Interoceptive Exposure for Panic Disorder
Interoceptive Exposure for Panic Disorder
Authored by: Christiana Louisa Ticoalu, M.A., Psychology & Management
Language Editor: Alda Belinda
Clinical Editor: Dr. phil. Edo S. Jaya, M.Psi., Psikolog
A Quick Refresher
What is Panic Disorder?
Panic disorder is a debilitating mental health condition characterized by repeated, unexpected, discrete fear, anxiety and apprehension. Panic disorder can be differentiated from other anxiety disorders as its symptoms are primarily somatic/physiological. These occurrences are dubbed “panic attacks”. Hallmarks of panic attacks include heart palpitations or increased heart rate, sweating, trembling, chest pain, lightheadedness, dizziness, hot flushes, derealization and depersonalization, and fear of dying.
Individuals who misconstrue these somatic anxiety symptoms often arrive at emergency care centres to undergo unnecessary assessments. For example, individuals experiencing shortness of breath may perceive they are suffocating; individuals who experience a racing heart may fear an impending heart attack. Oftentimes, panic attacks surface spontaneously and rapidly, giving almost no warning. A hallmark of a panic disorder is an immense fear of the recurrence of another impending panic attack.
Further, individuals may take drastic steps to avoid their recurrence. For instance, individuals who believe that a racing heart is indicative of a heart attack, or being out of breath is indicative of suffocation, may avoid exercise.
Collectively, the symptoms of panic disorder are detrimental to one’s day-to-day life and may lead to considerable distress and impairment across important life domains, interfering with functioning (social, occupational or otherwise). Normal functioning can only be maintained through conscious exertion and additional effort.
Importantly, the symptoms of panic disorder are not better explained by another mental health condition, or medical disorder, and are not better attributed to the effects of a substance or medication on one’s central nervous system.
Symptoms of Panic Disorder
For a comprehensive list of panic disorder symptomatology, we recommend you visit the ICD-11 webpage.
What is Interoceptive Exposure?
Interoceptive exposure involves the strategic and measured planning and implementation of predictable exposure to situations that elicit automatic threat appraisals.
This treatment aims to induce the physiological symptoms associated with threat appraisal and anxiety whilst guiding the patient through the feared sensation. Optimally, this part of the process is carried out without any interruption or intentional pausing on the patient’s behalf. It is theorized that, through gradual professionally guided exposure, the physiological symptoms resulting from threatening situations can be greatly diminished.
How it works
A variety of different exercises may be incorporated into interoceptive exposure. Nevertheless, despite the idiosyncrasy of the exercises, they share a common goal: to induce subjective somatic sensations.
The process of Interoceptive Exposure is not rigid. For instance, therapists may introduce exercises in the context of a behavioural experiment, in which patients are asked to test the veracity of their predictions or appraisals. Alternatively, an exploratory approach may be deemed more suitable, wherein a clinician may assess the way a patient feels or appraise certain situations.
Tailored Treatment Plans
Dear Reader,
At IndoPsyCare, we formulate treatment plans on a case-by-case basis. Contingent upon your condition and situation, your therapeutic journey may or may not include a variation of the following components:
Assessments
Your therapist may administer assessments at various points throughout your therapeutic journey. This is done as a way of assessing your improvements and thus the effectiveness of the treatment plan. When treating panic disorder, our clinicians typically administer the Patient Health Questionnaire (PHQ) and Panic Disorder Severity Scale (PDSS). Nevertheless, we ask that you please keep in mind that assessments may vary depending upon your specific circumstances.
Psychoeducation
IndoPsyCare seeks to provide you with a contextual understanding of your condition. Your therapist may provide you with a comprehensive description of the panic disorder including the symptoms that those with the condition typically experience, the condition’s prevalence and its general nature. Psychoeducation will typically continue throughout your therapeutic journey as your therapist aims to increase your understanding of the factors that underpin and maintain your condition, and of the strategies that are used to address it.
Open Dialogue
Your therapist will discuss your responses to the different stimuli that elicited panic within you. Additionally, you and your therapist might discuss the somatic symptoms that you experienced and how you felt when you experienced them. In some cases, you will be asked to formulate a graded list of least to most anxiety-inducing somatic symptoms. All of the information gleaned from these sessions will assist your therapist to shape your ongoing treatment plan.
Intentional symptom provocation
In-session experiments allow therapists to identify safety-seeking behaviours that are only situationally activated. Your therapist may facilitate the intentional provocation of sensations including
- Cardiovascular sensations (such as a rapidly beating heart)
- Audiovestibular sessions (such as inducing dizziness or intentionally causing you to feel faint)
- Respiratory sensations (such as inducing shortness of breath)
Importantly, you may be asked to endure these uncomfortable sensations for an allocated time period in a safe environment. Essentially, you should focus on your bodily sensations throughout each exercise and resist any avoidance. Gradually, you will be asked to relinquish any behaviours that may interfere with your exercise.
