenaars, 2002). Hierarchical linear modeling
using SUDS rating within imaginal exposure sessions found that treatment
 Habituation 259

responders demonstrated greater between-session habituation than did non-

responders, but there was no difference regarding within-session habituation
(Sripada & Rauch, 2015). Notably, within-session habituation shows a pattern
of slight increase which was unrelated to treatment outcome, suggesting that
maintaining a sustained level of fear activation during an individual exposure
represents appropriate activation and engagement.
Several studies have also provided evidence that between-session habitu-
ation is related to the beneficial effects of exposure therapy for anxiety dis­
orders other than PTSD. For example, in a sample of patients with OCD,
self-reported distress and physiological indicators (i.e., heart rate and skin
conductance) during exposures showed habituation across 15 sessions of
exposure, and greater between-session habituation was associated with
greater treatment response (Kozak et al., 1988). It is important to note, how-
ever, that other studies suggest successful treatment outcomes can occur in
the absence of between-session habituation (e.g., Lang & Craske, 2000; Pitman
et al., 1996; Rowe & Craske, 1998; see Craske et al., 2008, for a review). For
example, in a study of PTSD patients who received exposure therapy, 64.7%
of the sample did not demonstrate a reliable change in SUDS during imaginal
exposures, yet they still received treatment benefit (Bluett et al., 2014).
Therefore, between-session habituation might be a helpful, but not necessary,
condition for exposures to be effective in promoting recovery for anxiety-
related disorders.

TROUBLESHOOTING

In contrast to the tenets of the emotional processing theory of exposure

(e.g., Foa & Kozak, 1986), research indicates that anxiety reduction during
exposure is not a reliable predictor of treatment outcome (see Craske et al.,
2008). Moreover, clinicians should be aware that overreliance on habituation
as an indicator of improvement during exposure could have unintended
negative consequences. Emphasizing the importance of fear reduction during
exposure implies that anxiety itself is inherently bad and that treatment is
only successful if the patient’s anxiety has declined within or between sessions.
This may perpetuate a “fear of fear” mind-set and lead the patient to interpret
inevitable (and normal) unexpected surges of fear (either within or outside of
exposure trials) as signs of failure (e.g., Jacoby & Abramowitz, 2016). Anxious
patients conducting exposure from within a habituation model might also use
exposures to control their anxiety, approaching treatment with a mind-set
such as, “I know I can do this exposure because my anxiety will come down.”
Such a posture is contrary to the aim of confronting fear cues and learning
that anxiety and fear are normal and nonthreatening experiences. Although
decades of success with exposure from an emotional processing theory
perspective are well-documented (Abramowitz et al., 2019), the treatment
literature speaks primarily to relatively short-term outcomes (e.g., Olatunji,
260 Maples-Keller and Rauch

Davis, Powers, & Smits, 2013). Therefore, relatively little is known about the
extent to which emphasizing fear reduction attenuates longer term retention
of treatment gains.
It is also important to consider a patient’s willingness and readiness to
directly evoke negative affective states to produce habituation of fear. Although
clinicians often inappropriately exclude patients from exposure because of
mistaken beliefs about the risks of inducing (vs. minimizing) anxiety in-session
(e.g., Meyer, Farrell, Kemp, Blakey, & Deacon, 2014), research does indicate
that exposure may not be appropriate for patients with certain comorbid
symptoms (e.g., severe suicidality, self-injurious behaviors, homicidality, active
psychosis; Foa, Hembree, & Rothbaum, 2007). However, it is important to note
that overall evidence suggests that exposure-based treatments can be used
safely and effectively with many comorbidities (van Minnen, Harned, Zoellner,
& Mills, 2012), and in cases with more severe comorbidity concurrent treat-
ment may be ideal (e.g., co-occurring anxiety and substance abuse; Mills et al.,
2012). In other situations, exposure might be most effective if delivered after
co-occurring symptoms are addressed (e.g., de Bont, van Minnen, & de Jongh,
2013; Frueh et al., 2009).

CONCLUSION

Habituation, or the reduction in fear response over repeated exposures,

remains a key potential mechanism of change in exposure therapy for clinical
anxiety. While implementing exposures, it is important to ensure appropriate
engagement with exposure stimuli, monitor subjective ratings of fear during
and across repeated exposures, decrease use of cognitive and behavioral
avoidance strategies, and structure exposures with regards to length and
stimuli to maximize chances of habituation. The association between with-
in-session habituation and treatment response has not received strong sup-
port in the empirical literature, suggesting that habituation within a single
exposure is not necessary for clinical improvement. Whereas closely inter-
twined with extinction, between-session habituation, or greater reductions in
distress across exposure trials, is more consistently related to clinical improve-
ment. This suggests that anxiety reduction across exposures is an important
mechanism to monitor during exposure therapy.

REFERENCES
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for
anxiety: Principles and practice (2nd ed.). New York, NY: Guilford Press.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders, fifth edition. Washington, DC: Author.
Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010).
Does habituation matter? Emotional processing theory and exposure therapy for
acrophobia. Behaviour Research and Therapy, 48, 1139–1143. http://dx.doi.org/10.1016/
j.brat.2010.07.009
 Habituation 261

Barlow, D., & Craske, M. (1994). Mastery of your anxiety and panic. San Antonio, TX:
The Psychological Corporation.
Bluett, E. J., Zoellner, L. A., & Feeny, N. C. (2014). Does change in distress matter?
Mechanisms of change in prolonged exposure for PTSD. Journal of Behavior Therapy
and Experimental Psychiatry, 45, 97–104. http://dx.doi.org/10.1016/j.jbtep.2013.09.003
Bouton, M. E. (2004). Context and behavioral processes in extinction. Learning &
Memory, 11, 485–494. http://dx.doi.org/10.1101/lm.78804
Cassiday, K. L. (2015). Involving the family in treatment. In K. Ressler, D. S. Pine, &
B. O. Rothbaum (Eds.), Anxiety disorders: Translational perspectives on diagnosis and
treatment (pp. 95–104). New York, NY: Oxford University Press. http://dx.doi.org/
10.1093/med/9780199395125.003.0007
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24,
461–470. http://dx.doi.org/10.1016/0005-7967(86)90011-2
Cooper, A. A., Clifton, E. G., & Feeny, N. C. (2017). An empirical review of potential
mediators and mechanisms of prolonged exposure therapy. Clinical Psychology
Review, 56, 106–121. http://dx.doi.org/10.1016/j.cpr.2017.07.003
Craske, M. G., Antony, M. M., & Barlow, D. H. (1997). Mastery of your specific phobia,
therapist guide. San Antonio, TX: The Psychological Corporation.
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., &
Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour
Research and Therapy, 46, 5–27. http://dx.doi.org/10.1016/j.brat.2007.10.003
Craske, M. G., & Mystkowski, J. L. (2006). Exposure therapy and extinction: Clinical
studies. In M. Craske & D. Hermans (Eds.), Fear and learning: From basic processes to
clinical implications (pp. 217–233). Washington, DC: American Psychological Associ-
ation. http://dx.doi.org/10.1037/11474-011
Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for
anxiety disorders: A review of meta-analytic findings. Journal of Clinical Psychology,
60, 429–441. http://dx.doi.org/10.1002/jclp.10255
de Bont, P. A., van Minnen, A., & de Jongh, A. (2013). Treating PTSD in patients with
psychosis: A within-group controlled feasibility study examining the efficacy and
safety of evidence-based PE and EMDR protocols. Behavior Therapy, 44, 717–730.
http://dx.doi.org/10.1016/j.beth.2013.07.002
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences, therapist guide. New York, NY: Oxford
University Press. http://dx.doi.org/10.1093/med:psych/9780195308501.001.0001
Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update.
In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and
treatment (pp. 3–24). New York, NY: Guilford Press.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to cor­
rective information. Psychological Bulletin, 99, 20–35. http://dx.doi.org/10.1037/
0033-2909.99.1.20
Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape. New York, NY:
Guilford Press.
Foa, E. B., Steketee, G., Grayson, J. B., Turner, R. M., & Latimer, P. R. (1984). Deliberate
exposure and blocking of obsessive-compulsive rituals: Immediate and long-term
effects. Behavior Therapy, 15, 450–472. http://dx.doi.org/10.1016/S0005-7894(84)
80049-0
Frueh, B. C., Grubaugh, A. L., Cusack, K. J., Kimble, M. O., Elhai, J. D., & Knapp, R. G.
(2009). Exposure-based cognitive-behavioral treatment of PTSD in adults with
schizophrenia or schizoaffective disorder: A pilot study. Journal of Anxiety Disorders,
23, 665–675. http://dx.doi.org/10.1016/j.janxdis.2009.02.005
Gallagher, M. W., & Resick, P. A. (2012). Mechanisms of change in cognitive processing
therapy and prolonged exposure therapy for PTSD: Preliminary evidence for the
262 Maples-Keller and Rauch

differential effects of hopelessness and habituation. Cognitive Therapy and Research,

36, 750–755. http://dx.doi.org/10.1007/s10608-011-9423-6
Hembree, E. A., Rauch, S. A., & Foa, E. B. (2003). Beyond the manual: The insider’s
guide to prolonged exposure therapy for PTSD. Cognitive and Behavioral Practice, 10,
22–30. http://dx.doi.org/10.1016/S1077-7229(03)80005-6
Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety
disorders: A meta-analysis of randomized placebo-controlled trials. The Journal of
Clinical Psychiatry, 69, 621–632. http://dx.doi.org/10.4088/JCP.v69n0415
Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure
therapy: A critical review and translation to obsessive-compulsive disorder. Clinical
Psychology Review, 49, 28–40. http://dx.doi.org/10.1016/j.cpr.2016.07.001
Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of emotional engagement
and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical
Psychology, 66, 185–192. http://dx.doi.org/10.1037/0022-006X.66.1.185
Jonas, D. E., Cusack, K., Forneris, C. A., Wilkins, T. M., Sonis, J., Middleton, J. C., . . .
Olmsted, K. R. (2013). Psychological and pharmacological treatments for adults with
posttraumatic stress disorder (PTSD). Rockville, MD: Agency for Healthcare Research
and Quality. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK137702/
Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety
disorders: An update on the empirical evidence. Dialogues in Clinical Neuroscience, 17,
337–346.
Kozak, M. J., Foa, E. B., & Steketee, G. (1988). Process and outcome of exposure
treatment with obsessive-compulsives: Psychophysiological indicators of emotional
processing. Behavior Therapy, 19, 157–169. http://dx.doi.org/10.1016/S0005-7894(88)
80039-X
Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based therapy to
reduce return of fear: A replication. Behaviour Research and Therapy, 38, 1–12.
http://dx.doi.org/10.1016/S0005-7967(99)00031-5
Ledley, D. R., Foa, E. B., & Huppert, J. D. (2005). Comprehensive cognitive behavior
therapy for social phobia: A treatment manual. Retrieved from https://www.div12.org/
wp-content/uploads/2014/09/Comprehensive-CBT-for-Social-Phobia-manual.pdf
McSweeney, F. K., & Swindell, S. (2002). Common processes may contribute to
extinction and habituation. Journal of General Psychology, 129, 364–400. http://
dx.doi.org/10.1080/00221300209602103
Meyer, J. M., Farrell, N. R., Kemp, J. J., Blakey, S. M., & Deacon, B. J. (2014). Why do
clinicians exclude anxious clients from exposure therapy? Behaviour Research and
Therapy, 54, 49–53. http://dx.doi.org/10.1016/j.brat.2014.01.004
Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., . . . Ewer,
P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic
stress disorder and substance dependence: A randomized controlled trial. JAMA,
308, 690–699. http://dx.doi.org/10.1001/jama.2012.9071
Myers, K. M., & Davis, M. (2007). Mechanisms of fear extinction. Molecular Psychiatry,
12, 120–150. http://dx.doi.org/10.1038/sj.mp.4001939
Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. J. (2013). Cognitive-
behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment
outcome and moderators. Journal of Psychiatric Research, 47, 33–41. http://dx.doi.
org/10.1016/j.jpsychires.2012.08.020
Pavlov, I. P. (1927). Conditioned re?exes. An investigation of the physiological activity of the
cerebral cortex. London, England: Oxford University Press.
Pitman, R. K., Orr, S. P., Altman, B., Longpre, R. E., Poiré, R. E., Macklin, M. L., . . .
Steketee, G. S. (1996). Emotional processing and outcome of imaginal flooding
therapy in Vietnam veterans with chronic posttraumatic stress disorder. Comprehen-
sive Psychiatry, 37, 409–418. http://dx.doi.org/10.1016/S0010-440X(96)90024-3
 Habituation 263

Rauch, S. A., Foa, E. B., Furr, J. M., & Filip, J. C. (2004). Imagery vividness and
perceived anxious arousal in prolonged exposure treatment for PTSD. Journal of
Traumatic Stress, 17, 461–465. http://dx.doi.org/10.1007/s10960-004-5794-8
Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., . . .
Ressler, K. J. (2014). A randomized, double-blind evaluation of d-cycloserine or
alprazolam combined with virtual reality exposure therapy for posttraumatic stress
disorder in Iraq and Afghanistan War veterans. The American Journal of Psychiatry,
171, 640–648. http://dx.doi.org/10.1176/appi.ajp.2014.13121625
Rowe, M. K., & Craske, M. G. (1998). Effects of varied-stimulus exposure training on
fear reduction and return of fear. Behaviour Research and Therapy, 36, 719–734.
http://dx.doi.org/10.1016/S0005-7967(97)10017-1
Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided threat
reappraisal on fear reduction during exposure: An experimental investigation.
Behaviour Research and Therapy, 40, 235–251. http://dx.doi.org/10.1016/S0005-
7967(01)00007-9
Sripada, R. K., & Rauch, S. A. (2015). Between-session and within-session habituation
in prolonged exposure therapy for posttraumatic stress disorder: A hierarchical
linear modeling approach. Journal of Anxiety Disorders, 30, 81–87. http://dx.doi.org/
10.1016/j.janxdis.2015.01.002
Telch, M. J., Valentiner, D. P., Ilai, D., Young, P. R., Powers, M. B., & Smits, J. A. (2004).
Fear activation and distraction during the emotional processing of claustrophobic
fear. Journal of Behavior Therapy and Experimental Psychiatry, 35, 219–232. http://
dx.doi.org/10.1016/j.jbtep.2004.03.004
van den Hout, M. A., van der Molen, G. M., Griez, E., Lousberg, H., & Nansen, A. (1987).
Reduction of CO2-induced anxiety in patients with panic attacks after repeated CO2
exposure. The American Journal of Psychiatry, 144, 788–791. http://dx.doi.org/10.1176/
ajp.144.6.788
van Minnen, A., & Foa, E. B. (2006). The effect of imaginal exposure length on outcome
of treatment for PTSD. Journal of Traumatic Stress, 19, 427–438. http://dx.doi.org/
10.1002/jts.20146
van Minnen, A., & Hagenaars, M. (2002). Fear activation and habituation patterns
as early process predictors of response to prolonged exposure treatment in PTSD.
Journal of Traumatic Stress, 15, 359–367. http://dx.doi.org/10.1023/A:1020177023209
van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential
contraindications for prolonged exposure therapy for PTSD. European Journal of
Psychotraumatology, 3, 18805. http://dx.doi.org/10.3402/ejpt.v3i0.18805
Watson, J. P., Gaind, R., & Marks, I. M. (1972). Physiological habituation to continuous
phobic stimulation. Behaviour Research and Therapy, 10, 269–278. http://dx.doi.org/
10.1016/0005-7967(72)90043-5
15
Inhibitory Learning
Amy R. Sewart and Michelle G. Craske

Exposure, the repeated and systematic confrontation with feared stimuli, is a

central component of cognitive behavior therapy (CBT) for anxiety and threat-
related disorders. Meta-analyses of randomized controlled trials over the past
several decades have demonstrated very large effect sizes for exposure therapy
for anxiety disorders, whether alone or combined with coping strategies such
as cognitive reappraisal or breathing/relaxation training (Cuijpers, Cristea,
Karyotaki, Reijnders, & Huibers, 2016). However, although the majority of indi-
viduals improve within 10 to 20 weekly sessions of typical treatment trials,
only approximately 55% achieve normative functioning (Loerinc et al., 2015),
and a number experience a return of fear, defined as resurgence of fear from the
end of exposure therapy to follow-up testing with the same object that was
targeted during exposure therapy.
Over recent decades, our fundamental knowledge of basic fear learning
processes has significantly evolved and has offered an explanation for return
of fear and its malignant nature. These advancements offer important treat-
ment implications and call for clinicians and researchers to adopt an advanced
theoretical understanding of the mechanisms underlying exposure-based
treatments based in modern associative fear learning. Within the updated inhib-
itory learning model of exposure, extinction is posited to be the critical process
that results in long-term reductions of fear (Craske et al., 2008; Craske, Treanor,
Conway, Zbozinek, & Vervliet, 2014). Understanding the basic role of fear

http://dx.doi.org/10.1037/0000150-015
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
265
266 Sewart and Craske

extinction in exposure therapy requires a general grasp of fear conditioning

phenomena.
In Pavlovian fear conditioning, a neutral stimulus (conditional stimulus
[CS], e.g., a shape) is coupled with an aversive unconditional stimulus (US,
such as a shock or loud noise). Following a number of CS–US pairing trials
(shape → shock/noise), the presentation of the CS develops into a reliable
predictor of the US. As a result, when the CS is presented, it generates antic-
ipatory fear, or a conditional response (CR, such as eyeblink) that resembles
the unconditional threat response (UR) to the related US. These phenomena
can be translated to the real world, wherein clinically elevated anxiety can
become associated with fear-relevant situations and stimuli. As an example, a
young woman by the name of Taylor is taking a walk around her neighbor-
hood when—out of nowhere—she is attacked and bitten by a German
Shepherd. Taylor was previously unafraid of dogs, but after being bitten (US,
dog bite) Taylor begins to fear (CR) all dogs (CS) and to avoid public spaces in
which she may encounter them. This fear of dogs and its related avoidance
has caused Taylor clinically significant distress and impairment.
To reduce or eliminate the CR, the CS must now lessen its status as a pre-
dictor of the US. This is achieved by fear extinction, which involves repeatedly
presenting the CS without the US (CS–noUS, shape → / shock/noise). Impor-
tantly, the original CS–US relationship is not erased during extinction, but
rather, a secondary relationship wherein the CS no longer predicts the US
develops as a result of extinction. Under certain conditions, this CS–noUS
relationship can inhibit the original, excitatory nature of the CS–US relation-
ship (Bouton, 1993). In the previous dog bite example, Taylor’s fear of dogs is
extinguished by exposing her to dogs in the absence of being bitten (CS–
noUS). After systematically exposing Taylor to dogs, the notion of dogs being
predictive of dog bite is dampened by new, inhibitory learning that dogs are
not predictive of dog bite. This new, inhibitory learning has extinguished
Taylor’s fear of dogs.
The original excitatory CS–US association, however, can be uncovered in
several ways, including spontaneous recovery (Quirk, 2002)—the reemergence
of a previously extinguished conditioned response after a delay. For example,
after completion of exposure therapy, Taylor’s fear of dogs may return in a
seemingly inexplicable manner. Furthermore, because extinction learning is
limited by context, renewal of conditional fear may occur if the surrounding
context is changed between extinction and retest (i.e., context renewal; Bouton,
2002). This highlights the importance of context variability in exposure therapy,
discussed in further detail later in the chapter. Finally, reinstatement of condi-
tional fear occurs if unsignaled US presentations occur between extinction
and retest (Haaker, Golkar, Hermans, & Lonsdorf, 2014). Clinically translated,
adverse events following exposure therapy may lead to a return of fear of the
previously feared stimulus. Fourth, rapid reacquisition of the CR is seen if the
CS–US pairings are repeated following extinction (Ricker & Bouton, 1996), as
may occur in dangerous environments. In addition to offering an explanation
 Inhibitory Learning 267

for return of fear following exposure therapy, these processes suggest possible
pathways through which exposure therapy can be optimized to reduce the
return of fear (Craske et al., 2014).
Traditional, habituation-based models of exposure therapy (see Chapter 14)
posit that fear reduction during and between exposure trials is required for
lasting changes in the perceived harm associated with a given phobic stimulus.
Thus, habituation-based exposure approaches have focused on fear reduction
within and between sessions as an index of treatment response and success (e.g.,
Foa, Huppert, & Cahill, 2006; Foa & Kozak, 1986). How­ever, our understanding
of the role of fear reduction—or habituation—in exposure has also evolved with
advances in associative learning theory. The amount that fear has been reduced
by the end of an exposure trial or series of exposure trials is not a reliable pre-
dictor of the fear level expressed at follow-up assessment (Baker et al., 2010;
Culver, Stoyanova, & Craske, 2012; Kircanski et al., 2012; Meuret, Seidel,
Rosenfield, Hofmann, & Rosenfield, 2012). Similar results have been found in
laboratory paradigms with animals and human samples (Plendl & Wotjak, 2010;
Prenoveau, Craske, Liao, & Ornitz, 2013; Rescorla, 2006). To combat return of
fear, inhibitory learning models of exposure do not emphasize fear reduction
during exposure trials and instead focus on optimizing the strength and dura-
bility of the CS–noUS relationship that occurs during extinction learning.
Numerous strategies translated from basic fear learning research can be
implemented during exposure to enhance inhibitory learning. These methods
include enhancing inhibitory learning through (a) expectancy violation,
(b) removal of safety signals, (c) attentional focus, (d) deepened extinction,
(e) stimulus variability, (f) occasional reinforced extinction, and enhancing
retrieval of inhibitory learning via (g) multiple contexts and (h) retrieval cues.
This chapter focuses on ways to implement and capitalize on these strategies
within treatment to achieve superior extinction learning.

IMPLEMENTATION

Expectancy Violation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 2013), anxiety disorders are
associated with the overprediction of aversive, negative outcomes. For exam-
ple, an individual with social anxiety may expect with absolute certainty that
if they were to attend a social gathering they would be rejected by peers.
Similarly, someone with panic attacks may expect with high confidence that
experiencing a rapid heart rate will result in a heart attack. Enhancing extinc-
tion learning during exposure requires that exposure exercises be designed to
maximally violate an individual’s elevated expectancies regarding the fre-
quency or intensity of predicted, aversive outcomes (Davey, 1992; Rescorla &
Wagner, 1972). Based in learning theory, expectancy violation posits that the
268 Sewart and Craske

mismatch between expectation and outcome for a given situation is critical

for new learning (Rescorla & Wagner, 1972). Specifically, expectancy viola-
tion leads to the development of alternative inhibitory expectancies that will
compete with current excitatory expectancies. In other words, the more the
expectancy can be violated in a given exposure, the stronger the inhibitory
expectancies that compete with excitatory expectancies will be.
Exposure therapy based in inhibitory learning principles requires that
exposures be designed to accommodate what the patient “needs to learn”
regarding feared outcomes (Craske et al., 2008, 2014). This is in contrast to
traditional habituation-based exposures that focus on fear reduction within
or between exposure exercises or “staying in the situation until fear declines.”
Expectancy violation ties exposure parameters directly to consciously stated
expectancies for aversive events. Within this approach to exposure, CSs are
defined as physical sensations, situations and settings, objects, or thoughts
and images predictive of a defined feared outcome or US. For example, a
patient with panic attacks may predict that an elevated heart rate over 120 BPM
during a panic attack will cause them to faint and injure themselves. Here, the
patient has identified a panic-relevant CS—conditional stimulus—as having
an elevated heart rate and the US—unconditional stimulus—as injury from
fainting. Thus, an exposure exercise for this patient should be designed to
directly violate the patient’s expectancy of fainting and becoming injured
during a panic attack when their heart rate is elevated above 120 BPM. Clini-
cians can use the questions outlined in Table 15.1 to assess fear-relevant CSs.

TABLE 15.1. Questions for Assessing Expectancies of Conditional Stimuli

for Exposure Practices
Excitatory conditional stimuli Assessment question
Physical sensations What physical sensations make you think you are
more likely to experience [defined feared outcome]?
Situations and settings What situations or settings make you think you are
more likely to experience [defined feared outcome]?
Feared objects What objects make you think you are more likely to
experience [defined feared outcome]?
Feared thoughts/images What thoughts or images make you think you are
more likely to experience [defined feared outcome]?
Duration How long do you need to experience the feared physical
sensation, situation, object, or thought until you are
convinced [defined feared outcome] will occur?
Inhibitory conditional stimuli Assessment question
Safety thoughts or behaviors What are some behaviors you engage in to avoid
[defined feared outcome] or that make you think
[defined feared outcome] is less likely to occur?
Safety objects What are some objects that make you think [defined
feared outcome] is less likely to occur (e.g., cell
phone, anxiety pills)?
Safe places What are some places that make you think [defined
feared outcome] is less likely to occur?
Note. From the UCLA Anxiety and Depression Research Center. Reprinted with permission of
Jonathan S. Abramowitz and Shannon M. Blakey.
 Inhibitory Learning 269

Identified CSs should be confronted over the course of exposure therapy.

Table 15.2 provides an overview of the various methods to enhance inhibi-
tory learning that we discuss in this section.
To facilitate extinction learning, each exposure trial is focused on deter-
mining whether the expected negative outcome occurred or not, or was as
“bad” as expected (i.e., was manageable or not). Following each exposure,
learning is consolidated by asking participants to judge what they learned
regarding the nonoccurrence of the feared event, discrepancies between what
was predicted and what occurred, and the degree of surprise from the expo-
sure practice (Craske et al., 2014). The phrase “test it out” is helpful to intro-
duce to patients when providing rationale for expectancy violation.
The end of an exposure trial is determined by conditions that violate
expectancies. Furthermore, exposures are continued for the duration deter-
mined to violate expectancies most effectively. An individual with social anx-
iety may avoid one-on-one conversations for fear of rejection. To determine
the duration of a related exposure exercise, the therapist should assess with
the patient how long the patient needs to participate in a one-on-one conversa­
tion until they are convinced that rejection will occur. If the patient states with
certainty that rejection will occur after only 5 minutes of conversation, the
duration of the exposure practice should be constructed to last for more than
5 minutes to maximally violate this excitatory expectancy. Using an inhibi-
tory learning approach, graduated exposure may be used by clinicians to pro-
gressively modulate conditions in which the feared outcome is judged most
likely to occur. For example, one-on-one conversation exposure exercises for
social anxiety may be conducted at increasingly longer trials (e.g., 5 minutes,
10 minutes), regardless of the observed fear reduction, in an effort to further
violate expectancies and extinguish related fear. In several studies, failure to

TABLE 15.2. Strategies for Enhancing Inhibitory Learning

Strategy Description Catchphrase
Expectancy violation Design exposures to violate specific Test it out
expectations
Remove safety behaviors Decrease the use of safety signals and Throw it out
behaviors
Variability Vary stimuli and contexts Vary it up
Deepened extinction Present two cues during the same Combine it
exposure after conducting initial
extinction with at least one of them
Reinforced extinction Occasionally present the US during Face your fear
exposures
Variability Vary stimuli and contexts Vary it up
Attentional focus Maintain attention on the target CS Stay with it
during exposure
Mental reinstatement/ Use a cue present during extinction or Bring it back
retrieval cues imaginally reinstate previous successful
exposures
Note. US = unconditional stimulus; CS = conditional stimulus. From the UCLA Anxiety and Depression
Research Center. Reprinted with permission of Jonathan S. Abramowitz and Shannon M. Blakey.
270 Sewart and Craske

habituate throughout exposure therapy was not associated with poorer out-
comes (e.g., Culver et al., 2012; Kircanski et al., 2012; Lang & Craske, 2000).
For most anxiety-related disorders, it is indisputable that the defined neg-
ative outcome has not occurred during a given exposure exercise. For exam-
ple, an individual predicts that experiencing panic-related symptoms (e.g.,
rapid heartbeat) will result in a heart attack. Testing out whether or not a heart
attack will occur during an interoceptive exposure practice is straightforward.
Similarly, determining whether or not a dog-phobic individual is actually bit-
ten in the presence of a dog during an exposure exercise is a clear-cut experi-
mental test. However, certain feared outcomes may be loosely defined by
anxious patients. For example, socially anxious individuals fear being rejected
in social situations. Determining whether social rejection has occurred is more
ambiguous than assessing for other feared outcomes, so it is integral that the
therapist and patient together define the behavioral indicators that represent
social rejection. Rejection indicators to look for in in vivo exposures for feared
social encounters may include a furrowed brow, squinted eyes, eye rolling,
denying a request, and walking away from the patient. After operationalizing
social rejection, an individual with social anxiety is instructed by the therapist
to gather evidence for the presence of rejection by looking for these predefined
indicators of rejection during inter­personal exposure practices.
Another common loosely defined outcome for individuals is that they will
be unable to tolerate the distress (e.g., uncertainty, disgust, stress) associated
with an anxiety-provoking event. This feared outcome is common for indi-
viduals suffering from panic disorder, posttraumatic stress disorder, and
obsessive-compulsive disorder. Therefore, it is important that the expecta-
tions surrounding inability to tolerate distress be clearly defined. For exam-
ple, an individual completing imaginal exposure for trauma may expect that
stress from recounting a trauma may cause them to be unable to function for
the rest of the day or lose control. To test out this feared outcome, a therapist
should have a patient complete minor tasks immediately following a given
exposure to demonstrate that the patient is able to function in the face of dis-
tress. Exhibit 15.1 is a worksheet that can be used when designing and com-
pleting exposure practices as we describe in this section.
Given that extinction learning is enhanced by the mismatch between
expectancy and actual outcome, reducing expectancy prior to a given expo-
sure trial can have a negative impact on extinction learning. Common cogni-
tive restructuring practices designed to lessen probability overestimation (e.g.,
“I am unlikely to be bitten by the dog”) and perceived negative valence (e.g.,
“It is not so bad to be rejected”) may be deleterious to inhibitory learning
when employed prior to or during exposures (Craske et al., 2014). As a result,
cognitive restructuring conducted prior to or during exposure may negatively
impact exposure effectiveness. Therefore, clinicians practicing exposure from
an inhibitory approach should limit cognitive restructuring to the consolida-
tion phase following exposure therapy. However, it should be noted that expo-
sure in and of itself provides experiences that lead to less negative expectancies
 Inhibitory Learning 271

EXHIBIT 15.1

Inhibitory Learning Exposure Worksheet

What feared outcome am I most worried about? or What am I worried I will not be able
to tolerate?

How am I testing it out (Situations, Settings)?

Strategies for this Session (Check All That Apply):

£ What am I throwing out?

£ How will I stay with it?

£ How will I combine it?

£ How will I face it?

Put it all together: What is my “exposure”?

Prior to How likely is it that what I am most worried about will occur
Exposure: (0 = Not at All, 100 = Certain)?

Now Complete Exposure Practice

After Did what I was most worried about occur? Yes ____   No ____
Exposure:

How do I know?

What did I expect to happen as a result of doing the exposure? What

happened? Did that surprise me?

What did I learn?

Imagine I repeated the same exposure practice. How likely is it that what I was
most worried about before will occur this time (0 = Not at All, 100 = Certain)?
____

Note. From the UCLA Anxiety and Depression Research Center. Reprinted with permission of
Jonathan S. Abramowitz and Shannon M. Blakey.
272 Sewart and Craske

or appraisals. Although not directly addressed during exposure trials, mal-

adaptive cognitions regarding the probability and perceived negative valence
of anxiety-provoking events are modified through inhibitory learning result-
ing from direct exposure to the events themselves.

Removal of Safety Signals and Behaviors

To maximally violate feared outcome expectancies, safety signals and/or behav-

iors must be removed during exposure practices. Indicators of safety include
cell phones, another person, and anxiolytic medications, for example. Safety
signals predict the absence of the feared outcome, or US, making safety signals
conditional stimuli of negative predictive value, or conditional inhibitors (CS−).
Thus, when a safety signal (CS−) is presented in concert with a feared condi-
tional stimulus (CS+), the safety signal (CS−) is posited to reduce expectation of
the feared outcome (US; McConnell & Miller, 2010). Therefore, safety signals
are posited to interfere with extinction learning and the development of sec-
ondary inhibitory associations with the presented CS+. This protection-from-
extinction phenomenon in the presence of conditional inhibitors has been
reliably observed in animal studies (e.g., Rescorla, 2003). Similar to safety sig-
nals, safety behaviors are deployed by individuals to avoid excitatory CSs that
are predictive of a feared outcome. As a result, safety behaviors, such as
diverting attention, reduce the salience of excitatory stimuli and interfere
with extinction learning (see Troubleshooting for further information). Safety
signals and behaviors should be discontinued as soon as possible given that
their immediate removal will expedite the formation of inhibitory associations
for excitatory stimuli. However, if a patient is unwilling to discontinue use of
safety signals and behaviors at the beginning of exposure therapy, these can be
gradually phased out over the course of treatment (Hermans, Craske, Mineka,
& Lovibond, 2006).
To assess for safety behaviors and signals, the therapist can query the patient,
“What are some behaviors you engage in to avoid [defined feared outcome]
or that make you think [defined feared outcome] is less likely to occur?”
When explaining the rationale for safety signal and behavior removal during
exposure, clinicians can use the phrase “throw it out.” For example, consider
the following case example and its removal of safety signals and behaviors.
Cameron has been diagnosed with social anxiety disorder.1 Currently, Cameron only feels
comfortable being in group settings with his partner. He feels that being with his partner
in a group reduces the likelihood of being evaluated negatively by others. To increase
expectancy of rejection, Cameron and his therapist have agreed to Cameron’s attending a
friend’s party without the partner present. Cameron will look for behavioral indicators of
rejection while engaging in group conversation at the party. Cameron will also refrain
from using his cell phone during the practice, another safety behavior. Here, Cameron is
“throwing out” safety signals of his partner and cellphone.

All clinical case material has been altered to protect patient confidentiality.
1
 Inhibitory Learning 273

Attentional Focus

One of the critical variables in modern associative learning models is the atten-
tional salience of presented CSs (Rescorla & Wagner, 1972). Thus, within an
inhibitory learning approach to exposure, increased salience of the CS (e.g.,
conspicuous, attention-grabbing; Pearce & Hall, 1980) enhances extinction
learning. To optimize salience and subsequent extinction, directing a patient’s
attention to excitatory CSs during all exposures trials is critical. Given that dis-
traction is a common avoidant safety behavior, clinicians should encourage
patients to “throw out” any methods they commonly use to divert attention
away from elements of the exposure stimulus in an effort to reduce anxiety
(see Troubleshooting). For example, as a safety behavior, an individual with
social anxiety may avoid making eye contact during social interactions, which
results in reduced attentional salience of the nonoccurrence of behaviors that
violate his feared outcome prediction (e.g., eye rolling). Furthermore, inhibi-
tory stimuli, specifically safety objects, may compete for attention from the
patient, thereby reducing sustained attention directed toward excitatory stimuli
present in a given exposure trial and interfering with extinction learning. Sim-
ilar effects are observed when two highly salient excitatory stimuli are pre-
sented at the same time during a given trial (i.e., overshadowing; cf. Cook &
Mineka, 1987). Considerations for presenting multiple stimuli at the same time
in an exposure trial are outlined in the Deepened Extinction section. The phrase
“stay with it” may be used to convey the rationale behind attentional salience.

Deepened Extinction

Extinction learning may also be enhanced through the simultaneous presenta-

tion of multiple feared stimuli during exposure therapy, resulting in a deepened
extinction of conditioned fear. This strategy is achieved by (a) extinguishing the
conditional fear response for each feared stimulus in isolation, followed by
(b) simultaneous presentation of the stimuli during subsequent exposures.
Deepened extinction may also occur by pairing an extinguished fear cue with
a feared stimulus that has not been previously presented. When two feared
stimuli are eventually presented together, expectation that the feared outcome
will occur is intensified. With expectancy elevated, there is a greater mismatch
between predicted and actual outcome and further extinction learning. Wher-
ever possible, clinicians should combine multiple feared stimuli during exposure
after conducting some exposure to each cue, or one cue, in isolation. To deepen
extinction learning, it is integral that the chosen feared stimuli predict the same
feared outcome or unconditional stimulus—US. Clinicians should draw atten-
tion to the increase in expectancy when presenting concurrent excitatory stim-
uli and its subsequent violation. The phrase “combine it” may be used by
clinicians to describe the principle of deepened extinction to patients. Consider
the following case example and its implementation of the deepened extinction
strategy.
Joel has been diagnosed with panic disorder. He is fearful that experiencing panic-related
sensations, specifically lightheadedness and hyperventilation, will result in experiencing a
274 Sewart and Craske

stroke. Joel has completed exposures for fear of light-headedness with chair spinning exer-
cises and confronted the fear of shortness of breath through straw breathing exercises.
Joel’s therapist may choose to deepen extinction learning by having Joel complete straw
breathing exercises while spinning in a chair.

Stimulus Variability

Research indicates that variable practice enhances the capacity for new learning
(Bjork & Bjork, 1992, 2006). Variation results in effortful encoding of learning
resulting from exposure trials and gives rise to a schema that may be applied
across a range of fear-provoking situations (Bjork & Bjork, 1992). Importantly,
varied practice has been shown to increase the array of associated cues that
may be present during retrieval (Estes, 1955), making inhibitory associations
of CSs more accessible at a later time. The following example highlights the
importance of stimulus variability during exposure.
Logan presents for treatment of his fear of spiders. To extinguish his fear, Logan’s therapist
conducts multiple exposure trials with the same large tarantula. Logan now reports that
his fear of spiders and avoidance of places where he may encounter a spider has disap-
peared. He and his therapist then terminate treatment. Months later, while hiking, Logan
walks into a golden banana spider’s web. Logan’s fear and avoidance of spiders return.

In this example, when hiking, Logan was unable to access the inhibitory
associations he had developed with his therapist months earlier. This return
of fear is likely due to the fact that inhibitory learning was confined to a
specific type of spider, rather than extended to a general schema of spiders.
Developing multiple retrieval cues and a general inhibitory rule relating to
spiders requires that Logan be exposed to multiple spider types with varying
features.
Variability in exposures can also be applied to exposure duration, timing of
exposures, levels of emotional intensity, and expectancy levels. This approach
is in contrast to moving through exposures in a stepped, hierarchical fashion.
Emphasizing variability has been shown to attenuate fear renewal and result
in superior outcomes at follow-up (e.g., Kircanski et al., 2012; Rowe & Craske,
1998; Tsao & Craske, 2000). “Change it up” is a helpful phrase for presenting
the rationale behind stimulus variability.

Multiple Contexts

Fear may also return when a phobic stimulus is encountered in an environment

that is different from the extinction or exposure context, resulting in context
renewal (Mineka, Mystkowski, Hladek, & Rodriguez, 1999; Mystkowski, Craske,
& Echiverri, 2002; Rodriguez et al., 2004). To buffer from context renewal and
enhance retrievability of inhibitory learning, exposures should be conducted in
multiple different contexts. Variation in contexts during exposure includes con-
ducting exposure in multiple locations, at varying times of day, in unfamiliar
places, and both alone and with a therapist.
 Inhibitory Learning 275

Occasional Reinforced Extinction

Evidence suggests that extinction can be enhanced by occasional paired pre-

sentations (CS–US) of the unconditional stimulus (US) and conditional stim-
ulus (CS) during extinction training (e.g., shape → noise; Bouton, Woods, &
Pineño, 2004). Occasional reinforced extinction is thought to result in an increase
in the salience of the CS or an increase in expectancy during subsequent
extinction trials (see Craske et al., 2014, for more details). Regardless of the
mechanism, occasional reinforced extinction results in attenuated, subsequent
reacquisition of fear in animals and humans (Bouton et al., 2004; Culver,
Stevens, Fanselow, & Craske, 2018).
Translated to clinical applications, extinction learning during exposure
therapy may be enhanced by occasionally presenting conditional stimuli
with the corresponding predicted feared outcome. For example, social anxiety
exposures may include the occasional presentation of social rejection, and
exposures for panic disorder may involve inducing intense physiological sen-
sations that increase the anticipation of a panic attack. Rapid reacquisition of
fear is most probable for presentations of anxiety in which the individual
might experience repeated aversive outcomes after treatment, such as social
rejection or panic. As a result, planning for occasional reinforced exposure
practices may be most beneficial in the treatment of social anxiety and panic
attacks. Occasional reinforcement may not always be appropriate, and cer-
tainly not when the aversive outcome may cause undue harm to an individ-
ual. As examples, it would clearly not be ethical to reexpose an individual
with posttraumatic stress symptoms to a traumatic experience or to expose
someone with a fear of snakes to an actual snake bite. Furthermore, occa-
sional reinforced extinction should be employed during the later phase of
treatment. When explaining the rationale to patients, we find the phrase “face
your fear” helpful for occasional reinforced extinction.

Retrieval Cues

Given that extinction learning is highly context dependent, the addition of

retrieval cues may also assist with accessing extinction learning after exposure
in completed. Posited to buffer individuals from deleterious context renewal,
a retrieval cue, such as a wristband or mental reinstatement (i.e., cognitive
exercises that retrieve the memory of previous extinction learning; see
Mystkowski, Craske, Echiverri, & Labus, 2006, for details), can be used in
different, unfamiliar contexts once therapy is completed (Brooks & Bouton,
1994; Dibbets & Maes, 2011; Vansteenwegen et al., 2006). Given that retrieval
cues may reduce expectancy during an exposure trial in a new context, they
should be used as a relapse prevention strategy prior to termination of therapy.
Of note, retrieval cues may acquire an inhibitory value and, as a result, become
safety signals (Dibbets, Havermans, & Arntz, 2008). The distinct difference
between retrieval cues and safety signals, however, is that retrieval cues act
276 Sewart and Craske

to retrieve inhibitory learning, whereas safety signals possess a direct associa-

tive relationship with the nonoccurrence of a given feared outcome (Craske
et al., 2014). For example, a therapist’s office where previous exposure ses-
sions had taken place can act as a retrieval cue for a new exposure, whereas
benzodiazepines (e.g., in the case of panic disorder) can act as a safety signal.
The process of developing retrieval cues with patients should be used spar-
ingly to mitigate the likelihood of retrieval cues becoming safety signals.
Using the phrase “bring it back” has been helpful in explaining this rationale.
Retrieval cues should be introduced as a relapse prevention strategy toward
the end of exposure therapy. The following is an example of how to explain
the process of mental reinstatement as retrieval cue for a patient with panic
disorder.
Although we’ve conducted many exposure practices over the course of treatment, we may
not be able to completely and permanently overpower the original fear associations that
led to your developing panic attacks. Over time, you may forget the new learning that was
formed during treatment, which can put you at risk for a return of fear. However, we
have a strategy that can help our brains remember our new learning and buffer us from
lapsing back into fear. To help our brains remember our new learning and override our
original fear associations, we can vividly recall an exposure practice that went well.
Think of one of our exposure practices that went especially well. I’d like you to recall this
as vividly as you can . . . the situation . . . the outcome. I’d like you to practice “bringing
it back” three times over the next week prior to conducting an exposure exercise. It is
important that we not rely on this as a safety behavior, though, so we don’t want to do
this every time we do an exposure.

OUTCOME INDICATORS

Given that fear expression during exposure is (a) incommensurate with fear
learning (see Craske et al., 2008) and (b) an unreliable predictor of treatment
outcomes, fear reduction (generally measured by subjective units of distress)
between and within sessions should not be used as an index of inhibitory
learning. Rather, expectancy ratings and their reduction pre- to postexposure
and across exposure trials with the same CSs provide a more appropriate
index of the potential for expectancy violation and extinction learning. Prior
to exposure, patients should give an expectancy rating for a given feared out-
come on a 0-to-100-point scale, where 0 represents the belief that the feared
outcome is not at all likely to happen and 100 is entirely certain the feared outcome
will happen. This rating can be assessed by asking the question “How likely is
it that what I am/you are most worried about will occur?” Using the same
rating anchors, the postexposure expectancy level can also be assessed by
asking, “Imagine you repeated the same exposure practice. How likely is it
that what I was/you were most worried about before will occur this time?”
Self-reported expectancy ratings may not provide a complete representa-
tion of achieved extinction learning during exposure therapy. Additional
measurement methods need to be developed and adopted for a more accurate
index of inhibitory learning that will aid therapists in clinical decision making.
 Inhibitory Learning 277

Personalized implicit association tests administered during treatment are a

promising avenue in the of assessment of inhibitory learning (see Vasey,
Harbaugh, Buffington, Jones, & Fazio, 2012). Such implicit measures may
provide less biased measures of extinction learning by removing demand char-
acteristics that exist in therapeutic settings and may influence self-reported
expectancies.

