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Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression
484 Interoceptive Exposure & Panic Attacks: How Facing Physical Sensations Can End the Fear Cycle
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You felt your heart start to race and then you started to notice the fear of your heart racing. And that exact moment, that second moment, is where you get locked into panic. Understanding this is the first step. But today I'm actually going to show you a step by step plan on how to practice interoceptive exposures for panic and panic disorder. My name is Kimberly Quindlen. I'm an anxiety and OCD specialist and I am on a mission to help 10 million people with anxiety. I know in my heart that we can suffer less. The world is hard enough and I want to make sure that you can manage your anxiety and go and live your life. Spread the love around. There is so much crap on the Internet these days about anxiety. So my hope is to give you evidence based skills where you can help reduce your own suffering with anxiety. So let's get started. So what actually is happening during a panic attack? Now, I want to explain it by using a graph that we use all the time with our students. And it's going to start here in the sensations of anxiety. What often happens is something happens and you feel an intense increase in sensations of anxiety. Might be a heart rate, it might be you start to sweat, your tummy might start hurting. When you have that anxiety, that is the first moment. But then what happens is we catastrophize or we misinterpret those sensations as dangerous. And then the cycle is off and it's running. And so what happens here is you've had this sensation you've interpreted as dangerous or problematic or that it means something, and then you have an even higher increase in anxiety. It's kind of like you're telling your brain like, yes, yes, in fact, this is dangerous. Then you have an increase in anxiety and then you have, you move on to have an actual panic attack. Now what happens is once the panic attack has risen and fallen, then you start to have anticipatory anxiety about when you will have the anxiety again. And now the cycle is in full swing. Then next time you have any sensations of anxiety, you do again, catastrophize that and make it mean that something dangerous is about to happen. And then you have even more anxiety, you have an even bigger panic attack, which again forces you to be even more afraid of the next panic attack. This is the cycle of panic disorder. Most people with panic disorder are afraid of panic. That's what they're mostly struggling with. Now, if we look at that cycle, the thing to remember is the sensation wasn't the problem. The problem is our response and how we interpreted that sensation. And here's the most critical part. Every time you have that sensation and you avoid it, or at least try to avoid it, you're actually reinforcing that cycle. The act of avoidance teaches your brain that we actually do need to be afraid of panic. And then your brain reminds you next time you have any kind of anxiety that danger is on its way. And that is how panic disorder is maintained. And if you're stuck in this situation, you're not alone and it's not your fault. We just need to make some pivots in how you respond to those physiological sensations that you experience. So let's go a little deeper and look at why avoidance doesn't work. Let's say that you have a sensation of dizziness and you interpret the dizziness as dangerous. You might say, oh my gosh, if I'm dizzy, that might mean I faint, and if I faint, I pass out. And if I pass out, then bad things will happen and I'll have to go to the hospital or I'll make a fool of myself. Now you've created an entire narrative that is going to reinforce this idea that anytime you even feel the slightest sensation of dizziness, even degrees that are within normal ranges, you're going to start to avoid it and reinforce that cycle. Now, there are other ways that we might try to avoid it. We might avoid places and people and locations where you've had panic attacks before. You might avoid going to the doctor, going out with friends. You might avoid certain situations that occur at work or school. That avoidance is a subtle nudge to your brain that panic is dangerous and that we shouldn't have any sensation beyond normal. What we end up doing is becoming hyper vigilant to any physical sensations in our body and doing whatever we can to avoid those sensations. But once again, avoidance does not reduce panic. It actually fuels it and reinforces it. So what is interoceptive exposures? Now, interoceptive exposures is a structured, evidence based, cognitive behavioral technique that we use to target this exact problem, this cycle that we get stuck in. The word interoceptive refers to your own internal bodily sensations. So think about it like when we're talking about exposure and response prevention. We might expose you to going to the supermarket, we might expose you to reading a story that makes you anxious. Interoceptive exposures is where we practice deliberately exposing ourselves to internal sensations of discomfort or whatever the panic symptoms are that you are trying to avoid, or the panic sensations