The goal of symptom provocation is to show you that the consequences you fear will not materialize. To illustrate, we have included some examples below:
|
Catastrophic Belief |
Example of exposure |
| A pounding heart is indicative of a heart attack | Doing jumping jacks or running in place |
| A tight feeling in my chest is indicative of me having a heart attack | Holding your breath |
| Dizziness means I am losing my mind | Spinning around in a chair or rolling head in circles |
Homework
Your therapist may also assign you homework to complete between sessions in which you might be asked to engage in behaviours that lead to symptom provocation for allocation amounts of time.
Relapse Prevention
During this phase, your therapist will reinforce your understanding of the strategies you have learned, including when and how they should be implemented. Furthermore, your therapist will equip you with the skills to recognize your own personal warning signs. It is essential that you understand these warnings so you can seek timely assistance from your therapist who will re-address your recovery treatment plan.
Treatment Duration
How many sessions will I need?
Our psychologists base your treatment plan upon scientific literature and recommendations from bodies such as the Cochrane Library, the UK’s National Institute of Health and Care Excellence (NICE) and IPK Indonesia’s National Clinical Practice Guidelines. This said, every patient is unique, thus it depends upon your personal situation. The number of sessions you require is typically influenced by:
- The severity of your symptoms
- Existing comorbidities (co-existing conditions)
- The length of time you have been experiencing your condition
- Your personal motivation and progress
- Your social support network
Making the Most of Therapy
Asking for help is commendable
Asking for help is understandably difficult, thus reaching out is a testament to the strength of each individual who does so. A call for help should never be seen as a sign of weakness, as it is the first step in your journey to recovery. Although sometimes uncomfortable, sharing your vulnerabilities with the right people may provide an appropriate, timely, and forthright avenue through which your problems can be assessed and addressed.
Be open and honest
Think of therapy as a journey in which you are steering the ship; your therapist is your guide, navigating the journey based on your account of what you see and experience. Reaching your desired destination and goals will be acquired with more proficiency when you share your feelings and fears. As your therapist acquires a clearer understanding of the intricacies of your situation, he or she will be in a better position to guide you in the right direction.
Be consistent
You will not see change overnight. True, lasting, cognitive and behavioural change takes time. Therapy is not a “quick fix”, rather it requires patience, consistency and tenacity on your part. Allow yourself time, communicate with your therapist, and share your feelings if you feel you are losing sight of your destination.
Trust the process
More often than not, improving your condition requires you to go beyond your comfort zone, letting go of your maladaptive coping strategies. Trust that, whilst this process may inevitably become uncomfortable or difficult at times, temporary discomfort may bring long-term and lasting benefits.
A Gentle Reminder
Dear Reader,
We sincerely appreciate your dedication; you have made it through this page of our library. We trust that you have gleaned valuable information from this page. Before we part ways we would like to reiterate that each treatment plan will be uniquely tailored to you, your situation and your requirements. Your personal treatment plan may or may not include the elements on this page.
If you feel as though you require professional assistance, please refrain from self-diagnosis. IndoPsyCare has professionals who are here to help
Resources and Recommended Readings
Disclaimer
We would like to emphasize that the information presented herein was derived from external sources. IndoPsyCare does not claim ownership of any information or research within these pages. For your convenience, our team has constructed a list of the sources utilized and included further research and reading.
National Institute for Health and Care Excellence. (2022). Generalised anxiety disorder and panic disorder in adults: management. Retrieved 1 July 2022, from https://www.nice.org.uk/guidance/cg113
World Health Organization. (2019). ICD-11: International Classification of Diseases (11th revision). Retrieved from https://icd.who.int/
Code for Panic Disorder: 6B01
Craske, M., Farchione, T., Allen, L., Barrios, V., Stoyanova, M., & Rose, R. (2007). Cognitive behavioral therapy for panic disorder and comorbidity: More of the same or less of more?. Behaviour Research And Therapy, 45(6), 1095-1109. doi: 10.1016/j.brat.2006.09.006
Meuret, A., Kroll, J., & Ritz, T. (2017). Panic Disorder Comorbidity with Medical Conditions and Treatment Implications. Annual Review Of Clinical Psychology, 13(1), 209-240. doi: 10.1146/annurev-clinpsy-021815-093044
Kaczkurkin, A., & Foa, E. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues In Clinical Neuroscience, 17(3), 337-346. doi: 10.31887/dcns.2015.17.3/akaczkurkin