A randomized controlled trial protocol for engaging distress tolerance and working memory to aid smoking cessation in low socioeconomic status (SES) adults

May combine two claims.

Low working memory capacity is strongly associated with delay discounting, many negative health behaviors, and addictive disorders.

“Consistent with this model, low WMC is strongly linked to delay discounting and a range of negative health behaviors and addictive disorders (Bickel, Quisenberry, Moody, & Wilson, 2015; M. W. Otto et al., 2016; Sheffer et al, 2013).”

• cites Bickel, Quisenberry, Moody, & Wilson, 2015 sourcePartly supported

  The Working Memory Training section (page unavailable) reports that working-memory training reduced delay discounting in stimulant users and that increased working-memory capacity accompanied reduced alcohol consumption in problem drinkers. The Delay Discounting section (page unavailable) links excessive discounting to addiction and several negative health behaviors. These passages do not establish the broader claim that low working-memory capacity itself is strongly associated with that whole range of behaviors and disorders. (LLM, conf=0.84)

  Experimental — accuracy not yet measured
• cites M. W. Otto et al., 2016 sourceNot checked — no full text of the source
• cites Sheffer et al, 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S1 (asserted).

It is hypothesized that high working memory capacity enables people to use cognitive and other self-control strategies against maladaptive urges.

“With respect to addictive behaviors, high WMC is hypothesized to allow use of cognitive and other self-control strategies to resist maladaptive urges”

• cites Bickel, Jarmolowicz, Mueller, Gatchaljan, &McClure, 2012Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Sheffer et al, 2012 sourcePartly supported

  The Introduction (page unavailable) hypothesizes that executive functions help people understand urges, regulate themselves, and respond to cognitive-behavioral treatment for tobacco dependence. It does not specifically attribute that ability to high working memory capacity, so the WMC-specific part of the claim is unsupported. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Distress tolerance can be measured through self-report or performance tasks covering various kinds of emotional or bodily distress.

“DT can be assessed by self-report or performance measures across any number of domains of emotional or somatic distress (McHugh & Otto, 2011).”

• cites McHugh & Otto, 2011 sourceSupported

May combine two claims.

Low distress tolerance predicts negative emotional or bodily sensations and also interacts with them to predict poor outcomes.

“Hence, low DT both predicts negative affective or somatic sensations and interacts with these to predict negative outcomes (Leventhal & Zvolensky, 2015; M. W. Otto et al., 2016).”

• cites Leventhal & Zvolensky, 2015 sourcePartly supported

  The DT and Smoking section reports that negative affect on quit day predicted smoking lapse more strongly among smokers with low distress tolerance. The Distress Tolerance section also suggests low distress tolerance may prolong negative affect. Neither passage establishes that low distress tolerance predicts the occurrence of negative emotional or bodily sensations, or that it interacts with bodily sensations to predict outcomes. (LLM, conf=0.87)

  Experimental — accuracy not yet measured
• cites M. W. Otto et al., 2016 sourceNot checked — no full text of the source

May combine two claims.

The McKee procedure tracks real-world predictors of smoking and responds to stress by shortening delay and increasing smoking amount.

“The McKee procedure has been shown to reflect non-laboratory predictors of smoking behavior and to be sensitive to the effects of stress on attenuating the latency and increasing the amount of smoking during the protocol (Kahler et al., 2014; McKee et al., 2006; McKee et al., 2011; Roche et al., 2014).”

• cites Kahler et al., 2014 sourcePartly supported

  The Method (Smoking lapse task; page unavailable) confirms that this paper used the McKee procedure to measure delay and amount smoked. The Discussion (page unavailable) compares alcohol’s effect on delay with a reported stress effect on the task, and the References name a study of stress and smoking intensity. This paper does not establish that the procedure reflects non-laboratory predictors of smoking behavior, nor does it itself test stress-induced increases in smoking amount. (LLM, conf=0.78)

  Experimental — accuracy not yet measured
• cites McKee et al., 2006Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites McKee et al., 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The QSU-Brief assesses smoking urges and craving.

“The QSU-Brief measures urge to smoke and craving (Cox, Tiffany & Christen, 2001; Toll, Katulak, & McKee, 2006).”

• cites Cox, Tiffany & Christen, 2001 sourceNot checked — no full text of the source
• cites Toll, Katulak, & McKee, 2006 sourceSupported

May combine two claims.

Lapsing early after a quit attempt is common and predicts a return to regular smoking.

