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  • Breaking the Link: Interoceptive Exposure for Panic – Part 7 of an 8-Part Series

    Some people often speak about the “Mind-Body connection” as if our minds and our bodies are somehow two separate parts of how we experience life. However, the uncomfortable experience of panic symptoms is one of the clearest ways we know that mind and body are inextricably linked, one and the same.

    This is especially the case for people who experience panic in very physiological ways.

    However, many if not most of these “symptoms” of panic are things that we experience on a regular basis, even when not in the throws of panic. For example:

    • We may experience a raised heart rate and shortness of breath when walking up stairs in our own home, jogging, or while watching exciting film and television.
    • We may experience sweating when walking or jogging, when the weather is hot, or when lifting or moving heavy items.
    • We can experience dizziness when getting up from a sitting or lying down position, when turning around to look at something behind us, or looking up at the sky.

    Most people have these sensations while going about their routine daily lives, and probably don’t think twice about them. But the difference for someone who tends to panic is that the raised heart rate, shortness of breath, sweating, and/or dizziness are associated with extreme anxiety, and can become warning signals. 

    When these otherwise ordinary and harmless physiological experiences become linked with anxious thoughts and feelings, the panic cycle can build up. We begin to automatically assume that these sensations signal the onset of a panic episode – even when at another point in our lives, we wouldn’t have worried about them at all.

    It’s this interpretation that we place on these sensations that can quickly create anxiety, which in turn, spirals back into elevated sensations and hooks us onto a path towards another episode.

    One important technique for breaking down that association between sensations and anxiety is to purposely create those physiological sensations, relearn that they are safe, and regain confidence in one’s ability to experience those sensations without significant anxiety. This is called Interoceptive exposure, and is done in a measured and methodical way.

    Common examples of interoceptive exposures include:

    • Shaking your head from side to side for 30 seconds (to simulate dizziness)
    • Swallowing quickly 10 times (to simulate tightness in your throat, or breathlessness)
    • Breathing through a straw for 30 seconds (to simulate shortness of breath, chest tightness)
    • Breathing in short, quick breaths for 60 seconds (to simulate hyperventilation)
    • Jogging in place for 60 seconds (to generate a raised heart rate, feelings of heat)
    • Holding one’s breath for 30 seconds (to simulate lightheadedness)
    • Spinning around in a chair, starting with just 2-3 times (to simulate dizziness)
    • Placing your head between your legs for 30 seconds, and then quickly sitting up (to simulate disorientation, or nausea)

    The reason why Interoceptive exposure is effective is that repeated, safe, and intentional practice of the exercises above starts to convince a panic sufferer that these sensations do not necessarily lead to panic, and can be tolerated safety. Confidence can then start to rebuild that a big spike in anxiety is not lurking behind these common every day sensations.

    Tips for success with Interoceptive Exposure

    • The amount of time you start with for any of these exposure exercises (above) can be adjusted to find a starting point if necessary. For example, some people may find that shaking their head from side to side for just 5 seconds (rather than 30) is a very difficult exercise to start with.
    • Consistency is key. As with any exposure, repeated and intentional exposure helps accelerate the process of re-learning that these sensations can be tolerated, and do not necessarily lead to panic episodes.
    • Increase the level of difficulty. Again, successful exposure may start small, but should increase in difficulty as lower levels of anxiety become well tolerated. In the previous example of shaking one’s head sided to side to induce dizziness, you could start the exercise by practicing for 5 (or even less) seconds at a time, until the induced anxiety decreases dramatically. Then, consider doing the exercise for an incrementally longer period (e.g. 10 seconds), and build up from there.

    Interoceptive exposure can be done by oneself, though starting out can be helpful to do in the safe company of a Cognitive Behavioral Therapist. It is a safe and effective way to sever the automatic connection between physiological symptoms and anxiety leading to panic.

    Read the rest of this blog series about how Cognitive Behavior Therapy can help reduce your panic symptoms:

    Part 1 addressed the different ways people may experience panic attacks

    Part 2 addressed an often unrecognized reason why we panic

    Part 3 discussed the most common unhelpful ways that people cope with panic

    Part 4 discussed the best way to cope with a panic attack

    Part 5 described the power of language and labeling with regard to panic episodes

    Part 6 highlighted the benefit of Mindfulness in treatment for panic

    Part 8 describes live “In vivo” exposure strategies for panic

    Martin Hsia, Psy.D. is the Clinical Director of CBT SoCal, and specializes in helping people with OCD, Anxiety, and Insomnia in Glendale, CA.

    1. Karen Kerschmann
      January 16, 2021 at 7:14 pm

      Thank you so much for these detailed articles! As a CBT practitioner who is seeing clients virtually, exposure can be particularly challenging. That said, blogs like yours provide evidence for my patients that recreating symptoms is a common and useful experiment.

    2. Martin Hsia

      Martin Hsia

      January 19, 2021 at 6:03 am

      Thanks Karen – Virtual therapy has its challenges for sure, though at the same time, it’s also opened up more opportunities for exposure work, as we can actually coach people to do them in their home environment as well!