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Interoceptive Exposure

Misappraisals of body sensations trigger emotional and physiological reactions of fear and heightened arousal. These feelings motivate behavioral responses, typically avoidance and safety behaviors, intended to protect oneself from danger. These interoceptive avoidance behaviors may provide effective relief of anxiety in the short-term but in the long-term they prevent new learning about the true nature of the threat and maintain a vicious cycle of anxiety. Exposure is the most effective psychological technique for the treatment for anxiety and can be adapted to expose patients to feared body sensations. 

Interoceptive exposure is the practice of strategically inducing the somatic symptoms associated with a threat appraisal and encouraging the patient to maintain contact with the feared sensations. It is an effective treatment technique for a range of anxiety conditions including panic attacks and panic disorder, health anxiety, chronic pain, and chronic dizziness.

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Introduction & Theoretical Background

The cognitive behavioral model of anxiety proposes that appraising a stimulus as threatening leads to emotional and bodily reactions of fear and arousal, which in turn motivate avoidance and safety behaviors. These behaviors may provide effective relief of anxiety in the short-term – explaining their repeated use – but in the long-term they prevent new learning about the true nature of the threat and maintain a vicious cycle of anxiety. 

Unhelpful beliefs about body sensations are critical maintaining factors in a wide range of disorders such as panic attacks and panic disorder, health anxiety, chronic pain, irritable bowel syndrome, and chronic dizziness. Misappraisals of body sensations trigger emotional and bodily reactions of fear and heightened arousal, which in turn trigger behavioral responses – typically avoidance and safety behaviors – designed to protect oneself from danger. It is often the case that a rapidly escalating feedback loop or vicious cycle is established: the physiological reactions to threat can exacerbate the feared body sensation, which in turn lead to increasingly catastrophic misinterpretations – a panic attack is the prime example of this kind of cycle. 

While it is sometimes possible to effectively avoid feared situations in the real world, it is more difficult to avoid one’s own physiology. Interoceptive avoidance – avoidance of body sensations – can result in significant behavioral changes which are rarely 100% effective. Some examples are given below:

  • A patient with panic disorder appraised her racing heart as “I’m having a heart attack” and reduced her physical activity in order to reduce strain on their heart.
  • A patient who experienced pain in his back had the appraisal “this is a sign of damage” and reduced his activity in order to avoid further painful sensations. This quickly resulted in physical deconditioning, leading to increased pain upon movement.
  • A patient with a family history of schizophrenia had a feeling of unreality when she drank a strong coffee to relieve her tiredness. She appraised this feeling as “I’m losing my mind” and felt terrified. She subsequently avoided caffeine and closely monitored her internal mental state leading to frequent frightening ‘false alarms’.
  • A patient who had experienced a severe attack of vertigo appraised even mild feelings of imbalance as “I’m having another attack of vertigo – I’m in danger”. She made strong efforts to keep her head very still, closely monitored herself for signs of imbalance, and refused to travel far from home in case she had an attack of vertigo.

Exposure to the feared stimulus is the most effective psychological treatment for anxiety. In the case where internal body sensations are the source of fear then interoceptive exposure is the treatment of choice. In its simplest form, interoceptive exposure involves strategically inducing the somatic symptoms associated with the threat appraisal and anxiety, and then encouraging the patient to maintain contact with the feared sensation without distraction. Interoceptive exposure exercises can take many forms, but all involve attempting to bring on changes in subjective somatic sensations. Different exercises can be used to target various physiological systems, and various psychological symptoms and threat appraisals.

  • Respiratory system: shortness of breath, tightness of throat, “I can’t breathe” “I will pass out”. Suggested interoceptive exposure exercise: deliberate hyperventilation, such as breathing rapidly for one minute.
  • Cardiovascular/circulatory system: heart racing, sweating “I’m going to have a heart attack”. Suggested interoceptive exposure exercise: intense physical exercise, such as running on the spot.
  • Vestibular system: dizziness, imbalance “I will fall over”. Suggested interoceptive exposure exercise: spinning, such as spinning in an office chair (with eyes open or closed).
  • Muscle tone: muscle tension, tightness, shaking, imbalance. Suggested interoceptive exposure exercise: muscle tension / applied tension.
  • Psychological system: feelings of unreality “I’m going mad” “I’m losing my mind”. Suggested interoceptive exposure exercise: staring into a mirror for an extended period.
  • Temperature / homeostatis system: feeling too hot, sweating “I’m going to pass out”. Suggested interoceptive exposure exercise: staying in a hot room.
  • Nociceptive system: pain “This is causing permanent damage”. Suggested interoceptive exposure exercise: performing bending and lifting movements.
  • Various / mixed systems: heart racing, mind racing “I’m going to lose control”. Suggested interoceptive exposure exercise: drinking caffeinated drinks.

