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Interoceptive Exposure Therapy: Panic Disorder & Agoraphobia

Interoceptive Exposure Therapy: Panic Disorder & Agoraphobia

I have a young client who has a full-blown panic attack every time she goes up or down the stairs. What do you think is happening there? Do you think that she's afraid of stairs? No, that's not what's happening. She has panic disorder and agoraphobia, and every time that her heart rate increases, her brain interprets that as if she is in danger and her brain activates the sympathetic nervous system, her fight or flight response and has a full-blown panic attack. Her brain has associated or wired together her increase in heart rate with her fight or flight response. This is the case for many people that are diagnosed with panic disorder. Their panic is initiated by internal body sensations, internal cues, and the internal sensation is wired together in the neuro pathways with the fight or flight system. The amygdala gets activated and initiates this sympathetic nervous system response, the fight or flight response.

Panic attacks can be triggered by external cues or internal cues. External cues are anything external to the body. They include things in the environment like maybe somebody is triggered and has a panic attack anytime that they are in a grocery store. That’s an external cue. Or a person may have a panic attack when they see dogs. Their brain has learned that dogs are dangerous. They had a bad experience. It may be triggered by being in social environments or crowds, or for some people it's driving in a car or driving over a bridge. All kinds of external cues can trigger panic attacks

There are also internal cues or internal body sensations that trigger panic attacks. There can be a whole number of different things like increased heart rate or difficulty breathing or shakiness or sweating or derealization. All kinds of symptoms can actually initiate at a panic attack. What do we do about external cues? We can do traditional exposure therapy to external cues. For internal cues, internal triggers, or internal body sensations, we use an exposure therapy called interoceptive exposure therapy. That’s what I'm describing today. In Interoceptive exposure therapy, we set up specific exercises where we are exposing the client to the same body sensations that trigger their anxiety and panic. If for example, a person’s increased heart rate triggers a panic attack. We are going to first, get approval from are physicians to do these exercises. That’s important. Then, we go right into recreating the sensations of increased heart rate. In this case we're going to have them maybe run in place for one minute and then we're going to have them rest for one minute and repeat that eight times. If their sensation that causes a panic is dizziness, we might have them twirl on a swivel chair and doing that slowly for a minute, resting for a minute, repeating that eight times. If their trigger is breathlessness, we're going to have them possibly hyperventilate or do breathing through a straw. I have a whole list of exercises, and I'm going to leave you a link in the description of all different exercises published by the University of Michigan for interceptive exposure therapy based on what particular body sensation triggers your anxiety and panic attack. When you're doing exposure therapy, this interceptive exposure therapy or any type of exposure therapy, your brain has to be anxious in order for the exposure to work. It's called activate to generate. We have to activate the amygdala, get our fear center, very anxious for the new neuropathways to be formed. If we do an exposure therapy and we're not anxious, it doesn't do anything. You have to be anxious, activate to generate those new neural pathways. You want to start gradually until your confidence builds. If you want to flood yourself and really challenge yourself, you can. However, most people like to work up gradually. You want to challenge yourself as you go. Challenge yourself in different environments. Even though you're doing interceptive exposure therapy on internal body symptoms, you want to try to keep challenging yourself in increasing that anxiety by doing it in different locations and adding anxious thoughts to really make it intense for yourself eventually without safety behaviors. We don't want you taking medicines or having medicines with you or having people with you or checking out the local hospital or doing anything to check your body's symptoms or your heart rate. Take off those apple watches. We don't want anything that is checking your heart rate for you, that your brain knows that that's a safety behavior, and it makes the exposure therapy less effective. Other things that make exposure therapy less effective is any type of asking for reassurance or Googling symptoms or taking benzodiazepines. If you're on a benzodiazepine and you want to do an exposure therapy, it will hinder its effectiveness. Sometimes people may take a medication to start doing the exposure, but eventually you will have to work with your doctor to go slowly off of those medications before your brain can learn that you are safe and create those new neuropathways. I'm going to run you through an example of actually using interceptive exposure therapy and this particular client, their trigger was dizziness. She in fact said that she didn't really know what brought on her panic attacks, but she, the first sensation she would have is a kind of a dizziness. And then that would make her anxious and then would come the full-blown panic