“Early lapse to smoking is both common and predictive of subsequent return to regular smoking (i.e., relapse; Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005; Shiffman et al., 1997; Zvolensky, Stewart, Vujanovic, Gavric, & Steeves, 2009).”

• cites Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Shiffman et al., 1997 sourceNot checked — no full text of the source
• cites Zvolensky, Stewart, Vujanovic, Gavric, & Steeves, 2009 sourcePartly supported

  The Results report that 74.5% of participants lapsed within 14 days of quitting, supporting that early lapse was common in this treatment sample. The Discussion says only that repeated lapses may increase longer-term relapse risk; the paper does not establish that an early lapse predicts a subsequent return to regular smoking. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

Low distress tolerance, measured by anxiety sensitivity, moderates the benefits of mindfulness interventions and appears to reduce their success in coping with negative affect and substance cravings.

“Specifically, low DT (assessed by anxiety sensitivity) has been found to moderate the benefits of mindfulness interventions, appearing to impair the success of mindfulness strategies for coping with negative affect (anxiety) and substance cravings (Arch & Ayers, 2013; Rogojanski, Vettese, & Antony, 2011; see also Raines et al., 2018; Zvolensky et al., 2015).”

• cites Arch & Ayers, 2013 sourceNot checked — no full text of the source
• cites Rogojanski, Vettese, & Antony, 2011 sourceNot checked — no full text of the source
• cites Raines et al., 2018 sourcePartly supported

  The Discussion reports an interaction between mindful attention and experiential avoidance in relation to anxiety and depressive symptoms among Latino primary-care patients. It does not show that low distress tolerance, assessed by anxiety sensitivity, moderates mindfulness-intervention benefits, nor does it assess substance cravings. The authors describe their data as cross-sectional and call for future intervention research. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

May combine two claims.

Interoceptive exposure or exercise interventions for smoking cessation have been validated, and their success appears to work through reductions in anxiety sensitivity and dysphoria.

“Use of IE or exercise interventions to aid smoking cessation have also been validated by members of our study team, with evidence that the mechanism of action for successful cessation relied on reduction in anxiety sensitivity and dysphoria (Feldner, Zvolensky, Babson, Leen-Feldner, & Schmidt, 2008; Zvolensky, Yartz, Gregor, Gonzalez, & Bernstein, 2008; Zvolesnky et al., 2018).”

• cites Feldner, Zvolensky, Babson, Leen-Feldner, & Schmidt, 2008 sourcePartly supported

  The Abstract (page unavailable) reports that a pilot intervention including interoceptive exposure reduced anxiety sensitivity in high-anxiety-sensitivity daily smokers. But the Method says participants were not asked to quit, and the Results report no statistically significant between-group difference in smoking cessation. The paper does not establish successful cessation through reductions in anxiety sensitivity or dysphoria, nor does it evaluate an exercise intervention. (LLM, conf=0.89)

  Experimental — accuracy not yet measured
• cites Zvolensky, Yartz, Gregor, Gonzalez, & Bernstein, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Zvolesnky et al., 2018Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Mindfulness-based interventions reliably affect several measures of stress and appear to improve distress tolerance and working memory capacity.

“Mindfulness-based interventions have reliable effects on multiple indices of stress (Goyal et al., 2014), and also appear to have beneficial effects on DT and WMC (e.g., Chiesa, Calati & Serretti, 2011; Jha, Stanley, Kiyonaga, Wong, & Gelfand, 2010; McCracken & Keogh, 2009).”

• cites Goyal et al., 2014 sourceSupported
• cites Chiesa, Calati & Serretti, 2011 sourceNot checked — no full text of the source
• cites Jha, Stanley, Kiyonaga, Wong, & Gelfand, 2010 sourceNot checked — no full text of the source

May combine two claims.

Brief interoceptive exposure training improves distress tolerance, shown by lower anxiety sensitivity, and helps reduce smoking.

“Brief training with IE has been found valuable for enhancing DT as assessed by reductions in anxiety sensitivity, and for facilitating reductions in smoking (Feldner et al., 2008).”

• cites Feldner et al., 2008 sourcePartly supported

  The Abstract reports reduced anxiety sensitivity after a brief intervention that included interoceptive exposure. However, the intervention also included smoking-cessation instruction, and the Results report no significant between-group difference in cigarette use or cessation; the paper does not establish that exposure itself enhanced distress tolerance or reduced smoking (page numbers unavailable). (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

The McKee protocol uses monetary rewards derived from empirical work so that smokers typically delay smoking during a 50-minute assessment, and it measures both resistance to the first cigarette and smoking after giving in.

