by Joye C. Anestis
Exposure treatments involve asking clients to confront their most feared objects, situations, emotions, etc. The goals for doing this vary by diagnosis, but the basic premise is that when people avoid the things that scare them, their anxiety becomes reinforced. Take for example, a snake phobia. If you are scared of snakes, then obviously seeing one causes you to experience great anxiety. If you run away from the snake, your anxiety decreases. That decrease in anxiety is highly rewarding - thus, avoidance of snakes becomes a reinforced behavior. In exposure therapy, that pattern of reinforcement is broken. You remain around a snake for as long as it takes for your anxiety to decrease naturally. At the same time, if you have a snake phobia, you also probably have incorrect beliefs about the danger snakes pose, for example overestimating the likelihood that a snake would bite and kill you. By being exposed to snakes in a variety of conditions, you 
also get an opportunity to correct such misinformation. Treatments involving exposure are well-established for the treatment of a variety of anxiety disorders, including obsessive-compulsive disorder, social anxiety disorder, specific phobias, and PTSD. Most of the time, exposure involves actively facing the thing you are afraid of in vivo (e.g., snakes, touching public bathroom doorknobs without washing one's hands) or imaginally (e.g., a trauma).
A newer variation of exposure has been developed to help individuals who are not scared of external things or of memories but of their own bodily sensations. This type of fear is most common in panic disorder, an illness consisting of recurrent panic attacks and great fear of having another panic attack (APA, 2000). Most individuals with this illness also avoid situations and places when panic attacks might occur. As you can imagine, this can greatly limit the number of places you can go and often leads to agoraphobia. The primary fear in panic disorder is of the panic attack sensations themselves and the implications of those attacks. Common misappraisals of panic attacks include "I'm having a heart attack," "I'm having a stroke," "I'm dying," "I'm losing my mind," and many other interpretations of panic attacks as dangerous. In reality, panic attacks are common, even in those without panic disorder (Norton, Cox, & Malan, 1992), and decidedly undangerous (e.g., the symptoms are vastly different from heart attacks and strokes). So how do you expose an individual to panic attack sensations, which include heart palpitations, sweating, shortness of breath, and dizziness? The answer: interoceptive exposure. Interoceptive exposure lessens the fear of these specific bodily cues through repeated and systematic exposure to them. The types of exposure differ based on each individual's cluster of panic symptoms. Some examples I have heard of or conducted myself include (but there are many many more possibilities):
- spinning around in a chair
- cardiovascular exercise
- breathing in and out of a cocktail straw
- carbon dioxide inhalation
- sitting is a steamy room
- ingesting caffeine
- holding one's breath for as long as possible
Constructing interoceptive exposure activities can require a lot of creativity on the part of the therapist! Click here for a clip from Good Morning America demonstrating interoceptive exposure. As with In vivo and imaginal exposure, once individuals quit avoiding the panic attack sensations, their anxiety regarding them will be begin to naturally decrease.
Interoceptive exposure for panic is part of a broader CBT protocol (see list of treatment manuals below), thus it is most effective when combined with cognitive restructuring, ample psychoeducation, and some in vivo exposure to situations that might induce panic attacks. This CBT is considered to be an EST for panic disorder. Studies have found that interoceptive exposure protocols are more effective for panic disorder than in vivo exposure + cognitive therapy and cognitive therapy alone (Smith et al., 2004). Panic disorder is sometimes described as a "fear of fear" - interoceptive exposure is one highly efficacious way to overcome that.
For more information on administering interoceptive exposure, try these treatment manuals:
Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
Mastery of Your Anxiety and Panic: Workbook (Treatments That Work)
Mastery of Your Anxiety and Panic: Therapist Guide (Treatments That Work)
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