attack. So we decided to work on dizziness. Now, step one is just identifying that trigger, that eternal cue that triggers the panic. So dizziness in her case. Step two is we're going to create a fear hierarchy where we are going to list a number of different exposure exercises. And she's going to give each one of them, each exercise that creates dizziness. She's going to give them a SUD score. SUD says S U D S. It stands for subjective unit of discomfort scale. And it's from one to a hundred on how uncomfortable is she to practice this exposure exercise? So she had four different exercises and she created a hierarchy. The first exercise was sitting in a swivel chair and slowly spinning for a minute, resting for a minute, repeating that eight times she gave that a SU score of 80. The next one was shaking her head side to side 30 seconds, resting for 30 seconds. Repeating that 15 times she gave that a SUD score of 70. Then she sitting straight in her chair, putting her head between her knees for 30 seconds, lifting it up for 30 seconds. Repeating that 15 times. That was the next exercise that a SU score of 60. And then finally hyperventilating, this was shallow breathing, 120 breaths per minute. And she would breathe like this for one minute, take a rest for one minute. Repeat that eight times hyperventilating is shallow breathing, kind of like, you know, that's the type of breathing. And that was, she gave that a SUD score of 50. So the next step is actually starting the exposure. Now doing the exposure. She started with the, the one that was the easiest for her or the, the least discomfort comfortable. And that would be the one with the SUD score of 50, which was the shallow breathing. So she practiced this every day for a week. And as she went through the exposures, she had to give herself a beginning Suco rating every day reached every time she practiced the exposure, what was her SUD score? You know, at first it was 50. As she kept going through the week, it kind of came down a little bit to 45 and 40 and 30, and then she had to give it an ending SUD score. So every day the ending SUD score was a little bit less. It, she had a little less anxiety after the exposure. So her brain was beginning to learn that this dizzy feeling was not dangerous and that rewiring was beginning to take place. Now, the next step is that as soon as she wasn't able to get more her anxiety, she started these exposures and she was at like, you know, almost a zero through 10 or 20, she wasn't able to get any anxiety going with this anymore. It mean that she had completed that exposure and it was time to move up on her hierarchy and start the next exposure. And so she would start the next one as she was going through her exposure therapy. And this was going on for weeks. I was encouraging her to continue to make herself anxious because your brain has to be anxious in order for the exposure to work. So when her SUD score was coming down, I would say, well, how could you make yourself more anxious to get that SUD score to come up again? When you're doing the exposure, could you try the exposure in a different environment? Could you add some fearful thoughts about maybe the, a dizziness will really create a panic attack and try to get yourself anxious? Let's get the most effectiveness out of the exposure that we can. And she actually completed her hierarchy in 10 weeks. And at that time she really couldn't get any anymore anxiety out of being dizzy. It, she had completely created a new neuro pathway in her brain. That being dizzy was not associated with fear anymore, and therefore did not create panic. So I want to say a few more words about panic disorder and When you're doing exposure therapy, this interceptive exposure therapy or any type of exposure therapy, your brain has to be anxious in order for the exposure to work. It's called activate to generate. We have to activate the amygdala, get our fear center, very anxious for the new neuro pathway to be formed. If we do an exposure therapy and we're not anxious, it doesn't do anything. You have to be anxious, activate to generate those new neural pathways. You want to start gradually until your confidence builds. If you want to flood yourself and really challenge yourself, you can. However, most people like to work up gradually. You want to challenge yourself as you go. Challenge yourself in different environments. Even though you're doing interceptive exposure therapy on internal body symptoms, you want to try to keep challenging yourself in increasing that anxiety by doing it in different locations and adding anxious thoughts to really make it intense for yourself eventually without safety behaviors. We don't want you taking medicines or having medicines with you or having people with you or checking out the local hospital or doing anything to check your body's symptoms or your heart rate. Take off those apple watches. We don't want anything that is checking your heart rate for you, that your brain knows that that's a safety behavior, and it makes the exposure therapy less effective. Other things that make exposure therapy less effective is any type of asking for reassurance or Googling symptoms or taking benzodiazepines. If you're on a benzodiazepine and you want to do an exposure therapy, it will hinder its effectiveness. Sometimes people may take a medication to start doing the exposure, but eventually you will have to work with your doctor to go slowly off of those medications before your brain can learn that you are safe and create those new neuropathways.

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