EMPIRICAL SUPPORT

Emphasizing expectancy violation in exposure therapy has demonstrated sim-

ilar to superior outcomes when compared with traditional habituation-based
approaches. For example, exposure durations that exceeded expectancies for
the timing of an aversive outcome in individuals with acrophobia (i.e., specific
phobia of heights) were as effective as standard exposure therapy, even though
exposure was conducted over many fewer exposure trials (i.e., repeated trials
of exposure each day vs. one trial of exposure per 2 days; Baker et al., 2010).
For individuals with elevated anxiety sensitivity, intensive interoceptive expo-
sure that was continued until a patient’s expectancy for a given feared outcome
reached less than 5% outperformed standard interoceptive exposure on vari-
ous outcome measures (Deacon et al., 2013). Of note, one significant limitation
of this study was that the “intensive” group received more trials of exposure,
making it unclear how total duration of exposure, rather than expectancy vio-
lation, affected outcome. Currently, the expectancy violation approach is pri-
marily supported by a substantial body of basic experimental findings (e.g.,
Rescorla & Wagner, 1972; see Craske et al., 2014, for a review).
Other methods employed during exposure trials aimed at optimizing
extinction learning are largely supported by experimental laboratory studies.
Deepened extinction has been shown to reduce spontaneous recovery and
reinstatement of fear in animals (Rescorla, 2006) and humans (Culver, Vervliet,
& Craske, 2015). Similarly, occasional reinforcement during extinction was
found to attenuate subsequent reacquisition of fear in both animal (Bouton
et al., 2004) and human studies (Culver et al., 2018). The strategy of variability
has been directly applied to exposure and examined in fearful samples with
promising results. In spider-phobic individuals, variability of timing between
exposure sessions and of the stimulus itself led to superior outcomes when
compared with nonvariable massed exposure (Lang & Craske, 2000; Rowe &
Craske, 1998; Tsao & Craske, 2000), although a study of contaminant anxiety
showed results only at the trend level (Kircanski et al., 2012).
Findings regarding removal of safety behaviors and signals are less consis-
tent than findings regarding other methods of optimizing extinction learning
(for an inhibitory-learning-based review, see Blakey & Abramowitz, 2016). In
clinical samples, the availability and use of safety signals and behaviors have
been shown to be detrimental to exposure therapy (Sloan & Telch, 2002).
Providing instructions to refrain from using safety behaviors has also been
shown to improve outcomes (Salkovskis, 1991). However, recent data suggest
278 Sewart and Craske

contradictory findings (Rachman, Shafran, Radomsky, & Zysk, 2011). Specif-

ically, the use of hygienic wipes following exposures for individuals with con-
tamination fears did not lead to any more spontaneous recovery of fear or
disgust than exposure without hygienic wipes. Similarly, continuing to engage
in safety behaviors, or having them available for use, was not observed to
affect outcomes deleteriously (Deacon, Sy, Lickel, & Nelson, 2010; Sy, Dixon,
Lickel, Nelson, & Deacon, 2011). Inconsistent results may be accounted for by
differences in the ratio of safety signal inhibition and excitatory stimuli within
exposure trials and across studies (see Craske et al., 2014, for a more detailed
explanation). Although these results are currently inconsistent, the general
consensus remains that safety signals and behaviors should be removed sys-
tematically over the course of exposure therapy (Hermans et al., 2006).
Strategies that increase retrievability of extinction learning possess less
consistent results than strategies that enhance extinction learning. Multiple
contexts have been shown to offset context renewal in human laboratory
studies (e.g., Balooch & Neumann, 2011; Balooch, Neumann, & Boschen,
2012) and in a clinical analog study of exposure therapy (Vansteenwegen
et al., 2007). However, one conditioning study with rodents (Bouton, García-
Gutiérrez, Zilski, & Moody, 2006) and another conditioning study with humans
(Neumann, Lipp, & Cory, 2007) failed to demonstrate detectable benefits of
multiple contexts throughout extinction on context renewal, suggesting that
the effects may be unstable. Similarly inconsistent results have been observed
regarding retrieval cues. Mental reinstatement of prior extinction learning
was demonstrated to limit context renewal in spider-phobic individuals
(Mystkowski et al., 2006). The effects of retrieval cues, such as distinctive pen
and clipboard, were found to be very weak in one study for public-speaking-
phobic individuals (Culver, Stoyanova, & Craske, 2011).
In sum, findings from basic research and treatment studies largely support
methods that enhance inhibitory learning (e.g., deepened extinction, occa-
sional reinforcement). Strategies that are geared toward enhancing retrieval
of extinction learning currently show inconsistent results in a limited number
of studies. Overall, additional translational research in clinical samples is nec-
essary to examine the extent to which inhibitory learning-based exposure
strategies enhance treatment outcomes or outperform traditional habituation-
focused exposure therapy.

TROUBLESHOOTING

Avoidance

Individuals with anxiety disorders tend to engage in excessive avoidance

behavior, resulting in limited experiences with situations, stimuli, or sensa-
tions that they perceive as threatening. As a result, avoidance prevents learn-
ing that feared stimuli are actually safe (i.e., inhibitory associations, fear
extinction; Craske, Hermans, & Vervliet, 2018). For these reasons, exposure
 Inhibitory Learning 279

treatments are designed to help the patient approach situations that have been
avoided. Patients are likely to engage in avoidance behaviors during exposure
treatment, resulting in an insufficient response or nonresponse to exposure
therapy.
Avoidance of feared stimuli during exposure therapy may be conspicuous
and easily identified by the therapist. Most commonly, patients engaging in
avoidance return to session with unfinished exposure assignments. Similarly,
to reduce the likelihood of a given feared outcome, patients engaging in avoid-
ance may only partially complete exposure assignments. For example, a patient
with panic disorder may be absolutely certain that hyperventilating for 1 minute
will result in a stroke. To violate this expectation, the patient’s therapist assigns
the patient to hyperventilate in 15-second intervals for 2 minutes as a take-
home exposure assignment. The patient returns next session reporting that they
completed the assignment but were able to hyperventilate for only 45 seconds.
In this example, the avoidance has reduced the potency of the learning expe-
rience because the patient did not exceed the duration that was defined to
result in a stroke (i.e., 1 minute). As a result, the patient’s new inhibitory
associations formed from the exposure were restricted and extinction learn-
ing suboptimal when compared with the initial planned exposure.
Patients may also engage in discreet avoidance or escape behaviors during
a given exposure trial. These behaviors may not be as easily observed and
therefore require therapists to watch attentively for their potential interfer-
ence. A common inconspicuous avoidance behavior often shown by patients
with anxiety disorders during an exposure is shifting attention away from
feared stimuli. In the absence of engagement with a feared stimulus, an indi-
vidual is likely to not notice whether or not the negative event they expected
even occurred. Unquestionably, this behavior compromises the development
of new inhibitory learning. Several studies in anxious adults have shown that
individuals who selectively attend toward threat (e.g., Price, Mehta, Tone, &
Anderson, 2011) or demonstrate greater difficulty disengaging from threaten-
ing stimuli (Barry, Sewart, Arch, & Craske, 2015) in laboratory tasks prior to
CBT show greater improvement of symptoms when compared to those who
show no bias or avoid threat.
For example, individuals with severe social anxiety may avoid eye contact
with other individuals as a safety behavior. As aforementioned, abstaining
from eye contact with others allows socially anxious persons to avoid salient
behavioral indicators of rejection, such as squinted eyes or a furrowed brow,
and may reduce distress associated with the event—which is likely to have an
added predictive value of rejection (e.g., “If I make eye contact, I will see
someone is judging me, which will make me anxious. This anxiety will lead
me to blush and stutter during the conversation. If I blush and stutter, people
will think I’m weird and reject me”). Thus, expectancy violation is limited
during an exposure in which avoidance of eye contact is employed by a
socially anxious patient. Individuals with specific phobia are likely to avoid
looking directly at phobic stimuli. Similarly, persons with panic disorder may
avoid internal physiological sensations related to panic by shifting their atten-
tion to other stimuli, internal or external.
280 Sewart and Craske

If a patient does not report reductions in expectancies for feared outcomes

during the course of treatment, avoidance may partially account for observed
treatment stagnation. Therefore, it is essential that therapists practicing expo-
sure from an inhibitory learning perspective provide substantial psychoedu-
cation on the role of avoidance in anxiety disorders. Together, therapists and
patients should identify pernicious avoidance behaviors at the first session and
continually monitor for their occurrence over the course of treatment. Fur-
thermore, therapists should constantly monitor for unidentified avoidance
behaviors that may reduce expectancy and interfere with new learning.
When new avoidance behaviors are identified, therapist and patient should
discuss how to monitor, reduce, and eliminate their future occurrence.
After the conclusion of exposure therapy, the return of previously extin-
guished fear responses is not uncommon. However, return of fear posttreat-
ment is problematic only when accompanied by escape or avoidance
behaviors. Return of fear itself is a transient state with limited clinical impli-
cations (Craske et al., 2018). In the absence of escape or avoidance, return of
fear is followed by additional experience that provides extinction learning
and eventual fear reduction. Prior to the conclusion of exposure therapy,
therapists should highlight the inevitability of residual anxiety and stress to
patients that continued exposure practice to feared stimuli following treat-
ment is essential in maintaining treatment gains.

Integration of Family Members

For anxious patients, family members or significant others may inadvertently

reinforce avoidance behaviors and, as a result, interfere with extinction learn-
ing. Aiding in avoidance is an understandable solution that reduces signifi-
cant anxiety from a family member’s or significant other’s perspective. Seeing
an anxious loved one in distress urges individuals to engage in and reinforce
behaviors that reduce the loved one’s negative outcome expectancies. How-
ever, an individual facilitating reduction of expectancy may acquire an inhib-
itory value and develop into a safety signal. If family members and significant
others are aiding in avoidance behaviors, therapists should incorporate
removal of these behaviors into exposure practices. Therapists should encour-
age patients to discuss the rationale for safety behavior removal with loved
ones. If loved ones continue to reinforce safety behaviors during treatment, it
may be beneficial to request that they attend a limited number of sessions so
that therapists may directly provide further treatment rationale and psycho-
education on anxiety disorders.

CONCLUSION

Advances in research on associative fear learning suggest that extinction learn-

ing, achieved through repeated presentation of a given CS without the US
(i.e., CS–noUS), is likely a critical mechanism underlying exposure therapy
 Inhibitory Learning 281

(Craske et al., 2008, 2014; Rescorla & Wagner, 1972). Development of CS–
noUS associations must occur to inhibit—not erase—existing excitatory asso-
ciations (CS–US) that are responsible for maladaptive fear responding and
anxiety (CR). To maximize treatment outcomes and maintain long-term
gains, this theoretical understanding of exposure therapy requires clinicians
to emphasize therapeutic strategies that increase inhibitory learning. Such
strategies translated from basic associative learning theory include expec-
tancy violation, immediate removal of safety behaviors and signals, stimulus
variability and multiple contexts, deepened extinction, attentional focus,
occasional reinforced extinction when appropriate, and retrieval cues. Inhib-
itory learning-focused strategies are distinct from traditional, habituation-
based exposure practices that aim to decrease fear responding (e.g., staying in
a situation until fear sufficiently declines). Evidence supporting inhibitory
learning-based exposure strategies is currently limited, and further research
is warranted to determine the extent to which inhibitory learning-based
exposure strategies enhance treatment outcomes or outperform traditional
habituation-focused exposure therapy. Overall, the translation of inhibitory
learning principles into exposure therapy is an exciting and critical step for-
ward toward science-driven practice.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Washington, DC: Author.
Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010).
Does habituation matter? Emotional processing theory and exposure therapy for
acrophobia. Behaviour Research and Therapy, 48, 1139–1143. http://dx.doi.org/10.1016/
j.brat.2010.07.009
Balooch, S. B., & Neumann, D. L. (2011). Effects of multiple contexts and context sim-
ilarity on the renewal of extinguished conditioned behaviour in an ABA design
with humans. Learning and Motivation, 42, 53–63. http://dx.doi.org/10.1016/
j.lmot.2010.08.008
Balooch, S. B., Neumann, D. L., & Boschen, M. J. (2012). Extinction treatment in mul-
tiple contexts attenuates ABC renewal in humans. Behaviour Research and Therapy,
50, 604–609. http://dx.doi.org/10.1016/j.brat.2012.06.003
Barry, T. J., Sewart, A. R., Arch, J. J., & Craske, M. G. (2015). Deficits in disengaging
attention from threat predict improved response to cognitive behavioral therapy for
anxiety. Depression and Anxiety, 32, 892–899. http://dx.doi.org/10.1002/da.22421
Bjork, R. A., & Bjork, E. L. (1992). A new theory of disuse and an old theory of
stimulus fluctuation. In A. Healy, S. Kosslyn, & R. Shiffrin (Eds.), From learning pro-
cesses to cognitive processes: Essays in honor of William K. Estes (pp. 35–67). Hillsdale,
NJ: Erlbaum.
Bjork, R. A., & Bjork, E. L. (2006). Optimizing treatment and instruction: Implications
of a new theory of disuse. In L. G. Nilsson & N. Ohta (Eds.), Memory and society: Psy-
chological perspectives (pp. 109–133). New York, NY: Psychology Press.
Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during expo-
sure therapy for anxiety: Critical analysis from an inhibitory learning perspective.
Clinical Psychology Review, 49, 1–15. http://dx.doi.org/10.1016/j.cpr.2016.07.002
Bouton, M. E. (1993). Context, time, and memory retrieval in the interference para-
digms of Pavlovian learning. Psychological Bulletin, 114(1), 80.
282 Sewart and Craske

Bouton, M. E. (2002). Context, ambiguity, and unlearning: Sources of relapse after

behavioral extinction. Biological Psychiatry, 52, 976–986. http://dx.doi.org/10.1016/
S0006-3223(02)01546-9
Bouton, M. E., García-Gutiérrez, A., Zilski, J., & Moody, E. W. (2006). Extinction in mul-
tiple contexts does not necessarily make extinction less vulnerable to relapse. Behaviour
Research and Therapy, 44, 983–994. http://dx.doi.org/10.1016/j.brat.2005.07.007
Bouton, M. E., Woods, A. M., & Pineño, O. (2004). Occasional reinforced trials during
extinction can slow the rate of rapid reacquisition. Learning and Motivation, 35,
371–390. http://dx.doi.org/10.1016/j.lmot.2004.05.001
Brooks, D. C., & Bouton, M. E. (1994). A retrieval cue for extinction attenuates
response recovery (renewal) caused by a return to the conditioning context. Journal
of Experimental Psychology: Animal Behavior Processes, 20, 366–379. http://dx.doi.org/
10.1037/0097-7403.20.4.366
Cook, M., & Mineka, S. (1987). Second-order conditioning and overshadowing in the
observational conditioning of fear in monkeys. Behaviour Research and Therapy, 25,
349–364. http://dx.doi.org/10.1016/0005-7967(87)90013-1
Craske, M. G., Hermans, D., & Vervliet, B. (2018). State-of-the-art and future direc-
tions for extinction as a translational model for fear and anxiety. Philosophical Trans-
actions of the Royal Society Series B. Biological Sciences, 373(1742), 20170025. http://
dx.doi.org/10.1098/rstb.2017.0025
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A.
(2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research
and Therapy, 46, 5–27. http://dx.doi.org/10.1016/j.brat.2007.10.003
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maxi-
mizing exposure therapy: An inhibitory learning approach. Behaviour Research and
Therapy, 58, 10–23. http://dx.doi.org/10.1016/j.brat.2014.04.006
Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2016). How
effective are cognitive behavior therapies for major depression and anxiety dis­
orders? A meta-analytic update of the evidence. World Psychiatry, 15, 245–258.
http://dx.doi.org/10.1002/wps.20346
Culver, N. C., Stevens, S., Fanselow, M. S., & Craske, M. G. (2018). Building physio­
logical toughness: Some aversive events during extinction may attenuate return
of fear. Journal of Behavior Therapy and Experimental Psychiatry, 58, 18–28. http://
dx.doi.org/10.1016/j.jbtep.2017.07.003
Culver, N. C., Stoyanova, M., & Craske, M. G. (2011). Clinical relevance of retrieval
cues for attenuating context renewal of fear. Journal of Anxiety Disorders, 25, 284–292.
http://dx.doi.org/10.1016/j.janxdis.2010.10.002
Culver, N. C., Stoyanova, M., & Craske, M. G. (2012). Emotional variability and sus-
tained arousal during exposure. Journal of Behavior Therapy and Experimental Psychi-
atry, 43, 787–793. http://dx.doi.org/10.1016/j.jbtep.2011.10.009
Culver, N. C., Vervliet, B., & Craske, M. G. (2015). Compound extinction: Using
the Rescorla–Wagner model to maximize exposure therapy effects for anxiety
disorders. Clinical Psychological Science, 3, 335–348. http://dx.doi.org/10.1177/
2167702614542103
Davey, G. C. (1992). Classical conditioning and the acquisition of human fears and
phobias: A review and synthesis of the literature. Advances in Behaviour Research
and Therapy, 14, 29–66. http://dx.doi.org/10.1016/0146-6402(92)90010-L
Deacon, B., Kemp, J. J., Dixon, L. J., Sy, J. T., Farrell, N. R., & Zhang, A. R. (2013).
Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learn-
ing: A randomized controlled trial. Behaviour Research and Therapy, 51, 588–596.
http://dx.doi.org/10.1016/j.brat.2013.06.006
 Inhibitory Learning 283

Deacon, B. J., Sy, J. T., Lickel, J. J., & Nelson, E. A. (2010). Does the judicious use of
safety behaviors improve the efficacy and acceptability of exposure therapy for
claustrophobic fear? Journal of Behavior Therapy and Experimental Psychiatry, 41,
71–80. http://dx.doi.org/10.1016/j.jbtep.2009.10.004
Dibbets, P., Havermans, R., & Arntz, A. (2008). All we need is a cue to remember:
The effect of an extinction cue on renewal. Behaviour Research and Therapy, 46,
1070–1077. http://dx.doi.org/10.1016/j.brat.2008.05.007
Dibbets, P., & Maes, J. H. (2011). The effect of an extinction cue on ABA-renewal: Does
valence matter? Learning and Motivation, 42, 133–144. http://dx.doi.org/10.1016/
j.lmot.2010.12.003
Estes, W. K. (1955). Statistical theory of distributional phenomena in learning. Psycho-
logical Review, 62, 369–377. http://dx.doi.org/10.1037/h0046888
Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An
update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology
and treatment (pp. 3–24). New York, NY: Guilford Press.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to cor­
rective information. Psychological Bulletin, 99, 20–35. http://dx.doi.org/10.1037/
0033-2909.99.1.20
Haaker, J., Golkar, A., Hermans, D., & Lonsdorf, T. B. (2014). A review on human rein-
statement studies: An overview and methodological challenges. Learning & Memory,
21, 424–440. http://dx.doi.org/10.1101/lm.036053.114
Hermans, D., Craske, M. G., Mineka, S., & Lovibond, P. F. (2006). Extinction in human
fear conditioning. Biological Psychiatry, 60, 361–368. http://dx.doi.org/10.1016/
j.biopsych.2005.10.006
Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., &
Craske, M. G. (2012). Challenges to the traditional exposure paradigm: Variability
in exposure therapy for contamination fears. Journal of Behavior Therapy and Experi-
mental Psychiatry, 43, 745–751. http://dx.doi.org/10.1016/j.jbtep.2011.10.010
Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based therapy to
reduce return of fear: A replication. Behaviour Research and Therapy, 38, 1–12. http://
dx.doi.org/10.1016/S0005-7967(99)00031-5
Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., & Craske, M. G.
(2015). Response rates for CBT for anxiety disorders: Need for standardized criteria.
Clinical Psychology Review, 42, 72–82. http://dx.doi.org/10.1016/j.cpr.2015.08.004
McConnell, B. L., & Miller, R. R. (2010). Protection from extinction provided by a
conditioned inhibitor. Learning & Behavior, 38, 68–79. http://dx.doi.org/10.3758/
LB.38.1.68
Meuret, A. E., Seidel, A., Rosenfield, B., Hofmann, S. G., & Rosenfield, D. (2012). Does
fear reactivity during exposure predict panic symptom reduction? Journal of Con-
sulting and Clinical Psychology, 80, 773–785. http://dx.doi.org/10.1037/a0028032
Mineka, S., Mystkowski, J. L., Hladek, D., & Rodriguez, B. I. (1999). The effects of
changing contexts on return of fear following exposure therapy for spider fear.
Journal of Consulting and Clinical Psychology, 67, 599–604. http://dx.doi.org/
10.1037/0022-006X.67.4.599
Mystkowski, J. L., Craske, M. G., & Echiverri, A. M. (2002). Treatment context and
return of fear in spider phobia. Behavior Therapy, 33, 399–416. http://dx.doi.org/
10.1016/S0005-7894(02)80035-1
Mystkowski, J. L., Craske, M. G., Echiverri, A. M., & Labus, J. S. (2006). Mental rein-
statement of context and return of fear in spider-fearful participants. Behavior Therapy,
37, 49–60. http://dx.doi.org/10.1016/j.beth.2005.04.001
Neumann, D. L., Lipp, O. V., & Cory, S. E. (2007). Conducting extinction in multi-
ple contexts does not necessarily attenuate the renewal of shock expectancy in a
284 Sewart and Craske

fear-conditioning procedure with humans. Behaviour Research and Therapy, 45, 385–394.
http://dx.doi.org/10.1016/j.brat.2006.02.001
Pearce, J. M., & Hall, G. (1980). A model for Pavlovian learning: Variations in the effec-
tiveness of conditioned but not of unconditioned stimuli. Psychological Review, 87,
532–552. http://dx.doi.org/10.1037/0033-295X.87.6.532
Plendl, W., & Wotjak, C. T. (2010). Dissociation of within- and between-session extinc-
tion of conditioned fear. The Journal of Neuroscience, 30, 4990–4998. http://dx.doi.org/
10.1523/JNEUROSCI.6038-09.2010
Prenoveau, J. M., Craske, M. G., Liao, B., & Ornitz, E. M. (2013). Human fear condi-
tioning and extinction: Timing is everything . . . or is it? Biological Psychology, 92,
59–68. http://dx.doi.org/10.1016/j.biopsycho.2012.02.005
Price, M., Mehta, N., Tone, E. B., & Anderson, P. L. (2011). Does engagement with
exposure yield better outcomes? Components of presence as a predictor of treat-
ment response for virtual reality exposure therapy for social phobia. Journal of
Anxiety Disorders, 25, 763–770. http://dx.doi.org/10.1016/j.janxdis.2011.03.004
Quirk, G. J. (2002). Memory for extinction of conditioned fear is long-lasting and per-
sists following spontaneous recovery. Learning & Memory, 9, 402–407. http://
dx.doi.org/10.1101/lm.49602
Rachman, S., Shafran, R., Radomsky, A. S., & Zysk, E. (2011). Reducing contamina-
tion by exposure plus safety behaviour. Journal of Behavior Therapy and Experimental
Psychiatry, 42, 397–404. http://dx.doi.org/10.1016/j.jbtep.2011.02.010
Rescorla, R. A. (2003). Protection from extinction. Learning & Behavior, 31, 124–132.
http://dx.doi.org/10.3758/BF03195975
Rescorla, R. A. (2006). Deepened extinction from compound stimulus presentation.
Journal of Experimental Psychology: Animal Behavior Processes, 32, 135–144. http://
dx.doi.org/10.1037/0097-7403.32.2.135
Rescorla, R. A., & Wagner, A. W. (1972). A theory of Pavlovian conditioning: Varia-
tions in the effectiveness of reinforcement and nonreinforcement. In A. H. Black &
W. F. Prokasy (Eds.), Classical conditioning II: Current research and theory (pp. 64–99).
New York, NY: Appleton-Century-Crofts.
Ricker, S. T., & Bouton, M. E. (1996). Reacquisition following extinction in appeti-
tive conditioning. Learning & Behavior, 24, 423–436. http://dx.doi.org/10.3758/
BF03199014
Rodriguez, B. F., Weisberg, R. B., Pagano, M. E., Machan, J. T., Culpepper, L., & Keller,
M. B. (2004). Frequency and patterns of psychiatric comorbidity in a sample of pri-
mary care patients with anxiety disorders. Comprehensive Psychiatry, 45, 129–137.
http://dx.doi.org/10.1016/j.comppsych.2003.09.005
Rowe, M. K., & Craske, M. G. (1998). Effects of varied-stimulus exposure training on
fear reduction and return of fear. Behaviour Research and Therapy, 36, 719–734.
http://dx.doi.org/10.1016/S0005-7967(97)10017-1
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety
and panic: A cognitive account. Behavioural Psychotherapy, 19, 6–19. http://dx.doi.org/
10.1017/S0141347300011472
Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided
threat reappraisal on fear reduction during exposure: An experimental investi-
gation. Behaviour Research and Therapy, 40, 235–251. http://dx.doi.org/10.1016/
S0005-7967(01)00007-9
Sy, J. T., Dixon, L. J., Lickel, J. J., Nelson, E. A., & Deacon, B. J. (2011). Failure to rep-
licate the deleterious effects of safety behaviors in exposure therapy. Behaviour
Research and Therapy, 49, 305–314. http://dx.doi.org/10.1016/j.brat.2011.02.005
Tsao, J. C., & Craske, M. G. (2000). Timing of treatment and return of fear: Effects of
massed, uniform-, and expanding-spaced exposure schedules. Behavior Therapy, 31,
479–497. http://dx.doi.org/10.1016/S0005-7894(00)80026-X
 Inhibitory Learning 285

Vansteenwegen, D., Vervliet, B., Hermans, D., Beckers, T., Baeyens, F., & Eelen, P.
(2006). Stronger renewal in human fear conditioning when tested with an acquisi-
tion retrieval cue than with an extinction retrieval cue. Behaviour Research and
Therapy, 44, 1717–1725. http://dx.doi.org/10.1016/j.brat.2005.10.014
Vansteenwegen, D., Vervliet, B., Iberico, C., Baeyens, F., Van den Bergh, O., &
Hermans, D. (2007). The repeated confrontation with videotapes of spiders in mul-
tiple contexts attenuates renewal of fear in spider-anxious students. Behaviour Research
and Therapy, 45, 1169–1179. http://dx.doi.org/10.1016/j.brat.2006.08.023
Vasey, M. W., Harbaugh, C. N., Buffington, A. G., Jones, C. R., & Fazio, R. H. (2012).
Predicting return of fear following exposure therapy with an implicit measure of
attitudes. Behaviour Research and Therapy, 50, 767–774. http://dx.doi.org/10.1016/
j.brat.2012.08.007
16
Cognitive Change via
Rational Discussion
Lillian Reuman, Jennifer L. Buchholz, Shannon M. Blakey,
and Jonathan S. Abramowitz

Cognitive change via rational discussion refers to the modification of dysfunctional

beliefs through the systematic, empirical, and collaborative process of identi-
fying, evaluating, challenging, and altering maladaptive thoughts and beliefs
that maintain clinical anxiety, such as those discussed in Chapter 1. As we
discuss in this chapter, a number of more or less verbal strategies can be used to
bring about such cognitive change. Commonly referred to as cognitive restruc-
turing, this mechanism of change is a core component of cognitive behavior
therapy (CBT) programs for a variety of anxiety and related disorders.
Pioneered by Ellis (1962), the basis for cognitive change via rational dis-
cussion is the assumption that human thinking and emotion are interrelated.
According to Ellis’s ABC model, behavioral and emotional “symptoms” are
the consequences (C) of irrational belief systems (B) about particular adverse
experiences, or activating events (A). This model assumes humans possess not
only innate tendencies to think irrationally (e.g., rigidly) but also the ability
to learn rational thinking through practice. Accordingly, reductions in unde-
sirable emotions (e.g., anxiety, fear) and behaviors (e.g., avoidance) can occur
as a result of verbal discussion in which rigid, unrealistic, and irrational beliefs
(e.g., catastrophic thinking, low frustration tolerance) are disputed and replaced
with more flexible and adaptive rational thinking (e.g., concern, dislike).

http://dx.doi.org/10.1037/0000150-016
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
287
288 Reuman et al.

Similar to Ellis’s (1962) model, Beck’s (1987, 1996) cognitive model of

emotion posits that distorted thinking and unrealistic appraisals negatively
affect one’s emotions and behaviors. Beck proposed that maladaptive cognitive
schemas are inaccurate belief systems based in negative early experiences
(e.g., stressful life events) that are continually reinforced by later experiences
and that form clusters of biased attitudes, beliefs, and assumptions. In the
context of anxiety, such biases include the tendency to exaggerate threat
(see Chapter 1, this handbook), overgeneralize, personalize, view the world
as uncontrollable, and view oneself as unable to cope well with adversity.
Such schemas are also thought to result in biased information processing
and faulty problem-solving. Accordingly, from this perspective, there are
two requirements for cognitive change via rational discussion (i.e., cognitive
restructuring): (a) identifying and evaluating maladaptive schemas to weaken
the automaticity of unhelpful and biased beliefs, and (b) substituting objec-
tive and adaptive cognitive schemas for maladaptive schemas to foster lasting
emotional and behavioral change.
Cognitive change via rational discussion to modify anxiety-related mal-
adaptive beliefs occurs via a multistep process that involves monitoring one’s
own thoughts, identifying faulty or irrational cognitions, verbally or experi-
entially challenging such cognitions, replacing them with more helpful and
rational beliefs, and deepening one’s conviction in one’s new ways of thinking
to update one’s cognitive schema. To illustrate, a student with social anxiety
might believe that she couldn’t stand to be embarrassed in front of her class-
mates. In this instance, cognitive restructuring would be used to identify this
belief as irrational (i.e., whereas embarrassment might feel uncomfortable, the
discomfort is temporary and it passes with time) and then dispute it based on
empirical evidence (e.g., like most people, she has felt embarrassed before,
but managed to get through the situation—that is, she withstood it). Next,
the student would be helped to generate a more flexible and rational way of
thinking about the situation (e.g., “I wouldn’t like to be embarrassed in front
of my classmates, but if this did happen, the unpleasant feelings would be
temporary and I would get through it just as I have in the past”) that would
help her feel less anxious about the possibility of embarrassment. The therapist
would also help this individual identify, challenge, and modify related sets of
core dysfunctional beliefs (i.e., schemas) that foster situation-specific assump-
tions about being embarrassed (e.g., beliefs that people are generally highly
judgmental and that one must always appear competent and confident in front
of others). Experiments to test the illogic of irrational beliefs and soften the
individual’s conviction, such as doing something to purposely embarrass
herself (e.g., asking a “stupid” question in class) to see that she can stand the
consequences, would also be used to consolidate changes in beliefs.
Teasdale and Barnard (1993) proposed two mechanisms by which changes
in beliefs occur via rational discussion. First, change occurs via the creation of
alternative schematic models that do not produce dysfunctional emotional
reactions. Second, certain strategies (e.g., thought records) can create change
 Cognitive Change via Rational Discussion 289

via shifts at a specific level of meaning that leads to either the creation of new,
higher level meanings or the creation of a modified mind-set (e.g., thoughts and
feelings as “mental events to be considered and examined” versus thoughts as
facts). Ultimately, the acceptance of adaptive schemas should override the
maladaptive processing.

IMPLEMENTATION

Given the suite of verbal interventions that may be used to change cogni-
tions, each portion, with accompanying steps and suggestions for implemen-
tation, is discussed in turn. First, we discuss the importance of collaborative
empiricism. Second, we outline how to provide a rationale for using rational
discourse. Third, we cover strategies for assessing and monitoring cognitions,
and identifying biased or distorted thinking patterns. Finally, we discuss
interventions for challenging and modifying faulty cognitions.

Collaborative Empiricism

Collaborative empiricism (Beck, Emery, & Greenberg, 1985) refers to the idea that
the patient and therapist make unique contributions to the process of therapy
and share responsibility in its direction and outcome. It is the therapist’s job
to help the patient discover for him- or herself an understanding of how mal-
adaptive thinking patterns contribute to anxiety, as well as the development
of more adaptive thinking patterns. In the spirit of teamwork with an emphasis
on mutual responsibility, the patient is tasked with openly sharing his or her
lived experience and describing the nuance of their his or her situation, while
the therapist brings his or her expertise in clinical training to case formulation
and the intervention at hand. This includes explaining the therapy model,
introducing associated skills, and guiding the patient with frequent feedback.
The therapist also assumes responsibility for establishing the treatment ratio-
nale, structuring homework assignments, asking questions throughout the
therapeutic process, and encouraging the patient to adopt an exploratory stance
in investigating his or her closely held beliefs. Jointly, the patient and therapist
determine goals for challenging and modifying these cognitions. This strong
therapeutic alliance is necessary for fostering engagement and vulnerability
in the cognitive restructuring process and becomes particularly important as
tasks increase in difficulty.
Empiricism—the idea that knowledge comes from data and sensory
experience—is vital for allowing the patient to strategically test the validity of
maladaptive schemas and alternative beliefs. It provides an opportunity for
patients to develop self-efficacy by learning about their beliefs via the gather-
ing of experiential evidence, rather than in a didactic format. Empiricism is
also important for helping the patient foster tolerance of anxiety by learning
firsthand that he or she can withstand subjectively threatening situations.
290 Reuman et al.

Rationale

When introducing cognitive restructuring to a patient, the therapist first pro-

vides an explanation of the cognitive model (including definitions of core
beliefs and automatic thoughts) and outlines the course of treatment. This
explanation is delivered using an interactive approach that includes soliciting
personal examples from the patient and checking periodically to gauge his or
her understanding. This introduction may include the use of diagrams to
illustrate the relationship between situations, cognitions, and emotions (i.e.,
the ABCs) in the context of anxiety (as is also described in Chapter 1). The
following is an example:
Many people believe that their emotions—in your case, anxious feelings—are a
direct result of the situations they encounter. But, this is not necessarily the case.
In fact, with any activating event (A), it is actually your belief (B) about that situ-
ation that largely determines the consequences (C)—how you feel and what you
do. Sometimes our thoughts and beliefs about a given situation are mistaken
or unhelpful. When this happens, it leads to negative, unproductive, or other
irrational emotional and behavioral responses.

The therapist can then provide examples to illustrate this pattern. For
example:
Let’s imagine that you’ve invited a friend for dinner at 7 o’clock. It’s now 7:30,
but there is no sign of your friend. What might be going through your mind?
[The patient provides a variety of assumptions about the situation, such as he’s
stuck in traffic, she doesn’t care about me, or he’s had an accident.] What emotions
would you feel as a result of each assumption? [Patient: frustration, sadness, and
anxiety, respectively.] Do you see how what you tell yourself in a given situation
predicts the way you feel and probably what you’ll do? There are two important
take-home messages here: The first is that any situation can have multiple inter-
pretations. The second is that you can control how you feel in any situation by
controlling how you view the situation.

After discussing this point and ensuring that the patient understands the
principle, the therapist can explain the concept of core beliefs, intermediate
thoughts, and automatic thoughts, using examples to illustrate how anxious
cognitions arise from the way people try to make sense of their world and
organize their experiences (Beck, 1987). For example:
Beginning in childhood, people develop ideas about themselves, other people,
and their world. We call these core beliefs because they’re deep, fundamental
understandings that seem like “absolute truths” or “the way things are.” When
these core beliefs are overgeneral and rigid, such as “I’m always socially
incompetent,” or “it’s terrible to make mistakes in front of others,” it can cause
problems such as social anxiety. Think of how the specific settings on a camera
influence the final picture. It’s similar with our thinking: What you focus on,
frame, and highlight affects what you experience. Then, the editing determines
what will be blown up or what will be glossed over. With anxiety, initial impres-
sions or assumptions, such as “everyone in my class is judging me,” can influence
your actions. Let’s talk more about how this applies to you. What are some of the
rules and assumptions you have? How might they affect your conclusions about
certain situations?
 Cognitive Change via Rational Discussion 291

Next, the therapist introduces the idea of shifting away from maladaptive
schematic thinking patterns to more rational, adaptive thoughts, which can
lead to a more balanced perspective and more pleasant emotions. To this end,
it is important to have a sense of the patient’s willingness to engage in cogni-
tive restructuring and consider alternative perspectives, as the intervention is
not feasible for those who refuse to examine their beliefs. Further, the thera-
pist should highlight that the intervention is often brief (i.e., time limited)
and structured with a significant, required, out-of-session commitment (i.e.,
homework) to reinforce and supplement the work done in the session.

Assessing and Identifying Cognitive Distortions

Verbal cognitive restructuring begins with identifying the patient’s core beliefs
and automatic thoughts, and teaching the patient to do the same. One useful
technique is to ask the patient to recall a recent situation in which he or she felt
anxious. The therapist can then guide the patient to identify automatic thoughts
by asking questions such as, “What was going through your mind when
[situation] happened?” (e.g., “When I heard thunder outside, my first thought
was that our house is going to be hit by lightning”). The therapist can then
reinforce the connection between beliefs (Bs) and consequences (Cs), such
as by stating,

Anxiety is generated when we perceive a serious threat to ourselves or someone

else. Do you see how your thoughts and beliefs (Bs) brought about the consequence
(C) of feeling anxious and fearful over the activating event (A) of hearing thunder?
The thunder itself doesn’t make you anxious—it’s your beliefs about the thunder
that cause these feelings.

With repeated practice recalling automatic thoughts, the therapist can train
the patient to observe the A-B-C sequence and highlight the important causal
relationship between B and C.
As part of learning about this sequence, as well as to aid with assessment,
the patient is asked to systematically self-monitor As, Bs, and Cs between ses-
sions using a log or diary, such as that shown in Figure 16.1. This process
helps the patient learn about his or her own automatic thoughts, including
identifying common themes that offer clues about more deeply held core
beliefs. Importantly, at this step, the therapist does not challenge the validity
of the patient’s thoughts and beliefs but instead merely observes them. When
patients point out the illogic in their own cognitions, however (e.g., “This
really sounds absurd when I write it down”), the therapist can reinforce such
critical thinking (e.g., “What about that seems absurd to you?”).
Once the therapist and patient have a good understanding of the patient’s
automatic thoughts and core beliefs, and their antecedents and consequences,
it is appropriate to lay the foundation for the techniques that will be used to
challenge and modify dysfunctional cognitions. This includes discussing how
people usually accept their own thoughts, beliefs, and assumptions as true
without questioning their logic but recognizing that such cognitions can be
292 Reuman et al.

FIGURE 16.1. Thought Log for Self-Monitoring Anxious Situations

(with an example)

Emotional and
Activating Beliefs (B) about
Date and time behavioral
event (A) the event
consequences (C)
June 11 at 7:30 p.m. About to leave for I will have a panic Anxiety, sweating,
the movie theatre attack and have to thinking about how I
on a date. leave. I will cause a can make sure I sit on
scene and embarrass the aisle.
myself. He won’t
want to be with me.

evaluated according to their validity and their utility. An important point is

that the patient will learn to regard thoughts as hypotheses, rather than as facts.
Accordingly, the next step of cognitive restructuring involves evaluating the
patient’s automatic thoughts to determine how accurate and useful they are.
The therapist can then introduce the notion of cognitive distortions by
explaining that everyone occasionally makes errors in their thinking but that
when they have recurring problems with fear and anxiety, it is usually an
indication that they are getting stuck making some consistent mistakes that
lead to exaggerated perceptions of threat. Table 16.1 lists cognitive distortions
(unhelpful thinking patterns) that individuals with clinical anxiety commonly
make. The therapist may review this list with patients and ask them about
times they have noticed thinking in one or more of these ways (and has iden-
tified such distortions in their own thought logs). The patient and therapist can
jointly identify these patterns while normalizing the experience by acknowl-
edging that almost everyone (with and without clinical anxiety) makes these
thinking mistakes on a daily basis.

Challenging and Modifying Faulty Cognitions

Helping a patient change automatic thoughts and core beliefs, such as those in
Table 16.1, requires generating more believable (rational) alternative thoughts
and beliefs. Thus, cognitive restructuring focuses on challenging existing mal-
adaptive cognitions by using primarily logical evidence that is inconsistent with
the patient’s anxiety-based cognitions. Different from exposure therapy, which
relies exclusively on experience and direct engagement with fear stimuli to
bring about behavioral extinction, cognitive restructuring relies primarily on
 Cognitive Change via Rational Discussion 293

TABLE 16.1. Common Anxiety-Related Cognitive Distortions

Thinking error Definition Clinical example
All-or-nothing Seeing things in “black or “No one will want to date
thinking white” categories me because of the scar on
my face.”
Overgeneralization Seeing a single negative event “I had a panic attack while
as a never-ending pattern driving, so I will never be
able to drive anywhere
without panicking.”
Mental filter Exclusively focusing on a neg- “I ruined the whole party
ative aspect(s) of a situation because I made a mistake
during my toast speech.”
Disqualifying the Rejecting positive experiences “The doctor said there’s
positive by insisting that they do not nothing wrong with me,
“count,” for one reason or but medical tests are never
another 100% accurate.”
Jumping to Making negative interpretations “My friend didn’t reply to my
conclusions without adequate evidence text right away, so she must
be mad at me.”
Catastrophizing Attributing or anticipating “If I fail the exam, it means
extremely awful conse- I’ll have to drop out of school
quences to events and I’ll never amount to
anything.”
Emotional Assuming that negative “I’m anxious, therefore there
reasoning emotions necessarily reflect must be danger.”
the situational reality
“Should,” “must,” Endorsing rigid yet arbitrary “I should be able to control my
or “ought to” rules anxiety.”
statements
Labeling and Assigning extremely over­ “I started crying when I saw a
mislabeling generalized negative spider . . . I’m weak and have
descriptive titles no backbone.”
Personalization Interpreting negative events as “Having thoughts of harming
indicative of some negative others means I am a bad
characteristic of oneself person.”
Maladaptive Endorsing thoughts that are “It’s not fair that social situa-
thoughts not necessarily irrational tions are so much harder for
or distorted but are never­ me than for other people.”
theless unproductive or
unhelpful

verbal discussion and disputation of cognitive distortions to bring about cog-

nitive change. Entire volumes have been written on cognitive therapy tech-
niques for anxiety disorders (e.g., Beck et al., 1985). In this chapter, we
provide an overview of these procedures, with attention to how they operate
mechanistically to promote changes in cognition.

Socratic Questioning
Generally speaking, the Socratic method (so named because it was developed
by the Greek philosopher Socrates) is used to help patients challenge and mod-
ify anxiety-related cognitions. This method entails asking patients questions to
294 Reuman et al.

promote critical thinking that challenges their beliefs, and it may be contrasted
with the didactic method in which the therapist simply tells a patient how to
think. Socratic questions promote cognitive change because they are open-
ended queries that give patients the opportunity to actively consider their own
thoughts and beliefs and then discover for themselves more adaptive alterna-
tives. Examples include “What do you mean when you say that you will
‘never amount to anything’?” and “What evidence do you have for or against
the belief that if you failed an exam you could never have a happy or success-
ful life?”
An important feature of effective Socratic questions is that patients have the
knowledge to answer them. More specifically, good questions help patients
retrieve information (e.g., facts, memories) that is relevant to the issues being
discussed, contradictory to their current beliefs, yet outside their current focus.
Indeed (and as highlighted in Chapters 1, 11, and 12), patients with anxiety
disorders have information-processing biases that lead them to interpret and
recall information and memories in ways that confirm their fears. Thus,
Socratic questions that require patients to retrieve and process disconfirmatory
information and memories will optimally promote the reevaluation of existing
ideas (and the construction of new ideas), and thus long-term cognitive change.
Effective Socratic questioning also moves from the more specific (or concrete)
to the more abstract. That is, the therapist first explores a particular situation or
belief (e.g., “What thoughts go through your mind when you notice a panic
attack coming on?”) before using more abstract questions to help the patient
learn something, challenge his or her beliefs, or experiment with an idea (e.g.,
“So, if panic attacks are nothing more than your fight-flight response, what do
you think would happen if you had a panic attack but didn’t take Xanax?”).
In this way, Socratic questions can help generate ideas for further testing
beliefs (or for conducting exposure therapy).

Using Objective Evidence

A more structured variant of general Socratic questioning and discussion is to
help patients systematically explore evidence for and against their dysfunc-
tional cognitions. As we have alluded to, patients rarely take the time to think
critically about their anxiety-related beliefs and assumptions. Thus, consider-
ing evidence and “putting beliefs on trial” or “thinking like a scientist” pro-
vides a basis for examining their thinking patterns and generating alternative,
and more realistic (and adaptive), thoughts and beliefs.
The patient is taught to treat his or her thoughts and beliefs as hypotheses—
that is, as possible but not forgone conclusions. The therapist and patient then
work collaboratively to explore facts from the patient’s past experiences and
information obtained from other sources (e.g., after surveying peers, the
patient concludes that some people don’t seem to mind being embarrassed)
guided by thought-provoking questions, such as those listed in Exhibit 16.1.
The “data” collected when considering these questions are then recorded on
a worksheet, such as that shown in Figure 16.2 where it can be laid out for
the patient to consider. Following this reflection and discussion, the therapist
 Cognitive Change via Rational Discussion 295

EXHIBIT 16.1

Questions to Ask When Putting Dysfunctional Thoughts

and Beliefs on Trial
• What evidence do I have for this thought? Against this thought? What would be the
worst thing that could happen?
º And if it happened, what would it mean, or “so what”?
º What would be so bad about that?
• Do I know for certain that the bad consequence will happen? What is its likelihood?
• Am I confusing a low-probability event with one of high probability?
• How have situations similar to this turned out before?
• Is there any alternative way of looking at the situation? Is there any alternative
explanation?
• How would someone else think about the situation? What would I tell a friend about
this same situation?
• Are my judgments based on how I felt rather than on what actually happened?
• Am I setting an unrealistic and unobtainable standard for myself?
• Am I forgetting relevant facts or focusing too much on irrelevant facts?
• Is this an example of all-or-nothing thinking?
• Am I overestimating how much control and responsibility I have in this situation?
• Is what happened really so important that my entire future resides with its outcome?
• How will things look, seem, or work months from now? Years from now?
• Am I underestimating what I can do to deal with the problem or situation?
• What are the advantages and disadvantages of thinking this way?

and patient work together to develop a rational response to the maladaptive

automatic thought(s) that synthesizes answers to the aforementioned questions
and represents an alternative, empirically and logically sound belief. The
patient practices this exercise between sessions in order to learn this skill to
the point that it becomes habitual—or at least easier to practice in vivo with-
out having to use the worksheet.
Behavioral experiments to further test the validity (or invalidity) of dys-
functional and adaptive thoughts and beliefs are also important for long-term
belief change. Such experiments involve planned experiences that provide
real-life, concrete demonstrations of the soundness of cognitions. The following
is an example of how a behavioral experiment might be used with a patient
with heart-focused anxiety and panic attacks:
Although numerous doctors had assured Grace (age 35) that her heart was quite
healthy, she remained concerned that it would “fail” if she exerted herself for
more than a few minutes at a time.1 After helping Grace identify dysfunctional
beliefs (e.g., “No doctor has ever been concerned about my heart”) and challenge
them with more realistic thoughts (e.g., “Physical exertion is good for a healthy
heart”), her therapist suggested conducting the next treatment session at a local
health club where Grace would practice walking or jogging on a treadmill for
gradually increasing periods of time without breaks, and at increasing speeds, to

All clinical case material has been altered to protect patient confidentiality.
1
296 Reuman et al.

