Interoceptive Exposure in Panic Disorder

The treatment of panic is based on the exposure to the physical sensations of it. However, it must be carried out by a specialist psychologist to achieve therapeutic success.

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Panic or anxiety crises are part of that list of frequent reasons why people come to consultation. Normally, these patients are attended by primary care physicians and if there is nothing organic or physical in the examination, they are referred to the specialist in clinical psychology.

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

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

Patients suffering from panic attacks are victims of a series of very unpleasant symptoms. The repertoire of faces with which anxiety can occur is great and in the attack of panic several of them can appear.

These symptoms can be: heart palpitations or jolts – most frequent symptom – sweating, tremors, choking sensation, choking sensation, chest tightness, nausea, instability or dizziness, derealization or depersonalization, fear of losing control or going crazy , fear of dying, paresthesias or sensations of chills or hot flashes.

These symptoms, which are no more than manifestations of one’s anxiety, are experienced with a very intense discomfort, as they are usually attributed to physical symptoms or imminent death. Imagine that suddenly you feel that the heart “comes out of your mouth”, that you faint, that you sweat without control or have a feeling that you are drowning.

The most normal thing is that you think something bad is happening to you. Is it a heart attack? I’m going to die? Will I be going crazy?

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 should 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 sin of reductionism if we did not say anything else. Although exposure is an easy technique to describe at the theoretical level, it may not be easy to apply. In addition, it has many modalities depending on the problem with which we find ourselves.

It is not the same exposure in a phobia to fly, which is usually done in imagination or virtual reality, than in a panic disorder, which is done interoceptively.

Same technique, same objective, but different procedures. Therefore, it is extremely important that the treatment be carried out by a specialist psychologist. If not done in this way, not only may the problem not disappear, but it may even worsen, increasing sensitivity.

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

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 …) in the sense that the person internalizes that these sensations are simply that, sensations.

They are not given more value than this because we can see how those premonitions that told us that we were going to have a heart attack are baseless because they never happen.

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

Interoceptive exposure exercises

In general, the procedure consists of generating symptoms for about a minute, through exercises that try to mimic the most common and feared symptoms of a crisis of distress characteristic of the patient. The most common strategies to achieve this are:

  • Intentional hyperventilation. It causes a sensation of daze, derealization, blurred vision and dizziness.
  • Spinning in a swivel chair. The goal is to cause dizziness and loss of orientation.
  • Breathe through a cannula. It causes dyspnea and choking sensation due to air restriction.
  • Hold your breath. It causes a choking sensation.
  • Run in the place of the exhibition. It causes an increase in heart rate, respiration and sweating.
  • Stress of muscular areas. It causes the sensation of being tense and hypervigilant.
  • Move the head from side to side. It causes dizziness and tension in the neck.

The induction of these symptoms should be between 3 and 5 times a day – the frequency varies depending on the case; On the other hand, it is more important to make the exposure well once again, often badly, until, thanks to habituation, the patient begins to see how the level of anxiety is reduced to levels in which 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 himself can deliberately provoke them.

In more advanced stages of treatment, the patient stops practicing these exercises and performs other more “natural” in their daily environment. For example, perform physical exercise, walk fast, climb stairs, enter 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 see 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 at which habituation begins. What should of course prevail in the intervention with a patient with panic is the therapeutic relationship based on empathy and understanding.

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