“This protocol uses empirically-derived monetary rewards so that smokers, on average, are able to delay smoking for effective assessment during a 50-minute assessment window, and provides measures of two critical features of lapse behavior: (a) the ability to resist the first cigarette and (b) subsequent smoking if a participant decides to “give in” and starts to smoke (McKee, 2009; McKee et al., 2”

• cites McKee, 2009 sourceSupported
• cites McKee et al., 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites McKee, Weinberger, Shi, Tetrault, & Coppola, 2012Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The ASI-3 has strong psychometric properties, including high internal consistency, predictive validity, and reliability in smokers seeking treatment.

“The ASI-3 has sound psychometric properties, including excellent internal consistency, predictive validity, and reliability among treatment-seeking smokers (Farris et al., 2015).”

• cites Farris et al., 2015 sourceSupported

May combine two claims.

Prior evidence indicates the interventions can activate mechanistic targets and that these targets relate to clinical outcomes at effect sizes larger than the powered values.

“Preliminary evidence shows that our interventions have the ability to activate mechanistic targets, and for mechanistic targets to be related to clinical outcomes, at effect sizes beyond these powered values (Ashare et al., 2014; M. W. Otto et al., 2010; McKee, 2009; Patterson et al., 2010; Tang et al., 2013).”

• cites Ashare et al., 2014 sourcePartly supported

  Section 2.2 (page unavailable) reports that nicotine-dependence treatments improve some cognitive measures and that withdrawal-related working-memory deficits predict smoking relapse. Section 4 describes cognitive enhancement as a plausible treatment target. The paper does not establish that the citing authors’ interventions activate their specified targets or that target–outcome relationships have effect sizes exceeding the powered values. (LLM, conf=0.84)

  Experimental — accuracy not yet measured
• cites M. W. Otto et al., 2010 sourcePartly supported

  The Results (BZ-Free Status) report large effects of exposure-based CBT on benzodiazepine discontinuation at six months. The Discussion proposes that changes in anxiety sensitivity, avoidance, and safety behaviors may explain the growing treatment effects, but does not establish that those targets changed or that target changes were associated with clinical outcomes. The paper also does not compare mechanistic effect sizes with the citing study’s powered values. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites McKee, 2009 sourcePartly supported

  The Introduction reports that nicotine gum and naltrexone altered craving responses to smoking cues, providing limited evidence that interventions can affect a potential mechanistic target. It also says the relationship of those craving effects to actual smoking behavior is unknown. The Summary and Conclusions calls for validation against clinical-response markers; the paper does not establish the claimed target–clinical outcome relationship or compare its effect size with the powered values. Page numbers are unavailable in our copy. (LLM, conf=0.79)

  Experimental — accuracy not yet measured

May combine two claims.

Low distress tolerance and low working memory capacity place people at risk for negative health behaviors.

“This work is based on a comprehensive accounting of the role of low DT and WMC in placing individuals at risk for negative health behaviors, and the potential improvements in health behaviors provided by ameliorating these deficits (Bickel et al., 2015; M.W. Otto et al., 2016).”

• cites Bickel et al., 2015 sourcePartly supported

  The Working Memory Training section says working memory correlates with self-control, and The Competing Neurobehavioral Decision System section links impaired self-control to negative health behaviors. The paper does not address low distress tolerance as a risk factor. Its working-memory training example improved delay discounting but did not measure clinical health outcomes; page numbers are unavailable in our copy. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites M.W. Otto et al., 2016 sourceNot checked — no full text of the source

May combine two claims.

Low socioeconomic status is associated with using negative health behaviors to manage stress, and negative affect or stress mediates the link between low SES and trouble quitting smoking.

“Similarly, low SES is associated with the use of negative health behaviors to regulate stress and negative affect/stress mediates the relation between low SES and difficulties with smoking cessation (Doan et al., 2012; Kendzor et al., 2009; Reitzel et al, 2012; Zvolensky et al., 2017).”

• cites Doan et al., 2012 sourceNot checked — no full text of the source
• cites Kendzor et al., 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Reitzel et al, 2012Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Socioeconomic status significantly predicts differences in working memory capacity, and deficits in that capacity appear in children from low- and middle-SES backgrounds and in those living in poverty.

“For example, SES is a significant predictor of individual differences in WMC, and WMC deficits have been found in children between low and middle SES and among those living in poverty (Evans & Schamberg, 2009; Noble, Norman, & Farah, 2005).”