Traditional models of exposure encourage prolonged and repeated exposures to feared situations and objects until habituation occurs. Newer understandings of exposure therapy based upon inhibitory learning theory (ILT) place more emphasis upon what exposure to a stimulus can help patients to learn. Both models are effective and clinicians can apply interoceptive exposure quite flexibly: exercises can be introduced in an exploratory fashion to assess a patient’s feelings and appraisals, or exercises can be introduced in the context of a behavioral experiment where a patient is invited to test a specific prediction or appraisal. Recent experimental data indicates that there is a dose-effect response with more intensive interoceptive exposure being more effective in reducing anxiety. 

The Interoceptive Exposure exercise is a three-page pack designed for patients. It gives information about the rationale for this technique, outlines important safety information regarding interoceptive exposure exercises, and then describes how to conduct different types of interoceptive exposure exercises and what to measure or attend to.

Therapist Guidance

Interoceptive exposure exercises are not dangerous, but they do tend to induce at least moderate feelings of discomfort. Clinicians should ensure that patients are in good general health before beginning. It is advisable to check with a medical practitioner whether it is safe for a patient to complete interoceptive exposure exercises if they are pregnant, or if they suffer from epilepsy or seizures; cardiac conditions; asthma or lung problems; or neck, back, or other physical difficulties. 

The Interoceptive Exposure exercise introduces a series of exposure tasks targeting a range of physiological systems and psychological symptoms. For each exercise there are brief instructions along with a recommended duration for which to attempt the task (which can be increased once clients have some proficiency with each exercise). Space is also given for recording any symptoms or sensations that the patient experiences, and for recording the peak anxiety that the patient experienced during the exercise. Patients may also be encouraged to record additional information such as how long it takes for any target body sensations to return to normal. 

If it is unclear which body sensations are of particular concern to a patient then all of the exercises can be attempted, leaving time between each exercise for feelings to normalize. A more efficient way of conducting interoceptive exposure is to identify the body sensations of concern to a patient, and to identify their unique appraisals. A therapist might ask “What do you think would happen if you didn’t avoid that feeling?” or “What do you think would happen if that feeling was allowed to continue indefinitely?”. In this way a prediction is generated which can be tested using a behavioral experiment / hypothesis-testing approach. 

Instructions that apply to all interoceptive exposure exercises include:

  • Patients should be encouraged to complete each exercise for the allotted time - stopping early can be understood as a form of avoidance.
  • Patients should be encouraged to focus on their body sensations during each exercise, and discouraged from any distraction or subtle avoidance.
  • Patients should be encouraged to relinquish any safety behaviors that might interfere with the exposure exercise.
  • Exercises should be attempted in a variety of contexts in order to maximize opportunities for learning. This might be accomplished in a graded way: beginning in the therapist’s office and then progressing to different environments; attempting the exercises alone or in company; and eventually combining the exercise with other threatening stimuli or situations.

References And Further Reading

  • Barlow, D. H. (2004). Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford press.
  • Barlow, D. H., Craske, M. G. (2007). Mastery of your anxiety and panic (Fourth edition). Oxford: Oxford University Press.
  • Chambless, D. L., & Gracely, E. J. (1989). Fear of fear and the anxiety disorders. Cognitive Therapy and Research, 13(1), 9-20.
  • Clark, D. M., Salkovskis, P. M., Öst, L. G., Breitholtz, E., Koehler, K. A., Westling, B. E., … & Gelder, M. (1997). Misinterpretation of body sensations in panic disorder. Journal of Consulting and Clinical Psychology, 65(2), 203.
  • Craske, M. G., Wolitzky-Taylor, K. B., Labus, J., Wu, S., Frese, M., Mayer, E. A., & Naliboff, B. D. (2011). A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations. Behaviour research and therapy49(6-7), 413-421.
  • Deacon, B., Kemp, J. J., Dixon, L. J., Sy, J. T., Farrell, N. R., & Zhang, A. R. (2013). Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learning: A randomized controlled trial. Behaviour Research and Therapy51(9), 588-596.
  • Deacon, B. J., Lickel, J. J., Possis, E. A., Abramowitz, J. S., Mahaffey, B. G., & Wolitzky-Taylor, K. (2012). Do cognitive reappraisal and diaphragmatic breathing augment interoceptive exposure for anxiety sensitivity? Journal of Cognitive Psychotherapy, 26(3), 257-269.
  • Lee, K., Noda, Y., Nakano, Y., Ogawa, S., Kinoshita, Y., Funayama, T., & Furukawa, T. A. (2006). Interoceptive hypersensitivity and interoceptive exposure in patients with panic disorder: specificity and effectiveness. BMC Psychiatry, 6(1), 32.