Exposure Therapy

If you are in cognitive-behavioral therapy (CBT) for panic disorder, then most likely you will be involved in some kind of exposure therapy. Exposure therapy is used to treat several anxiety disorders. In exposure therapy, the patient goes into feared situations until he or she is able to do so without an anxious response.

Exposure therapy is based on the principle of habituation -- the natural process in which a response to a stimulus decreases with repeated exposure. For example, if you are in your office working and a phone begins ringing in another room, you may notice it at first and feel irritated that someone isn't answering it. If the ringing continues, you might tune it out, your irritation subsiding as you become involved in your work again. Or, if phones continually ring in your place of work all day, you may tune them out most of the time because you need to do so in order to work.

Exposure Therapy and Panic Disorder

With panic disorder, exposure therapy usually aims to accomplish one or both of the following:

• Remove the associations of panic attacks with feared situations and places.
• Remove the patient's fears about what might happen during a panic attack.

People with panic disorder may come to associate panic attacks with a variety of situations where panic attacks may have occurred in the past (or might occur). Driving is a common example. Through a process known as classical conditioning, if a person has experienced panic attacks while driving, an assocation may develop between panic attacks and driving. The driving itself did not cause the panic attacks, but the person may become afraid of driving as a result of conditioning. The actual fear, however, is of having the panic attack itself.

The physical symptoms of panic attacks also may lead to catastrophic thoughts about what might happen during or because of the panic attacks. People with panic disorder generally fear one or all of the following during or after a panic attack:

• Being sick or dying
• Going crazy
• Losing control
• Being embarrassed

Exposure therapy can help eliminate these kinds of fears as the person comes to understand that nothing bad will happen during or because of a panic attack.

How Exposure Therapy Works

There is more than one way for exposure therapy to be conducted:

Systematic Desensitization
Systematic desensitization is a gradual process of exposure therapy used for phobias related to situations and places. One fear or phobia is faced at a time. The patient will break the situation down into a hierarchy of manageable steps. For example, with driving, the first step might be simply to sit in the car. The person spends time doing each step until he or she is able to do so without having anxiety or panicking before moving to the next step. The goal would be for the person to be able to drive alone without having anxiety or panic.

In order to practice the hierarchy, the patient must know at least one relaxation technique, such as progressive muscle relaxation. The relaxation technique is used when anxiety begins, giving the patient a tool for managing and reducing anxiety during the process. Systematic desensitization may be practiced in real life or by using visualization.

Intensive Exposure Therapy
Also known as flooding, this method puts the patient into the feared situation right away. The patient must stay in the situation until the anxiety diminishes. Just as with systematic desensitization, the patient must know relaxation techniques to use during the exercise. Intensive exposure may have quick results, but it also requires a patient who is ready for this kind of rapid exposure. Additionally, this process usually involves a therapist who is well-trained in the procedure.

Introceptive Exposure
Introceptive exposure therapy may be used to help patients learn that nothing will bad will happen during panic attacks. With this method, symptoms similar to panic attacks are induced in a controlled setting. For example, the patient will run up a flight of stairs, bringing on a rapid heart rate. Then, with the help of the therapist, the patient learns to accept these symptoms and let go of the accompanying thoughts that they might have a heart attack or pass out.

Exposure therapy may be patient-directed, in which the patient goes into feared situations alone and decides how quickly to take each step. Or, the process may be therapist-assisted, in which the therapist accompanies the patient and also challenges the patient to move at a certain pace. With a therapist, the process may go more quickly, and, indeed, intensive exposure generally requires the assistance of a professional.

^Sources:

Barlow, David H. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. 2nd ed. New York: Guildford Press, 2002.

Hersen, Michael and Alan S. Bellack, eds. Handbook of Comparative Interventions for Adult Disorders. 2nd ed. New York: John Wiley and Sons, 1999.

Rosenbaum, Jerrold F. and Mark H. Pollack, eds. Panic Disorder and Its Treatment. New York: Marcel Dekker, 1998.