FIGURE 16.2. Worksheet for Recording Cognitive Challenging Practice

Automatic
thoughts Rational thoughts
Situation and beliefs Thought challenges and beliefs
Taking a trip The plane will • Air travel is the safest The risk of a crash
on an airplane crash and form of travel is extremely slim, and
I will die • I don’t seem “unlucky” although I will probably
enough to be in a plane feel anxious on the plane,
crash this does not mean a
• I am confusing the fact crash is going to happen.
that plane crashes are The pilots are experienced
extremely rare for the fact and don’t want to crash
that they’re usually any more than I do.
catastrophic
• You hear about crashes
a few times per year,
but thousands of flights
land safely every day that
you don’t hear about
• The pilots know what
they’re doing and they
want to be safe
• My fear comes from the
fact that I don’t understand
how airplanes work
• I wouldn’t bet on the plane
crashing
• I tend to mistake my anxious
feelings as meaning that
danger is likely
• Thousands of people
fly every day

test her new beliefs and see whether her heart would really fail. After considering
the evidence, Grace agreed. Although she initially experienced palpitations
during the exercise (due to anxiety and to her being out of shape), she was
eventually able to convince herself that she did not need to be so concerned
about her heart.

Unlike in exposure therapy, behavioral experiments need not (and often

do not) include direct confrontation with fear triggers. Consider Manuel, a
university student who was worried that if he got a “poor grade” on an exam
he would never fulfill his dream of attending medical school and becoming a
doctor. Following a few sessions of cognitive restructuring, Manuel was able
to define a “poor grade” as a C or below and acknowledge that his belief about
such a grade was indicative of a rigidly held and extremely high standard.
Nevertheless, Manuel was having difficulty believing that he could get a C and
still attend medical school. To further help him consider alternative, more
realistic beliefs, Manuel’s therapist asked him to conduct an experiment in
which he asked 20 medical school students and 20 physicians whether they
had ever received a C or below on an exam in college. Manuel used the
 Cognitive Change via Rational Discussion 297

university directory to send e-mails to students and doctors at his university’s

medical center, asking about their grades. To his great surprise, three quarters
of the people he asked responded that they had indeed received a C or below
on exams. Some had even failed exams or received one or more C course
grades in college. This helped Manuel open his mind to alternative ways of
thinking. He was able to take some of the pressure off himself, believing that
receiving a poor grade did not necessarily mean he could not attend medical
school or become a doctor.
Effective behavioral experiments that foster long-term cognitive change
have a clear rationale that the patient understands. Moreover, it is important
that the faulty belief and the alternative, rational belief be clearly specified
so that it is clear what is being tested (e.g., Manuel defined a “poor grade” as
a C or worse). Behavioral experiments are also maximally helpful when the
therapist and patient jointly agree on how the beliefs will be tested, plan the
exercise together, and decide collaboratively how the experiment’s results
confirm or refute the patient’s hypothesis (e.g., “How will we know if your
belief is accurate?”). Behavioral experiments can be completed either within or
between therapy sessions but should be carefully and collaboratively reviewed
to maximize cognitive change. Readers interested in additional information
on behavioral experiments are referred to Bennett-Levy et al. (2004).

OUTCOME INDICATORS

One obvious way to measure effective cognitive change is to assess changes

in particular anxiety-related thoughts and beliefs. To assess such changes,
therapists can ask patients to quantify catastrophic appraisals of feared stimuli
(e.g., “I am 90% certain I will become ill”) before initiating cognitive restruc-
turing and compare these pretreatment ratings with revised estimates during
and after treatment. An advantage of such ratings is that they are patient spe-
cific. Belief ratings alone, however, may lack the sensitivity to track cognitive
change because the shift toward adaptive schematic processing is often non-
linear and influenced by circumstances and mood (Clark, 2014). Thus, it is
useful to use multiple indicators of cognitive change to measure the effects of
cognitive restructuring.
There are a number of reliable and valid self-report measures that assess
the presence and strength of dysfunctional beliefs relevant to various anxi-
ety-related disorders and fear domains, many of which are freely available
online and in the published literature. Some examples of these are listed in
Table 16.2. Such measures can be administered before and after treatment to
track changes in dysfunctional cognitions. It is important to note, however,
that the treatment of anxiety often involves the simultaneous use of cognitive
and behavioral components that have effects on cognition. As a result, it may
be challenging to disentangle the specific outcomes of cognitive restructuring
from those of interventions such as exposure therapy.
298 Reuman et al.

TABLE 16.2. Common Self-Report Measures of Dysfunctional Cognitions

Relevant to Different Anxiety-Related Conditions
Dysfunctional cognition
and measure name Source
Specific phobia
   Spider Phobia Beliefs Questionnaire Arntz, Lavy, Van den Berg, and Van Rijsoort
(1993)
   The Claustrophobia Questionnaire Radomsky, Rachman, Thordarson,
McIsaac, and Teachman (2001)
  Agoraphobic Cognitions Chambless, Caputo, Bright, and Gallagher
  Questionnaire (1984)
   Dental Anxiety Inventory Stouthard, Mellenbergh, and Hoogstraten (1993)
Social anxiety
   Social Cognitions Questionnaire Wells, Stopa, and Clark (1993)
   Beliefs About Appearance Scale Spangler and Stice (2001)
Obsessive-compulsive disorder
   Obsessive Beliefs Questionnaire-44 Steketee and Obsessive Compulsive
Cognitions Working Group (2005)
   Interpretation of Intrusions Steketee and Obsessive Compulsive
  Inventory Cognitions Working Group (2005)
   Contamination Cognitions Scale Deacon and Olatunji (2007)
Panic and health anxiety
   Anxiety Sensitivity Inventory-3 Taylor et al. (2007)

Traumatic events and posttraumatic

sequelae
   Posttraumatic Cognitions Inventory Foa, Ehlers, Clark, Tolin, and Orsillo (1999)

EMPIRICAL SUPPORT

Studies on the effects of cognitive restructuring, often termed cognitive therapy,

for anxiety have, for the most part, evaluated this mechanism of change as a
monotherapy or in comparison with exposure therapy. Indeed, a meta-analysis
found that cognitive therapy was as effective as exposure for posttraumatic
stress disorder (PTSD), obsessive-compulsive disorder (OCD), and panic dis-
order and was significantly more effective than exposure for social anxiety
disorder across several studies (Ougrin, 2011). Other studies have examined
whether cognitive therapy adds to the efficacy of exposure.
Although studies suggest that cognitive restructuring alone leads to a
significant reduction in panic-related symptoms (e.g., Bouchard et al., 1996;
Margraf & Schneider, 1991), cognitive restructuring does not appear to add
significantly to the efficacy of exposure therapy for panic (Öst, Thulin, &
Ramnerö, 2004; Van den Hout, Arntz, & Hoekstra, 1994). Cognitive restruc-
turing may be more critical to social anxiety treatment, as some studies show
that it augments the effects of exposure therapy (e.g., Mattick & Peters, 1988;
Mattick, Peters, & Clarke, 1989). Cognitive restructuring also appears to be an
efficacious monotherapy for OCD (e.g., Wilson & Chambless, 2005). Moreover,
 Cognitive Change via Rational Discussion 299

whereas some studies have found cognitive therapy and exposure and response
prevention (ERP) to produce equivalent results (Cottraux et al., 2001; Whittal,
Thordarson, & McLean, 2005), cognitive interventions do not appear to add
significantly to the efficacy of ERP (see Abramowitz, Taylor, & McKay, 2005).
Considerable research has explored the potential additive properties of
cognitive restructuring for PTSD. In a systematic review, Ponniah and Hollon
(2009) concluded that CBT that included exposure or cognitive restructuring
was efficacious for PTSD. Marks, Lovell, Noshirvani, Livanou, and Thrasher
(1998) found that both prolonged exposure and cognitive restructuring were
therapeutic for PTSD but were not mutually enhancing when combined. Foa
and Rauch (2004) found that the addition of cognitive restructuring did not
enhance treatment outcome for PTSD, and these results were later replicated
by Foa and colleagues (2005). As a result, some researchers have concluded
that cognitive interventions are unnecessary for PTSD treatment (see Longmore
& Worrell, 2007).
Some studies have used mediation analyses to determine whether cognitive
change precedes fear reduction during treatment, which would suggest that
cognitive change is a key mechanism of change in anxiety disorders. Hofmann
(2004), for example, found that change in beliefs about social events pre-
ceded reductions in social anxiety symptoms. Smits, Rosenfield, McDonald,
and Telch (2006) found that reductions in likelihood estimations predicted
self-reported fear during exposure. Similarly, Hofmann and colleagues (2007)
demonstrated that change in catastrophic thoughts was a significant mediator
of change in panic symptoms for individuals receiving CBT. Finally, working
with patients with OCD, Woody, Whittal, and McLean (2011) found that beliefs
about obsessional thoughts significantly accounted for improvement in symp-
toms. These findings were supported by a systematic review conducted by
Smits, Julian, Rosenfield, and Powers (2012), who found that change in
threat appraisal was causally related to reduction in fear. However, despite
mediation analyses suggesting a relationship between cognitive change and
symptom reduction, the question of temporal precedence remains unanswered.
Although some studies suggest that cognitive change precedes symptom
change, others position cognitive change as a consequence of symptom change,
and still others demonstrate a co-occurring change with bidirectional effects
(Clark, 2014).
Results from the studies just mentioned are mixed, and the vast majority
examine treatment efficacy in diagnostically homogenous (i.e., disorder-specific)
groups. In their review of CBT studies with varying methodologies, Longmore
and Worrell (2007) argued that there is insufficient evidence to conclude that
cognitive restructuring adds therapeutic value beyond exposure-based inter-
ventions. While the majority of treatment outcome studies compare symptoms
before and immediately after treatment, longer term follow-up data, when
available, can provide additional information about the importance of cognitive
restructuring. For example, Hofmann (2004) found that although full CBT
(which included cognitive restructuring) and exposure without cognitive
restructuring led to comparable symptom improvement at posttreatment,
300 Reuman et al.

only patients who received cognitive restructuring continued to improve after

the end of treatment. This suggests that the cognitive component of anxiety
treatment supports long-term gains; thus, the most significant contribution
of cognitive interventions for anxiety may lie in conferring more enduring
treatment.

TROUBLESHOOTING

A common objection to cognitive restructuring is that it is “too intellectual.”

Although therapists can address this objection by reducing their use of jargon
and using Socratic questioning to allow the patient to guide the conversation,
cognitive restructuring does rely on verbal communication and abstract
thought. Thus, patients with intellectual and/or developmental deficits, as well
as problems that affect cognition—such as substance use disorders, psychotic
disorders, organic brain syndromes, and neurodevelopmental disorders—
may require support beyond traditional cognitive restructuring strategies.
Some also criticize the “unemotional” nature of cognitive restructuring given
its emphasis on objectivity and rational thought. Critics suggest that therapy
sessions should include more emotional processing and validation, and argue
that cognitive restructuring is a superficial solution that does not address deeper
problems. Cognitive restructuring, however, starts with the identification of
emotion, and the goal of changing thought patterns is ultimately to help cope
with emotion and reduce anxiety.
Some patients are strongly convinced of their core beliefs, so it may be
challenging to provoke a shift in thinking patterns. Therapists must be cautious
about imposing their own value systems on the patient. For example, the use
of a term such as maladaptive thoughts might be avoided unless the patient and
therapist agree on the utility of the expression. Moreover, cognitive restruc-
turing often requires patients to disclose thoughts and emotions that are highly
personal. Therapists can address reluctance to self-disclose by reiterating con-
fidentiality and reminding patients that they will not be criticized or negatively
judged. Alternatively, some patients may share too much information and
have trouble staying on track. Therapists must be clear about the expectations
of cognitive therapy (e.g., the conversation will be structured by the ABC
model). Particularly talkative patients may benefit from having a few minutes
at the beginning or end of each session for less structured conversation.
Homework noncompliance can interfere with treatment, given the
importance of practicing cognitive restructuring outside of therapy sessions.
Therapists must be sure to emphasize the importance of homework and
consistently assign and review assignments (Ledley, Marx, & Heimberg, 2011).
Patients may also benefit from positive reinforcement for completing home-
work assignments. Finally, patients who struggle with perfectionism may avoid
homework assignments due to fear of doing them imperfectly, and other patients
who dislike school or academics may balk at the idea of completing homework
 Cognitive Change via Rational Discussion 301

as part of their therapy. Therapists can emphasize that homework (or out-of-
session practice) is not graded or judged but rather used to cement in-session
learning.

CONCLUSION

Changes in beliefs may occur as a result of various therapeutic procedures,

including exposure therapy and behavioral activation. The present chapter
focused on cognitive change resulting from verbal rational disputation of dys-
functional thinking patterns. This mechanism of change involves a systematic
process of identifying, appraising, challenging, and modifying the sorts of
maladaptive cognitions that maintain clinical anxiety. Such cognitive restruc-
turing constitutes a core component of CBT for a variety of presentations of
clinical anxiety that involve overestimates of the likelihood and severity of
threat, as well as underestimates of one’s ability to cope with adversity and
the very experience of anxiety. There is a great deal of empirical support for
cognitive change via rational discussion, yet therapists often make use of this
change process alongside other processes, such as extinction, within multi-
component therapy programs. This chapter also addressed ways of measuring
outcomes, as well as common obstacles to implementing cognitive restructuring.

REFERENCES
Abramowitz, J. S., Taylor, S., & McKay, D. (2005). Potentials and limitations of cog-
nitive treatments for obsessive-compulsive disorder. Cognitive Behaviour Therapy, 34,
140–147. http://dx.doi.org/10.1080/16506070510041202
Arntz, A., Lavy, E., Van den Berg, G., & Van Rijsoort, S. (1993). Negative beliefs of
spider phobics: A psychometric evaluation of the spider phobia beliefs questionnaire.
Advances in Behaviour Research and Therapy, 15, 257–277. http://dx.doi.org/10.1016/
0146-6402(93)90012-Q
Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy, 1,
5–37.
Beck, A. T. (1996). Beyond belief: A theory of modes, personality, and psychopathology.
In P. M. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 1–25). New York, NY:
Guilford Press.
Beck, A. T., Emery, G., & Greenberg, R. (1985). Anxiety disorders and phobias: A cognitive
perspective. New York, NY: Basic Books.
Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Meuller, M., & Westbrook, D.
(2004). Oxford guide to behavioural experiments in cognitive therapy. New York, NY: Oxford
University Press. http://dx.doi.org/10.1093/med:psych/9780198529163.001.0001
Bouchard, S., Gauthier, J., Laberge, B., French, D., Pelletier, M.-H., & Godbout, C.
(1996). Exposure versus cognitive restructuring in the treatment of panic disorder
with agoraphobia. Behaviour Research and Therapy, 34, 213–224. http://dx.doi.org/
10.1016/0005-7967(95)00077-1
Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear
of fear in agoraphobics: The body sensations questionnaire and the agoraphobic
cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090–1097.
http://dx.doi.org/10.1037/0022-006X.52.6.1090
302 Reuman et al.

Clark, D. A. (2014). Cognitive restructuring. In S. G. Hofmann (Ed.), The Wiley hand-

book of cognitive behavioral therapy (pp. 1–22). Sussex, England: Wiley and Sons.
Cottraux, J., Note, I., Yao, S. N., Lafont, S., Note, B., Mollard, E., . . . Dartigues, J.-F.
(2001). A randomized controlled trial of cognitive therapy versus intensive behavior
therapy in obsessive compulsive disorder. Psychotherapy and Psychosomatics, 70,
288–297. http://dx.doi.org/10.1159/000056269
Deacon, B., & Olatunji, B. O. (2007). Specificity of disgust sensitivity in the prediction
of behavioral avoidance in contamination fear. Behaviour Research and Therapy, 45,
2110–2120. http://dx.doi.org/10.1016/j.brat.2007.03.008
Ellis, A. (1962). Reason and emotion in psychotherapy. Oxford, England: Lyle Stuart.
Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The posttraumatic
cognitions inventory (PTCI): Development and validation. Psychological Assessment,
11, 303–314. http://dx.doi.org/10.1037/1040-3590.11.3.303
Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., & Yadin, E.
(2005). Randomized trial of prolonged exposure for posttraumatic stress disorder
with and without cognitive restructuring: Outcome at academic and community
clinics. Journal of Consulting and Clinical Psychology, 73, 953–964. http://dx.doi.org/
10.1037/0022-006X.73.5.953
Foa, E. B., & Rauch, S. A. (2004). Cognitive changes during prolonged exposure versus
prolonged exposure plus cognitive restructuring in female assault survivors with
posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72, 879–884.
http://dx.doi.org/10.1037/0022-006X.72.5.879
Hofmann, S. G. (2004). Cognitive mediation of treatment change in social phobia.
Journal of Consulting and Clinical Psychology, 72, 392–399. http://dx.doi.org/10.1037/
0022-006X.72.3.392
Hofmann, S. G., Meuret, A. E., Rosenfield, D., Suvak, M. K., Barlow, D. H., Gorman,
J. M., . . . Woods, S. W. (2007). Preliminary evidence for cognitive mediation during
cognitive-behavioral therapy of panic disorder. Journal of Consulting and Clinical
Psychology, 75, 374–379. http://dx.doi.org/10.1037/0022-006X.75.3.374
Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2011). Making cognitive-behavioral therapy
work: Clinical process for new practitioners. New York, NY: Guilford Press.
Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive
behavior therapy? Clinical Psychology Review, 27, 173–187. http://dx.doi.org/10.1016/
j.cpr.2006.08.001
Margraf, J., & Schneider, S. (1991, November). Outcome and active ingredients of cognitive-
behavioral treatments for panic disorder. Paper presented at the 25th annual meeting of
the Association for the Advancement of Behavior Therapy, New York, NY.
Marks, I., Lovell, K., Noshirvani, H., Livanou, M., & Thrasher, S. (1998). Treatment of
posttraumatic stress disorder by exposure and/or cognitive restructuring: A con-
trolled study. Archives of General Psychiatry, 55, 317–325. http://dx.doi.org/10.1001/
archpsyc.55.4.317
Mattick, R. P., & Peters, L. (1988). Treatment of severe social phobia: Effects of guided
exposure with and without cognitive restructuring. Journal of Consulting and Clinical
Psychology, 56, 251–260. http://dx.doi.org/10.1037/0022-006X.56.2.251
Mattick, R. P., Peters, L., & Clarke, J. C. (1989). Exposure and cognitive restructuring
for social phobia: A controlled study. Behavior Therapy, 20(1), 3–23. http://dx.doi.org/
10.1016/S0005-7894(89)80115-7
Öst, L.-G., Thulin, U., & Ramnerö, J. (2004). Cognitive behavior therapy vs exposure
in vivo in the treatment of panic disorder with agoraphobia. Behaviour Research and
Therapy, 42, 1105–1127. http://dx.doi.org/10.1016/j.brat.2003.07.004
Ougrin, D. (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders:
Systematic review and meta-analysis. BMC Psychiatry, 11, 200. http://dx.doi.org/
10.1186/1471-244X-11-200
 Cognitive Change via Rational Discussion 303

Ponniah, K., & Hollon, S. D. (2009). Empirically supported psychological treatments

for adult acute stress disorder and posttraumatic stress disorder: A review. Depression
and Anxiety, 26, 1086–1109. http://dx.doi.org/10.1002/da.20635
Radomsky, A. S., Rachman, S., Thordarson, D. S., McIsaac, H. K., & Teachman, B. A.
(2001). The claustrophobia questionnaire. Journal of Anxiety Disorders, 15, 287–297.
http://dx.doi.org/10.1016/S0887-6185(01)00064-0
Smits, J. A., Julian, K., Rosenfield, D., & Powers, M. B. (2012). Threat reappraisal as
a mediator of symptom change in cognitive-behavioral treatment of anxiety dis­
orders: A systematic review. Journal of Consulting and Clinical Psychology, 80, 624–635.
http://dx.doi.org/10.1037/a0028957
Smits, J. A., Rosenfield, D., McDonald, R., & Telch, M. J. (2006). Cognitive mechanisms
of social anxiety reduction: An examination of specificity and temporality. Journal of
Consulting and Clinical Psychology, 74, 1203–1212.
Spangler, D. L., & Stice, E. (2001). Validation of the beliefs about appearance scale. Cogni-
tive Therapy and Research, 25, 813–827. http://dx.doi.org/10.1023/A:1012931709434
Steketee, G., & Obsessive Compulsive Cognitions Working Group. (2005). Psycho­
metric validation of the obsessive belief questionnaire and interpretation of intrusions
inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research
and Therapy, 43, 1527–1542. http://dx.doi.org/10.1016/j.brat.2004.07.010
Stouthard, M. E., Mellenbergh, G. J., & Hoogstraten, J. (1993). Assessment of dental
anxiety: A facet approach. Anxiety, Stress & Coping: An International Journal, 6(2),
89–105. http://dx.doi.org/10.1080/10615809308248372
Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., . . .
Cardenas, S. J. (2007). Robust dimensions of anxiety sensitivity: Development and
initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19,
176–188. http://dx.doi.org/10.1037/1040-3590.19.2.176
Teasdale, J. D., & Barnard, P. J. (1993). Affect, cognition and change: Remodeling depressive
thought. Hillsdale, NJ: Lawrence Erlbaum.
Van den Hout, M., Arntz, A., & Hoekstra, R. (1994). Exposure reduced agoraphobia
but not panic, and cognitive therapy reduced panic but not agoraphobia. Behaviour
Research and Therapy, 32, 447–451. http://dx.doi.org/10.1016/0005-7967(94)90008-6
Wells, A., Stopa, L., & Clark, D. M. (1993). The social cognitions questionnaire. Unpublished
manuscript, Department of Psychiatry, University of Oxford, Warnerford Hospital,
Oxford, England.
Whittal, M. L., Thordarson, D. S., & McLean, P. D. (2005). Treatment of obsessive-
compulsive disorder: Cognitive behavior therapy vs. exposure and response pre-
vention. Behaviour Research and Therapy, 43, 1559–1576. http://dx.doi.org/10.1016/
j.brat.2004.11.012
Wilson, K. A., & Chambless, D. L. (2005). Cognitive therapy for obsessive-compulsive
disorder. Behaviour Research and Therapy, 43, 1645–1654. http://dx.doi.org/10.1016/
j.brat.2005.01.002
Woody, S. R., Whittal, M. L., & McLean, P. D. (2011). Mechanisms of symptom
reduction in treatment for obsessions. Journal of Consulting and Clinical Psychology,
79, 653–664. http://dx.doi.org/10.1037/a0024827
17
Behavioral Activation
Matt R. Judah, Jennifer Dahne, Rachel Hershenberg,
and Daniel F. Gros

Behavioral models of depression (e.g., Lewinsohn, 1974) posit that depression

results from a loss or lack of rewarding behavior (i.e., response-contingent posi-
tive reinforcement) in the environment and/or high rates of punished behavior
(Lewinsohn, 1974; Lewinsohn, Sullivan, & Grosscup, 1980). From this theory,
Lewinsohn and colleagues (1980) developed an intervention for depression with
the primary goal of promoting behavioral activation (BA). Treatments that capital-
ize on the mechanism of BA aim to decrease a patient’s avoidant behaviors and
increase opportunities for the patient to contact potential reinforcers. To this end,
a therapist might foster BA by helping a patient engage in activities that engender
a sense of enjoyment (e.g., going to the park with one’s child) and/or mastery
(e.g., submitting a job application). Although several variants of BA-focused
treatments exist (see Kanter et al., 2010), the therapeutic cornerstones include
(a) daily monitoring of mood and of activities, which helps the patient under-
stand the connection between mood and activity, and (b) daily activity planning,
which increases the frequency of important and/or pleasurable activities.
Compared with exposure therapy, which focuses on facilitating extinc-
tion via habituation of fear (see Chapter 14) and/or inhibitory learning
(see Chapter 15), BA-focused interventions emphasize the patient’s values
and feelings of enjoyment and mastery related to scheduled activities.
Accordingly, there is less focus on persisting in situations that engender
distress when targeting BA. In fact, the patient and the therapist may drift

http://dx.doi.org/10.1037/0000150-017
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
305
306 Judah et al.

from activities that elicit anxiety (or anxious arousal) altogether to incorporate
activities that are merely enjoyable or valued to increase BA.

SIMILARITIES BETWEEN BEHAVIORAL ACTIVATION–BASED

TREATMENTS AND EXPOSURE-BASED TREATMENTS

BA-focused treatments for depression have significant theoretical and practical

overlap with behavioral interventions for anxiety (i.e., exposure therapy; see
Table 17.1). Increasing approach behaviors toward avoided activities, a core fea-
ture of BA, is mirrored in exposure therapy for anxiety, in which patients con-
front anxiety-provoking situations without engaging in escape or avoidance
behaviors (see Chapter 2). In the same way that exposure is designed to chal-
lenge mistaken beliefs about threat and/or anxiety, scheduled activities in
BA-focused interventions aim to contradict the expectation of a patient with
depression that an activity will be unrewarding or punishing. Furthermore, BA-
and exposure-based therapies implicate avoidance (e.g., withdrawal, inactivity,
isolation) as a primary mechanism involved in symptom maintenance. Elimi-
nating such maladaptive avoidance behaviors is a core feature of both types of
interventions. Given this fundamental conceptual overlap, some transdiagnostic
protocols incorporate activity scheduling as “positive emotional exposures” and
have been shown to effectively reduce symptoms of anxiety and depression
(e.g., Bunnell & Gros, 2017; Gros, 2014).

ADVANTAGES OF INCREASING BEHAVIORAL ACTIVATION DURING

ANXIETY TREATMENT

In addition to conceptual overlap between BA- and exposure-based thera-

pies, there are practical reasons that increasing BA may be incrementally
useful when treating patients with clinical anxiety. Among these reasons,

TABLE 17.1. Common Features of Behavioral Activation and Exposure Therapies

Behavioral activation Exposure
Features therapy therapy
Reduce avoidance ✓ ✓
Increase approach behaviors ✓ ✓
Schedule and monitor activity ✓ ✓
Track mood/affect changes in relationship with ✓ ✓
behaviors
Design activities that contradict mistaken/ ✓ ✓
maladaptive expectations
Promote development of approach behaviors ✓
using a values or goals framework
Emphasize values and/or reward of activities ✓
Remain in situation until planned end of activity ✓
In-session practice/exposure ✓
Out-of-session practice/homework ✓ ✓
 Behavioral Activation 307

depression is highly comorbid with anxiety and may attenuate response to

exposure-based treatment for anxiety (Abramowitz, Franklin, Street, Kozak,
& Foa, 2000; Crino & Andrews, 1996). As such, treatment strategies that can
target anxiety and depression concurrently represent an opportunity to
improve treatment outcomes for this population (Gros, 2014; Gros, Price,
Magruder, & Frueh, 2012).
A second advantage regards the emphasis of BA-focused interventions
on generating self-sustained approach behaviors (i.e., activities) through
positive reinforcement. Exposure therapy sustains approach behaviors
primarily through helping patients learn that situations are less threatening
than anticipated, while simultaneously extinguishing avoidant safety
behaviors previously maintained via negative reinforcement. Within a values-
based BA framework (and consistent with other therapeutic approaches like
acceptance and commitment therapy; Hayes, Strosahl, & Wilson, 2011), a
patient may be more likely to implement and continue engaging with ther-
apeutic activities to the extent that such reinforcing behaviors are in line
with personal values rather than arbitrarily selected (e.g., Lejuez, Hopko,
Acierno, Daughters, & Pagoto, 2011). A patient with clinical anxiety may be
more motivated to engage in exposure tasks if the activities are reinforcing
and/or personally important, in addition to facilitative of habituation
(see Chapter 14, this handbook) and/or inhibitory learning (Chapter 15, this
handbook).

IMPLEMENTATION

After a series of studies underscored the superiority of behavioral, relative to

cognitive, interventions in the treatment of depression (Ekers et al., 2014;
Gortner, Gollan, Dobson, & Jacobson, 1998), Jacobson and colleagues (1996)
developed a manualized treatment for depression that centered around the
concept of BA. Jacobson’s behavioral activation program (JBA) involved up
to 24 sessions delivered over a 16-week period (Dimidjian et al., 2006;
Martell, Addis, & Jacobson, 2001). A second independent research program
concurrently developed another BA-focused intervention (i.e., brief BA treat-
ment for depression [BATD]; Lejuez, Hopko, & Hopko, 2001; Lejuez et al.,
2011). Compared with JBA, BATD is brief (typically eight to 12 sessions, though
as few as five) and has more frequently been tested in samples of depressed
patients with co-occurring psychological and physical conditions (Gros, Price,
Magruder, & Frueh, 2012; Hopko et al., 2011; Hopko, Lejuez, & Hopko, 2004;
Hopko, Lejuez, Ryba, Shorter, & Bell, 2016; MacPherson, Collado, Lejuez,
Brown, & Tull, 2016; Magidson et al., 2011). BATD also diverges from JBA in
that it takes a values-driven approach to selecting scheduled activities.
The next session discusses how the therapist may capitalize on BA when
working with a patient with clinical anxiety. Rather than focusing on a spe-
cific treatment manual, features common to multiple BA-focused inter­
ventions are described in the context of anxiety disorder treatment.
308 Judah et al.

Therapist Role

BA-focused interventions are directive, collaborative, and structured. The

therapist and the patient work together to explore a theory-based account
of the patient’s symptoms, as well as the behavioral steps predicted to resolve
them. As in traditional exposure-based interventions, the therapist fosters the
patient’s independence by fading from a directive and structured style and
gradually promoting patient responsibility and initiative. This builds patient
autonomy, which is important for maintaining treatment gains and prevent-
ing relapse.

Functional Analysis and Self-Monitoring

It is useful to begin by conducting a functional analysis to identify the ABCs

of avoidance—antecedents (i.e., “triggers”), behaviors, and consequences
(Ramnerö & Törneke, 2008). For an individual with anxiety, avoidance may
be so longstanding that he or she considers it normal behavior. It may be
equally challenging for a patient with ingrained avoidance to recognize the
specific antecedents and consequences of avoidant behavior.
Daily monitoring of behavior and mood is a cornerstone of psychothera-
pies that capitalize on the mechanism of BA. Tracking the intensity of anxiety
(and other relevant positive or negative affect) during activities allows the
patient to understand the relationship between behavior and mood, as well
as changes in mood over time because of changes in behavior. Given the
ubiquity of the subjective units of distress scale (SUDS; Wolpe, 1969) in
anxiety treatments, integrating SUDS (or 0–100 scales for other emotions)
provides an efficient means of tracking the effects of increased BA on mood.
Exposure therapy programs that deemphasize SUDS (e.g., Craske, Treanor,
Conway, Zbozinek, & Vervliet, 2014) often ask a patient with anxiety to iden-
tify and rate expectations about the outcome(s) of an exposure task; such
ratings may be easily integrated into BA-related daily monitoring.

Activity Scheduling

When seeking to increase BA among patients with clinical anxiety, it is

important to select activities that not only engender a sense of pleasure
or accomplishment (Lejuez et al., 2001) but that also elicit distress. Ranking
valued activities on the basis of anxiety and/or fearful avoidance is one way
to ensure that activities stand to reduce anxiety symptoms. Consistent with
the clinical convention of gradually progressing up a fear hierarchy during
exposure, most BA-focused treatment approaches recommend having the
patient start by scheduling a few activities that are easy to complete to achieve
early momentum prior to increasing the difficulty or frequency of scheduled
activities (e.g., Lejuez et al., 2011). Other treatments that target the principle
of BA begin with several activities to foster dramatic change and highlight the
contrast between activity and inactivity (e.g., Gros, 2014).
 Behavioral Activation 309

Areas of avoidance and potential activities to schedule may be more easily

identified by dividing the patient’s varied environment into specific contexts.
For example, Lejuez and colleagues (2011) provide a framework of life areas
that include discrete contexts like relationships, education/career, and hobbies/
recreation. Constructing a hierarchy of avoided situations in different life
areas can be helpful for organizing a comprehensive list to promote BA (and
fear extinction).

Considerations for Specific Disorders

Avoidance is a common maintenance factor in anxiety and related disorders,

but avoidance and other symptoms can manifest differently across diagnostic
categories. Considerations to guide the application of BA to specific diagnoses
are provided next.

Social Anxiety Disorder

In many cases, social anxiety disorder involves a withdrawal from social situ-
ations. Many patients will be able to identify a mismatch between valuing
social relationships and their withdrawal from others. If this is the case, moti-
vation to engage in social activities may be built by identifying and discussing
the patient’s relationship values and goals.
Social skills training is not unique to BA-focused treatments, nor included in
all BA-focused treatment manuals. However, including social skills training
complements theoretical models of BA. For example, participation in social
activities may not be therapeutic if the patient lacks the necessary skills to
behave in ways that others will reinforce (Lewinsohn, 1974). For this reason,
social skills training through therapist modeling, role-play, and feedback is
included in the treatment program developed by Martell and colleagues (2001).

Generalized Anxiety Disorder

Given the high comorbidity of unipolar mood disorders and generalized anxi-
ety disorder (Moffitt et al., 2007), as well as initial evidence that BA-focused
treatments for depression produce improvements in co-occurring anxiety dis-
order symptoms (Hopko et al., 2004), it may be appropriate to target BA in the
context of generalized anxiety disorder. With respect to anxiety symptoms,
increasing BA may help the patient engage in potentially rewarding behaviors
he or she avoids because of worry. Furthermore, focused engagement in activ-
ities may counter worry by giving the patient something else on which to
focus his or her attention (Bunnell & Gros, 2017). Accordingly, behavioral
activation for worry, an 8-session group treatment (Chen, Liu, Rapee, & Pillay,
2013), aims to increase activities that contradict specific worries.

Posttraumatic Stress Disorder

Increasing BA may be especially useful in the context of treatment for
posttraumatic stress disorder (PTSD), given the anhedonic features of this
condition (e.g., markedly diminished interest or participation in significant
310 Judah et al.

activities). Exposure to memories of traumatic events is a common feature of

evidence-based treatments for PTSD. This may be done through a detailed
reimagining of the event (i.e., imaginal exposure), as in prolonged exposure
(Foa, Hembree, & Rothbaum, 2007) or through writing out details of the
event, as in cognitive processing therapy (Resick & Schnicke, 1993). Although
BA-specific interventions for depression do not include an analogue to these
strategies, limited data suggest that BA treatment programs (with or without
imaginal exposure) are effective in reducing PTSD symptoms (e.g., Gros,
Price, Strachan, et al., 2012; Hershenberg, Smith, Goodson, & Thase, 2018;
Jakupcak et al., 2006; Strachan, Gros, Ruggiero, Lejuez, & Acierno, 2012).
Nevertheless, imaginal exposure can easily be integrated into treatment plans
centered around increasing BA.

Obsessive-Compulsive Disorder
Preventing avoidance behaviors (i.e., compulsive rituals or other safety
behaviors) is a critical component of successful treatment for obsessive-
compulsive disorder. For example, a patient with obsessions related to
cleanliness who is encouraged to go for a hike without using antibacterial
gel may only comply or withstand the exposure by subtly wiping his hands
on his clothing. Yet, if the therapist facilitates response prevention by incor-
porating an activity that has the potential to be maximally rewarding (e.g.,
prevent ritualistic hand wiping by walking outside while giving a beloved
child a “piggyback ride”), the patient may be better able to fully engage in
an exposure task that challenges anxiety-driven avoidance. Accordingly,
the therapist is encouraged to assess for a range of avoidance and safety
behaviors (as well as potential barriers to full response prevention) and
design exposure activities accordingly.

Specific Phobias
The features that distinguish BA- and exposure-based therapies may be espe-
cially evident in the treatment of specific phobias. Specific phobias typically
present with the clearest situational fear/avoidance and the least overlap with
symptoms of depression, suggesting that it may not be necessary to target BA
in this population (Gros, McCabe, & Antony, 2013). In addition, treatments
for specific phobia are straight-forward and effective, further limiting the
incremental utility of targeting BA in treatment (Gros & Antony, 2006).

Considerations for Special Populations

Certain issues should be considered when targeting BA in different popula-

tions. For example, a patient with chronic pain may struggle to distinguish
between maladaptive inactivity and reasonable withholding from activities
that exacerbate pain. Indeed, an energetic dive into new activities may result
in a highly punishing increase in pain. Activity selection should be in accord
with each patient’s physical limitations. A patients with chronic pain may
need guidance to recognize objective health indicators (e.g., presence of a
 Behavioral Activation 311

migraine) to distinguish when increasing activation is appropriate versus

temporarily contraindicated.
The therapist should also consider the patient’s cultural values when
selecting activities to incorporate into treatment (see Lejuez et al., 2011)
rather than assume that the patient exists in the same multicultural context
as the therapist or other patients. The role of the patient’s culture can be
incorporated into functional analysis; moreover, antecedents can be classified
as distal versus proximal. Distal antecedents include the patient’s upbringing
and culture, which are not easily amenable to change. Proximal antecedents
are those which exist in the “here and now,” and can be targeted during treat-
ment. Because treatments that act on BA focus on increasing values-guided
adaptive behaviors, a patient can select behaviors that are consistent with his
or her personal beliefs, reducing the risk that the therapist will impose values
that are inconsistent with the patient’s values.

Incorporating Partners and Family Members

As family members and partners are part of a patient’s context, it is important

for the therapist to ensure that the patient’s loved ones are facilitators rather
than barriers to treatment goals. It may be helpful to ask the patient to track
who is present during scheduled activities and whether this person’s presence
is energizing or depleting during the activity. Tracking this detail can enable the
therapist and the patient to adjust activities considering the realities of the
patient’s interpersonal context. Critical family members can be encouraged to
focus on (and reinforce) the patient’s efforts toward change (Lejuez et al.,
2001). Within BATD, the patient and family complete contracts so that family
behaviors reinforce the patient’s adaptive behaviors rather than the patient’s
avoidance.
Because BA-focused treatments can stall when a patient falls into a pattern
of failing to complete scheduled activities, family members and friends can be
enlisted to assist the patient’s homework compliance. One strategy is to
encourage the patient to voluntarily obligate himself or herself to complete
an activity with family members or friends. If necessary, the patient can call
and schedule activities that incorporate others during the session.

Case Example: Ricky

The following case example illustrates how a therapist might conceptualize

behavioral avoidance as well as implement treatment strategies to increase
BA within the context of treatment for clinical anxiety.
Ricky is a single, 20-year-old man living with his parents.1 Ricky stopped
attending college classes because of anxiety about being negatively evaluated
by his peers and instructors. He was also fired from a series of part-time jobs

All clinical case material has been altered to protect patient confidentiality.
1
312 Judah et al.

after absenteeism and failing to interact with customers. Ricky has few friends
and spends most of his time at home playing video games, watching televi-
sion, and playing with the family dog, whom he describes as “his best friend.”
A diagnostic assessment suggests that Ricky meets criteria for social anxiety
disorder. In Ricky’s case there is no clear deficit in social skills; therefore,
social skills training is not indicated prior to activity scheduling.
In the first session, the therapist worked collaboratively with Ricky to
understand his social anxiety symptoms as well as the role that Ricky’s avoid-
ance plays in maintaining his symptoms. Using functional analysis, the ther-
apist guided Ricky in identifying how his environment triggers avoidance
behaviors and the function (positive consequences) and dysfunction (nega-
tive consequences) of these behaviors (see Table 17.2). The therapist dis-
cussed the treatment plan with Ricky, checking for his understanding,
agreement, and commitment to treatment. Ricky was given a self-monitoring
form and asked to track his daily activities.
In the second session, Ricky identified his personal values in various life
areas. Among other values, Ricky likes to be good at what he does and likes
to help others. The therapist guided Ricky to keep such values in mind while
creating a hierarchy of avoided activities to be attempted during anxiety
treatment (see Table 17.3). Ricky used to enjoy going to eat with friends, but
he avoids this now because of anxiety about being judged by them. Using this
hierarchy, the therapist worked with Ricky to select two social activities per
day that are consistent with Ricky’s values (e.g., meet a close friend for coffee
in the morning, have a phone call with a different friend in the evening).
Throughout the course of therapy, Ricky routinely completed several social
activities (e.g., window-shopping at the mall with a friend, attending church)
while failing to complete others (e.g., attending class). Though Ricky achieved
some treatment gains, Ricky and his therapist believed that his progress had
hit a wall. Further discussion revealed that Ricky feels incompetent in class,
and that this is related to uncompleted coursework. Ricky decided to add
completion of coursework and attending a study group to his activity list.
By the end of therapy, Ricky generally felt that he had achieved his treat-
ment goals and increased his social behaviors. Not only does Ricky have

TABLE 17.2. Functional Analysis for a Patient With Social Anxiety Disorder
Avoidance Positive Negative
Antecedent behavior consequence consequence
Class time Playing video Distracted from Missing class,
approaching games anxiety about falling further
class behind in class
Dinner time Eating in the Avoided parental Isolation from
approaching basement, play- criticism parents, feelings
ing with dog of loneliness
Thinking about Watching a movie, Distracted from Remaining
needing a job/ playing video anxiety about job unemployed,
ruminating about games isolation from
past jobs others
 Behavioral Activation 313

TABLE 17.3. Hierarchy of Fear/Avoidance for a Patient With Social Anxiety

Disorder
Fear/
Activity anxiety Avoidance Value Enjoyment Mastery
Eating dinner with parents 7 8 5 2 0
Attending class 8 9 8 6 7
Applying for jobs 9 9 6 4 8
Eating with friends 5 7 7 8 2
Note. Rating scale ranges from 0 (none) to 10 (most).

several friends he sees multiple times throughout the week, but he had also
resumed attending classes and reported that his grades were improving. Ricky
and his therapist discussed Ricky’s now activated behavior in contrast with his
initial isolation and inactivity. Ricky said he feels proud of himself and gener-
ally feels confident that he can continue engaging in social activities despite
some residual anxiety about being judged by others. Experiences afforded by
Ricky’s activated behavior have disconfirmed his worst fears. In addition to
Ricky’s verbal reports, his scores on measures of BA and social anxiety symp-
toms were much improved over his pretreatment scores. Ricky’s therapist
transitioned to the relapse prevention and termination phase of treatment.

OUTCOME INDICATORS

Several available tools may be useful for measuring outcomes associated with
BA (see Manos, Kanter, & Busch, 2010 for a review). Among the most long-
standing, the Pleasant Events Schedule (PES; MacPhillamy & Lewinsohn,
1982) is a self-report measure of response-contingent positive reinforcement,
which is proposed to be a mechanism of depression in Lewinsohn’s (1974)
model. The patient reports how often a list of 320 enjoyable events occurred
and the subjective pleasure experienced during these events over the last
month. The average cross-product of frequency and subjective pleasure can
be used to assess obtained pleasure. Psychometric studies support the test–
retest reliability and discriminant validity of the PES (e.g., MacPhillamy &
Lewinsohn, 1982). At the same time, the length of this measure may be
unwieldy in routine clinical settings, especially in cases where a therapist
seeks to track changes in BA on a session-by-session basis.
The Reward Probability Index (RPI; Carvalho et al., 2011) is another
measure of response-contingent positive reinforcement, which consists of
20 Likert-scale items composing two subscales—reward probability and envi-
ronmental suppressors. The RPI has good convergent validity with measures of
related constructs, including activity, reinforcement, and depression (Carvalho
et al., 2011). The Environmental Reward Observation Scale (EROS; Armento &
Hopko, 2007) assesses subjective reinforcement over the past few months and
consists of 10 items loading on a single factor with good internal consistency and
314 Judah et al.

test–retest reliability. Research suggests that the EROS is moderately correlated

with the PES and RPI, and that it predicts daily diary reporting of reward behav-
iors even after controlling for depression (Armento & Hopko, 2007; Carvalho
et al., 2011). It is worth noting, however, that the RPI and EROS are measures
of response-contingent positive reinforcement, rather than BA per se.
The Behavioral Activation for Depression Scale (BADS; Kanter, Mulick,
Busch, Berlin, & Martell, 2007) assesses engagement in behavioral avoidance
and BA and contains 25 items comprising four subscales—activation, avoidance/
rumination, work/school impairment, and social impairment. A revised, shorter
version of the BADS (Manos, Kanter, & Luo, 2011) consists of nine items with
good psychometric properties. This shorter form was designed to improve psy-
chometric properties of the original BADS and may be more practical for ses-
sion-to-session administration in a clinical setting. Although items on the shorter
form load on two subscales (activation and avoidance), it is recommended to
use the total score only (Fuhr, Hautzinger, Krisch, Berking, & Ebert, 2016;
Manos et al., 2011). The BADS long and short form and other outcome indica-
tors can be used in research protocols investigating the effectiveness of BA for
anxiety and related disorders and in direct patient care.

