Exposure Therapy for Fear of Panic Attacks

The things that people fear are limitless. You might be afraid of flying, talking to an attractive person, being the victim of violent crime, animals, bugs, germs, needles, scary thoughts or memories, and so on.

Sometimes, however, what scares people the most is their own physical manifestations of fear. A racing heart beat, shortness of breath, dizziness and other sensations are enough to spiral them into a state of full-blown panic. The primary concerns include (1) the fear that such sensations will escalate into panic, (2) the panic will have catastrophic consequences such as death, insanity, or being forever stuck in a terrifying adrenalin overload, and (3) they will be unable to cope with such “disaster”.

Physiologically, though, there really isn’t a difference between a panic attack and how one’s body responds to other adrenalin pumping activities. Think about all of the people around the world who ride big roller-coasters each day. Their hearts pound, their breathing quickens, dizziness ensues and some primitive part of their brains interpret the sensation of being forcefully propelled towards the earth as being life-threatening (think how a poodle might interpret the situation). Now, how often do you hear of people dying from their own physiological reaction to roller coaster rides? Are people coming off of roller coasters being escorted either to a morgue or a locked psychiatric unit? Remember, the rush of anxiety and adrenalin (the “fight-or-flight” response) you experience when frightened is hardwired into us and other animals as a way to protect you from danger. It gives you a boost of energy that is adaptive if you are being stalked by a predator (though un-adaptive in the grocery store check-out line). It would be kind of silly if such a wonderful life-preserving bodily mechanism, in the absence of a serious underlying medical condition, actually killed or seriously injured you.

So what’s the difference between having the intense physical sensations experienced during a panic attack versus the roller coaster ride? Interpretation. The bodily response to a roller coaster ride is interpreted as safe, thrilling, and fun whereas the same sensations during a panic attack is interpreted catastrophically in someone who fears the fear itself.

So, if the fear of fear is predominately a misinterpretation of what are safe (though certainly unpleasant) sensations, what can someone suffering with this do to overcome their fear?

  1. Tell your doctor about your symptoms so that he or she rules-out a medical problem.
  2. Educate yourself as to what is happening in your body during an anxiety attack so that you are armed with the knowledge that it is safe and temporary. See www. for links to a number of educational websites and self-help book recommendations.
  3. Go towards the fear using exposure therapy.

After ruling out a medical condition and learning that the sensations you are having are not catastrophic, you still need to convince your nervous system that the feared physical sensations are ok to have—that it is safe to have a panic attack! I know, I know, you hate, dread, and are completely set on never feeling a panic attack again. That is why panic has so much power over over you (there is a saying—that which you resist, persists).

If your fear was of dogs and you wanted to get rid of this fear, you could not do it by avoiding dogs. You’d have to spend time around and interacting with one or more dogs. This could be something you do in an intense afternoon or gradually over several months of more gradual exposure (looking at dog pictures, driving by a dog park, etc.).

Occasionally someone with panic disorder will go into remission simply by understanding that what they are experiencing is safe, just like occasionally someone afraid to fly will get better by just reading safety statistics.  Most, however, will need to face the dreaded sensations themselves if they wish to get better.

This is where Interoceptive Cue Exposure (ICE) therapy comes in. The first step in ICE is the assessment. This involves a series of exercises designed to bring up various physical sensations such as increased heart rate, shortness of breath, dizziness, and more. Typically exercises will include activities such as:

  • Shaking head from side to side
  • Running in place
  • Spinning
  • Breath holding
  • Breathing through a small straw
  • Over-breathing

If you are doing thing with a therapist trained in ICE, they will guide you through each activity and then will want you to report which physical sensations were brought up by the exercise, degree of intensity and anxiety resulting from those sensations, and finally, the degree to which the exercise triggered similar sensations to what you feel during a panic attack. Based on the assessment outcome the therapist will work with you to design an exposure “hierarchy” of feared sensations and will then help you to repeat those exercises that triggered similar panic physical sensations in a gradual, controlled manner. You will then be asked to repeat daily between therapy sessions.

The aim is to get VERY familiar with these sensations and learn to not fight them or chase them away. With hard work and practice, the sensations tend to no longer shock or frighten and the theory that they will result in catastrophe gets disproven time and time again.  Then a wonderful thing happens: when you begin to experience panic sensations you know that they are safe and that you do not have to fight them. Coping and acceptance becomes second nature. As you allow the sensations to be there without fighting them, they tend to improve significantly for most people.

ICE therapy is considered state-of-the-art treatment for panic disorder. If you are looking for a therapist to treat your panic disorder, call them and ask, “Do you treat panic disorder with Interoceptive Cue Exposure therapy?” If the answer is “no” or “what is that???” then keep calling. WWW.adaa.org maintains a list of therapists with an anxiety treatment specialty. That’s a great place to start (after your MD rules out a medical problem, of course).

So, it’s ok. Have an uncomfortable day. It might be the key to a more comfortable future.

Eric Goodman, Ph.D.