Exposure Therapy for Panic

Graded Exposure

In theory, phobias can be overcome by facing the things that are feared. Treatment for both agoraphobia and social phobia involves reversing the vicious cycle by which a certain situation and anxiety were first linked, then the link consolidated by anticipatory anxiety and eventually avoidance. What has been learned must be unlearned and this is done by gradually re-introducing the patient to the situation in a slow and steady manner.

A detailed list of avoided or feared situations is constructed and then ranked in order to form a hierarchy of severity. Exposure commences at the lowest point on the hierarchy and needs to be graduated, repeated, prolonged and tasks must be clearly specified in advance. Tasks should be approachable and produce some anxiety but not excessive amounts. The patient needs to learn that they can "wait out" the anxiety, which naturally decays to lower levels over time. All exposure tasks require exposure until anxiety decreases significantly, usually 5 to 45 minutes is required but occasionally this may take some hours. Useful additional methods may include relaxation, distraction and challenging thoughts.

Interoceptive Exposure

A key aspect in the development of the panic attack is the cognitive misinterpretation placed on the physiological symptoms. The patients have an expectation of danger, medical catastrophe and/or a loss of control as has been demonstrated in the illustrated panic cycle. It needs to be emphasised that the physiological symptoms experienced are similar to those experienced in everyday situations such as exercise and excitement for any reason. Interoceptive exposure involves the controlled exposure to these symptoms in order to demonstrate to the patient that these symptoms are tolerable and not the harbingers of medical disaster.

Interoceptive exposure involves the careful production of symptoms followed by the control and then reduction of symptoms with techniques such as slow breathing and cognitive challenging/cognitive therapy. A good example is the production of panic symptoms by hyperventilation or running on the spot which often produce shortness of breath, palpitations, dizziness, derealisation and depersonalisation symptoms. After the patient produces these symptoms by hyperventilating for a short period of time, i.e. 15-30 seconds, the symptoms are controlled by slow breathing until they settle. The person then gradually increases the amount of hyperventilation as their tolerance to smaller amounts increases, resulting eventually in decreased reactivity to hyperventilation, the symptoms themselves and decreased cognitive misinterpretation the symptoms. This can be a frightening technique initially and should be firstly done with a therapist or helper before subsequently performing the activity alone. It can later be introduced to day-to-day life and maybe even into threatening situations to further improve the person's ability to tolerate these physiological symptoms without catastrophic misinterpretation.