EMPIRICAL SUPPORT

Though empirical support for efforts to increase BA within the context of

treatment for clinical anxiety is limited, there is abundant evidence that
increasing BA in patients with depression is efficacious and effective (see Ekers
et al., 2014; Mazzucchelli et al., 2009; Sturmey, 2009). Given the conceptual
and functional overlap of exposure- and BA-focused treatments—as well
as the practical advantages of targeting BA during treatment for clinical
anxiety—examining whether capitalizing on BA to treat anxiety and related
disorders is a clear next step. Whereas early studies noted improvements in
anxiety secondary to depression (e.g., Hopko et al., 2004), more recent studies
support targeting BA in the context of anxiety and related disorders, especially
PTSD (Hershenberg et al., 2018; Jakupcak et al., 2006; Jakupcak, Wagner,
Paulson, Varra, & McFall, 2010). Jakupcak and colleagues (2006) found that vet-
erans experienced moderate reduction in therapist-rated PTSD symptoms
(Hedge’s g = .58) after 16 sessions of BA-based treatment. Other researchers have
synthesized behavioral principles by combining exposure and BA-promoting
techniques (Gros, 2014; Gros, Price, Strachan, et al., 2012; Strachan et al., 2012).
Preliminary findings support the use of BA-promoting interventions in the
amelioration of clinical anxiety, either as a standalone treatment or in combi-
nation with exposure-based treatments. Nevertheless, evidence for the effi-
cacy of targeting BA in patients with clinical anxiety is mainly derived from
case studies and preliminary trials and should be considered preliminary at
this point. Table 17.4 provides a summary of studies that examined the effects
of BA-focused treatments on anxiety and related conditions.
 Behavioral Activation 315

TABLE 17.4. Studies of Behavioral Activation-Focused Interventions to Treat

Anxiety and Related Disorders
Study Sample Protocol Outcome
Hershenberg Veterans 12-week group Significant reduction in PTSD
et al., 2018 BA treatment symptoms (PCL) with 65%
improved or recovered.
Acierno Veterans BA–TE Significant reduction in PTSD
et al., 2016 symptoms (PCL) delivered in
person or through home-based
telehealth up to 12 months
posttreatment.
Strachan Veterans with BA–TE Significant reduction in PTSD
et al., 2012 PTSD and symptoms (PCL) and anxiety
MDD symptoms (BAI).
Wagner Survivors of 4–6 sessions Significant reduction in PTSD
et al., traumatic of BA symptoms (PCL), also better
2007 injury treatment than treatment as usual.
Jakupcak Veterans 5–8 sessions Significant reduction in PTSD
et al., 2010 of BA symptoms (PCL and CAPS).
treatment
Nixon and Community 12–16 sessions Significant reduction in symptoms
Nearmy, members of BA treat- (CAPS, DASS, PDS, & PTCI) main-
2011 with PTSD ment com- tained at 3-month follow-up;
and MDD bined with 60% of subjects no longer met
CBT for PTSD criteria for PTSD.
Chen, Liu, Community 8 sessions of 55% of BA group no longer met
Rapee, members group BAW criteria for GAD compared with
and Pillay, self-referred 0% in the waitlist control group;
2013 for worry significant reduction in worry
(PSWQ) for BA group.
Hopko et al., Women with BATD Clinically significant reduction
2016 breast cancer in anxiety (BAI) for 41% of
and MDD patients.
Turner and Middle-age 12 sessions of Clinically significant reduction
Leach, adults with BATA in anxiety (BAI, DARS, DASS)
2010 anxiety maintained through a 3-month
disorders posttreatment follow-up in each
patient.
Chu et al., 7th and 10 sessions of Clinically significant reduction
2009 8th graders GBAT in principal diagnosis severity
with affective (ADIS-IV-C) for 3 of 4 treatment
disorder completers.
Chu et al., Adolescents 10 weekly GBAT showed superior posttreat-
2016 with unipolar sessions of ment outcomes compared with
depression GBAT waitlist control group in overall
disorder or impairment and in secondary
anxiety diagnosis remission rates and
disorder impairment.
Note. Effects on depression and other nonanxiety outcomes are not reported in this table.
BA = behavioral activation; PTSD = posttraumatic stress disorder; PCL = PTSD checklist; BA–TE = behavioral
activation and therapeutic exposure; MDD = major depressive disorder; BAI = Beck anxiety inventory;
CAPS = Clinician-Administered PTSD scale; CBT = cognitive behavior therapy; DASS = Depression Anxiety
Stress Scales; PDS = Posttraumatic Stress Diagnostic Scale; PTCI = Posttraumatic Cognitions Inventory;
BAW = behavioral activation for worry; GAD = generalized anxiety disorder; PSWQ = Penn State Worry
Questionnaire; BATD = brief behavioral activation treatment for depression; BATA = behavioral activation
treatment for anxiety; DARS = Daily Anxiety Rating Scale; GBAT = group behavioral activation therapy;
ADIS-IV-C = Anxiety Disorders Interview Schedule for DSM–IV—child interview.
316 Judah et al.

CHALLENGES AND TROUBLE-SHOOTING

There are a number of potential challenges to targeting BA when working

with patients with anxiety disorders to improve the likelihood of treatment
success. Possible solutions (or prevention strategies) for each of these chal-
lenges are discussed next.

Therapist Challenges

From a therapist’s perspective, incorporating therapeutic procedures that pro-

mote BA in the context of treatment for anxiety disorders presents a few chal-
lenges. Most notably, evidence-based therapists tend to consider BA relevant
only for depression, without recognizing the overlap between BA- and
exposure-based therapies because of the lack of coverage of BA in nondepres-
sion treatment manuals. Without a therapist’s buy-in and understanding of
these overlapping approaches, it is unlikely that the patient will successfully
increase their application of BA principles. One approach is to conceptualize
BA-related activities and exposure practices under a transdiagnostic treatment
perspective. As noted previously, BA-focused treatments seek to address
avoidance of pleasurable activities that serves to maintain symptoms of depres-
sion and/or anxiety. Targeting BA can be considered a transdiagnostic practice
to address transdiagnostic symptoms. As an example, transdiagnostic behavior
therapy (TBT) conceptualizes avoidance as the key transdiagnostic symptom
for the depression and anxiety disorders and advocates for the use of trans­
diagnostic exposure practices (Gros, 2014). TBT incorporates the principle of
BA by framing activity scheduling as a type of exposure (i.e., positive emotions
exposure) that can be delivered in conjunction with typical in vivo exposure.
Research on the dissemination of TBT suggests that this approach is easily
understood and assimilated by therapists (Gros, Szafranski, & Shead, 2017).

Patient Challenges

Despite the potential for increases in BA to facilitate treatment gains for clin-
ical anxiety, strong or long-standing avoidance of anxiety-provoking situa-
tions may interfere with a patient’s ability to comply with the targeted
behavioral goal or ability to enjoy the behavior. This is exacerbated by the
reality that most BA-relevant scheduled activities are not traditionally com-
pleted in-session (as in the case of in-session exposure practice). For example,
a patient with panic disorder may be too afraid of experiencing a panic attack
(and the heart attack anticipated to follow) to complete activities that induce
physiological arousal (e.g., jogging with a friend). In these cases, the therapist
should consider having the patient complete situational exposure practices by
themselves in-session before approaching such activities with friends outside
of the session. Although standard depression treatment protocols centered on
BA do not include psychoeducation for anxiety or in-session behavioral prac-
tices, doing so is common in transdiagnostic treatment programs (e.g., Acierno
et al., 2016; Gros, 2014).
 Behavioral Activation 317

A patient also may use safety behaviors in an attempt to mitigate anxiety

during feared, positive activities. For example, a patient with PTSD may be
unwilling to go out in public unless carrying a firearm. As discussed in Chap-
ter 2, this handbook, safety behaviors tend to disrupt effective exposure to
feared situations (Helbig-Lang & Petermann, 2010). The therapist should
work with the patient to assess for engagement in safety behaviors that may
undermine the potential long-term benefit of BA-promoting activities. Con-
sistent with this, the patient may rely on subtle avoidance behaviors to man-
age anxiety while completing scheduled activities. For example, to check an
activity off the list (e.g., having meal with family in public location), a patient
with PTSD may only go if he or she can sit with his back to the wall. Although
the patient may have made progress that week by showing up at the restau-
rant despite an urge to avoid it, the therapist should reinforce this progress in
BA while simultaneously assessing for the presence of anxiety-reducing
behaviors that undermine long-term success.
Finally, symptoms and disorders that are frequently comorbid with certain
presentations of clinical anxiety may complicate the therapist’s attempts to
capitalize on the mechanism of BA during anxiety treatment. For example, a
patient with chronic pain symptoms or limited mobility may struggle to iden-
tify fulfilling positive activities (e.g., focusing only on what used to bring him
or her joy with inflexible ideas about in what he or she can still engage), or the
patient may overextend himself or herself when trying to increase BA (e.g.,
exacerbating pain or headaches). Similar difficulties are found in patients with
physical handicaps (e.g., blindness). The therapist and the patient must be
flexible in selecting potentially rewarding activities and setting their intensity
and duration (e.g., pacing for chronic pain). It is recommended to return to a
patient’s values in the flexible selection of these activities.

Resolving Therapy-Interfering Behaviors

As in any treatment, the patient may engage in behaviors that derail prog-
ress. Such behaviors may obstruct increases in BA if the patient expects ses-
sions to be a chance to vent frustrations or if he or she refuses to complete
between-session homework. One way to deal with this issue is to discuss
patient expectations about treatment in the initial session, checking with the
patient to ensure that the rationale and treatment plan underlying BA is
understood. Patient noncompletion of homework may also represent avoid-
ance of distressing emotions and/or situations. Guiding the patient to recog-
nize this avoidance redirects the patient toward the rationale and plan for
treatment. The therapist can also encourage activity completion by praising
completed activities. Rather than focus on extrinsic reinforcement (e.g., giv-
ing praise for behavior), the therapist might celebrate success by helping the
patient to reflect on what the goal completion means to the patient and how
that accomplishment might help the patient continue to be successful in
choosing healthy behaviors and improving mood. The therapist is cautioned
against using aversive control (e.g., chastising the patient), as doing so can
318 Judah et al.

generalize to participation in treatment, which risks premature treatment

discontinuation.

CONCLUSION

The mechanism of increasing contact with potential reinforcers in the envi-

ronment (e.g., BA) is most closely associated with behavioral treatments for
depression. This chapter suggested that capitalizing on BA may also serve to
facilitate treatment for clinical anxiety. Moreover, there is substantial concep-
tual and practical overlap between BA- and exposure-based therapies. Growing
evidence supports the utility of increasing BA in the context of anxiety treat-
ment, such that new transdiagnostic treatments (e.g., Gros, 2014) incorporate
BA-focused activity scheduling into exposure therapy. Future work that con-
tinues to incorporate the principle of BA into cognitive behavior treatments
for clinical anxiety is necessary and expected to have considerable benefit to
therapists and patients alike.

REFERENCES
Abramowitz, J. S., Franklin, M. E., Street, G. P., Kozak, M. J., & Foa, E. B. (2000). Effects
of comorbid depression on response to treatment for obsessive-compulsive disorder.
Behavior Therapy, 31, 517–528. http://dx.doi.org/10.1016/S0005-7894(00)80028-3
Acierno, R., Gros, D. F., Ruggiero, K. J., Hernandez-Tejada, B. M. A., Knapp, R. G., Lejuez,
C. W., . . . Tuerk, P. W. (2016). Behavioral activation and therapeutic exposure for post-
traumatic stress disorder: A noninferiority trial of treatment delivered in person versus
home-based telehealth. Depression and Anxiety, 33, 415–423. http://dx.doi.org/10.1002/
da.22476
Armento, M. E., & Hopko, D. R. (2007). The environmental reward observation scale
(EROS): Development, validity, and reliability. Behavior Therapy, 38, 107–119.
http://dx.doi.org/10.1016/j.beth.2006.05.003
Bunnell, B. E., & Gros, D. F. (2017). Transdiagnostic behavior therapy (TBT) for gener-
alized anxiety disorder. International Journal of Case Studies, 6, 1–8.
Carvalho, J. P., Gawrysiak, M. J., Hellmuth, J. C., McNulty, J. K., Magidson, J. F.,
Lejuez, C. W., & Hopko, D. R. (2011). The reward probability index: Design and val-
idation of a scale measuring access to environmental reward. Behavior Therapy, 42,
249–262. http://dx.doi.org/10.1016/j.beth.2010.05.004
Chen, J., Liu, X., Rapee, R. M., & Pillay, P. (2013). Behavioural activation: A pilot trial
of transdiagnostic treatment for excessive worry. Behaviour Research and Therapy, 51,
533–539. http://dx.doi.org/10.1016/j.brat.2013.05.010
Chu, B. C., Colognori, D., Weissman, A. S., & Bannon, K. (2009). An initial descrip-
tion and pilot of group behavioral activation therapy for anxious and depressed
youth. Cognitive and Behavioral Practice, 16, 408–419. http://dx.doi.org/10.1016/
j.cbpra.2009.04.003
Chu, B. C., Crocco, S. T., Esseling, P., Areizaga, M. J., Lindner, A. M., & Skriner, L. C.
(2016). Transdiagnostic group behavioral activation and exposure therapy for
youth anxiety and depression: Initial randomized controlled trial. Behaviour Research
and Therapy, 76, 65–75. http://dx.doi.org/10.1016/j.brat.2015.11.005
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maxi-
mizing exposure therapy: An inhibitory learning approach. Behaviour Research and
Therapy, 58, 10–23. http://dx.doi.org/10.1016/j.brat.2014.04.006
 Behavioral Activation 319

Crino, R. D., & Andrews, G. (1996). Obsessive-compulsive disorder and Axis I comor-
bidity. Journal of Anxiety Disorders, 10, 37–46. http://dx.doi.org/10.1016/
0887-6185(95)00033-X
Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis,
M. E., . . . Jacobson, N. S. (2006). Randomized trial of behavioral activation, cogni-
tive therapy, and antidepressant medication in the acute treatment of adults with
major depression. Journal of Consulting and Clinical Psychology, 74, 658–670. http://
dx.doi.org/10.1037/0022-006X.74.4.658
Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S.
(2014). Behavioural activation for depression; an update of meta-analysis of
effectiveness and sub group analysis. PLoS One, 9, e100100. http://dx.doi.org/10.1371/
journal.pone.0100100
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD:
Emotional processing of traumatic experiences, therapist guide. New York, NY: Oxford Uni-
versity Press. http://dx.doi.org/10.1093/med:psych/9780195308501.001.0001
Fuhr, K., Hautzinger, M., Krisch, K., Berking, M., & Ebert, D. D. (2016). Validation of
the behavioral activation for depression scale (BADS)–psychometric properties of
the long and short form. Comprehensive Psychiatry, 66, 209–218. http://dx.doi.org/
10.1016/j.comppsych.2016.02.004
Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, N. S. (1998). Cognitive-behavioral
treatment for depression: Relapse prevention. Journal of Consulting and Clinical
Psychology, 66, 377–384. http://dx.doi.org/10.1037/0022-006X.66.2.377
Gros, D. F. (2014). Development and initial evaluation of transdiagnostic behavior
therapy (TBT) for veterans with affective disorders. Psychiatry Research, 220,
275–282. http://dx.doi.org/10.1016/j.psychres.2014.08.018
Gros, D. F., & Antony, M. M. (2006). The assessment and treatment of specific phobias:
A review. Current Psychiatry Reports, 8, 298–303. http://dx.doi.org/10.1007/
s11920-006-0066-3
Gros, D. F., McCabe, R. E., & Antony, M. M. (2013). Using a hybrid model to investi-
gate the comorbidity and symptom overlap between social phobia and the other
anxiety disorders and unipolar mood disorders. Psychiatry Research, 210, 188–192.
http://dx.doi.org/10.1016/j.psychres.2013.05.005
Gros, D. F., Price, M., Magruder, K. M., & Frueh, B. C. (2012). Symptom overlap in post-
traumatic stress disorder and major depression. Psychiatry Research, 196, 267–270.
http://dx.doi.org/10.1016/j.psychres.2011.10.022
Gros, D. F., Price, M., Strachan, M., Yuen, E. K., Milanak, M. E., & Acierno, R. (2012).
Behavioral activation and therapeutic exposure: An investigation of relative symp-
tom changes in PTSD and depression during the course of integrated behavioral
activation, situational exposure, and imaginal exposure techniques. Behavior Modi-
fication, 36, 580–599. http://dx.doi.org/10.1177/0145445512448097
Gros, D. F., Szafranski, D. D., & Shead, S. D. (2017). A real-world dissemination and
implementation of transdiagnostic behavior therapy (TBT) for veterans with affec-
tive disorders. Journal of Anxiety Disorders, 46, 72–77. http://dx.doi.org/10.1016/
j.janxdis.2016.04.010
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy,
second edition: The process and practice of mindful change. New York, NY: Guilford Press.
Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review on
the effects of safety behavior across anxiety disorders. Clinical Psychology: Science and
Practice, 17, 218–233. http://dx.doi.org/10.1111/j.1468-2850.2010.01213.x
Hershenberg, R., Smith, R. V., Goodson, J. T., & Thase, M. E. (2018). Activating veterans
toward sources of reward: A pilot report on development, feasibility, and clinical
outcomes of a 12-week behavioral activation group treatment. Cognitive and Behav-
ioral Practice, 25, 57–69. http://dx.doi.org/10.1016/j.cbpra.2017.04.001
320 Judah et al.

Hopko, D. R., Armento, M. E., Robertson, S. M., Ryba, M. M., Carvalho, J. P.,
Colman, L. K., . . . Lejuez, C. W. (2011). Brief behavioral activation and problem-
solving therapy for depressed breast cancer patients: Randomized trial. Journal of Con-
sulting and Clinical Psychology, 79, 834–849. http://dx.doi.org/10.1037/a0025450
Hopko, D. R., Lejuez, C., & Hopko, S. D. (2004). Behavioral activation as an interven-
tion for coexistent depressive and anxiety symptoms. Clinical Case Studies, 3, 37–48.
http://dx.doi.org/10.1177/1534650103258969
Hopko, D. R., Lejuez, C. W., Ryba, M. M., Shorter, R. L., & Bell, J. L. (2016). Support
for the efficacy of behavioural activation in treating anxiety in breast cancer
patients. Clinical Psychologist, 20, 17–26. http://dx.doi.org/10.1111/cp.12083
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., . . .
Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for
depression. Journal of Consulting and Clinical Psychology, 64, 295–304. http://dx.doi.org/
10.1037/0022-006X.64.2.295
Jakupcak, M., Roberts, L. J., Martell, C., Mulick, P., Michael, S., Reed, R., . . . McFall, M.
(2006). A pilot study of behavioral activation for veterans with posttraumatic stress
disorder. Journal of Traumatic Stress, 19, 387–391. http://dx.doi.org/10.1002/
jts.20125
Jakupcak, M., Wagner, A., Paulson, A., Varra, A., & McFall, M. (2010). Behavioral acti-
vation as a primary care-based treatment for PTSD and depression among returning
veterans. Journal of Traumatic Stress, 23, 491–495. http://dx.doi.org/10.1002/
jts.20543
Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C.
(2010). What is behavioral activation? A review of the empirical literature. Clinical
Psychology Review, 30, 608–620. http://dx.doi.org/10.1016/j.cpr.2010.04.001
Kanter, J. W., Mulick, P. S., Busch, A. M., Berlin, K. S., & Martell, C. R. (2007). The
behavioral activation for depression scale (BADS): Psychometric properties and fac-
tor structure. Journal of Psychopathology and Behavioral Assessment, 29, 191–202.
http://dx.doi.org/10.1007/s10862-006-9038-5
Lejuez, C. W., Hopko, D. R., Acierno, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten-
year revision of the brief behavioral activation treatment for depression: Revised
treatment manual. Behavior Modification, 35, 111–161. http://dx.doi.org/10.1177/
0145445510390929
Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treat-
ment for depression. Treatment manual. Behavior Modification, 25, 255–286. http://
dx.doi.org/10.1177/0145445501252005
Lewinsohn, P. M. (1974). A behavioral approach to depression. In J. C. Coyne (Ed.),
Essential papers on depression (pp. 150–172). New York: New York University Press.
Lewinsohn, P. M., Sullivan, J. M., & Grosscup, S. J. (1980). Changing reinforcing
events: An approach to the treatment of depression. Psychotherapy: Theory, Research
& Practice, 17, 322–334. http://dx.doi.org/10.1037/h0085929
MacPherson, L., Collado, A., Lejuez, C. W., Brown, R. A., & Tull, M. T. (2016). Behav-
ioral activation treatment for smoking (BATS) in smokers with depressive symp-
tomatology. Advances in Dual Diagnosis, 9, 85–96. http://dx.doi.org/10.1108/
ADD-02-2016-0005
MacPhillamy, D. J., & Lewinsohn, P. M. (1982). The pleasant events schedule: Studies
on reliability, validity, and scale intercorrelation. Journal of Consulting and Clinical
Psychology, 50, 363–380. http://dx.doi.org/10.1037/0022-006X.50.3.363
Magidson, J. F., Gorka, S. M., MacPherson, L., Hopko, D. R., Blanco, C., Lejuez, C. W.,
& Daughters, S. B. (2011). Examining the effect of the life enhancement treatment
for substance use (LETS ACT) on residential substance abuse treatment retention.
Addictive Behaviors, 36, 615–623. http://dx.doi.org/10.1016/j.addbeh.2011.01.016
Manos, R. C., Kanter, J. W., & Busch, A. M. (2010). A critical review of assessment
strategies to measure the behavioral activation model of depression. Clinical Psychol-
ogy Review, 30, 547–561. http://dx.doi.org/10.1016/j.cpr.2010.03.008
 Behavioral Activation 321

Manos, R. C., Kanter, J. W., & Luo, W. (2011). The behavioral activation for depression
scale-short form: Development and validation. Behavior Therapy, 42, 726–739.
http://dx.doi.org/10.1016/j.beth.2011.04.004
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for
guided action. New York, NY: W. W. Norton.
Mazzucchelli, T., Kane, R., & Rees, C. (2009). Behavioral activation treatments for
depression in adults: A meta-analysis and review. Clinical Psychology: Science and Prac-
tice, 16, 383–411. http://dx.doi.org/10.1111/j.1468-2850.2009.01178.x
Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., &
Poulton, R. (2007). Depression and generalized anxiety disorder: Cumulative and
sequential comorbidity in a birth cohort followed prospectively to age 32 years. Archives
of General Psychiatry, 64, 651–660. http://dx.doi.org/10.1001/archpsyc.64.6.651
Nixon, R. D., & Nearmy, D. M. (2011). Treatment of comorbid posttraumatic stress dis-
order and major depressive disorder: A pilot study. Journal of Traumatic Stress, 24,
451–455. http://dx.doi.org/10.1002/jts.20654
Ramnerö, J., & Törneke, N. (2008). ABCs of human behavior: Behavioral principles for the
practicing clinician. Reno, NV: Context Press.
Resick, P. A., & Schnicke, M. k. (1993). Cognitive processing therapy for rape victims: A treat-
ment manual. Newbury Park, CA: Sage.
Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C. W., & Acierno, R. (2012). An inte-
grated approach to delivering exposure-based treatment for symptoms of PTSD and
depression in OIF/OEF veterans: Preliminary findings. Behavior Therapy, 43, 560–569.
http://dx.doi.org/10.1016/j.beth.2011.03.003
Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression.
Behavior Modification, 33, 818–829. http://dx.doi.org/10.1177/0145445509350094
Turner, J. S., & Leach, D. J. (2010). Experimental evaluation of behavioral activation
treatment of anxiety (BATA) in three older adults. International Journal of Behavioral
Consultation and Therapy, 6, 373. http://dx.doi.org/10.1037/h0100917
Wagner, A. W., Zatzick, D. F., Ghesquiere, A., & Jurkovich, G. J. (2007). Behavioral
activation as an early intervention for posttraumatic stress disorder and depression
among physically injured trauma survivors. Cognitive and Behavioral Practice, 14,
341–349. http://dx.doi.org/10.1016/j.cbpra.2006.05.002
Wolpe, J. (1969). The practice of behavior therapy. New York, NY: Pergamon Press.
18
Mindfulness and Acceptance
Clarissa W. Ong, Brooke M. Smith, Michael E. Levin,
and Michael P. Twohig

Mindfulness and acceptance are distinct but related constructs. Mindfulness

originated with the teachings of the Buddha, who lived and taught around
2,600 years ago in what is now India. Pali was the language of the Buddha, and
the word mindfulness is an English interpretation of the Pali word sati. Sati,
loosely translated, means “remembering.” As described by the Buddhist scholar
Ana–layo (2003), “it is due to the presence of sati that one is able to remember
what is otherwise only too easily forgotten: the present moment” (pp. 47–48).
Therefore, mindfulness refers to the act of remembering an experience as it
occurs in the present moment and may be aptly translated as “present moment
awareness” (Ana–layo, 2003). As described by the Buddha, at the core of
Buddhist meditation practice, “right mindfulness” or samma– sati is one of eight
factors on the path leading to the cessation of suffering. In its original Buddhist
context, mindfulness is one of a number of interrelated qualities that, when
cultivated, has the potential to lead one out of suffering. It is with this function
in mind that mindfulness was borrowed by Western psychological science.
Mindfulness, as adopted by Western psychology, has been difficult to oper-
ationalize. Generally, the construct is assumed to reflect its original Buddhist
meaning, but it is defined differently by researchers (Grossman & Van Dam,
2011). An influential psychological definition of mindfulness comes from Jon
Kabat-Zinn (1994), who called it “paying attention in a particular way: on pur-
pose, in the present moment, and nonjudgmentally” (p. 4). As a verb, “paying

http://dx.doi.org/10.1037/0000150-018
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
323
324 Ong et al.

attention” highlights mindfulness as an activity rather than as the stable trait

that is sometimes implied by common self-report measures of mindfulness
(Grossman & Van Dam, 2011). The cultivation of mindfulness requires dili-
gence and effort; as such, it is a practice. In addition, because mindfulness is a
type of awareness, it can be practiced at any moment in any situation. This
leads to the second part of Kabat-Zinn’s definition (1994): “on purpose.”
Mindfulness is not haphazard attention; it is purposeful and sustained atten-
tion, taking as its object whatever is occurring in the present moment (the
third part of his definition). As for the final part of the definition, nonjudg-
ment was not originally included in the meaning of sati. However, a mindful
state does engender nonjudgment through sustained attention on the direct
knowing of experience without added verbal material (e.g., internal com-
mentary, which is often evaluative). Through mindfulness, one is able to
notice judgment as it arises and realize that such verbal proliferations are not
a part of the direct experience, so judgment is simply dropped.
Acceptance is a construct commonly associated with mindfulness, but it was
not a term used by the Buddha (Bhikkhu, 2008). In fact, acceptance tends to
be the result of mindfulness rather than an aspect of its definition. As a purely
psychological construct, acceptance refers to an openness to internal experi-
ences (e.g., thoughts, emotions, physical sensations) and a willingness to
actively embrace those experiences, be they perceived as pleasant or unpleas-
ant. Acceptance is often contrasted with experiential avoidance (see Chap-
ter 7), which is an unwillingness to stay in contact with certain difficult
psychological experiences and deliberate attempts to avoid, escape, or some-
how alter the form of these experiences, even when doing so has a harmful
effect (Hayes, Strosahl, & Wilson, 2011).
When one is mindful of internal experiences, without adding additional
verbal material (e.g., judgment), an accepting stance naturally arises. Further­
more, to accept internal experiences, one must remain in contact with them
as they unfold in the moment; in other words, one must be mindful. Through
continued practice, the range of experiences one can accept expands and,
therefore, so does the range of objects of which to be mindful. In these ways,
mindfulness and acceptance complement and strengthen each other.

IMPLEMENTATION

Overview of Mindfulness- and Acceptance-Based Therapies

Mindfulness and acceptance have been integrated into various psychological

interventions, including among others: acceptance and commitment therapy
(ACT; S. C. Hayes et al., 2011), acceptance-based behavior therapy (Hayes-
Skelton, Roemer, & Orsillo, 2013; Roemer, Orsillo, & Salters-Pedneault,
2008), dialectical behavior therapy (DBT; Linehan, 2014), mindfulness-based
stress reduction (MBSR; Kabat-Zinn, 1990), and mindfulness-based cognitive
therapy (MBCT; Segal, Williams, & Teasdale, 2013). The following description
 Mindfulness and Acceptance 325

of implementation is based on an ACT approach. Details on the implementa-

tion of other mindfulness- and acceptance-based interventions may vary but
underlying processes of change likely overlap across therapies.
A crucial element of a mindfulness and acceptance approach is clarifying
treatment goals at the start of therapy. From this perspective, the goal of treat-
ment is to help patients live a life they find meaningful. Because individuals
wish for different things in life, the target outcomes will vary. Patients may
initially say that their goal is to reduce internal or external symptoms, which
could entail decreasing obsessions, worries, or anxiety. However, if the clini-
cian digs a little deeper, it is likely that reducing internal symptoms is simply
a means to a more meaningful life.
A second critical element is that, from a mindfulness and acceptance
approach, one learns to let go of evaluating inner experiences as good or bad.
Thoughts, feelings, and bodily sensations occur throughout the day. Some are
minor or even imperceptible, while others, such as obsessions and worries,
are substantial and salient. Taking a mindful and accepting stance toward
inner experiences makes it easier to choose how to react when an inner expe-
rience is occurring. The aim is to alter the function or effect of the inner expe-
rience in a contextually sensitive manner. Thus, inner experiences cannot be
categorically defined; they must be functionally defined. For example, it is
usually useful to act on the feeling of love or caring for one’s family, but there
are also times when it is more functional to “ignore” that inner experience
and carry on with the task in which one is engaged. A primary objective in
the treatment of anxiety is to alter the relationship with inner experiences
from one in which certain experiences demand action to one in which they
are only suggestions for action. It is helpful, or at least therapeutically consis-
tent, to be explicit about these two points from the onset of therapy.
The following sections outline the use of mindfulness and acceptance for
obsessive-compulsive disorder (OCD; see Eifert & Forsyth, 2005; Twohig,
2009; Twohig et al., 2010) and generalized anxiety disorder (GAD; see Roemer
& Orsillo, 2005; Roemer et al., 2008). We then discuss the common themes
and overarching ideas in treatment and how they can be applied to other clin-
ical manifestations of anxiety. Table 18.1 provides examples of therapeutic
exercises and metaphors that might be used to capitalize on mindfulness and
acceptance as processes of change.

Obsessive-Compulsive Disorder
Mindfulness and Acceptance in the Treatment of Obsessive-Compulsive Disorder.  
OCD is characterized by the presence of (a) intrusive and unwanted thoughts,
images, or urges (obsessions) and/or (b) repetitive behaviors (overt or men-
tal) that are performed to reduce anxiety or distress (compulsions; American
Psychiatric Association, 2013). Traditional exposure with response preven-
tion (ERP) continues to be the key ingredient in the treatment of OCD. Many
researchers have worked to add logically or empirically backed techniques to
bolster the effectiveness or acceptability of ERP, but nothing thus far, includ-
ing mindfulness and acceptance procedures, has increased the effectiveness of
326 Ong et al.

TABLE 18.1. Examples of Therapy Exercises and Metaphors Targeting Different

Mindfulness and Acceptance Processes
Process Exercise/metaphor
Effectiveness of controlling Polygraph metaphor
thoughts/feelings

Acceptance Obsessions/anxiety as a bully metaphor

Obsessions/anxiety as a child in a grocery store who is
whining for candy metaphor
Carry a piece of paper with obsession/worry written on it
exercise
Two games metaphor

Defusion Mind as an announcer from a sporting event or pop-ups

on a computer metaphor
Chessboard metaphor
Passengers on the bus metaphor
Mind as a GPS metaphor
Notepad physical metaphor
Word repetition exercise
Leaves on a stream mindfulness exercise

Mindfulness Concentration-based meditation exercise

Flexible attention mindfulness exercise

ERP (Olatunji, Davis, Powers, & Smits, 2013; Öst, Havnen, Hansen, & Kvale,
2015; Tolin, 2009; Twohig et al., 2018). Nonetheless, it is worthwhile to be
familiar with these procedures for situations in which ERP has been ineffec-
tive, patients refuse to complete exposures, or the use of mindfulness and
acceptance is indicated based on elements of the clinical presentation and
evidence-based practice in psychology (American Psychological Association,
Presidential Task Force on Evidence-Based Practice, 2006).

Allowing Obsessions to Be There: Acceptance. It is often helpful to start with a

discussion of how well attempts to control obsessions have worked in the
short term (minutes) and long term (days) and whether attempts to regulate
obsessions have improved life or made it harder—in terms of (a) the obses-
sions being more central and (b) time spent controlling the obsessions. The
answer to this question is known before it is asked, but it is helpful for patients
to work through it themselves. Control strategies (e.g., compulsions, avoid-
ance, reassurance) can lessen obsessions and anxiety briefly, but there is
nothing patients can do to stop obsessions for good. Moreover, the more
patients fight against obsessions, the more central obsessions become in their
lives; life then revolves around emotion regulation rather than increasing
meaningful actions.
Acceptance of obsessions is taught as an alternative to control. Acceptance
is not liking or believing the content of obsessions; it is allowing them to exist
within the person as one might allow an annoying coworker to work in the
 Mindfulness and Acceptance 327

same building. Acceptance is often taught through examples, including “deal-

ing with obsessions is similar to how you might deal with a bully” or “think
of your obsessions like a child in a grocery store who is whining for candy.”
Patients are also asked to write an obsession on a piece of paper and carry it
in their pocket throughout the week as an example of being willing to take
it along.
Another metaphor clinicians could use is the two-games metaphor. The
point of the metaphor is to have patients see that they need to step away from
attempts to regulate their obsessions in order to work on the important things
in life. The following script provides an example of how clinicians could
deliver the metaphor:

CLINICIAN: It’s like there are two games going on right now. In the first
game, the aim is to successfully control your obsessions. Win-
ning means defeating your obsessions and keeping them away.

PATIENT:  Yeah, that feels about right.

CLINICIAN: How often do you win that game?

PATIENT:  Well, I can probably win 10% of the time.

CLINICIAN: And how long is it before you find yourself getting back into
the game?

PATIENT:  Not long. I feel like I have to be constantly playing to even have
a chance of winning. It’s exhausting.

CLINICIAN: Sounds like it. What if there was a second game in the court
next to you? In this game, the aim is to live your life the way
you want. You win by doing things you care about. But the
catch is you can only play one game at a time.

PATIENT:  Hmm, I’ve never thought about it that way, but it makes sense:
the more I try to avoid my obsessions, the less I actually do the
things I want to do.

CLINICIAN: Which game seems more worth playing to you at this moment?

Seeing Obsessions for What They Are: Mindfulness and Defusion. Practicing
defusion or being mindful facilitates acceptance by helping patients see obses-
sions for what they are—thoughts, feelings, or bodily sensations. As evidenced
in research on topics such as thought action fusion (Shafran, Thordarson, &
Rachman, 1996), patients do not experience obsessions as mere thoughts;
obsessions are experienced as real, meaningful, and having the power to affect
events in the world.
Exercises such as treating the mind as an announcer from a sporting event,
or pop-ups on a computer, illustrate that we do not get to choose what occurs
in our heads. Similarly, watching thoughts in a formal meditation or while
being mindful during an activity (e.g., brushing teeth, driving) teach the
328 Ong et al.

discrimination between seeing a thought as a thought and buying into a

thought and experiencing it as reality. Being able to notice an obsession dis-
passionately gives patients the space to decide how to react to it. Another
useful exercise involves likening patients’ struggle with obsessions to a game
of chess. There are pieces on each side—one side represents obsessions and
the other represents the ways patients try to control the obsessions. Although
patients often root for one side over another, it can be useful for patients to
think of themselves as the board on which the game is played. The board does
not care who wins the game; the board just supports the game. An actual
board game can be used to illustrate this idea. Patients can also think of them-
selves as a driver of a bus, with all the obsessions as passengers on the bus. In
this exercise, patients are asked to describe what each obsession looks like.
They can be scary or demonic; they may even be someone supportive who is
pleading for a certain safe action. These passengers try to tell the driver where
to go, but only the driver gets to drive the bus and has the power to choose
where it goes. Patients can practice letting the passengers talk—or even yell—
without responding to them and heading in a valued direction. An example
of how this discussion might go follows:

CLINICIAN: We can think of it like you’re driving a bus full of passengers.

The passengers are always yelling at you and telling you what
to do: “Go left!” “Make a U-turn here!” As the driver, you have
your own agenda, places you want to visit and a direction that
matters to you, but listening to your passengers tends to get in
the way of that.

PATIENT: So true.

CLINICIAN: Who is the loudest passenger on your bus?

PATIENT: Definitely the “you are going to get sick and die” passenger.

CLINICIAN: What does this passenger look like?

PATIENT: Hmm, he kind of is dressed like a doctor with a stethoscope and

white coat. He’s middle-aged and is balding a little. He’s probably
of average height. He has an authoritative voice though—as if
he knows what he’s talking about.
[The clinician can elicit other examples of passengers to make
sure the patient is experientially engaged with the metaphor.]

CLINICIAN:  What do you do when the doctor tells you to go left?

PATIENT: I go left.

CLINICIAN:  How does that line up with your values?

PATIENT: It doesn’t, but at least the doctor leaves me alone.

CLINICIAN: Yeah, so you’ve kind of made a deal with the doctor: “Fine, I’ll
do what you tell me as long as you keep quiet.”
 Mindfulness and Acceptance 329

PATIENT: Exactly.

CLINICIAN: What’s that like for you?

PATIENT: Not fun. It’s like I’ve lost control of my own bus!

CLINICIAN: It sure sounds like it. How could you get control over where
your bus goes?

PATIENT: I don’t know; just drive it wherever I want.

CLINICIAN: What would that look like for you?

PATIENT: Well, the passengers are going to be mad and yell even louder;
but I’m the driver, so I have the power to pick where we go.

CLINICIAN: What if they get really upset and start coming to the front of
the bus? Would they have the power to control your bus then?

PATIENT: I don’t think so. I mean, I’m still the one with my hands on the
steering wheel.

CLINICIAN: What would it be like to keep practicing doing exactly that:

choosing where your bus goes regardless of what your passen-
gers do?

PATIENT: I’d probably get my life back, honestly.

Values and Behavior Change. As suggested in a meta-analysis (Levin,

Hildebrandt, Lillis, & Hayes, 2012), teaching mindfulness techniques results
in less behavior change than highlighting that mindfulness may be used to
support behavior change. In other words, it is critical to teach mindfulness
with a purpose when using it as a psychological intervention. The purpose in
this treatment is acting in line with values. To clarify values, clinicians have a
discussion with patients about the areas of life that are important to them and
into which they want to put time and effort. Career, education, family, and
spirituality are examples of valued domains. Honesty, loyalty, and kindness
are examples of ways of being that are also considered values. Patients define
how and which areas or ways of being are meaningful to them given their
beliefs, culture, upbringing, and lived experiences. Becoming aware of one’s
values can foster increased action in those areas. The most useful aspect of
discussing values in the treatment of OCD is to help patients look at behavior
more functionally. Clinicians can ask their patients, “Was that action in the
service of your values or was it to lessen an obsession?” Over the course of
treatment, patients learn to choose actions that are in the service of their val-
ues rather than in service of their emotion regulation.
Finally, clinicians can use behavioral commitments to establish patterns of
action in line with values; these commitments involve practicing acceptance,
mindfulness, and defusion. These can be integrated into traditional ERP pro-
cedures (Twohig, Abramowitz, et al., 2015). Whether within or outside of the
therapy session, patients are directed to connect with the value behind the
330 Ong et al.

action, engage in the action, and practice mindfully observing and making
room for their obsessions. If indicated, entire sessions can be devoted to expo-
sures as would typically be done in ERP. From a mindfulness and acceptance
perspective, however, the goal is improving the ability to act in values-consistent
ways in the presence of the feared stimulus (e.g., obsession, anxiety).

Generalized Anxiety Disorder

Exploring the Function and Workability of Worry. GAD is defined by a per-
vasive pattern of worry about a range of topics and unlikely negative out-
comes that is difficult to control (American Psychiatric Association, 2013).
Worry can be conceptualized as a behavior, meaning that just as with any
other behavior, clinicians can guide patients in clarifying the function or
purpose of worry and whether it helps them to engage in meaningful, effec-
tive activities.
One of the most common, core functions of worry is experiential avoid-
ance (Roemer & Orsillo, 2005). This can be somewhat paradoxical in that
worry often induces some degree of distress; however, this distress is typically
milder, more predictable, and prevents larger, unexpected increases in dis-
tress if unexpected negative events occur. In other words, worry is used
to prevent greater and more unpredictable distress. Clinicians might help
patients to notice the avoidant functions of worry with questions like “When
do you worry?” “If you didn’t worry, what would be different?” and “Some
people worry as a way to get away from scarier, unexpected, or otherwise
difficult thoughts and feelings. How might this apply to you?”.
Once the avoidant function of worry is clarified, clinicians can help patients
to explore its workability. Worry, like most avoidant behaviors, may be effec-
tive in the short term in relieving distress. However, patients generally find
that worry creates more problems than it solves in the long term. In terms of
treatment, it can help to break this down when exploring workability, asking
patients how worry has worked to help them feel better in the short term
versus the long term. Similarly, it helps to distinguish whether worry helps
with feeling goals (i.e., the goal to feel better) versus whether worry helps
with action goals (i.e., the goal to take more effective, meaningful actions in
one’s life).
Of note, patients fitting a GAD symptom profile are likely to engage in a
range of other avoidant behaviors, although these may be more diffuse than
a targeted anxiety disorder (e.g., avoidance of social situations within social
anxiety disorder). Thus, it is important to similarly identify and explore the
workability of patients’ other avoidant behaviors.
A variety of exercises and metaphors can help patients to further explore
the negative “side effects” of experiential avoidant behaviors such as worry.
One metaphor that helps illustrate the “worry about worry” spiral that can
develop is the polygraph metaphor. This metaphor describes a person who is
attached to the world’s most sensitive polygraph, and their only job is not to
get anxious—no matter what. To help motivate the person, patients can
imagine a looming threat, such as losing a large bet or sitting over a shark
 Mindfulness and Acceptance 331

tank, if they show any anxiety whatsoever. This metaphor can then be linked
to patients’ own experiences of trying not to be anxious at all costs, which
often leads to more anxiety and other problems in life.
Another common technique is to differentiate pain versus suffering. Pain
refers to the naturally occurring, difficult thoughts, feelings, and bodily sen-
sations (e.g., tension in the neck, panicky sensations) that arise as people
engage in the world and interact with things that are meaningful to them. For
example, it makes sense to feel anxiety if there is something important at
stake, but at which you could fail. Suffering, however, is all the added
unpleasant thoughts and feelings that arise when we focus on trying to make
our pain go away. This can be illustrated by eliciting an example from the
patient. For example, the patient may be guided to notice how anxiety arises
in relation to receiving a large bill in the mail (i.e., pain), while worrying
intensely and avoiding looking at the bill might make anxiety (and likely the
bill itself, due to late fees) bigger and bigger (i.e., suffering).
Ideally, by the end of this work, the patient will have learned how to iden-
tify actions (including worry) that function as experiential avoidance as well
as clarified their workability. This provides the foundation for introducing
mindfulness and acceptance strategies. Skipping this step can introduce the
potential problem of patients using mindfulness and acceptance as just
another experientially avoidant behavior (e.g., being mindful to make worry
go away). To shift to a radically different way of relating to thoughts and feel-
ings, it is important that patients first do this initial work to identify the func-
tion and workability of their coping strategies thus far.

Relating to Worry and Other Cognitions From a “Defused” Stance. The next
set of skills can be introduced in various sequences. A typical sequence might
next shift to exploring challenges related to how language works. This
includes helping patients notice how thoughts are automatic and relatively
out of our control, but can seem to have a lot of power over perceptions and
actions when allowed (which we refer to as cognitive fusion). This work
builds up to teaching cognitive defusion as an alternate way of responding to
thoughts as “just thoughts.”
There are a variety of metaphors that can help orient patients to a cogni-
tively fused versus defused stance toward thoughts. For example, “If your
mind were like a GPS (global positioning system), being fused would be like
driving wherever it told you to go, even if it ended up driving you into a
lake.” Cognitive defusion is like acknowledging what your GPS is saying, but
noticing it as just a GPS and that you can still choose where to drive. This brief
metaphor helps patients to shift how they approach their thoughts—equating
thoughts such as, “I have to go over all my deadlines right now,” with times
a GPS was clearly wrong and they chose to drive independent of what it said.
Another metaphor is to take a physical object such as a notepad and to tell
the patient, “Let’s say this notepad is your worry,” then having the patient
write down a few of their most worrisome thoughts. We then walk through a
variety of ways of interacting with the thought. Cognitive fusion is illustrated
332 Ong et al.

as the notepad up close to the patient’s face, so that the only thing the person
can see is the thought, thereby missing out on what is happening in the present.
Experiential avoidance (e.g., thought suppression, distraction) would be like
pushing the notepad out as far as it can go. The clinician can explore with the
patient what might happen—eventually your arm gets tired and the whole time
your focus (and one of your arms) is working to keep that worry away. Finally,
cognitive defusion is introduced as just letting the notepad lay in the patient’s
lap. This means being in touch with the thought, letting it be there without
fighting it. However, this frees the patient up to focus on what the patient wants
to focus on in the moment, and to have the patient’s hands be free to do what-
ever is needed. Physical metaphors like these, if they resonate with patients,
can provide a quick prompting tool in future sessions—helping patients notice
if the notepad is getting stuck against their face or if they are fighting hard to
push it away.
In addition to orienting to the concept of defusion, having patients experi-
entially practice relating to thoughts from a defused stance can be helpful.
Experiential exercises evoke a more dramatic, contextual shift in the moment
to help patients really “get” what it is like to see thoughts as just thoughts.
This is sometimes targeted with brief exercises such as repeating a word over
and over again until it loses its meaning and becomes just sounds, like odd
noises. An example of how to deliver this exercise follows:

CLINICIAN:  If you could boil down your worry to one word, what would
it be?

