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Interoceptive exposure is a cognitive behavioral therapy technique used in the treatment of panic disorder. [1] It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension, and in the process removing the patient's conditioned response that the physical sensations will cause an attack to happen.
By removing the fear of a panic attack happening whenever the person is exposed to a stimulus that has become a precursor to the attack, interoceptive exposure lessens the occurrences of attacks in patients who have received treatment. In short, interoceptive exposure seeks to remove the "fear of fear", where the attacks happen because of the fear of actually having an attack. [1] Interoceptive exposure can be contrasted with in vivo exposure, which exposes the person directly to a feared situation. Interoceptive exposure can be used as a means to induce depersonalization and derealization. [2]
Behavioral therapy began primarily between 1950 and 1970 by researchers in the United States, United Kingdom, and South Africa. Joseph Wolpe pioneered the method of systematic desensitization, which started the search for fear reduction techniques. Reiss and McNally developed an expectancy model of fear in 1985 based on the concept of "fear of fear," which they called anxiety sensitivity. They were some of the first researchers to begin examining how anxiety sensitivity influences panic disorder. This theory postulates that individuals with high anxiety sensitivity tend to believe that anxiety causes mental illness, leads to heart attacks, or produces more anxiety. [3]
Early experiments in the 1990s yielded mixed results on the effectiveness of interoceptive exposure. [4] [5] Throughout the 21st century, scientists began to create treatment protocol to help those with Panic Disorder. Barlow and Craske (2007) constructed a popular treatment procedure in which therapists use a low dose of IE therapy along with controlled breathing skills. [6] However, scientists still question whether a low-dose IE therapy or a more intensive approach is more effective.
Post traumatic stress disorder and chronic obstructive pulmonary disease, conditions commonly comorbid with Panic Disorder, can be treated using interoceptive exposures. [7] IE has been shown to reduce Anxiety Sensitivity, the main characteristic of those with Panic Disorder, which is also associated with Generalized Anxiety Disorder (GAD) and Social Phobia.
It is postulated that IE helps those with PTSD because many of the exercises serve as reminders of the individual's traumatic experiences. IE creates high anxiety reactions for those with PTSD and reduces their anxiety sensitivity for future encounters to the traumatic event. For example, a spinning exercise could make some individuals remember spinning in their vehicle after being hit. Also, after completing a tension exercise, individuals may remember a time when they were physically hit in some way (e.g. physical assault, recreational accident, road traffic collision). These exercises can make some individuals feel distressed from the recall of trauma. [8]
Panic disorder has been found to commonly co-occur with chronic obstructive pulmonary disease (COPD). COPD is a serious lung disease that involves restriction of airways from chronic bronchitis and/or emphysema. Research suggests that IE breathing exercises are safe and similar to the existing exercises that are used to help COPD. CBT (cognitive behavioral therapy) is not commonly used to help treat COPD, but recent research has shown that CBT including interoceptive exposures could be extremely beneficial. Specifically, IE extinguishes the learned fear response paired with breathing difficulties and disconfirms the catastrophic cognitions connected with increased physiological arousal. [7]
Researchers reported high degrees of anxiety sensitivity in patients with GAD, social phobia, and panic disorder. [9] [10] This led researchers to believe that there may be alternative treatment options involving IE therapy that would benefit these individuals. For example, for those with GAD, caffeine could be administered to make thoughts race and provoke worry about loss of cognitive control. Also individuals with social phobia could induce sweating before doing a speech challenge. Acknowledging these physical symptoms associated with high anxiety may be beneficial in reducing future anxiety when it does occur. [10]
Treatment manuals for IE are not consistent in how the therapy should be implemented. Despite minimal reports of adverse outcomes due to IE from both patients and therapists, therapists have been cautious when applying interoceptive exposure and have tended to implement it in a less prolonged and intense fashion than treatment manuals suggest. [6]
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.
Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.
Scrupulosity is the pathological guilt/anxiety about moral or religious issues. Although it can affect nonreligious people, it is usually related to religious beliefs. It is personally distressing, dysfunctional, and often accompanied by significant impairment in social functioning. It is typically conceptualized as a moral or religious form of obsessive–compulsive disorder (OCD), The term is derived from the Latin scrupus, a sharp stone, implying a stabbing pain on the conscience. Scrupulosity was formerly called scruples in religious contexts, but the word scruple now commonly refers to a troubling of the conscience rather than to the disorder.
Worry refers to the thoughts, images, emotions, and actions of a negative nature in a repetitive, uncontrollable manner that results from a proactive cognitive risk analysis made to avoid or solve anticipated potential threats and their potential consequences.
