Hybrid Cognitive Behavioral Therapy With Interoceptive Exposure for Irritable Bowel Syndrome: A Feasibility Study

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder, which severely impairs the quality of life of patients. Treatment of refractory IBS patients is needed, but it is not yet widely available. Therefore, we previously developed a Japanese version of cognitive behavioral therapy with interoceptive exposure (CBT-IE) involving 10 face-to-face sessions to treat refractory IBS patients. To disseminate this treatment of IBS in places where therapists are limited, we further developed a hybrid CBT-IE program with complementary video materials that include psychoeducation and homework instructions so that patients can prepare for face-to-face sessions in advance at home and the session time can be shortened, thereby reducing the burden on both patient and therapist. In this study, we conducted a trial to evaluate the feasibility, efficacy, and safety of the hybrid CBT-IE program for Japanese IBS patients. The study was a single-arm, open-label pilot clinical trial. A total of 16 IBS patients were included in the study and 14 patients completed the intervention, which consisted of 10 weekly individual hybrid CBT-IE sessions. We performed an intention to treat analysis. The primary outcome measure for the efficacy of the intervention was a decrease in the severity of IBS symptoms. The feasibility and safety of the intervention were examined by the dropout rate and recording of adverse events, respectively. The dropout rate of the hybrid CBT-IE was comparable to that of our previous CBT-IE with only face-to-face sessions and no adverse events were recorded. The severity of IBS symptoms within-group was significantly decreased from the baseline to mid-treatment [Hedges' g = −0.98 (−1.54, −0.41)], post-treatment [Hedges' g = −1.48 (−2.09, −0.88)], 3-month follow-up [Hedges' g = −1.78 (−2.41, −1.14)], and 6-month follow-up [Hedges' g = −1.76 (−2.39, −1.13)]. Our results suggest that the hybrid CBT-IE is effective and could be conducted safely. To confirm the effectiveness of the hybrid CBT-IE, it is necessary to conduct a multicenter, parallel-design randomized control trial.Clinical Trial Registration: [https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041376], identifier [UMIN000036327].

Therapist Materials for Interoceptive Exposures

The session in this chapter focuses on the importance of learning to tolerate physical sensations of emotion and to identify automatic thoughts that accompany physical sensations of emotion. Clients learn this by repeatedly practicing interoceptive exposure exercises (such as hyperventilating and breathing through a thin straw) that stimulate sensations associated with negative emotions. The authors encourage the clinicians leading this treatment to always do the exercises along with their clients. This participation demonstrates the full effort of doing the exercise thoroughly by provoking strong physical sensations in the therapists themselves; models the potential for having a nonthreatening experience of physical sensations; and normalizes the challenge of this exercise. Client avoidance and emotion-driven behaviors are bound to emerge through the course of this session.

Novel Ways to Use Exposure for Eating Disorders

Three relatively novel approaches to the use of exposure for eating disorders are considered. Each is relatively experimental in treating eating disorders but is well established in treating anxiety-based disorders. Interoceptive exposure can be used to treat distress over bodily cues (e.g., fullness). Imaginal exposure can be used to elevate and treat anxiety as a prelude to in vivo exposure, although it should be used only when necessary. Finally, exposure can be used to address “magical thinking,” such as thought–shape fusion. These methods show promise with eating disorder treatment but are in the early stages of conceptualization and development. Their use should be treated as experimental at present, and clinicians should be alert to their impact in clinical practice.

Overview of Exposure Therapy

Exposure therapy is an extremely powerful technique for reducing pathological anxiety. As demonstrated in this chapter, this very common-sense strategy can be adapted to address a wide range of anxiety-based disorders. Although the efficacy of exposure has been long recognized, researchers and clinicians continue to find new ways to adapt exposure to more effectively address anxiety and barriers to treatment. This chapter reviews the use of in vivo, imaginal, and interoceptive exposure using brief case studies involving, posttraumatic stress disorder, obsessive-compulsive disorder, general anxiety disorder, and panic disorder. The chapter also discusses the increasing use of virtual reality exposure therapy.