PATIENT: I think ultimately it comes down to being a failure. That’s what

drives a lot of my worry.

CLINICIAN:  I notice when you say “failure,” some emotion came up for
you. What just showed up?

PATIENT: I guess I’m just thinking about how I might be disappointing

people I care about and how crappy that feels.

CLINICIAN: Seems like that word has some power over you.

PATIENT: Yeah, that’s what it feels like.

CLINICIAN: All right, would you be willing to do a silly exercise with me?

PATIENT: Um, sure.

CLINICIAN: OK, we are going to say “failure” as many times as we can in

the next 30 seconds. I’ll keep an eye on the clock as we do it. I
need you to pay attention to what happens to that word as we
repeat it. Right now, it has a lot of power. I’m curious if that
stays true during this exercise.

PATIENT: Seems odd, but OK.

CLINICIAN: Are you ready?

 Mindfulness and Acceptance 333

PATIENT: Sure, I guess.

CLINICIAN: Let’s start now.

[Clinician and patient repeat “failure” as many times as they
can in 30 seconds. Clinician can prompt patient to “go faster” if
they notice the patient slowing down repetition.]

CLINICIAN: All right, that’s 30 seconds. What did you notice about “failure”
as you did that exercise?

PATIENT: It became weird!

CLINICIAN: What do you mean?

PATIENT: Like, it just sounds weird. I was so focused on saying “failure”

as quickly as possible and wasn’t thinking about the meaning.
I noticed it got a bit hard to say.

CLINICIAN: What did you notice about the effect of the word “failure”
on you?

PATIENT: It didn’t really have an effect. At least not like before we did the
exercise.

CLINICIAN: How interesting. What do you make of that?

PATIENT: I don’t know. It was kind of cool, I guess. It’s such a hard thing
for me to say or think about so that’s a new experience for me.

CLINICIAN: And the whole time, even though we didn’t do anything to

change the word “failure,” the power it had over you changed.

PATIENT: Sort of. Yeah, I didn’t have that same feeling of sadness when
we were repeating it.

Somewhat longer “eyes closed” experiential exercises are also often used
such as the “leaves on a stream” meditation where patients imagine a stream
and practice placing each thought they have on a passing leaf. Exercises like
these help patients to experience what it is to simply notice thoughts as
thoughts without fighting them or being fused with (controlled by) them.

Being Mindful of the Present Rather Than the Past or Future. Worry focuses
on imagined, feared futures, which means it naturally pulls patients away
from focusing on the present. This can lead to a lack of enjoyment or effec-
tiveness while engaging in valued activities (being on “autopilot”), missing
opportunities to take effective, meaningful action, and other challenges.
Mindfulness- and acceptance-based approaches include a variety of strategies
to help patients be more mindful of the present.
One core set of strategies are mindfulness exercises. These might include
more concentration-based meditation exercises in which patients focus on an
experience (e.g., breathing) and practice compassionately noticing it and
returning their attention to it when the mind wanders. These also might
334 Ong et al.

include exercises focused more on flexible attention—being able to shift to

notice a variety of experiences in the present moment rather than “getting
stuck” on any one experience.
Patients are guided on how to generalize the mindfulness developed in
these formal exercises to activities in which they engage throughout the day,
bringing the same mindful attentive qualities to their everyday lives. This
often also includes being mindful in the process of therapeutic interactions
(Wilson & DuFrene, 2009). Therapy provides a perfect context for helping
teach patients how to “slow down” in the moment, become more aware of
their internal reactions and what is happening around them in the moment,
and to purposefully engage in meaningful actions. Clinicians can model this
for patients, describing with a slow, purposeful quality what their experiences
are and then eliciting a similar mindful stance from patients. Clinicians might
also prompt patients to notice particular experiences, such as emotions,
thoughts, and sensations in their body. The key is that the conversation main-
tains a present-focused, compassionate, and accepting stance, so that experi-
ences are noticed and welcomed just for what they are.

Practicing Acceptance With Anxiety. GAD is often associated with emotional

reactivity and difficulties regulating emotions. Patients struggle to be “with”
their anxiety and other emotions, because these feelings tend to be experi-
enced as overly intense, uncontrollable, and possibly even dangerous. Part of
acceptance work is letting go of trying to make these unwanted emotions go
away, while also orienting patients toward what to do instead of avoidance.
One way of practicing acceptance is to engage in meaningful actions while
accepting whatever thoughts and feelings arise. A patient might be guided
in how to commit to a “bold move,” in which they choose to do something
important despite the fact that anxious thoughts and feelings may arise. An
important part of this practice is to be open and compassionate towards the
inner experiences that arise during such bold moves. In other words, the idea
is not to “white knuckle” through an anxiety-provoking situation, but to truly
accept anxiety as the patient mindfully engages in the activity. Similar to the
treatment described for OCD previously, this fits with in vivo exposure strat-
egies, except with a focus on practicing acceptance of inner experiences and
engaging in valued action, rather than focusing on habituation to feared
situations or changes in dysfunctional beliefs to reduce distress.
Another way of practicing acceptance is by actively “leaning in” to previ-
ously avoided emotions with mindfulness exercises. For example, patients
might be guided through steps such as acknowledging and labeling the emo-
tion they are experiencing, observing where they feel it in their body and
what sensations are associated with it, using their breath as a way of actively
opening up to the emotion (e.g., imagine breathing into where that emotion
is in their body), welcoming the emotion (e.g., repeating “welcome anxiety,
my old friend”), and so on (see Harris, 2009). These mindfulness strategies
provide another way of actively practicing acceptance as an alternative to
 Mindfulness and Acceptance 335

experiential avoidance, particularly as patients become more psychologically

flexible and willing to fully embrace painful internal experiences.

Common Treatment Themes

This section summarizes overarching therapeutic ideas covered in the preced-

ing OCD and GAD treatment discussions. These broader themes can be used
to inform a range of clinical presentations related to fear and anxiety.

Case Conceptualization
As with all psychological interventions, mindfulness- and acceptance-based
therapies are based on a theoretically driven case conceptualization, which
guides the ensuing therapeutic process. When hypothesizing mindfulness
and acceptance skill deficits as key etiological or maintaining mechanisms,
the clinician should explore what these processes look like and how they
function in the patient’s life. Typically, clinicians will find that the answers to
these questions tend to be similar, regardless of clinical presentation. Com-
mon avoidance or control strategies include emotional suppression, self-talk
(e.g., reassurance, rationalization), and distraction, as well as more extreme
examples of avoidance such as substance use or self-harm. Avoidance gener-
ally provides short-term relief from distress, although patients may note that
the long-term consequence of avoidance is disengagement from meaningful
activities. Clarifying these various aspects of the presenting concern and shar-
ing one’s case conceptualization with the patient can form a solid foundation
on which to base the rest of therapy. With the clinician and patient on the
same page about how fear and anxiety are getting in the way of valued living,
both can then collaboratively formulate treatment goals to move the latter
toward the life they would like to live.

Intervention
Because mindfulness- and acceptance-based techniques are more focused on
ineffective behavioral responses to stimuli than on the stimuli per se, com-
mon themes emerge across the interventions described for OCD and GAD.
Namely, both protocols outlined are grounded in a general assessment of the
function of anxiety in the patient’s life and aim to train different, more effec-
tive, ways of interacting with anxiety. The goal is not to change the frequency
or intensity of anxiety. The skills taught include mindfulness, acceptance, and
defusion, which encourage taking an open, nonjudgmental, observing stance
toward difficult thoughts, feelings, and sensations in the service of chosen
values—this set of skills is referred to as psychological flexibility. From this
perspective, anxiety does not need to be changed per se; rather, the way anxiety
is responded to can be directly targeted, with the aim being to facilitate mind-
fulness and acceptance.
Getting patients to listen to their lived experience, rather than to the
rules issued by their minds, is an important first step in therapy because
336 Ong et al.

mindfulness- and acceptance-based interventions emphasize experiential

learning. Related to this, behavioral exercises are an important component of
these interventions, with the objective of giving patients the opportunity to
practice interacting with fear and anxiety in new ways. Guidance from the
clinician when first starting exercises can be especially valuable as it frames
the purpose of the exercises—to learn how to be open to anxiety while engag-
ing in meaningful behavior.
Sometimes, it may be difficult to set up opportunities for purposeful behav-
ior within the confines of a therapy room. For example, it would be challenging
to conduct an exposure with patients with OCD whose fear of contamination
affects their ability to play with their children. If that is the case, it may be help-
ful for the clinician to elicit from the patient the link between exercises prac-
ticed in session and valued behavior outside of session. Questions such as,
“How may this activity apply to your life?” or “What would it mean for you if
you were able to be truly open to anxiety, as you were just now, in your
struggle with ____?” can prompt patients to think about their reason for
engaging in an experiential task. In the previous example, the clinician may
design an exercise in which the patient interacts with a feared stimulus (e.g.,
dirt) while allowing all kinds of internal experiences to “show up.” The act of
touching dirt may not connect with any specific patient value, but making an
intentional choice to engage in a difficult task to expand one’s behavioral
repertoire can be done in the service of ultimately engaging in meaningful
valued behavior outside the therapy room.
The specific skills taught and the method of case conceptualization are
similar across anxiety disorders and OCD. Although the content of distressing
stimuli and types of avoidance behaviors can look vastly different within the
same patient or from one patient to the next, the clinician can stay anchored
in a mindfulness and acceptance framework by returning to a functional
understanding of the patient’s concerns and the goals of therapy.

OUTCOME INDICATORS

Given the functional stance of mindfulness- and acceptance-based interven-

tions, metrics for treatment outcome evaluation emphasize effective ways of
interacting with internal experiences and behavioral consistency with values
(i.e., psychological flexibility) rather than symptom severity. Measures that
focus on valued living, the primary outcome of interest, are considered a more
useful way to gauge treatment progress than are measures of distress per se.
Although there are many exemplary measures, those included in Table 18.2
have demonstrated sensitivity to treatment effects in individuals with clinically
severe anxiety (e.g., Arch, Wolitzky-Taylor, Eifert, & Craske, 2012; Carmody,
Baer, Lykins, & Olendzki, 2009; Craske et al., 2014; Forman, Herbert, Moitra,
Yeomans, & Geller, 2007; Villatte et al., 2016; Wersebe et al., 2017).
It is also possible to determine patients’ progress based on their responses
in therapy; however, use of standardized measures may reveal specific areas
 Mindfulness and Acceptance 337

TABLE 18.2. Self-Report Assessment Measures of Treatment Progress

Measure name Source
Valued Living
Bull’s-Eye Values Survey Lundgren, Luoma, Dahl, Strosahl, and Melin
(2012)
Valued Living Questionnaire Wilson, Sandoz, Kitchens, and Roberts (2010)
Quality of Life Inventory Frisch et al. (2005)

Psychological Flexibility
Acceptance and Action Bond et al. (2011)
Questionnaire—II

Defusion
Believability of Anxious Feelings Herzberg et al. (2012)
and Thoughts Questionnaire

Mindfulness
Mindful Attention Awareness Scale Brown and Ryan (2003)
Five Facet Mindfulness Baer, Smith, Hopkins, Krietemeyer, and Toney
Questionnaire (FFMQ) (2006)
15-item FFMQ (FFMQ-15; Gu et al. (2016)
brief version)

in which patients struggle (e.g., nonjudgmental aspect of mindfulness) and

can be used to track progress on a particular skill over time. Similarly, valued
behavior can be assessed informally with individualized behavioral commit-
ments assigned to patients at each session. It is important that these goals are
specific and concrete, so that they can be used as a reliable tracking tool.

EMPIRICAL SUPPORT

Randomized controlled trials for anxiety disorders and OCD have found that
psychological flexibility, acceptance, and cognitive defusion mediate treatment
outcomes, including symptom severity, anxiety-related behavioral avoidance,
and quality of life (Arch et al., 2012; Forman et al., 2007; Twohig, Plumb
Vilardaga, Levin, & Hayes, 2015). Improvement in acceptance has been found
to significantly predict self-reported quality of life at posttreatment, controlling
for baseline quality of life, as well as predict treatment responder status (S. A.
Hayes, Orsillo, & Roemer, 2010). Thus, psychological flexibility and its com-
ponent processes appear to be important to target in therapy.
Furthermore, some evidence suggests that an increase in valued behaviors
precedes a reduction in suffering (distress due to anxiety) but not the other
way around (Gloster et al., 2017). Increases in valued action have also been
associated with higher levels of functioning and lower levels of panic symp-
toms among participants with a diagnosis of panic disorder (Wersebe et al.,
2017). These studies underscore the importance of establishing values-based
behavioral commitments in order to achieve improvement in well-being.
338 Ong et al.

Treatment manuals that describe acceptance-based interventions for clini-

cal anxiety in detail can be found online at https://contextualscience.org/
treatment_protocols. Clinicians who would like more information on
acceptance-based procedures for anxiety are also referred to Acceptance and
Commitment Therapy for Anxiety Disorders: A Practitioner’s Treatment Guide to Using
Mindfulness, Acceptance, and Values-Based Behavior Change Strategies (Eifert &
Forsyth, 2005). Another resource that focuses on integrating mindfulness
and acceptance into their cognitive behavioral approaches is Mindfulness- and
Acceptance-Based Behavioral Therapies in Practice (Roemer & Orsillo, 2009).

TROUBLESHOOTING

This section presents possible challenges and contraindications in the use of

mindfulness- and acceptance-based techniques with clinical anxiety. Because
much of the available data come from therapeutic approaches that emphasize
the use of formal meditation (i.e., MBSR, MBCT), these comprise the bulk of
what is reviewed here. Although therapies that emphasize informal mindful-
ness exercises do not require the inclusion of formal meditation, depending on
clinician style, preference, or expertise, or on patient presentation, these ther-
apies can and often do include formal meditation in their actual implementa-
tion. This discussion pertains mainly to the therapeutic use of formal meditation
with considerations for the use of informal mindfulness near its end.

Formal Meditation Practice

It is generally recognized that to date there has been a lack of systematic inves-
tigation into the possible adverse effects of mindfulness (Dobkin, Irving, &
Amar, 2012; Hanley, Abell, Osborn, Roehrig, & Canto, 2016; Lustyk, Chawla,
Nolan, & Marlatt, 2009). Most of the available information on contraindica-
tions of mindfulness comes from case studies and clinical anecdotes, both of
which focus mainly on the effects of formal meditation practices. One excep-
tion is a naturalistic study that looked at adverse effects of formal meditation
in 27 long-term meditators following either a 2-week or 3-month residential
meditation retreat (Shapiro, 1992). Effects of meditation were measured at
three time points before and after the retreat. Shapiro (1992) found that 38%
to 55.5% of participants reported at least one adverse experience at different
time points. Two participants (7.4%) experienced profound adverse effects.
Adverse effects included intrapersonal (e.g., boredom, pain), interpersonal
(e.g., increased judgment of others), and societal (e.g., increased alienation
and discomfort with the real world). Other adverse effects that have been
reported in association with meditation include depersonalization and dereal-
ization, psychosis, and feelings of mania (Lustyk et al., 2009). Many reports are
associated with intensive meditation retreats or intensive unguided practice
 Mindfulness and Acceptance 339

and connected to individuals with a history of severe mental illness (Kuijpers,

van der Heijden, Tuinier, & Verhoeven, 2007; VanderKooi, 1997).
Drawing conclusions on the safety of mindfulness as a therapeutic interven-
tion from the previous literature may be problematic because, in the context of
mindfulness-based interventions, meditation duration does not approach the
intensity of that which occurs on a retreat. Considering meditation in a thera-
peutic context, a systematic review of yoga and meditation for medical ill-
nesses found no serious adverse effects, although only one study (out of the
20 included studies) explicitly reported monitoring participants for such effects
(Arias, Steinberg, Banga, & Trestman, 2006). Arias et al. (2006) also conducted
an unsystematic review and concluded that such effects are rare and tend to be
associated with “misuse or overuse of meditation” (pg. 823).
In the context of formal meditation, it appears that serious adverse effects
can occur when meditation is undertaken in an intensive, unguided manner
and with those who have a history of severe mental illness. Therefore, clini-
cians using meditation as a therapeutic tool should be experienced in both
meditation and psychotherapy, and patient meditation practices should be
monitored to ensure that meditation is not occurring improperly or to excess.
Meditation may be contraindicated for some individuals with a history of
severe mental illness, especially psychosis. Patients should, therefore, be
screened prior to beginning meditation. A number of screening procedures
have been developed for this purpose (see Dobkin et al., 2012; Lustyk et al.,
2009). If adverse effects do occur, it is recommended to decrease or discon-
tinue meditation practice (VanderKooi, 1997).

Informal Mindfulness Practice

Many mindfulness-based interventions do not necessarily employ formal

meditation. For example, ACT (S. C. Hayes et al., 2011) and DBT (Linehan,
1993) include short, informal mindfulness exercises, although individual
clinicians may include more formal practices if they choose. Evidence for
adverse effects of short, informal practices is sparse. Within the literature, one
finding following treatment with a mindfulness-based intervention has been
an increase in the number of symptoms but a decrease in the functional
impact of those symptoms. For example, in 80 inpatients with positive psy-
chotic symptoms, Bach and Hayes (2002) showed that the number of par-
ticipants reporting symptoms increased when following an ACT protocol
compared to treatment as usual, but the number of participants who were
rehospitalized decreased. The authors suggested that these results may have
been due to greater awareness and acceptance, and decreased believability, of
symptoms. In other words, mindfulness may facilitate greater awareness of
internal experiences, both pleasant and unpleasant, but less identification
with and reactivity to those experiences (Kostanski & Hassed, 2008). The
Bach and Hayes study has since been replicated with similar effects (Bach,
340 Ong et al.

Gaudiano, Hayes, & Herbert, 2013; Bach, Hayes, & Gallop, 2012). In light of
the possible adverse effects of meditation in individuals with a history of psy-
chosis, these findings suggest that such patients may benefit from a therapy
that includes short duration, informal mindfulness practices (e.g., ACT) over
longer duration, formal meditation (e.g., MBSR).
In sum, on the basis of the limited empirical data available, adverse effects
can result from mindfulness, although they seem to be rare. When consider-
ing this topic, it is important to keep in mind that the term adverse is subjective
and, in Western society, most unpleasant experiences are interpreted as
“adverse.” However, mindfulness has its roots in Eastern philosophical and
religious traditions and what may be considered “adverse” in the West due to
its unpleasant nature is neither inherently nor necessarily so. Rather, psycho-
logical events such as sadness, stress, and even “depersonalization” should be
considered in the context of the impact they have on an individual’s life func-
tioning. If greater awareness of unpleasant experiences ultimately leads to a
better ability to cope with those experiences and more flexible functioning in
one’s life, then those experiences may be beneficial. It is this very awareness
that was originally identified as integral to the path leading to the end of suf-
fering as laid out by the Buddha over 2,600 years ago.

CONCLUSION

Interventions that focus on mindfulness- and acceptance-based processes of

change are employed in various multicomponent empirically supported ther-
apies, including ACT, DBT, MBSR, and MBCT. In Western psychology, mind-
fulness typically refers to noticing experiences as they occur in the present,
whereas acceptance describes being open to those experiences in a non­
judgmental way (e.g., psychological flexibility as described in Chapter 7).
Mindfulness- and acceptance-based approaches tend to emphasize intrinsi-
cally meaningful treatment goals identified by the patient and experiential
exercises to train relevant skills. Furthermore, such interventions are more
concerned with how patients respond to unpleasant stimuli (e.g., distress)
rather than the stimuli per se. As such, skills are focused on changing responses
to difficult experiences not the experiences themselves. The ultimate goal
from a mindfulness- and acceptance-based standpoint is to enhance well-
being and alleviate suffering rather than reduce symptoms.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Washington, DC: Author.
American Psychological Association, Presidential Task Force on Evidence-Based Practice.
(2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.
http://dx.doi.org/10.1037/0003-066X.61.4.271
Ana–layo. (2003). Satipa·t·tha–na: The direct path to realization. Birmingham, England:
Windhorse Publications.
 Mindfulness and Acceptance 341

Arch, J. J., Wolitzky-Taylor, K. B., Eifert, G. H., & Craske, M. G. (2012). Longitudinal
treatment mediation of traditional cognitive behavioral therapy and acceptance
and commitment therapy for anxiety disorders. Behaviour Research and Therapy, 50,
469–478. http://dx.doi.org/10.1016/j.brat.2012.04.007
Arias, A. J., Steinberg, K., Banga, A., & Trestman, R. L. (2006). Systematic review
of the efficacy of meditation techniques as treatments for medical illness. Journal
of Alternative and Complementary Medicine, 12, 817–832. http://dx.doi.org/10.1089/
acm.2006.12.817
Bach, P., Gaudiano, B. A., Hayes, S. C., & Herbert, J. D. (2013). Acceptance and commit-
ment therapy for psychosis: Intent to treat, hospitalization outcome and mediation by
believability. Psychosis, 5, 166–174. http://dx.doi.org/10.1080/17522439.2012.671349
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to
prevent the rehospitalization of psychotic patients: A randomized controlled trial.
Journal of Consulting and Clinical Psychology, 70, 1129–1139. http://dx.doi.org/
10.1037/0022-006X.70.5.1129
Bach, P., Hayes, S. C., & Gallop, R. (2012). Long-term effects of brief acceptance and
commitment therapy for psychosis. Behavior Modification, 36, 165–181. http://
dx.doi.org/10.1177/0145445511427193
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-
report assessment methods to explore facets of mindfulness. Assessment, 13, 27–45.
http://dx.doi.org/10.1177/1073191105283504
Bhikkhu, T. (2008). Mindfulness defined. Access to insight. Retrieved from http://
www.accesstoinsight.org/lib/authors/thanissaro/mindfulnessdefined.html
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., . . .
Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and
Action Questionnaire-II: A revised measure of psychological inflexibility and
experiential avoidance. Behavior Therapy, 42, 676–688. http://dx.doi.org/10.1016/
j.beth.2011.03.007
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and
its role in psychological well-being. Journal of Personality and Social Psychology, 84,
822–848. http://dx.doi.org/10.1037/0022-3514.84.4.822
Carmody, J., Baer, R. A., Lykins, E. L. B., & Olendzki, N. (2009). An empirical study of
the mechanisms of mindfulness in a mindfulness-based stress reduction program.
Journal of Clinical Psychology, 65, 613–626. http://dx.doi.org/10.1002/jclp.20579
Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P.,
Arch, J. J., . . . Lieberman, M. D. (2014). Randomized controlled trial of cognitive
behavioral therapy and acceptance and commitment therapy for social phobia: Out-
comes and moderators. Journal of Consulting and Clinical Psychology, 82, 1034–1048.
http://dx.doi.org/10.1037/a0037212
Dobkin, P. L., Irving, J. A., & Amar, S. (2012). For whom may participation in a
mindfulness-based stress reduction program be contraindicated? Mindfulness, 3,
44–50. http://dx.doi.org/10.1007/s12671-011-0079-9
Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety dis­
orders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based
behavior change strategies. Oakland, CA: Harbinger.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A ran-
domized controlled effectiveness trial of acceptance and commitment therapy and
cognitive therapy for anxiety and depression. Behavior Modification, 31, 772–799.
http://dx.doi.org/10.1177/0145445507302202
Frisch, M. B., Clark, M. P., Rouse, S. V., Rudd, M. D., Paweleck, J. K., Greenstone, A.,
& Kopplin, D. A. (2005). Predictive and treatment validity of life satisfaction and
the quality of life inventory. Assessment, 12, 66–78. http://dx.doi.org/10.1177/
1073191104268006
Gloster, A. T., Klotsche, J., Ciarrochi, J., Eifert, G., Sonntag, R., Wittchen, H.-U., &
Hoyer, J. (2017). Increasing valued behaviors precedes reduction in suffering: Findings
342 Ong et al.

from a randomized controlled trial using ACT. Behaviour Research and Therapy, 91,
64–71. http://dx.doi.org/10.1016/j.brat.2017.01.013
Grossman, P., & Van Dam, N. T. (2011). Mindfulness, by any other name . . .: Trials and
tribulations of sati in western psychology and science. Contemporary Buddhism, 12,
219–239. http://dx.doi.org/10.1080/14639947.2011.564841
Gu, J., Strauss, C., Crane, C., Barnhofer, T., Karl, A., Cavanagh, K., & Kuyken, W.
(2016). Examining the factor structure of the 39-item and 15-item versions of the
Five Facet Mindfulness Questionnaire before and after mindfulness-based cognitive
therapy for people with recurrent depression. Psychological Assessment, 28, 791–802.
http://dx.doi.org/10.1037/pas0000263
Hanley, A. W., Abell, N., Osborn, D. S., Roehrig, A. D., & Canto, A. I. (2016). Mind the
gaps: Are conclusions about mindfulness entirely conclusive? Journal of Counseling
& Development, 94, 103–113. http://dx.doi.org/10.1002/jcad.12066
Harris, R. (2009). ACT made simple: An easy-to-read primer on Acceptance and Commitment
Therapy. Oakland, CA: New Harbinger.
Hayes, S. A., Orsillo, S. M., & Roemer, L. (2010). Changes in proposed mechanisms of
action during an acceptance-based behavior therapy for generalized anxiety dis­
order. Behaviour Research and Therapy, 48, 238–245. http://dx.doi.org/10.1016/
j.brat.2009.11.006
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy:
The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.
Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M. (2013). A randomized clinical trial
comparing an acceptance-based behavior therapy to applied relaxation for general-
ized anxiety disorder. Journal of Consulting and Clinical Psychology, 81, 761–773.
http://dx.doi.org/10.1037/a0032871
Herzberg, K. N., Sheppard, S. C., Forsyth, J. P., Credé, M., Earleywine, M., & Eifert,
G. H. (2012). The Believability of Anxious Feelings and Thoughts Questionnaire
(BAFT): A psychometric evaluation of cognitive fusion in a nonclinical and highly
anxious community sample. Psychological Assessment, 24, 877–891. http://dx.doi.org/
10.1037/a0027782
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face
stress, pain, and illness. New York, NY: Random House.
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday
life. New York, NY: Hyperion.
Kostanski, M., & Hassed, C. (2008). Mindfulness as a concept and a process. Australian
Psychologist, 43, 15–21. http://dx.doi.org/10.1080/00050060701593942
Kuijpers, H. J. H., van der Heijden, F. M. M. A., Tuinier, S., & Verhoeven, W. M. A.
(2007). Meditation-induced psychosis. Psychopathology, 40, 461–464. http://dx.doi.org/
10.1159/000108125
Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treat-
ment components suggested by the psychological flexibility model: A meta-analysis
of laboratory-based component studies. Behavior Therapy, 43, 741–756. http://
dx.doi.org/10.1016/j.beth.2012.05.003
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
New York, NY: Guilford Press.
Linehan, M. M. (2014). DBT® skills training manual (2nd ed.). New York, NY: Guilford
Press.
Lundgren, T., Luoma, J. B., Dahl, J., Strosahl, K., & Melin, L. (2012). The Bull’s-
Eye Values Survey: A psychometric evaluation. Cognitive and Behavioral Practice, 19,
518–526. http://dx.doi.org/10.1016/j.cbpra.2012.01.004
Lustyk, M. K., Chawla, N., Nolan, R. S., & Marlatt, G. A. (2009). Mindfulness medita-
tion research: Issues of participant screening, safety procedures, and researcher
training. Advances in Mind-Body Medicine, 24, 20–30.
 Mindfulness and Acceptance 343

Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. J. (2013). Cognitive-
behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment
outcome and moderators. Journal of Psychiatric Research, 47, 33–41. http://dx.doi.org/
10.1016/j.jpsychires.2012.08.020
Öst, L.-G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments
of obsessive-compulsive disorder. A systematic review and meta-analysis of studies
published 1993–2014. Clinical Psychology Review, 40, 156–169. http://dx.doi.org/
10.1016/j.cpr.2015.06.003
Roemer, L., & Orsillo, S. M. (2005). An acceptance-based behavior therapy for general-
ized anxiety disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-
based approaches to anxiety: Conceptualization and treatment (pp. 213–240). New York,
NY: Springer. http://dx.doi.org/10.1007/0-387-25989-9_9
Roemer, L., & Orsillo, S. M. (2009). Mindfulness- and acceptance-based behavioral
therapies in practice. In J. B. Persons (Series Ed.), Guides to individualized evidence-
based treatment. New York, NY: Guilford Press.
Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-
based behavior therapy for generalized anxiety disorder: Evaluation in a random-
ized controlled trial. Journal of Consulting and Clinical Psychology, 76, 1083–1089.
http://dx.doi.org/10.1037/a0012720
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive
therapy for depression (2nd ed.). New York, NY: Guilford Press.
Shafran, R., Thordarson, D. S., & Rachman, S. (1996). Thought-action fusion in obses-
sive compulsive disorder. Journal of Anxiety Disorders, 10, 379–391. http://dx.doi.org/
10.1016/0887-6185(96)00018-7
Shapiro, D. H., Jr. (1992). Adverse effects of meditation: A preliminary investigation of
long-term meditators. International Journal of Psychosomatics, 39, 62–67.
Tolin, D. F. (2009). Alphabet Soup: ERP, CT, and ACT for OCD. Cognitive and Behavioral
Practice, 16, 40–48. http://dx.doi.org/10.1016/j.cbpra.2008.07.001
Twohig, M. P. (2009). The application of acceptance and commitment therapy to
obsessive-compulsive disorder. Cognitive and Behavioral Practice, 16, 18–28. http://
dx.doi.org/10.1016/j.cbpra.2008.02.008
Twohig, M. P., Abramowitz, J. S., Bluett, E. J., Fabricant, L. E., Jacoby, R. J., Morrison,
K. L., . . . Smith, B. M. (2015). Exposure therapy for OCD from an acceptance and
commitment therapy (ACT) framework. Journal of Obsessive-Compulsive and Related
Disorders, 6, 167–173. http://dx.doi.org/10.1016/j.jocrd.2014.12.007
Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J.,
Morrison, K. L., . . . Ledermann, T. (2018). Adding acceptance and commitment
therapy to exposure and response prevention for obsessive-compulsive disorder:
A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9. http://
dx.doi.org/10.1016/j.brat.2018.06.005
Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H.,
& Woidneck, M. R. (2010). A randomized clinical trial of acceptance and commit-
ment therapy versus progressive relaxation training for obsessive-compulsive dis­
order. Journal of Consulting and Clinical Psychology, 78, 705–716. http://dx.doi.org/
10.1037/a0020508
Twohig, M. P., Plumb Vilardaga, J. C., Levin, M. E., & Hayes, S. C. (2015). Changes in
psychological flexibility during acceptance and commitment therapy for obsessive
compulsive disorder. Journal of Contextual Behavioral Science, 4, 196–202. http://
dx.doi.org/10.1016/j.jcbs.2015.07.001
VanderKooi, L. (1997). Buddhist teachers’ experience with extreme mental states in
Western meditators. Journal of Transpersonal Psychology, 29, 31–46.
Villatte, J. L., Vilardaga, R., Villatte, M., Plumb Vilardaga, J. C., Atkins, D. C., & Hayes,
S. C. (2016). Acceptance and Commitment Therapy modules: Differential impact
344 Ong et al.

on treatment processes and outcomes. Behaviour Research and Therapy, 77, 52–61.
http://dx.doi.org/10.1016/j.brat.2015.12.001
Wersebe, H., Lieb, R., Meyer, A. H., Hoyer, J., Wittchen, H.-U., & Gloster, A. T. (2017).
Changes of valued behaviors and functioning during an acceptance and commit-
ment therapy intervention. Journal of Contextual Behavioral Science, 6, 63–70. http://
dx.doi.org/10.1016/j.jcbs.2016.11.005
Wilson, K. G., & DuFrene, T. (2009). Mindfulness for two: An acceptance and commitment
therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger.
Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. (2010). The Valued Living
Questionnaire: Defining and measuring valued action within a behavioral frame-
work. The Psychological Record, 60, 249–272. http://dx.doi.org/10.1007/BF03395706
19
Pharmacological Enhancement
of Extinction Learning
Valérie La Buissonnière-Ariza, Sophie C. Schneider,
and Eric A. Storch

Cognitive behavior therapy (CBT) is the gold-standard treatment for anxiety

disorders, obsessive-compulsive disorder (OCD), and posttraumatic stress
disorder (PTSD; American Psychiatric Association, 2009; Gene-Cos, 2006;
Koran, Hanna, Hollander, Nestadt, & Simpson, 2007; National Collaborating
Centre for Mental Health, 2011, 2013; Ursano et al., 2004). The core compo-
nent of CBT is exposure to objects or situations that provoke fear and anxiety,
which relies on fear extinction processes (Lissek et al., 2005). Although the
efficacy of exposure-based CBT has been consistently demonstrated both in
adults and youth (Abramowitz, Deacon, & Whiteside, 2019; Olatunji, Cisler,
& Deacon, 2010), a substantial proportion of individuals do not benefit or
respond only partially to treatment or experience symptom relapse upon dis-
continuation (McGuire, Lewin, & Storch, 2014; Olatunji et al., 2010). More-
over, the burden associated with treatment or limited access to adequate
treatment providers constitute challenges for the implementation of inter-
ventions of sufficient duration (McGuire et al., 2014; Olatunji et al., 2010),
underlining the necessity of improving and/or accelerating CBT outcomes.
With this aim, studies have emerged investigating the capacity of pharma-
cological cognitive enhancers to augment exposure-based CBT. The use of
cognitive enhancers derives from animal models of fear extinction that have
allowed the identification of pharmacologic agents that can augment fear
extinction mechanisms (Davis, Ressler, Rothbaum, & Richardson, 2006).

http://dx.doi.org/10.1037/0000150-019
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
345
346 La Buissonnière-Ariza, Schneider, and Storch

Hence, instead of directly reducing fear and anxiety symptoms as in the tradi-
tional use of pharmacotherapy (e.g., with selective serotonin reuptake inhib-
itors [SSRIs] or benzodiazepines), cognitive enhancers are substances that
can exert specific influences on brain regions and neurocircuitry involved in
fear learning and extinction (Singewald, Schmuckermair, Whittle, Holmes, &
Ressler, 2015). Consequently, these psychopharmacological agents have the
potential to enhance exposure-based CBT outcomes.
The chemical substrate d-cycloserine (DCS) is the most extensively inves-
tigated cognitive enhancer to augment exposure-based CBT in individuals
with anxiety and OCD (Storch et al., 2010; Sulkowski et al., 2014). DCS is a
partial N-methyl-D-aspartate (NMDA) agonist acting on the NMDA receptor
complex that was originally used for the treatment of tuberculosis (Hofmann,
Pollack, & Otto, 2006). Information on its safety and management is well
documented, and very low risks of side effects are reported (Storch et al.,
2010). DCS specifically facilitates learning of emotion-relevant stimuli and
may particularly influence learning of fear and safety associations (Kalisch
et al., 2009). Animal studies suggest DCS facilitates extinction of conditioned
fear by enhancing safety learning and maintaining and consolidating treat-
ment gains (McGuire, Wu, Piacentini, McCracken, & Storch, 2017; Storch
et al., 2010). DCS may also prevent the relapse of anxiety when reexposed to
anxiety-evoking stimuli by interfering with the reinstatement of the original
fear memories (McGuire et al., 2017; Storch et al., 2010). In other words,
DCS may augment the effects and speed the pace of exposure learning, such
that patients may need fewer sessions to experience significant improvements
in fear and anxiety (Chasson et al., 2010). In addition, the effects of DCS may
facilitate generalization of treatment gains to other anxiety-provoking stimuli
and situations (Sulkowski, Lewin, & Storch, 2012).

IMPLEMENTATION

Conditions of Implementation

A basic, critical criterion for using DCS is the conjunction with exposure-based
therapy. Unlike other types of medication, such as anxiolytics and SSRIs, that
can directly reduce fear and anxiety symptoms, DCS specifically facilitates
memory processes involved in fear extinction (Norberg, Krystal, & Tolin,
2008). Hence, DCS must be considered as an adjunctive component of CBT
rather than as a stand-alone treatment per se. Another important point to
consider is the need for a medical prescription by a registered physician or
nurse practitioner in order to access DCS. Even with this, however, access is
not easy because DCS is not readily available in most pharmacies. Further-
more, regular visits with a medical professional are required to continue to
monitor its safety. As DCS is a relatively new clinical approach, guidelines for
its effective use in clinical practice are still preliminary. However, as we dis-
cuss in this chapter, certain guidelines have been suggested for a successful
 Pharmacological Enhancement of Extinction Learning 347

implementation of DCS among different populations, including dosage, timing

of administration, and duration of treatment.

Target Populations

The administration of DCS to augment exposure-based CBT has been inves-

tigated within several populations, including individuals with specific phobia,
social anxiety disorder, panic disorder, PTSD, and OCD (for reviews, see
Hofmann, Otto, Pollack, & Smits, 2015; McGuire et al., 2017). Although the
content of exposure sessions may vary considerably across diagnostic groups,
similar dosages, number of doses, and timing of administration have been
reported (McGuire et al., 2017). McGuire and colleagues (2017) suggested
that because DCS affects memory reconsolidation mechanisms, problems
with greater fear-based symptoms and well-defined exposure targets (e.g.,
specific phobias, social phobia) will show better fear memory reconsolida-
tion in therapy in comparison to conditions with more heterogeneous
symptoms (e.g., fear-based symptoms vs. not-just-right OCD symptoms)
and more expansive triggers. However, results from recent meta-analyses
(Mataix-Cols et al., 2017; McGuire et al., 2017) suggest that the benefits of
DCS to exposure-based CBT do not differ for individuals with different
anxiety disorders.
There is evidence that the benefits of DCS differ depending on the severity
of anxiety symptoms—but in a somewhat unexpected pattern due to a ceil-
ing effect (Byrne, Farrell, Storch, & Rapee, 2014; Norberg et al., 2008). Spe-
cifically, individuals with milder anxiety symptoms tend to respond so
rapidly to exposure therapy that they do not often require augmentative
treatment approaches. Accordingly, relative to no augmentation, such indi-
viduals are less likely to evidence effects of DCS. Conversely, those with
severe or complex anxiety symptoms are likely to take longer to respond to
exposure (Byrne et al., 2014) and, thus, are more likely to show benefit
from augmentation with DCS. Moreover, greater symptom severity may
lead to an increased motivation to use DCS in patients (Byrne et al., 2014),
which can facilitate implementation of treatment. DCS may also be useful
for individuals who do not respond to CBT at the expected rate (Otto et al.,
2016). Indeed, significant effects of DCS augmentation relative to placebo
were reported in a study of youth with OCD recruited specifically because
they had failed to respond to CBT alone (Farrell et al., 2013). Hence, DCS
implementation may be particularly relevant for more severe or treatment-
refractory cases.
Animal studies have suggested important differences in fear extinction pro-
cesses between young and mature animals (Kim & Richardson, 2010), and it is
thought that these differences could lead to differences in DCS response (Byrne
et al., 2014). However, the relatively limited DCS literature in youth samples
has revealed results similar to those observed with adults regarding efficacy
(Byrne et al., 2014; Schneider & Storch, 2019). Further research, however,
348 La Buissonnière-Ariza, Schneider, and Storch

is needed to explore age differences in DCS response. Another important

aspect of DCS implementation in children is the involvement of parents in
treatment-related decisions. Despite minimal risks for side effects, studies have
shown that parents are generally not in favor of the use of DCS (Roberts,
Farrell, Waters, Oar, & Ollendick, 2016). It is essential, however, that parents
feel confident about treatment in order to successfully implement DCS. For-
tunately, providing sufficient information on potential risks and benefits leads
to significant increases in perceptions of acceptability in parents (Byrne et al.,
2014); it is therefore important to provide as much information as needed
and discuss any concerns. In particular, it should be communicated that DCS
is not a psychotropic medication (Byrne et al., 2014); that it is used only for
short periods of time (McGuire et al., 2017); and that the risks of aversive
effects (e.g., addiction, side effects) are low, and acute doses are extremely low
(Storch et al., 2007, 2008).

Dosage

A great variation in dosage has been employed in previous studies, with doses
ranging from 50 mg to 500 mg/day in adult studies (Mataix-Cols et al., 2017;
Storch et al., 2010). However, a majority of adult participants (> 80%) received
a dosage of 50 mg of DCS (Mataix-Cols et al., 2017), and recent reviews and
meta-analyses have reported a lack of additional benefits for elevated doses of
DCS (e.g., 250 mg/day or over; Hofmann et al., 2015; Mataix-Cols et al., 2017;
McGuire et al., 2017; Storch et al., 2010). In children, dosage is usually adjusted
to the child’s weight (e.g., 0.7 mg/kg/day), and doses ranging between 25 mg
and 70 mg have been reported (Byrne et al., 2014; Mataix-Cols et al., 2017;
Storch et al., 2010, 2016). Of note, transient adverse effects (i.e., transient motor
tics and echolalia) were reported at higher doses (e.g., 85 mg or 2.8 mg/kg/day)
in one study of youth with autistic spectrum disorder (Posey et al., 2004). There-
fore, relatively low dosages (approximately 30 mg or 0.7 mg/kg/day) have been
recommended for children and adolescents (Storch et al., 2010), although there
are no clearly established guidelines at the moment.

Timing of Administration

The timing of DCS administration is also important to consider, and adminis-

tration is recommended within 2 hours before or after completing therapeutic
exposure (Norberg et al., 2008). Notably, there are few data supporting
postexposure-session dosing—in most studies, DCS was administered prior to
exposure sessions. The 2-hour window is suggested in order to reach peak
DCS blood levels by the end of the session (Hofmann et al., 2015). If admin-
istered too early or too late, the concentrations of DCS may be suboptimal
and may compromise the drug’s ability to augment exposure. On the other
hand, some studies have reported that the effect of DCS varies depending on
the success of the exposure session itself—DCS may reinforce “good” but also
“bad” exposure sessions (Hofmann et al., 2015). That is, gains (i.e., learning
 Pharmacological Enhancement of Extinction Learning 349

that the trigger is no longer threatening) may be observed only when fear has
habituated and reduced at the end of the exposure session. Conversely, in the
absence of habituation and extinction (i.e., the persistence of fear responses
to the trigger through the entire exposure session), DCS may actually lead
to reinforcement of the fear memory (i.e., reinforcement of beliefs that the
trigger is threatening) as the association with threat persists (Hofmann et al.,
2015; Otto et al., 2016; Smits et al., 2013).
Animal studies have provided support for a tailored postexposure admin-
istration of DCS up to 2 hours after the exposure session (Otto et al., 2016).
However, recent studies in youth found no evidence that postexposure
administration or success with exposure therapy were associated with better
DCS outcomes (Mataix-Cols et al., 2014; Rapee et al., 2016). Moreover,
recent meta-analyses of human DCS studies in which the timing of adminis-
tration ranged between 4 hours prior to 1 hour after exposure session revealed
no effects of timing of administration on treatment efficacy (Mataix-Cols
et al., 2017; McGuire et al., 2017), suggesting this 5-hour window is adequate
for DCS administration. Additional research, however, is needed to determine
the ideal timing for DCS administration.

Duration of Treatment

Studies in humans have employed a variable number of DCS doses, ranging

from two to 12 doses of DCS across treatment sessions. Treatment response,
however, is similar no matter how many DCS-dosed sessions are held
(Bontempo, Panza, & Bloch, 2012; Mataix-Cols et al., 2017; McGuire et al.,
2017; Norberg et al., 2008). Studies have failed to show additional benefits of
chronic dosing on extinction outcomes (Storch et al., 2010), and the efficacy
of DCS may be attenuated across the progression of therapy sessions, particu-
larly when the effects of exposure therapy become more apparent (Sulkowski
et al., 2012). In animals, prolonged administration of DCS appears to lead to
a reduced response, potentially due to a desensitization of NMDA receptors
(e.g., Parnas, Weber, & Richardson, 2005). Thus, given the absence of benefits
of prolonged administration, which is likely explained by the effects of expo-
sure therapy and the attenuation of DCS effects over time, brief and acute
administrations are recommended.

Summary of Implementation

Although clear guidelines have not yet been developed for the implementa-
tion of DCS to augment exposure, results from research trials suggest DCS
is particularly useful for individuals with more severe anxiety presentations
or who do not respond to monotherapy using exposure-based CBT. DCS
should be administered at minimal doses (e.g., 50 mg/day for adults and
0.7 mg/kg/day for children) on an acute basis, shortly before or after expo-
sure sessions.
350 La Buissonnière-Ariza, Schneider, and Storch

Example of d-Cycloserine Implementation—Deon

Deon is a 36-year-old man who works as an accountant in a landscaping

maintenance company.1 Deon was diagnosed with social anxiety disorder in
adolescence. He became particularly anxious when he had to speak in groups
(e.g., at the company’s cafeteria during lunch time) and always avoided doing
so. His anxiety had caused him significant distress as it isolated him from
others and prevented him from substantially progressing professionally. Deon
started an exposure-based CBT program consisting of twelve 1-hour indi-
vidual therapy sessions, 10 of which involved some level of exposure. After
4 weeks, Deon had undergone two sessions of exposure and no progress had
been observed; despite slight reductions of fear levels at the end of each ses-
sion (i.e., habituation; see Chapter 14), there were no apparent changes from
one session to the other. Of note, Deon had also undergone exposure-based
therapy for social anxiety in adolescence and his progress at that time had been
very limited. Considering Deon’s profile, his therapist suggested using DCS to
augment the effects of CBT, a proposition Deon accepted after becoming aware
of the negligible risks of side effects.
Deon visited a psychiatrist colleague of his therapist to obtain a prescrip-
tion of DCS. Exposure sessions three through six were then conducted in
which Deon was gradually exposed to calling a stranger on the phone, speak-
ing to a stranger in person, and speaking in front of groups of people. Deon
took one 50 mg DCS pill, 1 hour prior to exposure sessions three to six, and
Deon’s fear level was monitored before and after each exposure session using
the subjective units of distress scale (Wolpe, 1958). Additional exposure ses-
sions (seven through 12) were conducted without the use of DCS. His social
anxiety severity was also assessed before and after treatment using the
Liebowitz Social Anxiety Scale (Liebowitz, 1987); the Sheehan Disability
Scale (Sheehan, 1983) was used to assess functional impairment. At the end
of session four and then at session six, Deon met with the prescribing psychi-
atrist to assess for potential adverse effects of DCS (of which there were none)
and general health status. A follow-up visit was also scheduled for one month
after the end of treatment to monitor Deon’s progress.