Phobophobia is a phobia defined as the fear of phobias, or the fear of fear, including intense anxiety and unrealistic and persistent fear of the somatic sensations and the feared phobia ensuing. Phobophobia can also be defined as the fear of phobias or fear of developing a phobia. Phobophobia is related to anxiety disorders and panic attacks directly linked to other types of phobias, such as agoraphobia. When a patient has developed phobophobia, their condition must be diagnosed and treated as part of anxiety disorders.
Cynophobia is the fear of dogs and canines in general. Cynophobia is classified as a specific phobia, under the subtype "animal phobias". According to Timothy O. Rentz of the Laboratory for the Study of Anxiety Disorders at the University of Texas, animal phobias are among the most common of the specific phobias and 36% of patients who seek treatment report being afraid of dogs or afraid of cats. Although ophidiophobia or arachnophobia are more common animal phobias, cynophobia is especially debilitating because of the high prevalence of dogs and the general ignorance of dog owners to the phobia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) reports that only 12% to 30% of those with a specific phobia will seek treatment.
In exposure therapy, an exposure hierarchy is developed to help clients confront their feared objects and situations in a manner that is systematic and controlled for the purpose of systematic desensitization. Exposure hierarchies are included in the treatment of a wide range of anxiety disorders.
Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger (desensitization). Doing so is thought to help them overcome their anxiety or distress. Procedurally, it is similar to the fear extinction paradigm developed for studying laboratory rodents. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and specific phobias.
Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.
Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.
Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences — even when doing so creates harm in the long run. The process of EA is thought to be maintained through negative reinforcement — that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the avoidance behavior will persist. Importantly, the current conceptualization of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings is thought to be linked to a wide range of problems.
Fear of flying is a fear of being on an airplane, or other flying vehicle, such as a helicopter, while in flight. It is also referred to as flying anxiety, flying phobia, flight phobia, aviophobia, aerophobia, or pteromerhanophobia.
PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.
Driving phobia, driving anxiety, vehophobia, amaxophobia or driving-related fear (DRF) is a pathological fear of driving. It is an intense, persistent fear of participating in car traffic that affects a person's lifestyle, including aspects such as an inability to participate in certain jobs due to the pathological avoidance of driving. The fear of driving may be triggered by specific driving situations, such as expressway driving or dense traffic. Driving anxiety can range from a mild cautious concern to a phobia.
Safety behaviors are coping behaviors used to reduce anxiety and fear when the user feels threatened. An example of a safety behavior in social anxiety is to think of excuses to escape a potentially uncomfortable situation. These safety behaviors, although useful for reducing anxiety in the short term, might become maladaptive over the long term by prolonging anxiety and fear of nonthreatening situations. This problem is commonly experienced in anxiety disorders. Treatments such as exposure and response prevention focus on eliminating safety behaviors due to the detrimental role safety behaviors have in mental disorders. There is a disputed claim that safety behaviors can be beneficial to use during the early stages of treatment.
Jonathan Stuart Abramowitz is an American clinical psychologist and Professor in the Department of Psychology and Neuroscience at the University of North Carolina at Chapel Hill (UNC-CH). He is an expert on obsessive-compulsive disorder (OCD) and anxiety disorders whose work is highly cited. He maintains a research lab and currently serves as the Director of the UNC-CH Clinical Psychology PhD Program. Abramowitz approaches the understanding and treatment of psychological problems from a cognitive-behavioral perspective.
Interoception is the collection of senses providing information to the organism about the internal state of the body. This can be both conscious and subconscious. It encompasses the brain's process of integrating signals relayed from the body into specific subregions—like the brainstem, thalamus, insula, somatosensory, and anterior cingulate cortex—allowing for a nuanced representation of the physiological state of the body. This is important for maintaining homeostatic conditions in the body and, potentially, facilitating self-awareness.
Michelle G. Craske is an Australian academic who is currently serving as Professor of Psychology, Psychiatry, and Behavioral Sciences, Miller Endowed Chair, Director of the Anxiety and Depression Research Center, and Associate Director of the Staglin Family Music Center for Behavioral and Brain Health at the University of California, Los Angeles. She is known for her research on anxiety disorders, including phobia and panic disorder, and the use of fear extinction through exposure therapy as treatment. Other research focuses on anxiety and depression in childhood and adolescence and the use of cognitive behavioral therapy as treatment. Craske has served as President of the Association for Behavioral and Cognitive Therapy. She was a member of the DSM-IV work group on Anxiety Disorders and the DSM-5 work group on Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative Disorders, while chairing the sub-work group on Anxiety Disorders. She is the Editor-in-chief of Behaviour Research and Therapy.
Imagery Rescripting is an experiential therapeutic technique that uses imagery and imagination to intervene in traumatic memories. The process is guided by a therapist who works with the client to define ways to work with particular traumatic memories, images, or nightmares.