that you misinterpret as dangerous and problematic. Now by doing these interoceptive exposures, we actually learn that we can tolerate those feelings. And often we also can learn that those feelings don't always mean that you will go into a full blown panic attack. Now, we're not really pushing to prove that that's not the goal. Our main goal is to practice having that sensation on repeat so that we can build mastery over it. So just to be clear, interoceptive exposures is a form of exposure and response prevention, but it's applied to the internal experience. So it's the same mechanism, same practice. It's just something you do internally to sensations instead of doing it to external experiences. One thing I want to really highlight here is often by the time clients come to us or students have come over and taken some of our courses, they have been to through multiple different types of treatment. Maybe more general cognitive behavioral therapy, where they've been taught to calm down and try to maybe reduce your anxiety, maybe restructure your thinking. There's nothing wrong with those techniques, but what often happens is they've missed the actual thing we're trying to expose them to. They're going and they're doing the things in their daily life, but they're still having this fear response to the physiological experience. Now, as you know, I have a private practice. I have six amazing therapists in Calabasas, California. However, we do not take insurance. Now, if you are looking for insurance covered OCD or BFRB treatment, I want to let you know about nocd. NOCD provides face to face live video sessions with specialized licensed OCD therapists. Now, their therapists use exposure and response prevention. We know this is the gold standard for ocd. So you can be absolutely confirmed that you're in the right place there. And they have a clinically proven app that helps you stay connected to your therapist and others who have OCD between sessions. So you'll always feel supported. Now the cool thing is NOCD is available in all 50 US states and even internationally and they accept most insurance plans, making it affordable and accessible. We love that. Now if you think you might have OCD or you're struggling to manage your symptoms and you can book a free call, just click the link in the show notes@nocd.com I am honored to partner with NOCD. I want to remind you that recovery is possible. Please do not forget that. Now big hugs and let's get back to the show. And so what we want to do in this case is practice those interoceptive exposures so we get at the actual core fear or the actual experience that you're actually most anxious about. Now, here are some interoceptive exposure examples that we use with clients all the time in my private practice. And again, I want you to understand that each person is going to be different. Every person experiences panic differently. But when we identify the specific experience that they're having or sensations that they're having, we can then craft exposures specific to the sensation that bothers them the most. So an example might be if you have dizziness and it really scares you to have the sensation of dizziness, you might actually sit in a chair just like the one I'm sitting in and spin around and around. And what we're doing there is we are inducing the sensation of dizziness. Then what we might do is say, okay, we're going to practice tolerating that feeling of dizziness. What we might also do is, because we want this to be in real world examples is we might spin around and then I might have my clients leave my office and we might walk the halls and they might practice walking the halls with the sensation of dizziness so that they can learn that they can actually tolerate that feeling. Another one might be is you're having a lot of anxiety about kind of that tight chest feeling, feeling like you can't breathe. We might get some straws, any straw that you would get from the gas station, and we would breathe through that thin straw to induce that experience of shortness of breath. Now, we're not doing this to actually inflict pain on the person. We're doing it in a very skillful way where we're saying, okay, how can we simulate this sensation not in the actual experience where you're having panic, but outside of that in your day to day, so that you can start to have a better relationship with those sensations and have a better reaction to those sensations. Another one is hyperventilation. In this case, we might actually encourage them to breathe short, rapid breaths just for a short period of time. Again, we're not here to try and induce pain on the person, but we're trying to give them an opportunity in small, short births to experience that feeling in a safe, very, very skillful way. Another one might be if you're afraid of that rapid heart rate that happens when you're anxious, we might do a lot of jumping jacks, we might do some push ups, we might do some sprints, whatever it is that helps you to induce that sensation. Another one might be holding your breath, if that's something that a tightness and the holding of breath tight Chest feeling might be a great interoceptive exposure for you. Another one is if you're really someone who struggles with disorientation, maybe dissociation, we