OUTCOME INDICATORS

Currently, there are no ways to directly measure the biochemical effects of

DCS in humans. However, the effects of DCS can be assessed indirectly,
through behavioral and self-report measures of fear and anxiety and func-
tional impairment. After successful exposure, the initially feared stimulus
(e.g., public speaking) should elicit less distress once encountered as habitua-
tion occurs and the individual learns that this trigger is not threatening any-
more; this effect should be maintained over time and may generalize to other

All clinical case material has been altered to protect patient confidentiality.
1
 Pharmacological Enhancement of Extinction Learning 351

situations relevant to the individual’s particular fear (e.g., eating in public).

DCS theoretically helps to improve and accelerate this learning. Accordingly,
the effects of DCS can be measured at different time points during the thera-
peutic process. For instance, progress can be assessed before and after each
CBT session, at posttreatment, or at follow-up assessment.
Measures of fear and anxiety may also be used to evaluate treatment out-
comes. For instance, the success of exposure sessions can be assessed before
and after exposure using self-reported symptom severity, such as the subjec-
tive units of distress scale (Wolpe, 1958). Progress can be also assessed by
determining how many steps of an exposure hierarchy have been attempted.
Disorder- or fear-specific measures can also be used to assess the effects of
DCS-reduction in symptom severity. Finally, treatment-related changes may
be measured in terms of daily life functioning and illness-related impairment
using clinician-administered and self-report scales (e.g., the Clinical Global
Impression-Severity and Clinical Global Impression Improvement scales,
1976). Importantly, absent a placebo control, it might be difficult to deter-
mine whether changes on such measures are attributable to DCS specifically,
or to the effects of exposure therapy.
Regarding the example of Deon, we would expect to observe a reduction of
distress vis-à-vis the content of exposure that would be maintained and
become more pronounced from one session to another, particularly between
sessions three and six. We would also expect to observe reductions in social
anxiety levels and functional impairment at posttreatment using psychometri-
cally validated measures (e.g., the Liebowitz Social Anxiety Scale [Liebowitz,
1987]; the Sheehan Disability Scale [Sheehan, 1983]).

EMPIRICAL SUPPORT

Results from individual DCS studies have produced inconsistent results.

Accordingly, it is useful to consider meta-analytic reviews that aggregate find-
ings across studies. Large effects (d = 1.19) of DCS augmentation of extinction
training have been found in animal studies (Norberg et al., 2008). In humans,
early meta-analyses suggested overall only moderate benefits of DCS in aug-
menting exposure with effect sizes of 0.46 to 0.60 at posttreatment and of 0.47
at follow-up (Bontempo et al., 2012; Norberg et al., 2008). These effects, how-
ever, appeared to diminish in later studies, with more recent meta-analyses
reporting small effects (d = 0.25–0.34) of DCS relative to placebo at post­treatment
(Mataix-Cols et al., 2017; Rodrigues et al., 2014) or no significant differences
with placebo at midtreatment, posttreatment, and/or follow-up (Mataix-Cols
et al., 2017; McGuire et al., 2017; Ori et al., 2015). Taken together, these find-
ings, on the average, do not provide evidence for robust effects of DCS aug-
mentation of exposure-based CBT. It has been proposed, however, that there
are certain individuals for whom DCS augmentation is efficacious, such as
those with higher pretreatment anxiety levels and successful exposure sessions
and those not taking antidepressant medications (Hofmann, 2016). Further,
352 La Buissonnière-Ariza, Schneider, and Storch

it has been suggested that rather than amplifying the overall exposure effects,
DCS accelerates response to exposure, so that the effects are better observed
during the first few sessions (Chasson et al., 2010). Conversely, when the
number of exposure sessions is large, which allows for increased learning
opportunities, the effects of DCS are attenuated over time as the effects of
CBT become more apparent (Otto et al., 2016). Faster response to exposure
may reduce treatment duration, cost, and premature patient dropout (Byrne
et al., 2014); thus, even a modest speeding effect of DCS may be clinically
useful. More studies, however, are needed to better understand the underlying
mechanisms of DCS and to personalize its use to optimize effects (Schneider &
Storch, 2019).

TROUBLESHOOTING

Despite very low risks of aversive side effects, there may be patient-specific
considerations as well as contraindications to the use of DCS. First, as we dis-
cussed previously, some clinical presentations of anxiety may be more or less
suitable for DCS implementation. For instance, there is some evidence that the
utility of DCS is limited for mildly anxious individuals who respond quickly to
exposure-based CBT alone (Norberg et al., 2008). Although there is no clear
evidence that the effects of DCS are dependent on Diagnostic and Statistical
Manual of Mental Disorders diagnosis, individuals with complex presentations
characterized by increased comorbidities, mixed fear-based psychopathologies,
and multiple fear triggers (as often observed in OCD and PTSD) may respond
less well to exposure and, therefore, benefit less from DCS augmentation
(McGuire et al., 2017). A recent meta-analysis also reported poorer outcomes
of DCS augmentation of anxiety-focused exposure for individuals with comor-
bid depression, younger age, or female gender (McGuire et al., 2017). These
latter findings suggest that those without comorbid depression, older indi-
viduals, and males show increased benefits from DCS augmentation, although
further studies are needed to confirm these assumptions.
Another important factor is treatment acceptance. As mentioned previ-
ously, patients (and parents of child patients) may be reticent to the use of
medication (Byrne et al., 2014), which may affect the implementation of DCS.
Treatment acceptability has been suggested as a strong predictor of engage-
ment in the therapeutic process and treatment success (Calvert & Johnston,
1990). Conversely, reluctance to use DCS may reduce motivation towards
treatment and generate negative biases within the patient, which may com-
promise treatment adherence and outcomes.
Currently, it is unclear whether the presence of psychotropic medication
is a contraindication in the use of DCS. Some authors have suggested that
antidepressants attenuate DCS effects and interfere in the extinction pro-
cesses necessary for successful exposure (Otto et al., 2016). Although there
is some support for this proposal in animals (for a review, see Otto et al.,
2016) and humans (Andersson et al., 2015), recent meta-analyses have not
 Pharmacological Enhancement of Extinction Learning 353

found that antidepressant medication attenuated the effects of DCS aug-

mentation (Mataix-Cols et al., 2017; McGuire et al., 2017). In fact, increased
DCS augmentation was observed in studies of anxiety disorders and PTSD in
which a greater percentage of patients were taking SSRI medication (McGuire
et al., 2017). The authors suggested SSRIs may indirectly strengthen fear
extinction learning through enhancing synaptic plasticity of fear extinction
(McGuire et al., 2017). Alternatively, a greater percentage of patients on
medication might indicate a more severe sample, with greater room for
augmentation of exposure with DCS relative to less severe samples. These
findings notwithstanding, concomitant SSRI medication does not appear to
be a contraindication to DCS use and could even facilitate its effects. Still,
studies assessing specifically this question are needed in order to verify this
hypothesis.
Finally, in individuals where exposure sessions are unsuccessful (i.e., whose
fear levels increase or do not change following exposure), DCS may facilitate
fearful learning (Smits et al., 2013). Thus, unsuccessful trials may represent a
contraindication for DCS administration. However, mixed findings have been
reported in humans regarding this issue (e.g., Rapee et al., 2016; Smits et al.,
2013), which deserves to be further explored in the future.

CONCLUSION

Novel strategies using cognitive enhancers have recently emerged with the
aim of improving and accelerating psychological treatment outcomes. Build-
ing on successful rodent models (e.g., Ledgerwood, Richardson, & Cranney,
2003, 2004, 2005; Walker, Ressler, Lu, & Davis, 2002), the use of DCS to
augment exposure-based CBT has gained increased interest over the past
decade; studies have been conducted on samples of adults and youth with
anxiety disorders, OCD, and PTSD. There is inconsistent evidence regarding
the effectiveness of DCS to augment exposure-based CBT. Some studies
reported encouraging results, whereas others show no evidence for effects of
DCS on CBT outcomes. Knowledge regarding optimal DCS implementation
is still limited, and further research is needed to develop guidelines regarding
dosage, timing of administration, and contraindications. Nevertheless, there
is hope that DCS can be useful for speeding up the effects of exposure ther-
apy for people with more severe anxiety and those who have not benefitted
from exposure therapy in the past. Hence, more studies are needed to better
guide DCS implementation and to identify critical factors that may moderate
treatment effects.

REFERENCES
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for
anxiety: Principles and practice (2nd ed.). New York, NY: Guilford Press.
American Psychiatric Association. (2009). Practice guideline for the treatment of patients
with panic disorder (2nd ed.). Arlington, VA: American Psychiatric Association.
354 La Buissonnière-Ariza, Schneider, and Storch

Andersson, E., Hedman, E., Enander, J., Radu Djurfeldt, D., Ljótsson, B., Cervenka, S., . . .
Rück, C. (2015). d-Cycloserine vs placebo as adjunct to cognitive behavioral ther-
apy for obsessive-compulsive disorder and interaction with antidepressants: A ran-
domized clinical trial. JAMA Psychiatry, 72, 659–667. http://dx.doi.org/10.1001/
jamapsychiatry.2015.0546
Bontempo, A., Panza, K. E., & Bloch, M. H. (2012). d-Cycloserine augmentation of
behavioral therapy for the treatment of anxiety disorders: A meta-analysis. The
Journal of Clinical Psychiatry, 73, 533–537. http://dx.doi.org/10.4088/JCP.11r07356
Byrne, S. P., Farrell, L. J., Storch, E. A., & Rapee, R. M. (2014). d-Cycloserine aug-
mented treatment of anxiety disorders in children and adolescents: A review of pre-
liminary research. Psychopathology Review, 1, 157–168. http://dx.doi.org/10.5127/
pr.033013
Calvert, S. C., & Johnston, C. (1990). Acceptability of treatments for child behavior
problems: Issues and implications for future research. Journal of Clinical Child
Psychology, 19, 61–74. http://dx.doi.org/10.1207/s15374424jccp1901_8
Chasson, G. S., Buhlmann, U., Tolin, D. F., Rao, S. R., Reese, H. E., Rowley, T., . . .
Wilhelm, S. (2010). Need for speed: Evaluating slopes of OCD recovery in behavior
therapy enhanced with d-cycloserine. Behaviour Research and Therapy, 48, 675–679.
http://dx.doi.org/10.1016/j.brat.2010.03.007
Clinical Global Impressions Scale. (1976). In W. E. Guy (Ed.), ECDEU assessment manual
for psychopharmacology (Rev. ed., pp. 217–222). Rockville, MD: U.S. Department of
Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and
Mental Health Administration.
Davis, M., Ressler, K., Rothbaum, B. O., & Richardson, R. (2006). Effects of d-cycloserine
on extinction: Translation from preclinical to clinical work. Biological Psychiatry, 60,
369–375. http://dx.doi.org/10.1016/j.biopsych.2006.03.084
Farrell, L. J., Waters, A. M., Boschen, M. J., Hattingh, L., McConnell, H., Milliner,
E. L., . . . Storch, E. A. (2013). Difficult-to-treat pediatric obsessive-compulsive dis­
order: Feasibility and preliminary results of a randomized pilot trial of d-cycloserine-
augmented behavior therapy. Depression and Anxiety, 30, 723–731. http://dx.doi.org/
10.1002/da.22132
Gene-Cos, N. (2006, September). Post-traumatic stress disorder: The management of PTSD
in adults and children in primary and secondary care. [Review of the book Post-traumatic
stress disorder: The management of PTSD in adults and children in primary and secondary
care, by National Collaborating Centre for Mental Health]. The Psychiatrist, 30, 357.
Hofmann, S. G. (2016). Schrödinger’s cat and d-cycloserine to augment exposure
therapy—both are alive and dead. JAMA Psychiatry, 73, 771–772. http://dx.doi.org/
10.1001/jamapsychiatry.2016.1132
Hofmann, S. G., Otto, M. W., Pollack, M. H., & Smits, J. A. (2015). d-Cycloserine
augmentation of cognitive behavioral therapy for anxiety disorders: An update.
Current Psychiatry Reports, 17, 532. http://dx.doi.org/10.1007/s11920-014-0532-2
Hofmann, S. G., Pollack, M. H., & Otto, M. W. (2006). Augmentation treatment of
psycho­ therapy for anxiety disorders with d-cycloserine. CNS Drug Reviews, 12,
208–217. http://dx.doi.org/10.1111/j.1527-3458.2006.00208.x
Kalisch, R., Holt, B., Petrovic, P., De Martino, B., Klöppel, S., Büchel, C., & Dolan, R. J.
(2009). The NMDA agonist d-cycloserine facilitates fear memory consolidation in
humans. Cerebral Cortex, 19, 187–196. http://dx.doi.org/10.1093/cercor/bhn076
Kim, J. H., & Richardson, R. (2010). New findings on extinction of conditioned fear
early in development: Theoretical and clinical implications. Biological Psychiatry, 67,
297–303. http://dx.doi.org/10.1016/j.biopsych.2009.09.003
Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., & Simpson, H. B. (2007). Prac-
tice guideline for the treatment of patients with obsessive-compulsive disorder. The
American Journal of Psychiatry, 164(7, Suppl.), 5–53.
 Pharmacological Enhancement of Extinction Learning 355

Ledgerwood, L., Richardson, R., & Cranney, J. (2003). Effects of d-cycloserine on extinc-
tion of conditioned freezing. Behavioral Neuroscience, 117, 341–349. http://dx.doi.org/
10.1037/0735-7044.117.2.341
Ledgerwood, L., Richardson, R., & Cranney, J. (2004). d-Cycloserine and the facilita-
tion of extinction of conditioned fear: Consequences for reinstatement. Behavioral
Neuroscience, 118, 505–513. http://dx.doi.org/10.1037/0735-7044.118.3.505
Ledgerwood, L., Richardson, R., & Cranney, J. (2005). d-Cycloserine facilitates extinc-
tion of learned fear: Effects on reacquisition and generalized extinction. Biological
Psychiatry, 57, 841–847. http://dx.doi.org/10.1016/j.biopsych.2005.01.023
Liebowitz, M. R. (1987). Social phobia. In D. F. Klein, Anxiety. Modern Problems of
Pharmacopsychiatry, 22, 141–173. http://dx.doi.org/10.1159/000414022
Lissek, S., Powers, A. S., McClure, E. B., Phelps, E. A., Woldehawariat, G., Grillon, C.,
& Pine, D. S. (2005). Classical fear conditioning in the anxiety disorders: A meta-
analysis. Behaviour Research and Therapy, 43, 1391–1424. http://dx.doi.org/10.1016/
j.brat.2004.10.007
Mataix-Cols, D., Fernández de la Cruz, L., Monzani, B., Rosenfield, D., Andersson, E.,
Pérez-Vigil, A., . . . the DCS Anxiety Consortium. (2017). d-Cycloserine augmentation
of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive,
and posttraumatic stress disorders: A systematic review and meta-analysis of indi-
vidual participant data. JAMA Psychiatry, 74, 501–510. http://dx.doi.org/10.1001/
jamapsychiatry.2016.3955
Mataix-Cols, D., Turner, C., Monzani, B., Isomura, K., Murphy, C., Krebs, G., &
Heyman, I. (2014). Cognitive-behavioural therapy with post-session d-cycloserine
augmentation for paediatric obsessive-compulsive disorder: Pilot randomised con-
trolled trial. The British Journal of Psychiatry, 204, 77–78. http://dx.doi.org/10.1192/
bjp.bp.113.126284
McGuire, J. F., Lewin, A. B., & Storch, E. A. (2014). Enhancing exposure therapy
for anxiety disorders, obsessive-compulsive disorder and post-traumatic stress dis-
order. Expert Review of Neurotherapeutics, 14, 893–910. http://dx.doi.org/10.1586/
14737175.2014.934677
McGuire, J. F., Wu, M. S., Piacentini, J., McCracken, J. T., & Storch, E. A. (2017).
A meta-analysis of d-cycloserine in exposure-based treatment: Moderators of treat-
ment efficacy, response, and diagnostic remission. The Journal of Clinical Psychiatry,
78, 196–206. http://dx.doi.org/10.4088/JCP.15r10334
National Collaborating Centre for Mental Health. (2011). Generalised anxiety disorder
in adults: Management in primary, secondary and community care. Leicester, England:
British Psychological Society.
National Collaborating Centre for Mental Health. (2013). Social anxiety disorder: Recogni-
tion, assessment and treatment. Leicester, England: British Psychological Society.
Norberg, M. M., Krystal, J. H., & Tolin, D. F. (2008). A meta-analysis of d-cycloserine
and the facilitation of fear extinction and exposure therapy. Biological Psychiatry, 63,
1118–1126. http://dx.doi.org/10.1016/j.biopsych.2008.01.012
Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral
therapy for anxiety disorders: A review of meta-analytic findings. Psychiatric Clinics
of North America, 33, 557–577. http://dx.doi.org/10.1016/j.psc.2010.04.002
Ori, R., Amos, T., Bergman, H., Soares-Weiser, K., Ipser, J. C., & Stein, D. J. (2015).
Augmentation of cognitive and behavioural therapies (CBT) with d-cycloserine for anxiety
and related disorders. Available from Cochrane Database of Systematic Reviews
(CD007803). http://dx.doi.org/10.1002/14651858.CD007803.pub2
Otto, M. W., Kredlow, M. A., Smits, J. A. J., Hofmann, S. G., Tolin, D. F., de Kleine,
R. A., . . . Pollack, M. H. (2016). Enhancement of psychosocial treatment with
d-cycloserine: Models, moderators, and future directions. Biological Psychiatry, 80,
274–283. http://dx.doi.org/10.1016/j.biopsych.2015.09.007
356 La Buissonnière-Ariza, Schneider, and Storch

Parnas, A. S., Weber, M., & Richardson, R. (2005). Effects of multiple exposures to
d-cycloserine on extinction of conditioned fear in rats. Neurobiology of Learning and
Memory, 83, 224–231. http://dx.doi.org/10.1016/j.nlm.2005.01.001
Posey, D. J., Kem, D. L., Swiezy, N. B., Sweeten, T. L., Wiegand, R. E., & McDougle,
C. J. (2004). A pilot study of d-cycloserine in subjects with autistic disorder.
The American Journal of Psychiatry, 161, 2115–2117. http://dx.doi.org/10.1176/
appi.ajp.161.11.2115
Rapee, R. M., Jones, M. P., Hudson, J. L., Malhi, G. S., Lyneham, H. J., & Schneider,
S. C. (2016). d-Cycloserine does not enhance the effects of in vivo exposure among
young people with broad-based anxiety disorders. Behaviour Research and Therapy,
87, 225–231. http://dx.doi.org/10.1016/j.brat.2016.10.004
Roberts, C. L., Farrell, L. J., Waters, A. M., Oar, E. L., & Ollendick, T. H. (2016). Parents’
Perceptions of Novel Treatments for Child and Adolescent Specific Phobia and Anxiety
Disorders. Child Psychiatry & Human Development, 47, 459–471. http://dx.doi.org/
10.1007/s10578-015-0579-2
Rodrigues, H., Figueira, I., Lopes, A., Gonçalves, R., Mendlowicz, M. V., Coutinho, E. S. F.,
& Ventura, P. (2014). Does d-cycloserine enhance exposure therapy for anxiety
disorders in humans? A meta-analysis. PLoS ONE, 9, e93519. http://dx.doi.org/
10.1371/journal.pone.0093519
Schneider, S. C., & Storch, E. A. (2019). Pharmacologic-augmented treatments.
In L. J. Farrell, T. H. Ollendick, & P. Muris (Eds.), Innovations in CBT for childhood
anxiety, OCD, and PTSD: Improving access and outcomes (pp. 407–427). Cambridge,
England: Cambridge University Press.
Sheehan, D. V. (1983). The anxiety disease. New York, NY: Scribner.
Singewald, N., Schmuckermair, C., Whittle, N., Holmes, A., & Ressler, K. J. (2015).
Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety
and trauma-related disorders. Pharmacology & Therapeutics, 149, 150–190. http://
dx.doi.org/10.1016/j.pharmthera.2014.12.004
Smits, J. A. J., Rosenfield, D., Otto, M. W., Marques, L., Davis, M. L., Meuret, A. E., . . .
Hofmann, S. G. (2013). d-cycloserine enhancement of exposure therapy for social
anxiety disorder depends on the success of exposure sessions. Journal of Psychiatric
Research, 47, 1455–1461. http://dx.doi.org/10.1016/j.jpsychires.2013.06.020
Storch, E. A., McKay, D., Reid, J. M., Geller, D. A., Goodman, W. K., Lewin, A. B.,
& Murphy, T. K. (2010, July). d-Cycloserine augmentation of cognitive-behavioral therapy:
Directions for pilot research in pediatric obsessive-compulsive disorder. Paper presented at
the Child & Youth Care Forum, Boston, MA.
Storch, E. A., Merlo, L. J., Bengtson, M., Murphy, T. K., Lewis, M. H., Yang, M. C., . . .
Goodman, W. K. (2007). d-Cycloserine does not enhance exposure–response
prevention therapy in obsessive-compulsive disorder. International Clinical Psycho-
pharmacology, 22, 230–237. http://dx.doi.org/10.1097/YIC.0b013e32819f8480
Storch, E. A., Merlo, L. J., Lehmkuhl, H., Geffken, G. R., Jacob, M., Ricketts, E., . . .
Goodman, W. K. (2008). Cognitive-behavioral therapy for obsessive-compulsive dis-
order: A non-randomized comparison of intensive and weekly approaches. Journal of
Anxiety Disorders, 22, 1146–1158. http://dx.doi.org/10.1016/j.janxdis.2007.12.001
Storch, E. A., Murphy, T. K., Goodman, W. K., Geffken, G. R., Lewin, A. B., Henin, A., . . .
Geller, D. A. (2010). A preliminary study of d-cycloserine augmentation of
cognitive-behavioral therapy in pediatric obsessive-compulsive disorder. Biological
Psychiatry, 68, 1073–1076. http://dx.doi.org/10.1016/j.biopsych.2010.07.015
Storch, E. A., Wilhelm, S., Sprich, S., Henin, A., Micco, J., Small, B. J., . . . Geller, D. A.
(2016). Efficacy of augmentation of cognitive behavior therapy with weight-
adjusted d-cycloserine vs placebo in pediatric obsessive-compulsive disorder: A
randomized clinical trial. JAMA Psychiatry, 73, 779–788. http://dx.doi.org/10.1001/
jamapsychiatry.2016.1128
 Pharmacological Enhancement of Extinction Learning 357

Sulkowski, M. L., Geller, D. A., Lewin, A. B., Murphy, T. K., Mittelman, A., Brown, A.,
& Storch, E. A. (2014). The future of d-cycloserine and other cognitive modifiers in
obsessive-compulsive and related disorders. Current Psychiatry Reviews, 10, 317–324.
http://dx.doi.org/10.2174/1573400510666140619224942
Sulkowski, M. L., Lewin, A. B., & Storch, E. A. (2012). d-Cycloserine augmentation of
fear extinction and exposure-based anxiety treatment. In J. Murray (Ed.), Exposure
therapy: New developments (pp. 217–228). New York, NY: Nova Science Publishers.
Ursano, R. J., Bell, C., Eth, S., Friedman, M., Norwood, A., Pfefferbaum, B., . . . the
Steering Committee on Practice Guidelines. (2004). Practice guideline for the treat-
ment of patients with acute stress disorder and posttraumatic stress disorder. The
American Journal of Psychiatry, 161(11, Suppl.), 3–31.
Walker, D. L., Ressler, K. J., Lu, K.-T., & Davis, M. (2002). Facilitation of conditioned fear
extinction by systemic administration or intra-amygdala infusions of d-cycloserine as
assessed with fear-potentiated startle in rats. The Journal of Neuroscience, 22, 2343–2351.
http://dx.doi.org/10.1523/JNEUROSCI.22-06-02343.2002
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Palo Alto, CA: Stanford University
Press.
20
Interpretation Bias
Modification
Courtney Beard and Andrew D. Peckham

Daily life is full of ambiguity. For example, getting rejected for a job, a friend
not returning a call, or a racing heart can all be interpreted in multiple ways.
As described in Chapter 2, people with clinical levels of anxiety tend to
jump to negative conclusions when faced with ambiguity, which has a sub-
stantial impact on how they feel and what they do. For example, someone
who interprets a racing heart as a sign of a cardiac problem will certainly
feel more anxious and possibly seek medical attention. In contrast, someone
who attributes a racing heart to benign nervousness or normal somatic
fluctuation will not experience increased anxiety and will continue going
about their day.
Interpretation bias refers to the tendency to resolve ambiguity in a nega-
tive or threatening manner (i.e., jumping to negative conclusions). Although
the specific content of biased interpretations may differ depending on a person’s
diagnosis (e.g., physical sensations in panic disorder, interpersonal rejection
in social anxiety disorder), the processes by which biased interpretations
maintain anxiety and the intervention approaches to address this cognitive bias
are similar across disorders. Interpretation bias often manifests in the form of
negative automatic thoughts (e.g., “what if I’m having a heart attack?”). Cog-
nitive behavior therapy (CBT) targets such negative automatic thoughts via
behavioral experiments and cognitive restructuring, an explicit process that

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Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
359
360 Beard and Peckham

relies on specific techniques to help patients reappraise a situation in a more

objective manner. Because therapists are rarely with a patient at the moment
the patient encounters the ambiguous situation, cognitive restructuring is typ-
ically reappraising situations in an “offline” manner, usually before or after
the situation occurs.
Although cognitive change via rational discussion can be effective (see
Chapter 16), therapists and patients may experience challenges when
attempting to apply cognitive techniques. Cognitive restructuring relies on
the patients’ ability to recognize when they are making an interpretation in
the form of a negative automatic thought. Indeed, often the first step in cogni-
tive therapy is to simply ask patients to record negative automatic thoughts to
increase their awareness. This process of identifying negative automatic thoughts
is difficult because interpretation bias can operate automatically, unintention-
ally, and outside of awareness (see Hirsch, Meeten, Krahé, & Reeder, 2016).
In other words, our brains are constantly and efficiently resolving ambiguity
for us. This “online” interpretation bias occurs at the moment of encounter-
ing ambiguity and, most of the time, we are not aware that we even made an
interpretation. Because of the nature of interpretation bias, the typical method
of identifying one negative interpretation from the week and evaluating it in
a post hoc manner during a therapy session may be difficult and inefficient.
Even when patients actually practice this skill daily, they will only evaluate
one or two biased interpretations out of the countless interpretations made
that day.
In contrast, interpretation bias modification (IBM), which is also known as
cognitive bias modification for interpretation, aims to change interpretation
bias in an “online” manner, more closely matching the natural way interpre-
tations are made in the moment. IBM facilitates a more adaptive interpretive
style via repeated practice on a cognitive training task. A typical IBM training
task involves a computer program that presents many ambiguous situations
in a short amount of time (e.g., 15 to 30 min). The cognitive task instructions
encourage the individual to resolve each ambiguous situation in a benign
manner. Thus, when an individual interprets an ambiguous situation in a
benign manner, performance on the task improves. Speed and accuracy on
IBM tasks are emphasized, making this intervention more game-like com-
pared to the elaborate and introspective process of cognitive therapy.

IMPLEMENTATION

IBM programs are not yet accessible outside of research studies. However,
IBM interventions will likely soon be available via online programs and
smartphone apps. Thus, in this section, we describe the two most commonly
used IBM tasks, helpful hints when implementing these interventions with
patients, and various potential ways IBM may be implemented with anxious
individuals.
 Interpretation Bias Modification 361

Types of Interpretation Bias Modification

Numerous variations of IBM training tasks have been developed and tested in
research settings. We describe the two most common types of IBM to date.
For each, we present the most common variant of the task and note advan-
tages and disadvantages of each task.

Ambiguous Scenario Training

Mathews and Mackintosh (2000) published the first IBM study using an
ambiguous scenario training task. Since that time, the ambiguous scenario
training task has become the most widely used type of IBM in research
studies. Figure 20.1 illustrates the sequence of the task for one training trial.
In this task, an ambiguous situation is described in approximately three sen-
tences. In the most common version of the task, the scenario remains ambig-
uous until the final word, which is presented in the form of a word fragment.
Your partner asks you to go to an anniversary dinner that their company is holding. You
have not met any of their work colleagues before. Getting ready to go, you think that the
new people you meet will find you [f r i_ _ _ _ y] (correct response: friendly).

FIGURE 20.1. Example of Ambiguous Scenario Training

Step 1: Individual reads and imagines themselves in a short scenario that remains
ambiguous until the final word, which is in the form of a word fragment.

Your partners asks you to go to an anniversary dinner that their company is

holding. You have not met any of their work colleagues before. Getting ready
to go, you think that the new people you meet will find you [f r i_ _ _ _ y].

Step 2: Individual’s task is to complete the word fragment by

typing first missing letter.

FRIENDLY

Step 3: Individual answers a comprehension question

that reinforces the desired interpretation.

Will you be disliked by your new

TIME acquaintances?

YES NO

Step 4: Program provides feedback

about accuracy.

Correct!
362 Beard and Peckham

The task instructions are to complete the word fragment as quickly as possi-
ble, typically by pressing the key that corresponds to the first missing letter. To
encourage a healthier interpretive style, this final word always resolves the
ambiguous situation in a benign manner. Finally, after completing the word
fragment, an individual answers a comprehension question that reinforces
the benign interpretation, and individuals are given feedback about the accu-
racy of their response to the comprehension question. A single training ses-
sion typically includes approximately 64 different training scenarios, which
requires roughly 20 minutes to complete.

Word-Sentence Association Training

Another commonly used IBM training method is based on the Word-Sentence
Association Paradigm (WSAP). The goal of the word-sentence association
training is to reinforce benign interpretations and extinguish threat inter­
pretations of ambiguous situations. To accomplish this goal, this task requires
individuals to decide if a word representing either a threat (“criticize”) or
neutral/positive (“praise”) interpretation is related to an ambiguous sentence
that follows (“Your boss wants to meet with you”). Individuals indicate by
button press if they think the word is related to the sentence. The program
provides positive feedback (“You are correct!”) if the individual endorses
benign interpretations or rejects threat interpretations. Conversely, the pro-
gram provides negative feedback (“You are incorrect!”) if the individual
endorses threat interpretations or rejects benign interpretations. Individuals
complete the task as quickly and as accurately as possible, thereby prompting
more automatic responding. A single training session typically includes 100 to
150 different word-sentence pairs, which requires roughly 15 minutes to
complete. Figure 20.2 presents the task sequence.

Selecting an Interpretation Bias Modification Task

The Ambiguous Scenario Training task and the WSAP share many qualities
and both are empirically supported. Both tasks involve numerous presenta-
tions of ambiguous situations and task contingencies that encourage healthier
interpretations. Both tasks can be tailored to address specific anxiety concerns
by changing the situations presented in the task (see Selection of Stimuli and
Personalization). Both tasks also provide positive reinforcement (“correct!”)
as part of the training.
There are also some notable differences between the two tasks. First, the
ambiguous scenario training task provides more context because it typically
uses three-line paragraphs to describe an ambiguous situation. Patients may be
better able to imagine themselves in the scenarios because of these additional
details. In contrast, the WSAP relies on very brief, single sentences to convey
an ambiguous situation. Although this feature limits the context, on the other
hand, it may facilitate speedy and more automatic responding. In other
words, it may help individuals more quickly “jump” to a positive conclusion.
 Interpretation Bias Modification 363

FIGURE 20.2. Example of a Word-Sentence Association Paradigm Trial

Step 1: Word representing a threat or benign

interpretation appears briefly (500 ms).

criticize

Step 2: Ambiguous situation appears and remains

on screen until individual responds.

Your boss wants to meet with you

Step 3: Individual decides if word and sentence are

related and presses corresponding button.

TIME YES NO

Step 4: Program provides feedback about accuracy.

Correct = “yes” to benign / “no” to threat interpretations
Incorrect = “yes” to threat / “no” to benign interpretations

You are correct!

Second, the WSAP presents both benign (neutral and positive) and threat
interpretations for each situation throughout the course of training, whereas
the ambiguous scenario training task only presents benign resolutions. Because
the WSAP requires people to make decisions about both negative and positive
interpretations of the same situation, the task may allow people to notice how
often they endorse the threat interpretation and how often they did not even
think of the benign interpretation. Indeed, individuals who have completed
WSAP training often comment that the WSAP increased their awareness of
their tendency to jump to negative conclusions (Beard, Rifkin, Silverman, &
Björgvinsson, 2019). Additionally, the WSAP’s presentation of multiple ways
of interpreting the same situation over hundreds of examples may reveal the
inherent ambiguity of day to day situations.

Selection of Stimuli and Personalization

Both IBM tasks can be tailored to specific anxiety problems by selecting

appropriate stimuli. Tables 20.1 and 20.2 provide examples of different stim-
uli for each of the tasks including references to the original articles. In most
research studies, samples are selected based on symptoms of a specific anxiety
364 Beard and Peckham

TABLE 20.1. Example Ambiguous Scenario Training Stimuli

for Different Anxiety Disorders
Social anxiety disordera,b Adult
You are at a course that your company has sent you
to attend. Your tutor asks each member of the
group to stand up and introduce themselves. After
your brief presentation, you guess that the others
thought you sounded con - - d - - t (confident).
A friend invites you to a dinner party that she is
holding. She tells you who the other guests are,
but you do not recognize any of the other names.
You go anyway and on the way there, you think
that the other guests will find you so - - a - le
(sociable).

Child and Adolescentc

It is the first day of term. Your new teacher asks
everyone to stand up and introduce themselves.
After you have finished, you guess the others
thought you sounded cl - v - r (clever).

Generalized anxiety disorderd,e In your work, you often have to call radio stations to
promote the business. Yesterday, you were unable
to call all of the stations that you were supposed
to and you think that your boss will put it down to
you being b - sy (busy).
You are given the task of arranging the annual office
party. Despite having very little time, you do your
best to prepare food, drink, and entertainment. As
the night approaches, you think that the event will
be a suc - - ss (success).

Panic disorder f You are jogging. Your heart starts to beat quickly.
This is in - igorating (invigorating).

Height phobiag You are riding a Ferris wheel at a carnival. When you
reach the top, you realize you are so high up that
you can no longer see your family down below.
This makes you uneasy, but your anxiety can be
hand - ed (handled).

Spider phobiah You wake up in the middle of the night and see
something on your alarm clock. You realize it is a
spider. You think that it is h - - mless (harmless).
Note. Examples drawn from aSalemink, van den Hout, and Kindt (2007a); bSalemink, van den Hout,
and Kindt (2007b); cLothmann, Holmes, Chan, and Lau (2011); dHayes, Hirsch, Krebs, and Mathews
(2010); eHirsch, Hayes, and Mathews (2009); fSteinman and Teachman (2010); gSteinman and Teachman
(2014); and hTeachman and Addison (2008).
 Interpretation Bias Modification 365

TABLE 20.2. Example Word-Sentence Association Paradigm Stimuli for Different

Anxiety Disorders
Benign Threat
Ambiguous sentence interpretation interpretation
Social anxiety People laugh after something Funny Embarrassing
disordera you said.
Your boss wants to meet with Praise Criticize
you.

Generalized You hear a loud noise at night. Fireworks Robber

anxiety disordera The chest was opened slowly. Treasure Hospital

Panic disorderb You feel dizzy as you wait in Momentary Dangerous

line.
You start to feel nauseous at a Indigestion Vomit
restaurant.

Intolerance of Your doctor called. Appointment Disease

uncertaintyc
You feel short of breath as you Normal Alarming
Height phobiad
are climbing up a fire escape
to a fourth story landing.
As you are cleaning leaves Alright Threatening
from your gutter, the ladder
you are on makes a creaking
sound.
Note. Examples drawn from aBeard and Amir (2008); bBeard et al. (2017); cOglesby, Raines, Short,
Capron, and Schmidt (2016); and dSteinman and Teachman (2014).

diagnosis (e.g., social anxiety disorder, generalized anxiety disorder), and the
same stimuli set is used for all participants. Thus, social anxiety stimuli are
presented to socially anxious samples and the stimuli are likely relevant to
each person. This degree of personalization appears to be sufficient for IBM to
induce changes in interpretive style and emotional reactivity.
It is currently unknown whether further personalization would enhance
acceptability, task engagement, or clinical effects. However, IBM can be fur-
ther personalized to the individual in a variety of ways. For example, prior to
starting IBM, individuals could complete assessment versions of the training
tasks (e.g., in the WSAP, the assessment version does not provide feedback
about responses). The training version could then only present situations that
the individual got “wrong” in the assessment. Similarly, individuals could rate
all potential ambiguous scenarios or sentences for how negative or positive
they were to them personally using a Likert scale (−3 to +3; Lichtenthal et al.,
2017). These ratings can then be used to create individualized stimulus sets
that only contain situations rated as negative (implying the individual origi-
nally interpreted the sentence in a negative manner). Advantages of these
methods are that they should yield more personally relevant situations; a
disadvantage is that they are time-consuming for a patient to rate hundreds
of potential stimuli.
366 Beard and Peckham

Simple checklists may be used to ask patients which of the fear domains
concern them and then only present situations from those domains. Thus, an
individual with generalized anxiety who worries about finances would see
situations related to this domain but not see health-related situations. Finally,
personalization may also include aspects of the individual’s life. For example,
this level of personalization would ensure that someone who does not have
children would not see situations related to parenting. To fully personalize
IBM, computerized algorithms have been developed that incorporate anxiety
disorder diagnosis, fear domains, and life circumstances to create a unique
stimulus set maximally relevant to the individual (Beard et al., 2017).

Dosage

Research protocols have tested a variety of doses of IBM, and there are cur-
rently no firm guidelines about this. Each session typically presents 64 ambig-
uous scenario training trials or 100 WSAP trials and requires 15 to 30 minutes,
depending on the individual’s speed of reading and decision making. The
most common protocol tested in clinical samples involves eight sessions com-
pleted over 4 weeks (twice per week). However, variations have also been
tested, such as daily sessions over a 1-week period. Overall, IBM has led to
positive effects in relatively brief time periods. It is unknown whether long-
term practice would lead to larger, more generalizable or sustained benefits.
In clinical practice, it is likely that the dosage will depend upon the individual
patient’s needs and access to the IBM program. Similar to CBT, some patients
may require many sessions to achieve results, whereas others may benefit
more quickly. If delivered via an online program or smartphone app, an acute
phase of IBM intervention could easily be followed by a maintenance phase
or booster sessions.

Interpretation Bias Modification Delivery Methods

IBM interventions are not yet available to clinicians or consumers. Thus, in

this section, we describe the delivery methods and settings researched to date.

At a Provider’s Office
Most research studies testing this intervention delivered it via experimental
software programs installed on a computer and required individuals to come
into a research lab or clinic to complete the intervention. Although part of
IBM’s appeal is the potential to deliver it online in peoples’ homes, there may
be benefits related to coming into an office setting to complete IBM. Coming
into an office often requires individuals to face their feared situations (e.g.,
social interactions, anxious arousal). Exposing oneself to these feared situa-
tions twice a week for 4 weeks, for example, could positively affect anxiety on
its own. Moreover, it ensures that individuals are encountering ambiguous
situations in their daily lives, providing opportunity for new interpretive
styles to start taking effect. Related to this, it is possible that IBM may work
 Interpretation Bias Modification 367

better when people’s fears are activated. Thus, particularly for people with
social anxiety, coming into an office and interacting with staff may activate
dysfunctional beliefs and heighten anxiety during the IBM intervention,
enhancing the effects of the treatment when compared to using the interven-
tion in the comfort of home. An office setting also ensures a quiet, uninter-
rupted IBM session. More specifically, several potential implementation methods
have been developed and tested for IBM.

Stand-Alone Self-Help
Because IBM is typically delivered via a computer task, it is easily implemented
as a form of self-help. Several studies have tested IBM as an online interven-
tion with no clinician involvement or human contact (e.g., Pictet, Jermann, &
Ceschi, 2016). There may be benefits to delivering it online or via a smart-
phone app. Home delivery overcomes many of the barriers to accessing treat-
ment (e.g., transportation, scheduling, childcare, stigma). It also expands the
dosing options, such as shorter, more frequent training sessions throughout
the day. This method may be preferable for individuals who do not have access
to therapy, who are not interested in face-to-face therapy, or who have symp-
toms that do not require a higher intensity treatment. However, like any online
treatment, attrition is more likely with no human contact.

Preparation for Cognitive Behavior Therapy

Several studies have tested IBM as a precursor to face-to-face or online
CBT (e.g., Brosan, Hoppitt, Shelfer, Sillence, & Mackintosh, 2011; Williams,
Blackwell, Mackenzie, Holmes, & Andrews, 2013). This method might be
implemented for therapeutic or logistical reasons. Therapeutically, it is pos-
sible that completing IBM would help patients better engage in CBT. If IBM
successfully induces more flexibility in interpretive style, individuals should
be more amenable to cognitive restructuring following IBM. Additionally, if
an individual is better able to generate positive interpretations, behavioral
exercises may be perceived as a more positive experience. Logistically, IBM
may be used prior to face-to-face CBT in circumstances of long waiting lists.

Concurrent With Cognitive Behavior Therapy

IBM may also benefit patients who are currently engaging in CBT. Either IBM
task could be used as homework exercises to facilitate the more top-down
explicit approach of CBT. For example, the WSAP task may be used to help
individuals more efficiently learn to identify negative automatic thoughts. In
the WSAP task, individuals respond to both negative and benign interpreta-
tions of 100+ situations in 15 minutes. This unique experience may increase
an individual’s awareness of their biases as they notice how often they auto-
matically jumped to a negative conclusion. In other words, this form of IBM
may illuminate the brain’s process of efficiently resolving ambiguous situa-
tions in daily life before individuals are aware that they are making an inter-
pretation (e.g., “It was helpful by simply making me aware of how I react to
situations”).
368 Beard and Peckham

Primary Care
IBM may be an ideal low-intensity intervention in primary care settings.
Most individuals first seek treatment for anxiety disorders from their primary
care physician (Verhaak et al., 2009), and individuals with anxiety disorders
are among the highest utilizers of primary care (Simon, Ormel, VonKorff, &
Barlow, 1995). Although the integration of behavioral health providers into
primary care practices is becoming more common, there remains a huge
unmet treatment need. Psychological interventions like IBM are unique and
appealing for this setting because they can be “prescribed” and monitored by
a primary care physician, similar to pharmacotherapy. Primary care patients
could (a) complete IBM in the office and check in with clinic staff, (b) com-
plete IBM at home, or (c) both.

Helpful Hints

In this section, we provide a list of things to consider before implementing

IBM with patients. Some recommendations are based on empirical evidence,
whereas others come from hands on experience delivering IBM to different
populations in a variety of real-world settings.

Provide a Rationale
Like any treatment, providing a clear and compelling rationale is important for
initial buy-in from patients as well as for setting expectations about the nature
of the intervention (e.g., computerized, repetitive training). Developers of
IBM have typically referred to this intervention as changing “mental habits.”
An example of a written informational handout is provided in Exhibit 20.1.
This specific IBM rationale was used in a recent study testing IBM as an aug-
mentation to a CBT-based partial hospital program (Beard et al., 2015).

Prepare for and Normalize Errors

It is important that individuals expect to make many errors in IBM (i.e., on the
comprehension question in the ambiguous scenario task and on the relatedness
judgment in the WSAP). Thus, prior to starting IBM, explicitly inform individ-
uals that they should expect to get many trials “incorrect.” Emphasize that if
they got everything correct at the beginning, then they would not actually
need or benefit from the intervention. At the same time, encourage individuals
to use the program’s feedback to improve accuracy before starting each session.
Additionally, it is helpful to tell people that it is okay if they “miss” a word in
the WSAP, as the words flash very quickly. If they do not see a particular word,
they should just guess on that trial and get ready to attend to the next one.

Facilitate Generalization
IBM will only be helpful if individuals start interpreting situations differently
in their daily life (not just on the computer program!). There are not yet
empirical guidelines for facilitating generalization in IBM, but we offer some
suggestions. It may be helpful to ask patients about how they are applying
 Interpretation Bias Modification 369

EXHIBIT 20.1

Example Interpretation Bias Modification (IBM) Treatment Rationale

How does IBM work?

No matter what caused your anxiety, the way you’ve learned to think about situations can
keep it going. It’s not your fault that you have these thinking habits, and IBM can help.

IBM encourages you to interpret situations in a healthier way. Individuals who have
completed previous versions of I-Change said that the program increased their awareness
of their negative thinking habits and helped them become more flexible in their thinking.
People find it most beneficial if they try to apply what they learn in the computer program
to situations in their actual life.

IBM targets your interpretation style. Because in everyday life many situations are ambiguous
(can be interpreted in more than one way), a negative interpretation bias will lead to most
situations being seen as negative. Moreover, by expecting a negative outcome people
often create what is called a “self-fulfilling prophecy.” For example, if you walk into a party
and expect people will not want to talk to you, you may avoid conversation and, as a result,
it is more likely that they will not talk to you.