• cites Evans & Schamberg, 2009 sourceNot checked — no full text of the source
• cites Noble, Norman, & Farah, 2005 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Nearly half of smokers try to quit each year, yet fewer than one in ten succeed.

“Although almost half of smokers report making a quit attempt each year, less than 10% do so successfully (Babb, Malarcher, Schauer, Asman, & Jamal, 2017)”

• cites Babb, Malarcher, Schauer, Asman, & Jamal, 2017 sourceNot checked — no full text of the source

May combine two claims.

Greater exposure to multiple stressors in low-SES environments is a major contributor to smoking among low-SES people and adds to cognitive and emotional vulnerabilities.

“Moreover, a major contributing factor to smoking among low SES persons appears be the increased exposure to multiple stressors associated with low SES environments, which in turn, contribute to cognitive and emotional vulnerabilities (Doan, Fuller-Rowell, & Evans, 2012; Kendzor et al., 2010; Ludman et al., 2002; Reitzel et al., 2011).”

• cites Doan, Fuller-Rowell, & Evans, 2012 sourceNot checked — no full text of the source
• cites Kendzor et al., 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Ludman et al., 2002 sourceNot checked — no full text of the source

May combine two claims.

Low distress tolerance and low working memory capacity are distinct vulnerabilities for lapses in health behavior and self-control, especially when stress is high.

“M.W. Otto and associates (2016) provided a model for the way in which low DT and low WMC represent separate liabilities for health-behavior and self-control lapses, particularly under conditions of stress.”

• cites M.W. Otto et al., 2016 sourceNot checked — no full text of the source

May combine two claims.

Having low income or low education is one of the strongest predictors of smoking prevalence and of returning to smoking after a quit attempt.

“Low income and low educational attainment are among the strongest predictors of both smoking prevalence and lapse (i.e., return) to smoking following cessation attempts.”

May combine two claims.

Those with higher working memory capacity have more top-down, goal-directed attention available to suppress associative tendencies, hold competing goals, use knowledge about short- versus long-term outcomes, and apply strategies to resolve goal conflict.

“For those higher in WMC, more top-down, goal-directed attentional resources are available to (a) suppress the influence of associative tendencies when they interfere with other active goal-states, (b) maintain conflicting goals in active memory, (c) draw on more knowledge concerning potential short vs. long-term outcomes, and (d) apply one of several cognitive processing strategies to resolve the”

• cites Grenard et al., 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

Distress tolerance and working memory capacity are prime examples of mechanistic targets that matter across many health behaviors.

“Accordingly, DT and WMC appear to be prototypical examples of the sort of mechanistic targets relevant to a wide range of health behaviors that the SOBC program seeks to elucidate and validate.”

May combine two claims.

Working memory capacity moderates stress effects; higher capacity may help people withstand stress and pursue adaptive goals better than lower capacity.

“Furthermore, WMC moderates the effects of stress, such that high WMC may help individuals better withstand the derailing and demotivating effects of stress, and help them apply adaptive behaviors or pursue adaptive goals relative to their low WMC counterparts (A.R. Otto, Raio, Chiang, Phelps, & Daw, 2013; M. W. Otto et al., 2016).”

• cites A.R. Otto, Raio, Chiang, Phelps, & Daw, 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites M. W. Otto et al., 2016 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Participants and interventionists are informed of the treatment assignment at the first intervention session.

“Interventionists and participants learn of the allocation at the first intervention visit.”

Classified as probably not a substantial claim.

Multilevel models are the recommended approach for longitudinal data analysis.

“We will analyze data using multilevel models because they allow inclusion of all participants regardless of missing data (which improves power and generalizability) and are the recommended method for longitudinal data analysis (Hamer & Simpson, 2009).”

• cites Hamer & Simpson, 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Eligible participants are assigned to an intervention condition by computer-generated random numbers in blocks of six, with the sequence sent from the principal investigator to the research coordinator.

“Following the baseline assessment, eligible participants are allocated to an intervention condition using computer-generated random numbers in block sizes of 6, transmitted by the PI to the research coordinator.”

May combine two claims.

In the McKee paradigm, stress changes smoking intensity by increasing puffs, shortening the interval between puffs, and raising peak puff velocity.

“Initial work indicates that stress alters the intensity of smoking (increased puffs, shorter inter-puff interval, and greater peak puff velocity) in the McKee paradigm (McKee et al., 2011; see also Borges, Leyro, Rosen, Zvolensky, & Farris, 2019).”