might spin your head from side to side. We might watch YouTube videos of bizarre movements that create this sort of weird, spacious, weird sensation for the person. These are all very creative interoceptive ways that we can expose someone to the specific sensations of panic that they struggle with. If you're looking for a step by step program on how to do these interoceptives, let me give you a very brief understanding. First, what we're going to do is we're going to build a fear hierarchy. We're going to get very clear about what are the sensations you don't like feeling. Then we're going to rate them out of 10 of how much discomfort or how much fear you have around experiencing those sensations. And we're probably going to start in the very low and work our way up to the higher. Then step three is we're going to practice that interoceptive exposure. We are going to be creative and come up with ways to induce that sensation. And step number four, just like any exposure and response prevention plan, we are going to practice the reduction of safety behaviors. That means that we're not not going to be seeking reassurance, we're not going to be avoiding, we're not going to be ruminating, we're not beating ourselves up, we're not doing any internal checking behaviors. We're going to work at just allowing that discomfort. And step number five, and you've heard me say this before, is repeat, repeat, repeat. It's not a one and done. It's something we do over and over and over again so that you can build mastery. Now what's actually happening here is a scientific term called inhibitory learning. What's happening here is you're not taking away the discomfort. You're just getting new neuro pathways. You're learning new ways that you can handle this discomfort or this sensation. I always think of it like the Rubik's Cube. When you first start doing it, you're like, I have no idea, like, I can't do this. But then after you practice it, you start to build a sense of mastery over your ability to handle this Rubik's Cube. And these interoceptives are no different. They might seem really complex and almost impossible to start with. But with practice, practice, practice, you will start to feel confident and you're like, you actually get the hang of it. Like, oh, okay, I can actually handle this now, the major shift, like I just said, is instead of going, oh my gosh, I can't handle it. How can I make it go away? We move to, this is uncomfortable. I felt it before. I know what it is. I don't have to do anything about it. How it translates is if you're getting really good at doing interoceptives in your day to day, when you're out and about and you do start to experience those sensations, you'll be able to go, okay, I know this feeling. I know how to, how to handle it. I know how to tolerate it. I've had practice doing it. Okay, so I know what you're thinking. Before we move on, I want to really get to the honesty here. Doing interoceptive exposures is genuinely uncomfortable. It is not easy. There will be moments where your brain is like, absolutely, like, don't want to do this. This is terrible. This sucks. How can I run away? How can I avoid? And I totally get it. That is a part of the process. That is the function of panic disorder. It wants you to run away. It wants you to reduce or remove that discomfort. But the best way out of this disordered cycle is to lean in, is to willingly have the discomfort, willingly have the sensations that create discomfort for you. As I always say, it is a beautiful day to do hard things. This work is hard. But I promise you that you will not regret your ability to have a sensation and learn to respond in a skillful, kind, compassionate and empowered way. The goal of interoceptives is not to be calm, is not to reduce or remove those sensations forever. It's really actually more about freedom. It's about you knowing that you can have any sensation and you've already practiced having them on purpose. It's sort of like homework, you know, I know everyone hates homework when you're in high school or you're in elementary school, but the reason they give it to you is it. It reinforces what you've learned the first time you do it over and over and through that there is this sort of rote practice where you're like, oh, yeah, yeah, yeah, yeah, like, it's in my head now. I know what to do. And by practicing having those sensations, you will have the same experience. Now, when you're ready to go deeper, I would really encourage you to head over to your anxiety and panic toolkit. It is a complete course, step by step, showing you exactly what I teach my clients with generalized anxiety and panic. It is there for you at CBT school or you can connect by by clicking the link in the show notes. Now, as always, I want to thank you for being here. Please do share this with anyone you think this would be helpful for. It is my goal to help as many people as possible. So just know that I'm sending you so much love and I hope you have a beautiful day. Please note that this podcast or any other resources from CBTSchool.com should not replace professional mental health healthcare. If you feel you would benefit, please reach out to a provider in your area. Have a wonderful day and thank you for supporting cbtschool. Com.