The IBM program is very simple and repetitive. These mental habits are often hard to
control. These habits are so automatic that it is very difficult to “catch” or change on
purpose. Gaining control over automatic mental habits is like strengthening a muscle in
your body, it takes regular training. As you repeat this training each day, it will become
easier to do, and you will be faster and more accurate.

what they learned from the computer task to their daily lives. Many indi-
viduals will be able to generate specific examples of situations in which they
noticed themselves jumping to a negative conclusion and thinking about the
alternative interpretations provided in the computer program. Other indi-
viduals may start doing things they used to avoid, such as going to the store.
Reinforcing such behavioral changes in the context of a purely cognitive
intervention may be especially important. Introducing new situations in the
IBM task at each session could also facilitate generalization as more and more
real-life situations are reinterpreted.

Harness the Power of Imagery

The ambiguous scenario training form of IBM has been found to be most
effective when positive imagery is incorporated. Thus, it is critical for individ-
uals to imagine themselves in each scenario. Failure to imagine oneself in the
positively resolved scenarios may actually lead to negative mood effects if
people compare themselves to the “person” in the scenario (Standage, Harris,
& Fox, 2014). In addition to asking patients to form an image of the scenario
in their mind, it may be helpful to ask patients to describe a subset of scenarios
in order to ensure that they are imagining being in the scenario itself, rather
than imagining another person in that scenario. This issue also speaks to the
importance of using personalized, appropriate stimuli, so that patients can
readily form a relevant image in their mind.
370 Beard and Peckham

Track Progress
Patients may find IBM more engaging and rewarding if they track their accu-
racy and speed across sessions. Graphing these scores over time may be espe-
cially impactful. Online programs or smartphone apps will likely automatically
incorporate this feature. Additionally, tracking progress can alert providers to
problems. For example, if accuracy does not improve over time, this could
indicate several potential issues, such as (a) not understanding the task,
(b) actively resisting alternative interpretations, or (c) limited literacy.

OUTCOME INDICATORS

Multiple studies have confirmed that IBM is efficacious at modifying negative

interpretations of ambiguity (for reviews, see Hirsch et al., 2016; Jones &
Sharpe, 2017; Menne-Lothmann et al., 2014). In turn, changes in interpreta-
tive style resulting from IBM are associated with reductions in anxiety, worry,
and negative mood more broadly (reviewed in Hirsch et al., 2016; Menne-
Lothmann et al., 2014). Objective outcome indicators can assess if an IBM
intervention is having the desired clinical effect and if an individual’s inter-
pretive style is changing beyond the task itself.
Assessment versions exist for both Ambiguous Scenario Training paradigms
and the WSAP. Thus, a patient’s baseline level of interpretation bias can be
assessed by their initial responses to ambiguous stimuli. This baseline bias can
then be compared with a patient’s performance on test items administered after
IBM. For Ambiguous Scenario Training, this involves a scenario recognition
test; for the WSAP, it involves word–sentence pairs presented without feed-
back. In the scenario recognition test, patients are provided with an ambiguous
situation similar to the training itself; unlike in the training, the final word in
this situation maintains the scenario as ambiguous. Patients are then given four
possible interpretations of this situation (including positive and negative inter-
pretations) and are asked to rate the similarity of these interpretations to their
own interpretation of the situation. Yet, assessing change in interpretive style
solely based on IBM task performance limits the conclusions that can be drawn
regarding the generalizability of training effects. For this reason, self-report
measures of interpretation bias can also assess effects of IBM.
Many questionnaire measures share conceptual similarities to Ambiguous
Scenario Training, in that they assess individuals’ responses to brief descrip-
tions of ambiguous situations. Questionnaires vary in terms of their response
format, including open-response, ranked choice, and multiple choice. Exam-
ples of these measures are described below; more comprehensive reviews of
interpretation bias paradigms are available from several other sources (e.g.,
Hirsch et al., 2016; Schoth & Liossi, 2017).

Ambiguous Social Situation Interpretation Questionnaire

The Ambiguous Social Situation Interpretation Questionnaire (ASSIQ) is a

self-report measure that includes brief descriptions of both social (14 items)
 Interpretation Bias Modification 371

and nonsocial (10 items) ambiguous scenarios, followed by the prompt

“Why?” (Stopa & Clark, 2000). The ASSIQ is a comprehensive measure of
interpretive style, with interpretations of ambiguity assessed in three different
ways for each scenario. First, individuals write an open-ended answer. Sec-
ond, individuals read three possible interpretations of each scenario (one neg-
ative, one neutral, one positive) and rank order the likelihood they would
think of each interpretation “in a similar situation.” Third, participants rate
the believability of these three interpretations on a 0–8 scale. This scale may
be particularly relevant for patients with anxiety about social situations. Similar
questionnaires that ask individuals to rank the likelihood of example inter-
pretations are available as well (e.g., see Amir, Foa, & Coles, 1998).

Ambiguous Scenarios Test-Depression

The Ambiguous Scenarios Test-Depression (AST-D; Berna, Lang, Goodwin,

& Holmes, 2011) was developed to assess interpretative styles relevant to
depressed mood, but the scale has also been correlated with anxiety symp-
toms (e.g., Cooper & Wade, 2015), and the content of the ambiguous scenar-
ios are general enough that this measure may also be relevant for assessing
interpretation bias in fear and anxiety disorders. Participants read a series of
24 ambiguous scenarios and are asked to imagine themselves in each; after
reading the scenario, participants rate the “pleasantness” of the image they
are imagining on a 9-point scale, ranging from extremely unpleasant to extremely
pleasant (Berna et al., 2011). Thus, a more positive or negative interpretive
style can be inferred from the overall “pleasantness” of a person’s imagined
responses to ambiguity. The AST-D is relatively brief to administer, and it has
the advantage of yielding one overall score of the “pleasantness” of a person’s
imagined interpretations. The scenarios provided on the AST-D contain a
range of content, including themes related to performance (e.g., “You have
recently taken an important exam. Your results arrive with an unexpected
letter of explanation about your grade”), physical threat (e.g., “You are lost in
a part of a big city you don’t know well. You ask someone on the streets for
directions when they pull something out of their pocket”), and social anxiety
(e.g., “You go to a wedding where you know very few other guests. After the
party, you reflect on how the other guests behaved”).

Interpretation and Judgmental Questionnaire

The Interpretation and Judgmental Questionnaire (IJQ; Voncken, Bögels, &

de Vries, 2003) is a self-report interpretation bias measure that includes
descriptions of 20 ambiguous social situations and four ambiguous nonsocial
situations. After reading each description, participants rank the likelihood of
four different interpretations from 1 (least likely) to 4 (most likely). Each situa-
tion includes an ambiguous interpretation, a positive interpretation, and two
negative interpretations (one “mildly” and one “profoundly” negative). Over-
all interpretation bias can be inferred by calculating the average ranking of
profoundly negative interpretations, with higher scores indicating a more
372 Beard and Peckham

negative interpretive bias. As with the ASSIQ, the IJQ may be a particularly
good measure for patients with social anxiety.

EMPIRICAL SUPPORT

Evidence supporting the efficacy of IBM comes from a variety of settings and
samples. To date, the available data are limited primarily by small sample
sizes, but they are rigorous in design with double-blind randomized con-
trolled trials comparing IBM with a placebo task. IBM has been evaluated
among individuals diagnosed with specific anxiety disorders as well as in
people without a formal diagnosis who report elevated anxiety symptoms on
standardized measures. When studies of IBM are aggregated together, there is
consistent evidence that IBM successfully modifies interpretive styles across
these varied settings and symptom groups (Hallion & Ruscio, 2011; Jones &
Sharpe, 2017; Menne-Lothmann et al., 2014). In other words, there is clear
evidence that IBM is effective at engaging the underlying mechanism of
interpretation bias.
To date, what is less clear is the extent to which IBM can be used as a
clinical intervention for specific fear and anxiety disorders. The most recent
empirical reviews of IBM show that it is efficacious for reducing anxiety
(Jones & Sharpe, 2017) and negative affect (Menne-Lothmann et al., 2014);
however, there is not yet consistent evidence that IBM can be used as inter-
vention in clinical samples (Cristea, Kok, & Cuijpers, 2015; Hirsch et al.,
2016). Evidence supports the efficacy of IBM (alone or in combination with
other cognitive bias modification methods) in reducing multiple transdiag-
nostic processes that are relevant for fear and anxiety disorders, including
state anxiety (Brosan et al., 2011; Hoppitt, Illingworth, MacLeod, Hampshire,
Dunn, & Mackintosh, 2014), trait anxiety (Mathews, Ridgeway, Cook, &
Yiend, 2007; Salemink, van den Hout, & Kindt, 2009), anticipatory anxiety
(Murphy, Hirsch, Mathews, Smith, & Clark, 2007), social anxiety (Beard &
Amir, 2008; Beard, Weisberg, & Amir, 2011; Brettschneider, Neumann,
Berger, Renneberg, & Boettcher, 2015; Hoppitt et al., 2014), anxiety sensitiv-
ity (Capron, Norr, Allan, & Schmidt, 2017; MacDonald, Koerner, & Antony,
2013; Steinman & Teachman, 2010), and worry (Hayes, Hirsch, Krebs, &
Mathews, 2010). Several of these studies have included patients diagnosed
with specific anxiety disorders, such as generalized anxiety disorder (Brosan
et al., 2011; Hayes et al., 2010), social anxiety disorder (Amir & Taylor, 2012;
Beard et al., 2011), or significant symptoms of specific phobias (Steinman &
Teachman, 2014; Teachman & Addison, 2008). Few studies have tested the
long-term effects of IBM. Preliminary evidence suggests that cognitive and
symptom changes may endure for at least 2 weeks and up to 6 months
(Blackwell et al., 2015; Pictet et al., 2016; Torkan et al., 2014). Research in
clinical samples is ongoing, as more studies are needed to develop treatment
guidelines for the use of IBM in clinical practice.
 Interpretation Bias Modification 373

TROUBLESHOOTING

Patient-Specific Considerations

Children and Adolescents

IBM interventions have been developed and tested in children and adoles-
cents using age-appropriate stimuli (Lothmann, Holmes, Chan, & Lau, 2011;
Vassilopoulos, Banerjee, & Prantzalou, 2009). Younger individuals may be
more amenable to this type of intervention because their mental habits are
less ingrained, and they have less prior negative memories to challenge the
positive alternatives. Eventually, IBM may even be a good prevention strategy
for children at risk for developing anxiety disorders. However, more large clin-
ical trials in children and adolescents are needed to determine the usefulness
of IBM.

Sociocultural Considerations
Most initial development studies of IBM took place in university psychology
departments. Thus, the original stimulus sets are likely most relevant to
young adults attending a 4-year college. When selecting an IBM program to
use with a patient, it is important to ensure that the stimulus set is not only
personally relevant to their specific anxiety symptoms (e.g., social anxiety
stimuli for a socially anxious patient), but also to their demographic characteris-
tics. For example, for nonstudents or older adults, it is important that stimuli
do not exclusively (or predominantly) focus on classroom situations.
Finally, when implementing any type of cognitive therapy, such as cogni-
tive restructuring or IBM, it is crucial for the clinician to be aware of different
ethno-racial and religious minority experiences. For example, a Black male
patient may respond differently to the ambiguous situation “the sales clerk
calls in the manager” than a White woman would. For any patient with a stig-
matized identity, it may be important to discuss how sociocultural factors, such
as discrimination, have shaped their interpretive style. With patients identify-
ing as a sexual or gender minority, it is important to make sure stimuli do not
include heterosexist language.

Baseline Level of Interpretation Bias

IBM is most appropriate for individuals for whom interpretation bias main-
tains their anxiety. An individual who already interprets most situations
positively may not benefit from such an intervention.

Computer Anxiety and Credibility

Individuals who experience anxiety when using new technology or com-
puters may be hesitant to try IBM. Additionally, some people may be skepti-
cal about a computer program helping with a mental health problem. It may
be helpful to spend additional time presenting the treatment rationale and
empirical evidence with these individuals.
374 Beard and Peckham

Patient Reactions

Individuals experience a range of reactions to IBM. Although most are posi-

tive, others can be negative. Such negative reactions can often be prevented
or mitigated if the IBM provider anticipates problems. For example, particu-
larly for the Ambiguous Scenario Training task, it is important to emphasize
that individuals need to imagine themselves in the situation, rather than
compare their own experience to the “character” in the situation. Comparing
oneself to the positive outcomes in each scenario can worsen mood. Individ-
uals who are extremely sensitive to failure or rejection may also experience
increased distress when first attempting IBM, particularly for the WSAP task
that tells people they are incorrect. Providers should emphasize to all individ-
uals that they are expected to get most trials incorrect at first.
Finally, some individuals with extremely rigid thinking may not “buy-in”
to IBM. Such individuals may get stuck on the fact that the situations pre-
sented are inherently ambiguous and resist the program from guiding them
to a particular resolution. With additional discussion, individuals may con-
tinue with IBM and eventually become more flexible in their thinking.

Technological Considerations

As with all computer or smartphone delivered interventions, technological

programs may arise. When using IBM with patients, it is important to develop
a plan for handling any technological problems (e.g., whom patients should
call, whether they should wait until the next face-to-face session). Therapists
should also be aware of the various issues surrounding recommending health
care smartphone apps to patients (see American Psychiatric Association, 2018),
including how to evaluate an app’s data security.

CONCLUSION

Interpretation bias is a form of cognitive bias in which ambiguous situations

are appraised as negative or threatening. Although the domain of interpreta-
tion bias can vary by diagnosis (e.g., social anxiety vs. panic), the general
process of interpreting ambiguity in a negative manner is transdiagnostic.
IBM encompasses a family of cognitive training programs, typically adminis-
tered using a computer or smartphone, designed to help individuals practice
generating benign or positive interpretations of ambiguity. Rather than
attempting to modify negative interpretations out of the situational context
(prospectively or retrospectively, as in cognitive restructuring techniques),
IBM allows for online, in-the-moment practice with modifying interpreta-
tions. Many research studies have established IBM’s efficacy in modifying
underlying interpretation biases. Research on IBM has also yielded encourag-
ing findings that may eventually lead to integrating IBM into clinical care and
providing more personalized treatment options.
 Interpretation Bias Modification 375

REFERENCES

American Psychiatric Association. (2018). App evaluation model. Retrieved from http://
www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-
model
Amir, N., Foa, E. B., & Coles, M. E. (1998). Negative interpretation bias in social phobia.
Behaviour Research and Therapy, 36, 945–957. http://dx.doi.org/10.1016/S0005-
7967(98)00060-6
Amir, N., & Taylor, C. T. (2012). Interpretation training in individuals with general-
ized social anxiety disorder: A randomized controlled trial. Journal of Consulting and
Clinical Psychology, 80, 497–511. http://dx.doi.org/10.1037/a0026928
Beard, C., & Amir, N. (2008). A multi-session interpretation modification program:
Changes in interpretation and social anxiety symptoms. Behaviour Research and Therapy,
46, 1135–1141. http://dx.doi.org/10.1016/j.brat.2008.05.012
Beard, C., Gonsalves, M., Fuchs, C., Arriaga, E., Francis, S. F., Fletcher, V., . . . Weisberg,
R. B. (2017, April). A cognitive bias modification treatment for anxiety disorders in
primary care. In R. Brady (Chair), Novel modifications of evidence-based treatments of
anxiety for delivery in primary care settings. Symposium conducted at the 37th annual
meeting of the Anxiety and Depression Association of America, San Francisco, CA.
Beard, C., Rifkin, L., Lee, J., Garner, L., Stein, A., Cook, A., & Björgvinsson, T. (2015,
November). A randomized controlled trial of a transdiagnostic cognitive bias
modification-interpretation adjunct treatment in a partial hospital. In C. Beard
(Chair), Changing minds via cognitive bias modification: Expanding to new populations
and settings. Symposium conducted at the 49th annual meeting of the Association
for Behavioral and Cognitive Therapies, Chicago, IL.
Beard, C., Rifkin, L. S., Silverman, A. L., & Björgvinsson, T. (2019). Translating
CBM-I into real world settings: Augmenting a CBT-based psychiatric hospital pro-
gram. Behavior Therapy, 50, 515–530. http://dx.doi.org/10.1016/j.beth.2018.09.002
Beard, C., Weisberg, R. B., & Amir, N. (2011). Combined cognitive bias modification
treatment for social anxiety disorder: A pilot trial. Depression and Anxiety, 28, 981–988.
http://dx.doi.org/10.1002/da.20873
Berna, C., Lang, T. J., Goodwin, G. M., & Holmes, E. A. (2011). Developing a measure
of interpretation bias for depressed mood: An ambiguous scenarios test. Personality
and Individual Differences, 51, 349–354. http://dx.doi.org/10.1016/j.paid.2011.04.005
Blackwell, S. E., Browning, M., Mathews, A., Pictet, A., Welch, J., Davies, J., . . .
Holmes, E. A. (2015). Positive imagery-based cognitive bias modification as a web-
based treatment tool for depressed adults: A randomized controlled trial. Clinical
Psychological Science, 3, 91–111. http://dx.doi.org/10.1177/2167702614560746
Brettschneider, M., Neumann, P., Berger, T., Renneberg, B., & Boettcher, J. (2015).
Internet-based interpretation bias modification for social anxiety: A pilot study.
Journal of Behavior Therapy and Experimental Psychiatry, 49, 21–29. http://dx.doi.org/
10.1016/j.jbtep.2015.04.008
Brosan, L., Hoppitt, L., Shelfer, L., Sillence, A., & Mackintosh, B. (2011). Cognitive bias
modification for attention and interpretation reduces trait and state anxiety in
anxious patients referred to an out-patient service: Results from a pilot study. Jour-
nal of Behavior Therapy and Experimental Psychiatry, 42, 258–264. http://dx.doi.org/
10.1016/j.jbtep.2010.12.006
Capron, D. W., Norr, A. M., Allan, N. P., & Schmidt, N. B. (2017). Combined “top-
down” and “bottom-up” intervention for anxiety sensitivity: Pilot randomized trial
testing the additive effect of interpretation bias modification. Journal of Psychiatric
Research, 85, 75–82. http://dx.doi.org/10.1016/j.jpsychires.2016.11.003
Cooper, J. L., & Wade, T. D. (2015). The relationship between memory and interpreta-
tion biases, difficulties with emotion regulation, and disordered eating in young
376 Beard and Peckham

women. Cognitive Therapy and Research, 39, 853–862. http://dx.doi.org/10.1007/

s10608-015-9709-1
Cristea, I. A., Kok, R. N., & Cuijpers, P. (2015). Efficacy of cognitive bias modification
interventions in anxiety and depression: Meta-analysis. The British Journal of Psychi-
atry, 206, 7–16. http://dx.doi.org/10.1192/bjp.bp.114.146761
Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of the effect of cognitive bias
modification on anxiety and depression. Psychological Bulletin, 137, 940–958. http://
dx.doi.org/10.1037/a0024355
Hayes, S., Hirsch, C. R., Krebs, G., & Mathews, A. (2010). The effects of modifying
interpretation bias on worry in generalized anxiety disorder. Behaviour Research and
Therapy, 48, 171–178. http://dx.doi.org/10.1016/j.brat.2009.10.006
Hirsch, C. R., Hayes, S., & Mathews, A. (2009). Looking on the bright side: Accessing
benign meanings reduces worry. Journal of Abnormal Psychology, 118, 44–54. http://
dx.doi.org/10.1037/a0013473
Hirsch, C. R., Meeten, F., Krahé, C., & Reeder, C. (2016). Resolving ambiguity in emo-
tional disorders: The nature and role of interpretation biases. Annual Review of Clinical
Psychology, 12, 281–305. http://dx.doi.org/10.1146/annurev-clinpsy-021815-093436
Hoppitt, L., Illingworth, J. L., MacLeod, C., Hampshire, A., Dunn, B. D., & Mackintosh, B.
(2014). Modifying social anxiety related to a real-life stressor using online Cogni-
tive Bias Modification for interpretation. Behaviour Research and Therapy, 52, 45–52.
http://dx.doi.org/10.1016/j.brat.2013.10.008
Jones, E. B., & Sharpe, L. (2017). Cognitive bias modification: A review of meta-
analyses. Journal of Affective Disorders, 223, 175–183. http://dx.doi.org/10.1016/
j.jad.2017.07.034
Lichtenthal, W. G., Corner, G. W., Slivjak, E. T., Roberts, K. E., Li, Y., Breitbart, W., . . .
Beard, C. (2017). A pilot randomized controlled trial of cognitive bias modification
to reduce fear of breast cancer recurrence. Cancer, 123, 1424–1433. http://dx.doi.org/
10.1002/cncr.30478
Lothmann, C., Holmes, E. A., Chan, S. W. Y., & Lau, J. Y. F. (2011). Cognitive bias
modification training in adolescents: Effects on interpretation biases and mood. The
Journal of Child Psychology and Psychiatry, 52, 24–32. http://dx.doi.org/10.1111/
j.1469-7610.2010.02286.x
MacDonald, E. M., Koerner, N., & Antony, M. M. (2013). Modification of interpretive
bias: Impact on anxiety sensitivity, information processing and response to induced
bodily sensations. Cognitive Therapy and Research, 37, 860–871. http://dx.doi.org/
10.1007/s10608-012-9519-7
Mathews, A., & Mackintosh, B. (2000). Induced emotional interpretation bias and
anxiety. Journal of Abnormal Psychology, 109, 602–615. http://dx.doi.org/10.1037/
0021-843X.109.4.602
Mathews, A., Ridgeway, V., Cook, E., & Yiend, J. (2007). Inducing a benign inter­
pretational bias reduces trait anxiety. Journal of Behavior Therapy and Experimental
Psychiatry, 38, 225–236. http://dx.doi.org/10.1016/j.jbtep.2006.10.011
Menne-Lothmann, C., Viechtbauer, W., Höhn, P., Kasanova, Z., Haller, S. P.,
Drukker, M., . . . Lau, J. Y. F. (2014). How to boost positive interpretations? A
meta-analysis of the effectiveness of cognitive bias modification for interpretation.
PLoS One, 9, e100925. http://dx.doi.org/10.1371/journal.pone.0100925
Murphy, R., Hirsch, C. R., Mathews, A., Smith, K., & Clark, D. M. (2007). Facilitating
a benign interpretation bias in a high socially anxious population. Behaviour Research
and Therapy, 45, 1517–1529. http://dx.doi.org/10.1016/j.brat.2007.01.007
Oglesby, M. E., Raines, A. M., Short, N. A., Capron, D. W., & Schmidt, N. B. (2016).
Interpretation bias for uncertain threat: A replication and extension. Journal of
Behavior Therapy and Experimental Psychiatry, 51, 35–42. http://dx.doi.org/10.1016/
j.jbtep.2015.12.006
Pictet, A., Jermann, F., & Ceschi, G. (2016). When less could be more: Investigating the
effects of a brief Internet-based imagery cognitive bias modification intervention in
 Interpretation Bias Modification 377

depression. Behaviour Research and Therapy, 84, 45–51. http://dx.doi.org/10.1016/

j.brat.2016.07.008
Salemink, E., van den Hout, M., & Kindt, M. (2007a). Trained interpretive bias and
anxiety. Behaviour Research and Therapy, 45, 329–340. http://dx.doi.org/10.1016/
j.brat.2006.03.011
Salemink, E., van den Hout, M., & Kindt, M. (2007b). Trained interpretive bias: Valid-
ity and effects on anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 38,
212–224. http://dx.doi.org/10.1016/j.jbtep.2006.10.010
Salemink, E., van den Hout, M., & Kindt, M. (2009). Effects of positive interpretive bias
modification in highly anxious individuals. Journal of Anxiety Disorders, 23, 676–683.
http://dx.doi.org/10.1016/j.janxdis.2009.02.006
Schoth, D. E., & Liossi, C. (2017). A systematic review of experimental paradigms for
exploring biased interpretation of ambiguous information with emotional and neutral
associations. Frontiers in Psychology, 8, 171. http://dx.doi.org/10.3389/fpsyg.2017.00171
Simon, G., Ormel, J., VonKorff, M., & Barlow, W. (1995). Health care costs associated
with depressive and anxiety disorders in primary care. The American Journal of Psy-
chiatry, 152, 352–357. http://dx.doi.org/10.1176/ajp.152.3.352
Standage, H., Harris, J., & Fox, E. (2014). The influence of social comparison on cog­
nitive bias modification and emotional vulnerability. Emotion, 14, 170–179. http://
dx.doi.org/10.1037/a0034226
Steinman, S. A., & Teachman, B. A. (2010). Modifying interpretations among indi-
viduals high in anxiety sensitivity. Journal of Anxiety Disorders, 24, 71–78. http://
dx.doi.org/10.1016/j.janxdis.2009.08.008
Steinman, S. A., & Teachman, B. A. (2014). Reaching new heights: Comparing inter-
pretation bias modification to exposure therapy for extreme height fear. Journal of
Consulting and Clinical Psychology, 82, 404–417. http://dx.doi.org/10.1037/a0036023
Stopa, L., & Clark, D. M. (2000). Social phobia and interpretation of social events. Behaviour
Research and Therapy, 38, 273–283. http://dx.doi.org/10.1016/S0005-7967(99)00043-1
Teachman, B. A., & Addison, L. M. (2008). Training non-threatening interpretations in
spider fear. Cognitive Therapy and Research, 32, 448–459. http://dx.doi.org/10.1007/
s10608-006-9084-z
Torkan, H., Blackwell, S. E., Holmes, E. A., Kalantari, M., Neshat-Doost, H. T., Maroufi, M.,
& Talebi, H. (2014). Positive imagery cognitive bias modification in treatment-seeking
patients with major depression in Iran: A pilot study. Cognitive Therapy and Research,
38, 132–145. http://dx.doi.org/10.1007/s10608-014-9598-8
Vassilopoulos, S. P., Banerjee, R., & Prantzalou, C. (2009). Experimental modification
of interpretation bias in socially anxious children: Changes in interpretation, antic-
ipated interpersonal anxiety, and social anxiety symptoms. Behaviour Research and
Therapy, 47, 1085–1089. http://dx.doi.org/10.1016/j.brat.2009.07.018
Verhaak, P. F. M., Prins, M. A., Spreeuwenberg, P., Draisma, S., van Balkom, T. J. L. M.,
Bensing, J. M., . . . Penninx, B. W. J. H. (2009). Receiving treatment for common
mental disorders. General Hospital Psychiatry, 31, 46–55. http://dx.doi.org/10.1016/
j.genhosppsych.2008.09.011
Voncken, M. J., Bögels, S. M., & de Vries, K. (2003). Interpretation and judgmental
biases in social phobia. Behaviour Research and Therapy, 41, 1481–1488. http://
dx.doi.org/10.1016/S0005-7967(03)00143-8
Williams, A. D., Blackwell, S. E., Mackenzie, A., Holmes, E. A., & Andrews, G. (2013).
Combining imagination and reason in the treatment of depression: A random-
ized controlled trial of Internet-based cognitive-bias modification and Internet-
CBT for depression. Journal of Consulting and Clinical Psychology, 81, 793–799. http://
dx.doi.org/10.1037/a0033247
INDEX

A
AAQ (Acceptance and Action Question- reducing, 233–234
naire), 121, 122 with social anxiety disorder, 229–230
AAQ-II. See Acceptance and Action with specific phobias and separation
Questionnaire–2 anxiety, 230
ABC model of cognitive change, 287, Acierno, R., 315
291, 292 Action goals, 330
ABM (attention bias modification therapy), Activating events, in ABC model, 287
212 Activation
Abramowitz, J. S., 231–232 behavioral. See Behavioral activation
Acceptance physiological, 136
with anxiety, 334–335 Active psychosis, 260
in conceptualization of experiential Activity scheduling, 305, 306, 308–309
avoidance, 116 ACT model. See Acceptance and commitment
defined, 324 therapy model
exercises/metaphors targeting, 326 Adaptive perfectionism, 154–155, 160–161
of obsessions, 326–327 Adjustment, relationship, 227–228
Acceptance and Action Questionnaire Adolescents. See Children and adolescents
(AAQ), 121, 122 Agoraphobia
Acceptance and Action Questionnaire–2 accommodation behaviors with, 220,
(AAQ-II), 121, 122, 337 224, 230
Acceptance and commitment therapy anxiety sensitivity with, 73
(ACT) model, 116, 324, 325, 339–340 autobiographical memory bias with,
Acceptance-based behavioral model of 187, 195
anxiety, 117, 128 habituation during exposure therapy for,
Acceptance-based behavior therapy, 324 252
Accommodation behaviors, 228–231 perfectionism with, 163
defined, 220 safety behaviors associated with, 30, 36
with OCD, 228–229 threat overestimation with, 18
with panic disorder, agoraphobia, and worry and rumination with, 143
illness anxiety, 230 Agoraphobic Cognitions Questionnaire, 13,
with PTSD, 230–231 68–69, 298

379
380 Index

Alcaine, O. M., 197 cognitive change as key mechanism of

Alcohol consumption, anxiety sensitivity change in, 299
and, 76 cognitive therapy techniques for,
All-or-nothing thinking, 293 293–297
Ambiguous information processing, biased. DCS augmentation for treatment of, 353
See Information-processing bias diagnosis-driven treatment of, 4
Ambiguous Scenarios Test-Depression distress intolerance with, 106
(AST-D), 371 inhibitory learning strategies in
Ambiguous Scenario Training, 361–364, treatment of, 267, 278–280
366, 369, 374 interpersonal factors as target for
Ambiguous Social Situation Interpretation treatment of, 231, 232
Questionnaire (ASSIQ), 370–371 interpretation bias modification for, 368
A-M-C framework, 174 manualized treatments for, 244, 245
American Psychiatric Association. See safety behaviors of individuals with, 33,
Diagnostic and Statistical Manual of 103
Mental Disorders, Fifth Edition (DSM–5) uncertainty intolerance with, 49, 52
Amir, N., 221 Word-Sentence Association Paradigm
Amygdala, 136, 189 stimuli for, 365
Anagram persistence task, 105 worry with, 123
Anger, 143 Anxiety-related disorders, 3, 4, 46
Anger Rumination Scale, 140 Anxiety-related safety behaviors, 29, 41
Anhedonia, 309 Anxiety sensitivity (AS), 65–77
Animals, disgust response to, 85 assessment of, 68–72
Animals, fear of (animal phobias) defined, 65–66
autobiographical memory bias with, 192 in disorder-specific treatments, 74–76
disgust sensitivity in, 82, 87, 90 and distress intolerance, 104, 106–107
safety behaviors associated with, 30, 40 empirical/conceptual foundations of, 66
threat overestimation with, 13–15 etiology of, 67
Anterior cingulate cortex, 67 and experiential avoidance, 124
Anticipatory anxiety, 372 historical perspective on, 73–74
Anticipatory beliefs, 100 interpretation bias modification for, 372
Anticipatory processing, in social anxiety programs targeting, 76–77
disorder, 161 stability of, 67
Antidepressant medications, 353 structure of, 67
Antony, M. M., 158 in transdiagnostic treatments, 76
Anxiety as treatment target, 73
and accommodation behaviors, 221 Anxiety Sensitivity Index (ASI), 69
and attention bias, 205 Anxiety Sensitivity Index-3 (ASI-3), 67, 69
BA-based treatment of, 306–307, Anxiety Sensitivity Inventory-3, 298
314–315 Anxiety Sensitivity Inventory–Revised, 13
defined, 3 Anxiety thermometer, 254
distress intolerance and, 106–107 Anxious Thoughts Inventory, 176
and experiential avoidance, 116, 117 Arias, A. J., 339
and maladaptive perfectionism, Arousal, 123, 189
156–158 Arousal-related bodily sensations, 65–66,
overlap in assessments of disgust and, 87 68–69
practicing acceptance with, 334–335 AS. See Anxiety sensitivity
safety behaviors in development/ ASI (Anxiety Sensitivity Index), 69
escalation of, 31–32 ASI-3 (Anxiety Sensitivity Index-3), 67, 69
Anxiety disorders. See also specific disorders Assessment
ABM therapy for, 212 of anxiety sensitivity, 68–69
Ambiguous Scenario Training stimuli for, of attention bias, 206–211
364 of autobiographical memory, 190–191
anxiety sensitivity as target for treatment of disgust sensitivity, 86–90
of, 73, 76–77 of distress intolerance, 103–106
autobiographical memory bias with, 184, of experiential avoidance, 119–122
185, 187, 188, 198 of interpersonal processes, 224–228
behavioral activation in treatment of, of metacognition, 175–177
316–318 of perfectionism, 158–160
 Index 381

of safety behaviors, 34–37 identifying, 291

of threat overestimation, 11–13 in interpretation bias, 359, 360
of uncertainty intolerance, 50–52 perfectionism-related, 158, 161
of worry and rumination, 139–142 Autonoetic consciousness, 185
ASSIQ (Ambiguous Social Situation Aversive control, 317
Interpretation Questionnaire), Avoidance. See also Experiential avoidance
370–371 in BA-focused treatments, 306, 309
Associative learning theory, 267, 273, 280 and distress intolerance, 103
AST-D (Ambiguous Scenarios Test- in exposure therapy to bring about
Depression), 371 habituation, 253, 255–256
Attachment to conceptualized self, 116 functional analysis of, 308
Attention and uncertainty intolerance, 54
in ACT model, 116 worry and rumination as, 138
and distress intolerance, 101 Avoidance and Fusion Questionnaire, 122
flexible, 334 Avoidance behavior(s)
in mindfulness, 323–324 in acceptance-based behavioral model of
selective, 10, 279 anxiety, 117
Attentional focus, 269, 273, 279, 309 accommodation of, 222, 223, 228–231,
Attentional resources hypothesis, 33–34 280
Attention bias, 203–214 BA-based treatment of, 310
and anxiety, 205 and behavioral activation, 305
assessment of, 206–211 disgust-based, 84–87, 90, 92, 93
clinical implication of, 211–213 and disgust-induced avoidance, 90
defined, 203–205 and experiential avoidance, 120, 122
etiology and developmental aspects of, and inhibitory learning approach,
206 278–280
increased, with distress intolerance, 109 and mindfulness and acceptance-based
threat-related, 203–206 therapies, 330–331, 335
Attention bias modification therapy with perfectionism, 161
(ABM), 212 safety behaviors as, 30–31, 38, 40
Autobiographical memories, 85–86, 196 as treatment outcome indicator, 314
Autobiographical memory bias, 183–198 Avoidant coping, 157
assessment of, 190–191
defined, 183–185
B
emotion in, 189–190
episodic/semantic components of, BA. See Behavioral activation
185–186 Bach, P., 339–340
with fear of having or contracting an BADS (Behavioral Activation for
illness, 195–196 Depression Scale), 314
with fear of intrusive thoughts, Barlow, D. H., 76
contamination, and NJREs, Barnard, P. J., 288–289
193–194 BATD (brief BA treatment for depression),
with fear of negative self-exposure and 307, 311
evaluation, 192–193 BATs (behavioral approach tests), 258
with fear of somatic cues and symptoms, Baucom, D. H., 226–227, 231–232
195 BDD. See Body dysmorphic disorder
with fear of traumatic memories and Beck, A. T., 222, 288, 290
posttraumatic sequelae, 196–197 Behar, E., 197
with fear of uncertain or negative Behavior, limiting, as anxiety suppression
outcomes, 197 strategy, 118
mental images in, 188–189 Behavioral activation (BA), 305–318
origin of, 186 and activity scheduling, 308–309
and sense of self, 186–188 case example of, 311
with specific phobias, 192 defined, 305–306
Automatic thoughts empirical support for, 314
assessing, 292 and functional analysis/self-monitoring,
cognitive behavior therapy for, 308
359–360 in generalized anxiety disorder
examining evidence for, 295 treatment, 309
382 Index

incorporating partners/family members, Biases. See also Interpretation bias

311 modification
increasing, during treatment, 306–307 attention. See Attention bias
in OCD treatments, 310 autobiographical memory. See Auto­
and outcome indicators, 313–314 biographical memory bias
patient challenges with, 316–317 in Beck’s cognitive model of emotion,
in PTSD treatments, 309–310 288
resolving therapy-interfering behaviors confirmation, 10
during, 317–318 information-processing, 10–11, 48
in social anxiety disorder treatment, 309 memory, 10–11
for special populations, 310–311 Blood, injection, and injury phobias
in specific phobia treatments, 310 autobiographical memory bias with, 192
therapist challenges with, 316 disgust sensitivity with, 86, 87, 91
and therapist role, 308 distress intolerance with, 91
treatments focused on, 305–307, 316 safety behaviors associated with, 40
Behavioral Activation for Depression Scale threat overestimation with, 13, 21
(BADS), 314 Bodily sensation
Behavioral approach tests (BATs), 258 arousal-related, 65–66, 68–69
Behavioral avoidance. See Avoidance catastrophic misinterpretation of, 66, 70
behaviors Body-dysmorphic concerns, uncertainty
Behavioral commitments, 329–330, 337 with, 53
Behavioral exercises, mindfulness and Body dysmorphic disorder (BDD), 55, 57,
acceptance-based, 336 122, 193
Behavioral experiments, on validity of Body image, worry and rumination about,
thoughts and beliefs, 295–297 144
Behavioral measures Body Sensations Interpretations Question-
of DCS-based treatment outcome, naire, 69
350–351 Body Sensations Questionnaire, 68–69
of distress intolerance, 104–105 Boeding, S., 231–232
of uncertainty intolerance, 52 Borkovec, T. D., 197
Behavioral models of depression, 305 Brief BA treatment for depression (BATD),
Behavioral processes, in anxiety-related 307, 311
disorders, 4 Brief Experiential Avoidance Question-
Behavior change, with mindfulness and naire, 122
acceptance-based therapies, Brief Measure of Worry Severity, 140
329–330 Buddhist meditation, 323
Behavior therapy, 242, 305 Bull’s Eye Values Survey, 337
Beliefs About Appearance Scale, 13, 298 Burns, D. D., 154
Beliefs About Memory Questionnaire,
175, 177
C
Beliefs About Rituals Inventory, 177
Beliefs and belief systems Calvocoressi, L., 225, 226
in ABC model, 287 Camberwell Family Interview, 226–227
about repetitive negative thinking, Caregiver-assisted exposure, 232–233, 256
136–137 Caring, accommodation as, 223
anticipatory, 100 Carroll, E. M., 92
in Beck’s cognitive model of emotion, CAS (cognitive attentional syndrome),
288 173–174, 177–180
changes in, via rational discussion, CAS-1 measure, 176
287–289 Catastrophic misinterpretation of bodily
core, 290–292 sensation, 66, 70
events, emotional consequences, and, 9 Catastrophizing, 101, 123, 293. See also
fusion, 179 Severity overestimation
maladaptive, 288–289 CBT. See Cognitive behavior therapy
metacognitive, 172, 174 Ceiling effect, 347
Believability of Anxious Feelings and Certainty, worry/rumination and, 138
Thoughts Questionnaire, 337 Certainty-seeking behaviors, 49, 54–56
Benzodiazepines, 16, 276 Chambless, D. L., 66
“Better safe than sorry” heuristic, 84 Change mechanisms, 241–245
 Index 383

Checking rituals, 229 Cognitive behavior therapy (CBT)

Chemical contamination, fear of, 38–39 anxiety sensitivity reduction in, 73–76
Chen, J., 315 attention bias modification therapy
Child Disgust Scale, 88 with, 212
Children and adolescents. See also Youth cognitive restructuring in, 287
attention bias for, 205 exposure in, 265
caregiver accommodation of, 225, 226, interpersonal processes as target in,
230, 231 231–234
interpretation bias modification for, 373 interpretation bias modification as
perfectionism assessments for, 160 preparation for, 367
Chronic dosing with D-cycloserine, 349 interpretation bias modification
Chronic pain, patients with, 310–311, 317 concurrent with, 367
Chu, B. C., 315 mechanisms of change in, 246
Circumscribed fears, 40–41. See also Specific for negative automatic thoughts,
phobias 359–360
Clark, D. M., 66, 196 pharmacological enhancement of,
Claustrophobia, 28 345–346, 353
Claustrophobia Questionnaire, 13, 298 requirements for, 288
Cleaning compulsions, 19, 162, 228–229 Cognitive bias modification for inter­
Clinical assessments of distress intolerance, pretation. See Interpretation bias
105–106 modification (IBM)
Clinical Global Impression Improvement Cognitive change, measuring, 297–298
scale, 351 Cognitive change via rational discussion,
Clinical Global Impression-Severity scale, 287–301
351 assessing/identifying cognitive distortions,
Clinical interviews 291–293
on accommodation behaviors, 226–227 challenges with, 360
on anxiety sensitivity, 69–70 challenging/modifying faulty cognitions,
on experiential avoidance, 119–120 292–297
on habituation, 258 and collaborative empiricism, 289
on perfectionism, 158–159 defined, 287–289
on safety behaviors, 35–36 empirical support for, 298–300
on worry and rumination, 141–142 and outcome indicators, 297
Clinical perfectionism, 153. See also rationale of, 290–291
Perfectionism troubleshooting, 300–301
Clinical Perfectionism Examination, 159 Cognitive distortions, assessing/identifying,
Clinical Perfectionism Questionnaire 291–293
(CPQ), 160 Cognitive distress intolerance, 105
Clinical symptoms, impact of exposure Cognitive enhancers, 345–346. See also
therapy and habituation on, 258 D-cycloserine (DCS) administration
Cognitions. See also Thoughts Cognitive fusion, 116, 331–332
with anxiety-related disorders, 4 Cognitive model of emotion, 8–9,
defusion of, 331–333 222–223, 288
faulty, challenging/modifying, 292–297 Cognitive processing therapy, 310
perfectionistic, 161, 162 Cognitive restructuring, 287. See also
perseveration, 136–137 Cognitive change via rational
Cognitive–affective functions, of worry and discussion
rumination, 137–138 anxiety sensitivity reduction with, 73
Cognitive appraisals, distress intolerance and exposure therapy, 298–300
and, 101, 103 with inhibitory learning, 270, 272
Cognitive attentional syndrome (CAS), Cognitive therapy, 298
173–174, 177–180 Coherence, 187
Cognitive attentional syndrome-1 (CAS-1) Collaborative empiricism, 289
measure, 176–177 Color-naming Stroop task, 207
Cognitive behavior models Combat-induced anxiety disorder, 73
of distress intolerance, 100–102 Combat-related trauma experiences,
of intolerance of uncertainty, 47, 57 disgust related to, 92
of perfectionism, 155 Communication skills training, 233
of social anxiety disorder, 161 Complex anxiety symptoms, 347
384 Index

Compulsive behaviors (compulsions) Coping Cat, 241

accommodation of, 228–229 Core beliefs, 290–292
cleaning, 19, 162, 228–229 Core Beliefs Module, 191
disgust sensitivity and, 82, 91 Corumination, 139
perfectionism about completion of, Cost Questionnaire, 13
162–163 Couples Satisfaction Index, 228
thought–action fusion with, 125 CPQ (Clinical Perfectionism Questionnaire),
washing, 82, 91 160
Compulsive neurosis, 242–243 CR (conditional response), 266–267
Computer anxiety, 373 Criticism, 159, 227
Concentration-based meditation exercises, Crombez, G., 210
333–334 CS. See Conditional stimulus
Conceptual reorientation, 93 CS− (conditional inhibitors), 272, 273
Conditional inhibitors (CS−), 272, 273 Culture, 120, 311, 373
Conditional response (CR), 266–267
Conditional stimulus (CS)
D
in fear conditioning, 266–267
in inhibitory learning approach, 268, Davey, G. C. L., 90
269, 273 DBT (dialectical behavior therapy),
in reinforced extinction, 275 324, 340
Conditioned fear, extinction of. See D-cycloserine (DCS) administration,
Extinction (fear extinction) 346–353
Confirmation bias, 10 case example, 350
Conflict, relationship, 220–222, 224–225 dosage variation, 348
Conscientiousness, 155 duration of treatment, 349
Consciousness, autonoetic, 185 empirical support for, 351–352
Consequences, in ABC model, 287 implementation conditions, 346–347
Contagion, law of, 84 outcome indicators for, 350–351
“Contagious pencil” experiment, 91–92 target populations for, 347–348
Contamination, fear of timing of, 348–349
autobiographical memory bias with, troubleshooting, 352–353
193–194 Deacon, B., 31
disgust sensitivity with, 91–92 Decontamination rituals, 18, 57, 228–229
intolerance of uncertainty with, 53 Deepened extinction, 269, 273–274, 277
safety behaviors associated with, 38–39 Defusion, 326–329, 331–333, 337
threat overestimation with, 13, 14, De Houwer, J., 210
18–19 Dental Anxiety Inventory, 13, 298
Contamination, uncertainty about, 53, Depersonalization, 76, 340
56–57 Depressed mood, interpretation bias
Contamination Cognitions Scale, 13, 298 measure for, 371
Contamination obsessions, 162, 228–229 Depression
Contamination-related OCD, 39 and accommodation behaviors, 221
Contextual renewal, 266, 274, 275, 278 behavioral activation-focused interven-
Contextual stressors, 126–127 tions for, 307, 314
Contextual variability, in inhibitory and maladaptive perfectionism, 156, 158
learning, 274, 278 worry and rumination with, 143
Contrast-Avoidance Questionnaire–Worry, Depressive symptoms, distress intolerance
140 in, 101, 103
Control and control strategies Diagnosis-driven approach to anxiety-
acceptance of obsessions vs. using, 326 related disorders, 4–5
aversive, 317 Diagnostic and Statistical Manual of Mental
with blood, injection, and injury Disorders, Fifth Edition (DSM–5), xiii,
phobias, 91 xiv, 3–4, 8, 12, 13, 16, 17, 40, 46,
and experiential avoidance, 118–119 187–188, 192, 193, 241, 242, 244,
with perfectionism, 162, 163 245, 267
social, 172 Dialectical behavior therapy (DBT), 324,
thought, 175 340
Coping behaviors and strategies, 100, 135, Didactic method, 294
157, 256 DII (Distress Intolerance Index), 104
 Index 385