• cites McKee et al., 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Borges, Leyro, Rosen, Zvolensky, & Farris, 2019Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Research assistants receive training in all assessment procedures, and fidelity to procedures is reviewed regularly.

“Research assistants are trained in all assessment procedures with regular review of fidelity to procedures.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The FTND is a six-item instrument intended to measure gradations of nicotine dependence.

“The FTND is a six-item scale designed to assess gradations in nicotine dependence (Heatherton, Kozlowski, Frecker, & Fagerström, 1991).”

• cites Heatherton, Kozlowski, Frecker, & Fagerström, 1991 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Participants are assigned at random to one of three arms: health-education control, mindfulness training, or mindfulness training with interoceptive exposure.

“participants selected on the basis of inclusion/exclusion criteria will be randomized to one of three intervention conditions: (1) a health-education control condition (CC), (2) a mindfulness training condition (MT), or (3) a mindfulness training condition combined with training applying mindfulness skills in the context of interoceptive exposure (MT+IE).”

May combine two claims.

Multilevel models permit all participants to be included despite missing data, which increases power and generalizability.

“We will analyze data using multilevel models because they allow inclusion of all participants regardless of missing data (which improves power and generalizability) and are the recommended method for longitudinal data analysis (Hamer & Simpson, 2009).”

• cites Hamer & Simpson, 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Distress tolerance and working memory capacity are modifiable risk factors, and mindfulness training is at least one intervention that targets both.

“Evidence suggests that both DT and WMC are modifiable risk factors, and they appear to have at least one intervention in common – mindfulness training (M. W. Otto et al., 2016).”

• cites M. W. Otto et al., 2016 sourceNot checked — no full text of the source

May combine two claims.

With N=75 at the deprivation assessment, the study has more than .80 power to detect effect sizes of d=.40 for Aim 1, d=.39 for Aim 2, and d=.48 for Aim 3.

“PinT indicated that we had greater than .80 power to detect an effect size of d =.40 for Aim 1, d =.39 for Aim 2, and d =.48 for Aim 3.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The relevant Institutional Review Board approved all study procedures.

“All procedures have been approved by the relevant Institutional Review Board (IRB).”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). May combine two claims.

Nicotine abstinence is checked with expired carbon monoxide, using a cutoff of half the screening-session CO level or less than 10 ppm.

“Upon arrival to the lab, nicotine abstinence will be verified by expired CO levels, as determined by a criterion of half of the participant’s screening session CO concentration”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The analyses will treat FTND score, QSU score, BRIEF-A Behavioral Regulation Index score, and K6+ psychological distress as meaningful baseline covariates.

“For all analyses, the following baseline assessments will be assessed as meaningful covariates in the analyses: FTND score, QSU score, BRIEF-A scores for the Behavioral Regulation Index, and psychological distress from the K6+ symptoms.”

Classified as probably not a substantial claim.

The enhanced laboratory lapse-behavior assessment, supplemented by smoking topography, allows the influence of behavioral mechanisms to be evaluated in a clinically meaningful way.

“Finally, this study utilizes an enhanced laboratory lapse-behavior assessment (supplemented by smoking topography assessments), permitting an evaluation of the influence of behavioral mechanisms in a clinically important manner, while implementing a rigorous laboratory-based assessment protocol.”

Probably not a substantial claim: may not pass S3 (load-bearing).

No interim analyses are planned.

“No interim analyses are planned.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Study staff monitor data, evaluating study progress and procedures weekly and data completeness and retention monthly.

“Data monitoring is conducted by study staff in this single-site trial, with weekly evaluation of study progress and procedures and monthly evaluation of data completeness and participant retention.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

No adverse event screen is used; reported adverse events are recorded, reviewed regularly, and summarized at trial end.

“Given the nature of the interventions under study, no adverse event screen is used in this study; reported adverse events (other than the anticipated nicotine withdrawal symptoms assessed by the WSWS) are recorded in study files, are regularly reviewed by the study team, and will be summarized at trial endpoint.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All data are double entered for accuracy, and only de-identified data are placed in the statistical analysis database.

“All data will be double entered to help ensure accuracy; only de-identified data are entered in the statistical analysis database.”

Classified as probably not a substantial claim.

Interoceptive exposure procedures let patients practice therapeutic skills while experiencing stress-related sensations.

“First, they allow patients to learn therapeutic skills under conditions of stress-related sensations.”