Appendix IV

Interoceptive Exposure

Interoceptive exposure 1 involves using exercises that reproduce or mimic body sensations associated with panic, such as rapid heartbeat, shortness of breath, feeling hot or flushed, dizziness or lightheadedness, or shakiness and weakness in your legs. Because people who struggle with panic come to fear these sensations, overcoming panic disorder involves exposing themselves to these very same sensations.

Included here is a full range of exercises typically used for interoceptive exposure. You can briefly try them all, and then fully expose yourself to the exercises that feel most similar to your own panic sensations.

Interoceptive Desensitization

Interoceptive desensitization is among the most effective—and challenging—components of the treatment program for panic disorder. What you’re about to do is recreate, in a safe way, bodily sensations similar to those you associate with panic. You can learn to experience these sensations as something uncomfortable but not frightening. Dizziness, rapid heartbeat, even feelings of unreality can become no more than annoying effects of the fight-or-flight response. And when these feelings are no longer associated with panic, you’ll find yourself less vigilant toward, and less focused on, the sensations inside your body.

Desensitizing to frightening bodily sensations is accomplished in three stages. In the first stage you briefly expose yourself to ten specific sensations and then rate your reactions. Most of the following exposure exercises were developed and tested by Michelle Craske and David Barlow (2007). They induce feelings similar to those many people report prior to or during a panic.

Shaking your head from side to side

Lowering your head between your legs, then lifting it

Running in place (check with your doctor first)

Running in place wearing a heavy jacket

Holding your breath

Tensing the major muscles—particularly in your abdomen

Spinning while you sit in a swivel chair (not to be done standing up)

Breathing very rapidly

Breathing through a single, narrow straw

Staring at yourself in a mirror

As you review this list, you can probably already tell that some of these sensations will be quite uncomfortable. But it is precisely the feelings you most fear that you must desensitize to in order to recover from panic disorder. If exposing yourself to these interoceptive (physically arousing) experiences feels too frightening to do alone, enlist a support person to be present throughout the exercise. Later you can discontinue support as you get more comfortable with the sensations.

When you expose yourself to each of the ten sensations, you’ll need to keep records to identify which ones create the most anxiety and have the greatest similarity to your panic feelings. Fill in the Interoceptive Assessment Chart that follows as you sequentially expose yourself to each interoceptive experience.

Interoceptive Assessment Chart

Exercise	Duration	Anxiety 0–100	Similarity to panic sensations0–100%
Shaking head from side to side	30 seconds
Lowering your head between your legs, then lifting it (keep repeating)	30 seconds
Running in place	60 seconds
Running in place wearing a heavy jacket	60 seconds
Holding your breath	30 seconds (or as long as you can)
Tensing the major muscles—particularly in your abdomen	60 seconds (or as long as you can)
Spinning while you sit in a swivel chair	60 seconds
Breathing very rapidly	Up to 60 seconds
Breathing through a single narrow straw	120 seconds
Staring at yourself in a mirror	90 seconds

When rating your anxiety intensity, the scale ranges from 0 to 100, where 100 is the worst anxiety you’ve ever felt. The column where you rate each exercise’s similarity to panic sensations is very important. The range is from 0 percent similarity to 100 percent—absolutely identical feelings.

Stage 2 of interoceptive desensitization involves making a hierarchy of frightening sensations from the Interoceptive Assessment Chart. Here’s what you do: Put a check by each exercise that you rated 40 percent or above in similarity to actual panic sensations. Now, on the Interoceptive Hierarchy/Anxiety Intensity Chart, rank the checked exercises from the least to the greatest anxiety-intensity rating. Fill in the anxiety rating from your first exposure under Trial 1.

Interoceptive Hierarchy/Anxiety Intensity Chart

Exercise	Trial 1	Trial 2	Trial 3	Trial 4	Trial 5	Trial 6	Trial 7	Trial 8
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Once you’ve developed your hierarchy, it’s time to begin stage 3—the actual desensitization process. Start with the item lowest in anxiety on your hierarchy chart. If you need to have a support person present during initial exposure, that’s fine. Here’s the actual desensitization sequence:

Begin the exercise and note the point where you first experience uncomfortable sensations. Stick with the exercise at least thirty seconds after the onset of uncomfortable sensations—the longer the better.
As soon as you stop the exercise, rate your anxiety in the box for each exposure trial (on your Interoceptive Hierarchy/Anxiety Intensity Chart).
Immediately following each exercise, begin controlled breathing.
Following each exercise, remind yourself of the medical realities relevant to the bodily sensations you’re experiencing. For example, if you feel light-headed or dizzy after rapid breathing, remind yourself that this is a temporary and harmless sensation caused by reduced oxygen to the brain. Or, if you have a rapid heart rate after running in place, you could remind yourself that a healthy heart can beat 200 times a minute for weeks without damage, and it’s certainly built to handle this little bit of exercise.
Continue trials of desensitization with each exercise until your anxiety rating is no more than 25.

Sample Interoceptive Hierarchy/Anxiety Intensity Chart

Exercise	Trial 1	Trial 2	Trial 3	Trial 4	Trial 5	Trial 6	Trial 7	Trial 8
1. Staring in the mirror	40
2. Holding breath	45
3. Breathing through straw	50
4. Running in place	60
5. Running wearing jacket	70
6. Breathing rapidly	80
7.
8.
9.
10.

Interoceptive Desensitization in Natural Settings

When you’ve worked through your hierarchy to the point where each exercise triggers an anxiety-intensity rating of no more than 25, you can begin desensitization in real-life settings. With medical clearance, you can begin exposure to activities and experiences you’ve avoided because you feared a panic attack. Make a list of these activities and arrange them on the Interoceptive Hierarchy/Anxiety Intensity Chart. Rank them from least anxiety-evoking to most.