Direct observation, of safety behaviors, DPSS–R (Disgust Propensity and Sensitivity

36, 37 Scale—Revised), 88, 93
Disasters DS (Disgust Scale), 86
fear of natural environment and, DSM–5. See Diagnostic and Statistical Manual
13–16, 40 of Mental Disorders, Fifth Edition
uncertainty about, 53–55 DS–R (Disgust Scale—Revised), 86–88, 91
Discomfort Intolerance Scale, 104 DTS (Distress Tolerance Scale), 103–104
Disconfirmatory information, 93, 294 Dyadic Adjustment Scale, 227–228
Discrimination, 126–127
Disgust, 81, 84–85, 92–93
E
Disgust Emotion Scale for Children, 88
Disgust Propensity and Sensitivity Scale EA. See Experiential avoidance
(DPSS), 87–88 Eclectic treatment approach, 242
Disgust Propensity and Sensitivity EE. See Expressed emotion
Scale—Revised (DPSS–R), 88, 93 Effort, concealment of, 161
Disgust Scale (DS), 86 Egan, S. J., 158
Disgust Scale—Revised (DS–R), 86–88, 91 Ehlers, A., 196
Disgust sensitivity, 81–93 Ehring, T., 141
assessment of, 86–90 Eifert, G. H., 125
and blood/injection/injury phobias, 91 Ellis, A., 287
defined, 81–83 EMDR (eye movement desensitization and
“laws” of disgust, 84 reprocessing) therapy, 244–245
mental stimuli, 85–86 Emotion(s). See also Negative emotions
and OCD, 91–92 (negative emotional states)
overlap of fear and disgust, 84–85 and autobiographical memory bias,
and PTSD, 92–93 189–190
and specific phobias, 90–91 beliefs, events, and emotional
Disorder-driven approach to anxiety, consequences, 9
xiii–xiv, 3–4 cognitive model of, 8–9, 222–223, 288
Dispositional fear of the unknown. See leaning in to, 334–335
Anxiety-related disorders Emotional arousal, 189
Dissociation, 126, 256 Emotional awareness, 120
Distal antecedents, 311 Emotional expressiveness training, 233
Distancing, 81 Emotional intolerance, 101
Distraction techniques, 30, 39–40, 172 Emotional numbing, 231
Distress, 100, 154, 232 Emotional overinvolvement, 222, 226–227
Distressing internal experiences, avoiding. Emotional processing theory, 250, 259
See Experiential avoidance Emotional reasoning, 11, 93, 293
Distress intolerance, 99–110 Emotional spatial cuing task, 208, 210
assessment of, 103–106 Emotional Stroop task, 207–208, 210
and avoidance/safety behaviors/negative Emotional suppression, with worry,
reinforcement, 103 123–124
cognitive appraisals and, 101, 103 Emotion control, in panic disorder, 163
cognitive behavior model of, 100–102 Emotion regulation, 109, 116
defined, 99–100 Empathy, 221
and fear-based conditions, 106–107 Empirically supported interventions,
identifying indicators of, 270 242–243
and obsessive-compulsive spectrum Empirical research
conditions, 107–108 on behavioral activation, 314
and trauma-related conditions, 108–109 on cognitive change via rational
Distress Intolerance Index (DII), 104 discussion, 298–300
Distress Tolerance Scale (DTS), 103–104 on D-cycloserine administration,
Domain-specific perfectionism measures, 351–352
160 on habituation, 258–259
Dot-probe task, 207–208, 210 on inhibitory learning, 277–278
Doubts, about actions, 159 on interpretation bias modification, 372
Downward arrow technique, 12, 69 on mindfulness and acceptance-based
DPSS (Disgust Propensity and Sensitivity therapies, 337–338
Scale), 87–88 Environment, fear of, 192
386 Index

Environmental context enhancing inhibitory learning in, 267.

for anxiety sensitivity, 67 See also Inhibitory learning
for inhibitory learning, 274, 278 fear extinction in, 265–267
Environmental Reward Observation Scale habituation in, 249, 250, 252–256, 259.
(EROS), 313–314 See also Habituation
Episodic memories, 185 pharmacological enhancement of,
ERP. See Exposure and response prevention 345–346, 353. See also D-cycloserine
Errors, in interpretation bias modification, (DCS) administration
368 Expressed emotion (EE), 221, 224,
Escape responses, 230, 253, 279 226–227
Events, beliefs, emotional consequences, Extinction (fear extinction), 249–250
and, 9 accommodation and prevention of, 223
Evidence requirements, of individuals with D-cycloserine administration without,
perfectionism, 164 349
Exactness, uncertainty regarding, 53 deepened, 269, 273–274, 277
Excitatory conditional stimuli, 268, 273, in exposure therapy, 265–267
281 and inhibitory learning, 250
Expectancy violation occasional reinforced, 275
and avoidance, 279–280 safety behaviors and, 31–33
empirical support for, 277 Extinction learning, 267, 345–346, 353.
and inhibitory learning, 267–270, 272 See also D-cycloserine (DCS) adminis-
Experiential avoidance (EA), 115–128 tration; Inhibitory learning
and anxiety, 117 Extrinsic reinforcement, 317
assessment of, 119–122 Eye movement desensitization and
consequences of, 119 reprocessing (EMDR) therapy,
with contextual stressors, 126–127 244–245
defined, 115–116 “Eyes closed” experiential exercises, 333
and failed suppression/control, Eye-tracking measures, 206, 211, 213
118–119
with fear about thought meaning/
F
significance, 125–126
with fear of negative evaluations, FaceReader, 90
122–123 Facial EMG, assessing disgust with, 90
with fear of somatic cues, 124–125 Facial expression, 82, 89–90
with fear of traumatic events, 126 Failure, fear of, 128, 157
as function of worry, 330–331 Family Accommodation Scale (FAS),
and negative/judgmental thoughts, 118 225–226
with perfectionism, 163, 164 Family members, 256, 280, 311
with procrastination, 127–128 Fear(s)
with worry, 123–124 acquisition of, 249
Experiential practices, assessing/treating EA circumscribed, 40–41. See also Specific
with, 121 phobias
Exposure, 106, 265 as driver of behavior, 4
Exposure and response prevention (ERP) of fear, 37, 68, 259. See also Anxiety
behavioral commitments with, 329–330 sensitivity
and cognitive restructuring, 299 hierarchy of, 253, 274, 308, 313
for obsessive-compulsive disorder, inhibition of, 249
243–244, 252, 325, 326 response overlap for disgust and, 84–85
under- and overengagement with stimuli return of, 265, 267, 280
during, 255–256 Fear-based conditions, 106–107. See also
Exposure-based lifestyle, 256 specific fears and phobias
Exposure therapy Fear conditioning, 11, 266–267
accommodation and, 223 Fear domains (fear stimuli), 53, 233,
anxiety presentation-specific, 251–252 273–274
avoidance behaviors and, 278–280 Fear extinction. See Extinction
BA-based treatments vs., 305–307, 316 Fear reduction, as outcome indicator, 276
caregivers in, 232–233, 256 Fear structures, 250
and cognitive restructuring, 298–300 Feedback, 158
empirical evidence for, 250 Feeling goals, 330
 Index 387

Finkenauer, C., 87 Generalized worry, 53

5-HTTLPR (serotonin transporter gene), 206 Goal(s)
Five Facet Mindfulness Questionnaire harm-avoidance, 84–85, 162
(FFMQ), 337 treatment, clarification of, 325
Flett, G. L., 154, 161 and workability of worry, 330
Flexible attention, 334 Goldstein, A. J., 66
FMPS (Multidimensional Perfectionism Guilt sensitivity, 221
Scale), 159
Foa, E. B., 221, 299
H
Focus
attentional, 269, 273, 279, 309 Habituation, 249–260
on negative emotional states, 100 between-session, 254, 255, 257–259
Formal meditation practice, 338–339 D-cycloserine administration without,
Forsyth, J. P., 125 349
Foy, D. W., 92 defined, 249–250
Fredman, S. J., 226–227 measurement of, 254, 257
Free-viewing tasks, 209, 211 optimization of, 252–256
Frenchman, S. J., 39 overreliance on, 259
Freshman, M., 221 threat overestimation and, 22
Frost, R. O., 154 within-session, 254–255, 257–259
Frustration–Discomfort Scale, 104 Habituation-based exposure approach,
Function (as term), 172 251–260
Functional analysis, 308, 311 caregivers in, 256
Fusion beliefs, 179 empirical support for, 258–259
Future, conceptualized, 116 inhibitory learning vs., 267–270, 277
Future orientation, 333–334 optimizing habituation in, 252–256
outcome indicators for, 257–258
presentation-specific exposures in,
G
251–252
GAD. See Generalized anxiety disorder treatment outcomes for, 277
Gap filling (as term), 179 troubleshooting, 259–260
Gardner, F. L., 164 Harm
Gaudreau, P., 155 avoidance of, as goal, 84–85, 162
Gaze contingent music reward therapy responsibility for, 53
(GC-MRT), 213 uncertainty about, 53–55
Generalization, 254, 368–369 Harris, M., 225
Generalized anxiety disorder (GAD), 66, Hayes, S. C., 339–340
178, 197 Health, uncertainty about, 53, 56–57
acceptance-based behavioral model of Health anxiety
anxiety for, 117 AS-based intervention for, 76
Ambiguous Scenario Training stimuli for, attention bias with, 205
364 autobiographical memory bias with,
autobiographical memory bias with, 197 187, 195
behavioral activation-based treatment of, dysfunctional cognition measures for,
309 298
and experiential avoidance, 125 fear of somatic cues with, 124
interpretation bias modification for, 372 metacognitive model of, 173
metacognition with, 178 safety behaviors associated with, 36
mindfulness and acceptance-based Heart rate, 124–125, 257
treatment of, 330–335 Height phobia, 364, 365
perfectionism with, 163–164 Helplessness orientation, 157
procrastination with, 127 Hershenberg, R., 315
rumination with, 142–144 Hewitt, P. L., 154, 161
safety behaviors associated with, 30, 36 Hewitt and Flett Multidimensional
threat overestimation with, 17–18, 20 Perfectionism Scale (HMPS),
uncertainty intolerance with, 54, 57 159–160
Word-Sentence Association Paradigm High anxiety sensitivity (high AS), 67
stimuli for, 365 Higher-order autobiographical representa-
worry with, 123, 134, 142–144 tions, 185
388 Index

High-risk behavior, with distress retrieval cues in, 275–276

intolerance, 109 stimulus variability in, 274
HMPS (Hewitt and Flett Multidimensional strategies for enhancing, 269
Perfectionism Scale), 159–160 troubleshooting, 278–280
Hodgson, R. J., 243 Injection phobias. See Blood, injection, and
Hofmann, S. G., 299 injury phobias
Hollon, S. D., 299 Injury phobias. See Blood, injection, and
Homework compliance, 300–301, 311, 317 injury phobias
Homicidality, exposure therapy and, 260 Insula, 67
Hopko, D. R., 307, 315 Intentional thought suppression, 40
Hopko, S. D., 307 Internal experiences
Hypervigilance, 55–56 in acceptance-based behavioral model of
anxiety, 117
acceptance of, 324
I
failed suppression and control of,
IAD. See Illness anxiety disorder 118–119
IBM. See Interpretation bias modification in mindfulness and acceptance-based
ICD–10. See International Classification of therapies, 325
Diseases, Tenth Edition (WHO) International Classification of Diseases, Tenth
ICD–11. See International Classification of Edition (ICD–10; WHO), 12, 13, 17
Diseases, Eleventh Edition (WHO) International Classification of Diseases, Eleventh
Identity, 126–127 Edition (ICD–11; WHO), xiii, xiv, 3–4,
IJQ (Interpretation and Judgmental 8, 241, 242, 245
Questionnaire), 371–372 Interoceptive exposure
Iketani, T., 163 in AS-related interventions, 73–74
Illness assessing anxiety sensitivity with,
fear of having or contracting, 195–196 70–72
severe anxiety related to, 252 and expectancy violation, 277
Illness anxiety disorder (IAD) in habituation-based treatments, 251,
accommodation behaviors with, 252
220, 230 Interpersonal processes, 219–235. See also
safety behaviors associated with, 30 Accommodation behaviors
threat overestimation with, 17–18, 21 assessment of, 224–228
uncertainty intolerance with, 53, 56 in caregiver-assisted exposure therapy,
Imagery, 184, 188, 369 232–233
Imaginal exposure to trauma, 251 defined, 219–221
inhibitory learning with, 270 impact of worry and rumination on,
for obsessive-compulsive disorder, 252 138–139
for posttraumatic stress disorder, 252, psychoeducation on, 232
254, 258–259, 310 and relationship conflict, 221–222
Implicit assessment of state disgust, 89 as treatment target, 231–232
Implicit Association Test, 89, 277 Interpersonal relationships, 119, 160,
Impression management, 31 219, 234
Incompleteness, feelings of, 162 Interpersonal rumination, 157
Infectious disease, 82–83 Interpretation and Judgmental
Informal meditation practices, 339–340 Questionnaire (IJQ), 371–372
Information gathering, for habituation, 253 Interpretation bias modification (IBM),
Information-processing biases, 10–11, 48 359–374
Inhibitory conditional stimuli, 268 defined, 359–360
Inhibitory learning, 250, 265–281 delivery methods, 366–368
attentional focus in, 273 dosage, 366
deepened extinction with, 273–274 empirical support for, 372
defined, 265–267 outcome indicators, 370–372
empirical support for, 277–278 personalization of, 363, 365–366
and expectancy violation, 267–270, 272 selection of stimuli and personalization,
multiple contexts for, 274 363–366
occasional reinforced extinction in, 275 selection of task, 362–363
outcome indicators for, 276–277 steps before implementation,
removal of safety signals/behaviors, 272 368–370
 Index 389

troubleshooting, 373–374 Kazdin, A. E., 241

types of, 361–362 Koster, E. H. W., 210
variation in dosage, 366
Interpretation of Intrusions Inventory, 298
L
Intolerance of distress. See Distress
intolerance Labeling, 293
Intolerance of uncertainty (IU), 45–58 Lamers-Winkelman, F., 87
about health, somatic cues, and Law of contagion, 84
contamination, 56–57 Law of similarity, 84
about safety, harm, and disasters, 53–55 Leach, D. J., 315
about social evaluation, 55 “Leaning in” to emotions, 334–335
about thought meaning/significance, Learning. See also D-cycloserine (DCS)
55–56 administration; Inhibitory learning
assessment of, 50–52 extinction, 267, 345–346, 353
biased ambiguous information reward framework for, 103
processing in, 48 Learning theory, 267, 268, 273, 280
certainty-seeking behaviors in, 49 “Leaves on a stream” meditation, 333
cognitive behavior model of, 47 Lebowitz, E. R., 226
and core beliefs about uncertainty, LEE (Level of Expressed Emotion)
47–48 scale, 227
defined, 45–46 Lejuez, C. W., 307, 309
inhibitory, 46 Level of Expressed Emotion (LEE) scale,
negative reinforcement in, 49–50 227
with “not just right experiences,” 57 Lewinsohn, P. M., 305, 313
and perfectionism, 163 Lewis, B., 225
prospective, 46 Liebowitz Social Anxiety Scale,
samples of, across different fear stimuli, 53 350, 351
threatening interpretations of uncertainty Likelihood overestimation, 8, 14–16,
in, 48–49 18–19, 21
Word-Sentence Association Paradigm Liu, X., 315
stimuli for, 365 Livanou, M., 299
Intolerance of Uncertainty Index, 51 Loneliness, 157
Intolerance of Uncertainty Scale (IUS), 51 Longmore, R. J., 299
Intrusive imagery, 188 Lovell, K., 299
Intrusive thoughts, 13, 14, 193–194 Low anxiety sensitivity (low AS), 67
Intrusive trauma memories, 135
Invalid-cue condition, 210
M
In vivo exposure, 251, 252
In vivo observation of safety behaviors, M. levator anguli oris, 90
36, 37 M. levator labii superioris alesque nasii
IU. See Intolerance of uncertainty contraction, 90
IUS (Intolerance of Uncertainty Scale), 51 Maack, D. J., 31
Mackintosh, B., 361
Maladaptive behaviors, 54–56, 103
J
Maladaptive certainty-seeking behavior,
Jacobson, N. S., 307 55, 56
Jakupcak, M., 314, 315 Maladaptive cognitive schemas, 288
Jones, J., 226 Maladaptive perfectionism, 154–155, 160.
Joormann, J., 164 See also Perfectionism
Judgment, fear of, 122–123 Maladaptive reassurance seeking, 54
Judgmental thoughts, 118 Maladaptive thoughts, 287–289, 293,
Julian, K., 299 299–300
Jumping to conclusions, 293. See also Manualized treatment programs,
likelihood overestimation 241–245, 307, 338
Marginalization, 126–127
Marks, I., 299
K
Martell, C. R., 309
Kabat-Zinn, J., 323, 324 Matchett, G., 90
Kamphuis, J. H., 29–30 Mathews, A., 361
390 Index

MBCT (mindfulness-based cognitive “Mind as GPS” metaphor, 331–332

therapy), 324, 340 Mindful Attention Awareness Scale, 337
MBSR (mindfulness-based stress Mindfulness
reduction), 324, 340 defined, 323–324
McDonald, R., 299 and defusion of obsessions, 327–329
McEvoy, P. M., 141 exercises/metaphors targeting, 326
McGuire, J. F., 347 indicators of, 337
McLean, P. D., 299 and values/behavior change, 329
MCQ-30. See Metacognitions Questionnaire Mindfulness and acceptance-based
MCQ-65 (Metacognitions Questionnaire), therapies, 323–340
176 common themes of, 335–336
Meaningful action, engaging in, 334 defined, 323–324
Medial prefrontal cortex, 67 empirical support for, 337–338
Mediation analyses, 299 for generalized anxiety disorder,
Medical procedures, disgust response to, 85 330–335
Memories for OCD, 325–330
autobiographical, 85–86, 196 outcome indicators for, 336–337
episodic, 185 troubleshooting, 338–340
intrusive, 135 Mindfulness-based cognitive therapy
self-defining, 187 (MBCT), 324, 340
semantic, 185–186 Mindfulness-based stress reduction
traumatic, fear of, 40, 196–197 (MBSR), 324, 340
Memory bias, 10–11. See also Auto­ Mirror tracing persistence task (MTPT), 105
biographical memory bias Misattribution of safety hypothesis, 33
Memory reconsolidation, 347 Mislabeling, 293
Mental distraction, 30, 39–40, 172 Mistakes, concern over, 159, 161
Mental filter, 293 Mood disorders, 309
Mental images, in autobiographical Moral disgust, 82, 87, 90
memory bias, 188–189 Motivation, accommodation and,
Mental reinstatement, 269, 275, 278 223–224
Mental stimuli, disgusting, 81–83, 85–86 MTPT (mirror tracing persistence task), 105
Metacognition, 171–180 Multicomponent treatment programs,
about worry and rumination, 136–137 241–242
assessment of, 175–177 Multidimensional approach to perfection-
defined, 171–173 ism, 154, 155
with generalized anxiety disorder, 178 Multidimensional Experiential Avoidance
metacognitive model, 174–175 Questionnaire, 121, 122
with OCD, 178–179 Multidimensional Perfectionism Scale
with PTSD, 179–180 (FMPS), 159
with social anxiety disorder, 180 Multiple Stimulus Types Ambiguity
Metacognitions Questionnaire (MCQ-30), Tolerance-I, 104
140, 175, 176 “Must” statements, 293
Metacognitions Questionnaire (MCQ-65),
176
N
Metacognitive experiences, 173
Metacognitive knowledge, 172 Natural environment and disasters, fear of,
Metacognitive model, 174–175 13–16, 40
Metacognitive therapy, 176–177 Nearmy, D. M., 315
Metaphors Negative affective valence, 135–136
in EA treatment, 121 Negative emotional contrasts, 137
in exposure therapy to bring about Negative emotions (negative emotional
habituation, 253 states)
in mindfulness and acceptance-based accommodation to avoid, 221
therapies, 326–329, 331–332 catastrophizing of, 101
Metaworry, 173 focus on, 100
Meta-Worry Questionnaire, 176 trauma-related, 109
Meyer, V., 243 worry-related, 136, 137
Microaggressions, 127 Negative evaluation, distress intolerance
Miklowitz, D. J., 226–227 related to, 107
 Index 391

Negative evaluation, fear of behavioral activation-based treatment of,

autobiographical memory bias with, 310
192–193 and cognitive change, 299
and experiential avoidance, 122–123 cognitive restructuring for, 298
safety behaviors associated with, 37–38 D-cycloserine in treatment of, 347
threat overestimation with, 13, 14, 16 disgust sensitivity in, 82, 87, 91–92
worry and rumination with, 143–145 distress intolerance with, 107–108
Negative feedback, 158 dysfunctional cognitions related to, 298
Negative fusion metabeliefs, 179 empirically supported interventions for,
Negative metacognitive beliefs, 172, 174 242
Negative outcomes, fear of, 197 experiential avoidance in, 125, 126
Negative reinforcement, 49–50, 103, 242 habituation during exposure therapy for,
Negative self-exposure, fear of, 192–193 252, 253, 259
Negative thoughts, in experiential metacognitions with, 172, 175, 178–179
avoidance, 118 mindfulness and acceptance-based
Negative urgency, 108 treatment of, 325–330
Neutralization, 18, 39, 108, 135 perfectionism in, 160, 162–163
Newman, M., 134, 141 safety behaviors associated with, 28, 30,
Nixon, R. D., 315 36, 38–39
NJREs. See “Not just right experiences” threat overestimation with, 16–18, 21
Nock, M. K., 241 uncertainty intolerance with, 54–58
Nontarget trials, 211 worry and rumination experienced with,
Noshirvani, H., 299 146
“Not just right experiences” (NJREs) Obsessive-compulsive personality disorder
autobiographical memory bias about, (OCPD), 156
193–194 Obsessive-compulsive spectrum conditions
forms of, 22 distress intolerance with, 107–108
perfectionism and, 162 worry and rumination with, 143, 146–147
threat overestimation related to, 14, Occasional reinforced extinction, 275
21–22 OCD. See Obsessive-compulsive disorder
uncertainty regarding, 53, 57 Other-oriented perfectionism, 154, 157,
Numbing, emotional, 231 159–160
“Ought to” statements, 293
Overcompensatory behaviors, 161
O
Overestimation of threat. See Threat
Objective evidence, in cognitive therapy, overestimation
294–296 Overgeneralization, 293
Obsessions
acceptance of, 326–327
P
accommodation of, 228–229
contamination, 162, 228–229 Paced Auditory Serial Addition Test
control and harm avoidance with, 162 (PASAT), 105
defined, 16 Pain
fear of significance/meaning of thoughts chronic, 310–311, 317
related to, 125, 126 fear of, 76
mindfulness and defusion of, 327–329 suffering vs., 331
perfectionism and, 162 Panic attacks
as repetitive negative thinking, 135 anxiety sensitivity with, 66
taboo, 229 attention bias with, 205
worry and rumination experienced autobiographical memory bias with, 195
with, 147 and cognitive change via rational
Obsessive Beliefs Questionnaire, 13, 51, discussion, 295, 296
298 fear of somatic cues with, 124
Obsessive-compulsive disorder (OCD) habituation during exposure therapy for,
accommodation behaviors with, 220, 252, 253
224–226, 228–229 inhibitory learning approach to treating,
anxiety sensitivity with, 75 275
autobiographical memory bias with, 188, relationship conflict due to, 221–222
193–194, 197 uncertainty intolerance with, 53, 56
392 Index

Panic Belief Inventory, 69 Perfectionistic self-presentation (PSP), 161

Panic Control Treatment, 241 Peritraumatic disgust, 92–93
Panic disorder (PD) Peritraumatic dissociation, 126
accommodation behaviors with, 220, 230 Perseveration cognition, 136–137
Ambiguous Scenario Training stimuli Perseverative Cognitions Questionnaire, 140
for, 364 Perseverative Thinking Questionnaire, 140
anxiety sensitivity with, 66, 73, 74 Personalization, 293
BA-focused treatment for, 316 Personal standards, 159
cognitive restructuring for, 298 PES (Pleasant Events Schedule), 313, 314
D-cycloserine in treatment of, 347 Pharmacological enhancement of extinc-
dysfunctional cognitions related to, 298 tion learning, 345–346, 353. See also
habituation during exposure therapy for, D-cycloserine (DCS) administration
252 Pharmacotherapy, 345–346
perfectionism with, 160, 163 Phobias. See Specific phobias
safety behaviors associated with, 30, 36 Phobic anxiety, worry/rumination with, 143
threat overestimation with, 17 Physical contact, preventing, 84–85
uncertainty intolerance with, 56, 58 Physical distress intolerance, 105, 107
Word-Sentence Association Paradigm Physical handicaps, individuals with, 317
stimuli for, 365 Physiological activation, 136
worry and rumination experienced Physiological arousal, 123, 189
with, 145 Piacentini, J., 231
Panic symptoms, cognitive change and, 299 Pillay, P., 315
Parents Pinto, A., 226
accommodation behaviors of, 225, 226, Pleasant Events Schedule (PES), 313, 314
230, 231 Polygraph metaphor, 330–331
and DCS administration to children, Polymorphisms, 67
348, 352 Ponniah, K., 299
disgust responses by, 82 Positive, disqualifying, 293
expectations of and criticism by, 159 Positive Beliefs About Rumination Scale, 140
exposure therapy with, 256 Positive metacognitive beliefs, 172
PASAT (Paced Auditory Serial Addition Positive reinforcement, 307
Test), 105 Posner, M., 210
“Passengers on a bus” metaphor, 328–329 Postevent processing, 161
Past, conceptualized, 116 Post-Event Processing Questionnaire–
Past orientation, 333–334 Revised, 140
Pathogen disgust, 82–84, 87, 88 Postevent rumination, 144
Pavlovian fear conditioning, 266–267 Posttraumatic Cognitions Inventory, 13, 298
PD. See Panic disorder Posttraumatic sequelae, fear of
Penn State Worry Questionnaire, 139, 140 autobiographical memory bias with,
Perceived Criticism (PC) measure, 227 196–197
Perceived negative valence, 270, 272 dysfunctional cognitions related to, 298
Perfectionism, 153–164 threat overestimation with, 13, 14, 19–20
adaptive, 154–155, 160–161 Posttraumatic stress, uncertainty related
assessment of, 158–160 to, 53
cognitive factors of, 158 Posttraumatic stress disorder (PTSD)
coping with, 157 accommodation behaviors with, 220,
defined, 153–156 224, 230–231
with generalized anxiety disorder, anxiety sensitivity with, 66, 73–75
163–164 autobiographical memory bias with,
maladaptive, 154–155, 160 187–188, 193, 196–197
with OCD, 162–163 behavioral activation-based treatment of,
with panic disorder/agoraphobia, 163 309–310, 314
and perception of reduced social catastrophic interpretation of, 20
support/feedback, 157–158 cognitive restructuring for, 298, 299
with social anxiety disorder, 160–161 common themes of, 20
and stress, 156 D-cycloserine in treatment of, 347, 353
Perfectionism/Certainty subscale of the disgust sensitivity in, 82, 87, 92–93
Obsessive Beliefs Questionnaire, 51 distress intolerance with, 108–109
Perfectionistic cognitions, 161, 162 dysfunctional cognition measures for, 298
 Index 393

fear of traumatic events with, 126 Reflexive adaptation process, 179

habituation during exposure therapy for, Reinforced extinction, 269
252, 254, 256, 258–259 Reinforcement
interpersonal processes for individuals extrinsic, 317
with, 230–231 negative, 49–50, 103, 242
metacognitions with, 175, 179–180 positive, 307
safety behaviors associated with, 30, 40 subjective, 313–314
symptoms of, 19–20 Reinstatement of conditional fear, 266
threat overestimation with, 18 Relapse prevention strategies, 275,
uncertainty intolerance with, 54–55, 57 276, 346
Powers, M. B., 299 Relational frame theory, 118
Prescriptions, D-cycloserine, 346 Relationship adjustment, 227–228
Presentation–Related Safety Behaviors Relationship conflict, 220–222, 224–225
Scale, 36 Relationship distress, 232
Present orientation, 333–334 Relationship satisfaction, 228
Preventative safety behaviors, 31, 38 Relaxation techniques, 30
Probability overestimation, 270, 272 Repetition, for defusion, 332–333
Probability Questionnaire, 13 Repetitive negative thinking (RNT),
Problem-solving, worry/rumination and, 138 135–137, 139–141
Procrastination, 127–128, 157 Repetitive Thinking Questionnaire, 140
Prolonged exposure therapy, 310 Response-contingent positive reinforce-
Proximal antecedents, 311 ment, 313
PSP (perfectionistic self-presentation), 161 Response Styles Questionnaire, 139
Psychoeducation, 73, 232 Responsibility for harm, 53
Psychological flexibility, 116, 121n3, 128, Restorative safety behaviors, 31
335, 337 Retraumatization, fear of, 20
Psychological maintenance processes, 3–5 Retrieval cues, 269, 274–276, 278
Psychopathology, 66, 184 Return of fear, 265, 267, 280
Psychophysiological indices for habituation, Reward learning framework, 103
257, 258 Reward Probability Index (RPI), 313, 314
Psychosis, active, 260 Risky behaviors, 119
Psychotropic medication, D-cycloserine Ritual completion, perfectionism about,
interactions with, 352–353 162–163
PTSD. See Posttraumatic stress disorder RNT (repetitive negative thinking),
135–137, 139–141
Romantic partners, 232, 256, 311. See also
Q
Accommodation behaviors
Quality of Life Inventory, 337 Rosenfield, D., 299
Questionnaire for Assessing Safety RPI (Reward Probability Index), 313, 314
Behavior in Hypochondriasis/Health Rueger, D. B., 92
Anxiety, 36 Rumination, 133–147
amygdala reactivity due to, 136
assessment of, 139–142
R
cognitive–affective functions of, 137–138
Rachman, S. J., 243 defined, 133–134
Rapee, R. M., 315 with generalized anxiety, 142, 144
Rapid reacquisition of conditional response, interpersonal, 157
266–267 and negative affective valence, 135–136
Rational discussion. See Cognitive change negative impact on interpersonal
via rational discussion processes, 138–139
Rational thinking, 287 with negative social evaluation, 144–145
Rauch, S. A., 299 with obsessive-compulsive spectrum,
Reaction-time based approach-avoidance 146–147
task, 89 and perfectionist cognitions, 161
Reaction-time based measures of attention and perseveration cognition, 136–137
bias, 206–211 problem-solving and, 138
Reasoning, emotional, 11, 93, 293 self-report inventories for, 139
Reassurance, providing, as accommodation, with somatic concerns, 145
229–231 with trauma-related concerns, 146
394 Index

Rumination on Sadness Scale, 140 Self-oriented perfectionism (SOP), 154,

Ruminative Response Scale, 139, 140 158–160, 163
Self-presentation, perfectionist, 161
Self-Regulatory Executive Function
S
(S-REF) model, 171
SAD. See Social anxiety disorder Self-report measures
“Safe person,” acting as, 230 of accommodation behaviors, 224–227
Safety, 33, 53–55 of anxiety sensitivity, 68–69
Safety Behavior Checklist, 36 of DCS-based treatment outcome,
Safety behaviors, 27–41, 49 350–351
and accommodation behaviors, of disgust, 88–89
222, 223, 231 of distress intolerance, 103–104
in anxiety development/escalation, 31–32 of dysfunctional cognitions, 297–298
anxiety-related, 29, 41 of experiential avoidance, 121–122
anxiogenic effects of, 33–34 of habituation, 258
assessment of, 34–37 of inhibitory learning outcomes, 276
and BA-focused treatments, 317 of interpretation bias, 369–371
defined, 27–29 of mindfulness and acceptance-based
and distress intolerance, 103 therapy outcomes, 337
and extinction of conditioned fear, of perfectionism, 159–160
32–33 of safety behavior use, 36
with fear of contamination, 38–39 of uncertainty intolerance, 51–52
with fear of fear, 37 of worry and rumination, 139–141
with fear of negative evaluation, Self-sacrifice, excessive, 226
37–38 Self-schemas, 185, 187
with fear of traumatic memories, 40 Self-sustained approach behaviors, 307
with fear of unacceptable thoughts, 39 Self-talk, 335
with generalized anxiety disorder, 41 Semantic memories, 185–186
and inhibitory learning, 269, 272, 273, Sensation-based perfectionism, 162
277–278 Separation anxiety, 220, 230
phenomenology of, 29–31 Serotonin transporter gene (5-HTTLPR),
preventative vs. restorative, 31 206
with specific phobias, 40–41 Severity overestimation, 8, 14–16,
in threat overestimation, 9, 10 18–19, 21
Safety Behaviors Questionnaire, 36 Sexual disgust, 82, 85, 87
Safety signals (safety cues) Shafran, R., 155, 158, 160
in exposure therapy to bring about Sheehan Disability Scale, 350, 351
habituation, 253 “Should” statements, 293
and inhibitory learning, 272, 273, Significant others, 35–36. See also Romantic
277–278 partners
retrieval cues vs., 275–276 Similarity, law of, 84
Salkovskis, P. M., 33 Sipprelle, R. C., 92
Samma sati, 323 Situational exposure, 73
Santanello, A. W., 164 Situational phobias, 40, 192
Sati, 323, 324 Skin conductance measures of habituation,
Satisfaction, relationship, 228 257
Scenario recognition test, 369 Small animal phobias, 82, 87, 90
Scharfstein, L., 226 Smits, J. A., 299
Selective attention, 10, 279 Smoking cessation programs, 76
Selective serotonin reuptake inhibitors SMS (self-memory system), 186–187
(SSRIs), 353 Social anxiety
Self, sense of, 116, 186–188 and cognitive change, 299
Self-critical perfectionism, 161 cognitive change via rational discussion
Self-defining memories, 187 for, 288
Self-disclosure, 300 dysfunctional cognitions related to, 298
Self-help, 367 habituation during exposure therapy
Self-injurious behaviors, 260 for, 252
Self-memory system (SMS), 186–187 inhibitory learning approach to treating,
Self-monitoring, 37, 305, 308 269–270, 275
 Index 395

interpretation bias measures for, Specific phobias

370–372 accommodation behaviors with, 220,
metacognitions with, 173, 180 230
and perfectionism, 157 Ambiguous Scenario Training stimuli
relationship conflict due to, 221 for, 364
uncertainty intolerance with, 53 anxiety sensitivity with, 75–76
and worry and rumination, 144–145 autobiographical memory bias with, 192
Social Anxiety—Acceptance and Action behavioral activation-based treatment
Questionnaire, 122 of, 310
Social anxiety disorder (SAD) D-cycloserine in treatment of, 347
accommodation behaviors with, 220 disgust sensitivity with, 90–91
Ambiguous Scenario Training stimuli dysfunctional cognitions related to, 298
for, 364 habituation during exposure therapy for,
anxiety sensitivity with, 75 251, 257, 258
attention bias with, 213 inhibitory learning for treatment of, 274
autobiographical memory bias with, 193 interpretation bias modification for, 372
behavioral activation-based treatment of, safety behaviors associated with, 30,
309 40–41
cognitive restructuring for, 298 uncertainty intolerance with, 53, 54
D-cycloserine in treatment of, 347 Word-Sentence Association Paradigm
fear of negative evaluations with, 122–123 stimuli for, 365
interpretation bias modification for, 372 Spider phobia, 90–91, 364
metacognition with, 180 Spider Phobia Beliefs Questionnaire, 13,
overestimation of threat with, 18 298
perfectionism with, 160–161 Spontaneous recovery, 266
procrastination with, 127 SPP. See Socially prescribed perfectionism
safety behaviors associated with, 30, 36, S-REF (Self-Regulatory Executive
37–38 Function) model, 171
uncertainty intolerance with, 55, 57 SSRIs (selective serotonin reuptake
Word-Sentence Association Paradigm inhibitors), 353
stimuli for, 365 Stability, of anxiety sensitivity, 67
Social Behavior Questionnaire, 36 Standards of individuals with perfectionism,
Social Cognitions Questionnaire, 298 153, 155, 159, 161
Social control, 172 Stanton, S. E., 226–227
Social evaluation, uncertainty about, 53, 55 State anxiety, 372
Social feedback, 158 State disgust, 88–90
Social isolation, 55 Stimulus variability, in inhibitory learning,
Socially prescribed perfectionism (SPP), 269, 274
154, 157–160, 163 Stöber, J., 164
Social Phobia Safety Behaviors Scale, 36 Strachan, M., 315
Social referencing, 82 Stress and stressors, 126–127, 156, 222
Social rejection, 270 Strivings, perfectionistic, 160
Social skills training, 309 Stroop task, 207, 208
Social support, 157–158 Subjective reinforcement, 313–314
Sociocultural factors, in interpretation bias Subjective units of distress scale (SUDS)
modification, 373 for BA-focused interventions, 308
Socrates, 293 for DCS administration vs. exposure
Socratic questioning, 293–295 therapy, 350
Solomon, R., 242–243 for habituation during exposure therapy,
Somatic cues, fear of, 124–125 254–255, 257, 258
autobiographical memory bias with, 195 for PTSD treatment, 258
with experiential avoidance, 124–125 Substance abuse, 260
threat overestimation with, 13, 14, Substance use, 109, 119
17–18 Subtle Avoidance Frequency Examination,
worry and rumination with, 143, 145 36
Somatic cues, uncertainty about, 53, 56–57 SUDS. See Subjective units of distress scale
SOP. See Self-oriented perfectionism Suffering, 331, 337
Special populations, BA-based therapy Suicidality, 260
with, 310–311 Symmetry, uncertainty regarding, 53
396 Index

Symptom accommodation. See Accommo- with fear of blood, injection, and

dation behaviors injury, 21
Symptom severity, D-cycloserine adminis- with fear of contamination, 18–19
tration and, 347, 351 with fear of natural environments/
Symptom–system fit, 224–225 disasters, 15–16
Szkodny, L., 134, 141 with fear of “not just right experiences,”
21–22
with fear of significance/meaning of
T
thoughts, 16–17
Taboo obsessions, 229 with fear of somatic cues, 17–18
Task-related anxieties, procrastination with fear of traumatic events, 19–20
and, 128 information-processing bias in, 10–11
TBT (transdiagnostic behavior therapy), negative evaluation, fear of, 16
316 origins of, 11
TCQ (Thought Control Questionnaire), safety behaviors in, 9, 10
175, 176 Threat-related attention bias, 203–206
TDDS (Three Domain Disgust Scale), 87 Threat-related thoughts, 68
Teasdale, J. D., 288–289 Threat-safety behavior linkage, 29, 30
Telch, M. J., 29–30, 34, 299 Threat transmission hypothesis, 34
Temporal focus, of worry vs. rumination, Three Domain Disgust Scale (TDDS), 87
135–136 Toffolo, M. B. J., 32
Texas Safety Maneuver Scale, 30, 36 Tolerance of Ambiguity Scale-12, 104
TFI (Thought Fusion Instrument), 175, 177 Trait anxiety, 372
Therapists Trait disgust, 86–88
in BA-focused interventions, 308, 316 Trait perfectionism, 161
mechanisms of change in training for, Transdiagnostic approach to mechanisms of
245 change, 245
Therapy-interfering behaviors, 317–318 Transdiagnostic behavior therapy (TBT),
Thompson, A., 155 316
Thought–action fusion, 125, 179 Transdiagnostic cognitive vulnerability
Thought-Action Fusion Scale, 13 factor, 57
Thought Control Questionnaire (TCQ), Transdiagnostic processes, xiv, 155,
175, 176 228–231
Thought control strategies, 175 Transdiagnostic treatments, anxiety
Thought–event fusion, 179 sensitivity in, 76
Thought Fusion Instrument (TFI), 175, 177 Transdiagnostic vulnerability factors, 73
Thought–object fusion, 179 Trauma-related concerns, worry and
Thoughts. See also Automatic thoughts; rumination with, 143, 146
Cognitions Trauma-related conditions, 108–109
intrusive, 13, 14, 193–194 Trauma survivors, 19–20
judgmental, 118 Traumatic events, fear of
maladaptive, 287–289, 293, 299–300 dysfunctional cognitions related to, 298
negative, 118 experiential avoidance with, 126
suppression of, 118–119 threat overestimation with, 13, 14,
unacceptable, 39, 53 19–20
uncertainty about significance/meaning Traumatic memories, fear of, 40, 196–197
of, 53, 55–56 Treatment efficiency, mechanisms of
Thought significance or meaning, fear of, change and, 244–245
13, 14, 16–17, 125–126 Treatment goal clarification, 325
Thrasher, S., 299 Trufan, S. J., 225
Threat appraisal, change in, 299 “Tug of war with a monster” metaphor, 121
Threat disconfirmation attenuation Turner, J. S., 315
hypothesis, 34 “Two-games” metaphor, 327
Threat-neutral pairs, 207 Tybur, J. M., 87
Threat overestimation, 7–23
assessment of, 11–13
U
in cognitive model of emotion, 8–9, 222
defined, 7–8 Unacceptable thoughts, 39, 53
with fear of animals, 13, 15 Uncertain outcomes, fear of, 197
 Index 397

Uncertainty Willingness to Pay scale (WTP-DI), 105

about health, somatic cues, and Woody, S. R., 299
contamination, 53, 56–57 Word-Sentence Association Paradigm
about safety, harm, and disasters, 53–55 (WSAP), 362, 363, 365–367, 369, 374
about social evaluation, 53, 55 Working self (as term), 187
about thought meaning/significance, 53, World Health Organization. See International
55–56 Classification of Diseases, Tenth Edition
core beliefs about, 47–48 (ICD–10); International Classification of
with “not just right experiences,” 57 Diseases, Eleventh Edition (ICD–11)
threatening interpretations of, 48–49 Worrell, M., 299
Uncertainty intolerance. See Intolerance of Worry, 133–147
uncertainty (IU) assessment of, 139–142
Unconditional response, 266 cognitive-affective functions of,
Unconditional stimulus (US), 266–268, 275 137–138
Unidimensional approach to perfectionism, cognitive–affective functions of, 137
154, 160 defined, 133–134
Unnecessary protective actions, 35 defusion of, 331–333
Unwanted intrusive thoughts, 13, 14 with experiential avoidance, 123–125
Unworkable behaviors, 116 function and workability of, 330–331
US (unconditional stimulus), 266–268, 275 generalized, 53
with generalized anxiety, 142, 144
interference with problem-solving, 138
V
interpretation bias modification for, 372
Valid-cue condition, 210 and negative affective valence, 135–136
Valued behaviors, 337 negative emotion due to, 136
Valued Living Questionnaire, 337 negative impact on interpersonal
Values clarification, 116, 329, 336 processes, 138–139
Van Delft, I., 87 with negative social evaluation, 144–145
Van Noppen, B., 226 with obsessive-compulsive spectrum,
Van Uijen, S. L., 32 146–147
Verschuere, B., 210 and perfectionism, 164
Vicarious conditioning, 11 and persecution cognition, 136–137
Virtual reality–based exposure, 251 self-report inventories for, 139
Visual imagery, anxious, 184 with somatic concerns, 145
Visual search tasks, 209, 210–211 with trauma-related concerns, 146
Voluntary retrieval of autobiographical Worry Behaviors Inventory, 36
memories, 196 Worry Domains Questionnaire, 140
Vomiting, fear of, 192 Worrying, pathological, 41. See also
Generalized anxiety disorder (GAD)
WSAP. See Word-Sentence Association
W
Paradigm
Wade, T. D., 158 WTP-DI (Willingness to Pay scale), 105
Wagner, A. W., 315
Washing compulsions, 82, 91
Y
Waterloo Images and Memories
Interview, 191 Yale–Brown Obsessive-Compulsive Scale,
Wegner, D. M., 121 225
Well-being, social support and, 157 Youth. See also Children and adolescents
White bear exercise, 121 D-cycloserine administration for,
Whittal, M. L., 299 347–349, 352
Why Worry-II, 140 disgust assessments with, 88
ABOUT THE EDITORS

Jonathan S. Abramowitz, PhD, is a professor of psychology and psychiatry,

and director of the Anxiety and Stress Disorders Clinic at the University of
North Carolina. An internationally recognized expert on obsessive-compulsive
disorder and anxiety, he has published over 300 research articles, books,
and book chapters. Dr. Abramowitz is a past president of the Association
for Behavioral and Cognitive Therapies and editor-in-chief of the Journal of
Obsessive-Compulsive and Related Disorders. He also maintains a practice in
Chapel Hill, North Carolina. Dr. Abramowitz’s contributions to the field have
been recognized with numerous awards.

Shannon M. Blakey, PhD, is a postdoctoral clinical research fellow at the

Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education and
Clinical Center and Durham VA Health Care System. She conducts research
on psychological processes involved in the maintenance and treatment of
anxiety and related disorders. She also investigates ways to enhance treatments
for anxiety and co-occurring problems such as depression and substance use
disorder. Dr. Blakey has published over 50 peer-reviewed articles and book
chapters and has been selected for multiple awards by organizations such as
the Association for Behavioral and Cognitive Therapies and the Society for a
Science of Clinical Psychology.

399