Interoceptive Exposure In Panic Disorder

Panic or panic attacks are part of that list of frequent reasons why people go for consultation. Normally, these patients are cared for by primary care physicians and if there is nothing organic or physical in the examination, they are referred to a specialist in clinical psychology.

On other occasions, most due to lack of professionals, they are treated with antidepressants or anxiolytics, without leading to a substantial improvement in the problem.

Specifically, DSM5 tells us about an episode of intense fear or discomfort that is accompanied by a feeling of danger or imminent death with an impulse to escape. It starts off abruptly and peaks in the first 10 minutes. It must be accompanied by at least 4 or more symptoms out of the 13 that appear.

These symptoms can be: palpitations or jolts in the heart -the most frequent symptom-, sweating, tremors, feeling of suffocation, feeling of choking, chest tightness, nausea, instability or dizziness, derealization or depersonalization, fear of losing control or going crazy , fear of dying, paresthesias, or feelings of chills or flushing.

These symptoms, which are nothing more than manifestations of anxiety itself, are experienced with very intense discomfort, as they are usually attributed to physical symptoms or imminent death. Imagine that you suddenly feel like your heart is “leaking out of your mouth”, that you faint, that you sweat uncontrollably or have the feeling that you are drowning.

If your thoughts go in this direction, what will inevitably happen is that those feelings of fear will increase. It is what is known as phobia or fear of fear. Therefore, the treatment must be aimed at the interpretation and tolerance of these physical sensations, so that they do not escalate in intensity. We delve into it below.

How does interoceptive exposure work?

In any anxiety disorder, the technique of choice is almost always exposure, but we would be sinful of reductionism if we did not say anything else. Although exposure is an easy technique to describe on a theoretical level, it may not be easy to apply. In addition, it has a multitude of modalities depending on the problem we encounter.

Same technique, same goal, but different procedures. Therefore, it is extremely important that the treatment is carried out by a specialist psychologist. If it is not done in this way, not only may the problem not go away, but it may even get worse, increasing sensitivity.

The objective of the exhibition is to get used to the phobic stimulus. This stimulus can be something in particular, as it happens in specific phobias, a situation, as it happens in social phobia or a sensation, as in the subject that concerns us. Habituation is a physiological process that occurs when the person experiences by himself how the phobic stimulus does not carry the consequences that at first he thought could occur.

In the case of interoceptive exposure, the fact that the patient is exposed to their physical sensations without carrying out any safety behavior that covers the discomfort (anxiolytics, going with a family member, drinking water, wearing sunglasses …) works in the sense that the person internalizes that these sensations are simply that, sensations.

Therefore, the clinician, in consultation and also outside of it, must encourage the patient to voluntarily provoke feelings of panic. In addition, it is extremely important not to engage in any behavior that hinders exposure or facilitates avoidance.

Interoceptive exposure exercises

In general, the procedure consists of generating symptoms for approximately one minute, using exercises that try to mimic the most common and feared symptoms of a characteristic panic attack of the patient. The most common strategies to achieve this are:

• Intentional hyperventilation. It causes a feeling of lightheadedness, derealisation, blurred vision, and dizziness.
• Spinning around in a swivel chair. The goal is to cause dizziness and loss of orientation.
• Breathe through a cannula. It causes dyspnea and a sensation of suffocation due to air restriction.
• Hold their breath. It causes a feeling of suffocation.

• Running at the exhibition site. It causes an increase in heart rate, respiration and sweating.
• Tension of muscular areas. It causes the feeling of being tense and hyper-vigilant.
• Move your head from side to side. It causes dizziness and tension in the neck.

The induction of these symptoms should be carried out between 3 and 5 times a day – the frequency varies depending on the case; on the other hand, it is more important to do the exposure well once than to do it wrong many times – until, thanks to habituation, the patient begins to see how the level of anxiety is reduced to levels where he is able to control it.

The patient learns that these internal signals should not be feared because they are not associated with any type of threat. In fact, he can deliberately provoke them himself.

In more advanced stages of treatment, the patient stops practicing these exercises and performs other more “natural” ones in their daily environment. For example, doing physical exercise, walking fast, climbing stairs, going into saunas … In this case, the exercises should not last more than three minutes.

Although interoceptive exposure is a very effective treatment for panic attacks, we must prioritize the case we have and check if it is necessary to add any other technique or carry out other alternative treatments.

Some patients reject this type of exposure because they feel unable to endure to that point where habituation begins. What of course should prevail in the intervention with a patient with panic is the therapeutic relationship based on empathy and understanding.

Second, psychoeducation is essential. When the patient understands what is happening to him and recognizes the vicious cycle of his anxiety, he is much more likely to accept the exposure.