Your Ultimate Interoceptive Exposure Therapy Guide

When fearful, we experience a range of physical sensations, including sweating, shaking, shortness of breath, and a pounding heart (McCabe & Milosevic, 2015).

One theory suggests that panic disorder is the outcome of sensitivity to such physical sensations and, as a result, can be treated by intentionally recreating them. Treating this vulnerability can be particularly valuable for clients who are overly sensitive to anxiety (Lee et al., 2006).

This article explores interoceptive exposure therapy, along with some real-life examples, and introduces exercises and worksheets to guide therapists and clients along the journey to a positive outcome.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free. These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

What Is Interoceptive Exposure in Therapy?

Interoceptive exposure therapy can be helpful in the treatment of panic and anxiety disorders and phobias.

“This technique involves the planned and predictable confrontation of one’s own feared object or situation” and intentionally exposes clients to the bodily sensations they typically experience at that time (McCabe & Milosevic, 2015, p. 138). They learn that while uncomfortable, such sensations are ultimately not harmful.

This approach is particularly helpful in treating clients who fear the physical sensations accompanying their panic, anxiety, or phobia more than the mental event itself. An essential part of the process involves understanding whether fear of the physical sensations plays a role in their phobia (McCabe & Milosevic, 2015).

Interoceptive exposure therapy attempts to recreate feared physical sensations through different exercises. Examples include:

• Spinning around on a swivel chair or turning your head from side to side to simulate feelings of dizziness or light-headedness
• Fast, shallow breathing to recreate a racing heart
• Running up stairs and experiencing being out of breath to simulate breathlessness

The above actions recreate sensations that often accompany phobias or panic and may be more feared than the object or event itself.

Interoceptive exposure vs in vivo exposure

“Exposure procedures have two forms: exposure to environmental situations that each person fears, termed in vivo exposure; and exposure to exercises that evoke the physical sensations associated with panic attacks” (Lee et al., 2006, p. 2).

For example, in vivo exposures may involve taking the client to an airport if they are frightened of flying or increasingly higher in a building if they are fearful of heights. On the other hand, interoceptive exposure focuses on recreating the sensations that accompany flying or heights, perhaps the noise of an airplane, changing pressure in the ears, or feelings of nausea.

Can it help with panic disorders?

Interoceptive exposure therapy has had considerable success with treating panic disorders. Theory suggests that panic disorder may be “conceptualized as a phobic fear of physical sensations caused by traumatic conditioning from unexpected panic attacks and catastrophic misinterpretation of physical sensations” (Lee et al., 2006, p. 2). This fear of the fear may be tackled head on by re-exposure to sensations causing discomfort.

4 Real-Life Examples

“Interoceptive exposures are often used with individuals who have specific phobias, especially when their fear is related to the physical sensations that are triggered when faced with the feared object or situation” (McCabe & Milosevic, 2015, p. 138). Here are some examples of such conditions.

Claustrophobia

An individual who experiences fear of small or enclosed spaces may find extreme discomfort in the physical sensation the situation brings about.

For example, hyperventilation (overly rapid and deep breathing, which is commonly associated with panic) may be perceived as a lack of air and even suffocation, leading to further terror.

Fear of heights

Those with a fear of heights often experience a feeling of weakness in their legs when they are high up. They may perceive such sensations as falling, further exacerbating their fear and increasing feelings of panic.

Injection phobias

A phobia of injections or having blood taken can be accompanied by light-headedness, a source of panic in itself. The fear associated with the symptom may be worse than the needle, event, or environment and spiral the experience out of control.

Post-traumatic stress disorder (PTSD)

PTSD is closely linked to anxiety sensitivity and may enhance symptoms of hyperarousal and hypervigilance. Perhaps unsurprisingly, interoceptive exposure therapy has proven helpful in treating even those PTSD patients with treatment-resistant symptoms (Boettcher, Brake, & Barlow, 2016).

6 Proven Benefits of Interoceptive Exposure

Repeated exposure to physical sensations is a successful treatment plan for clients with anxiety disorders and phobia. Interoceptive exposure therapy offers several benefits, including (Lee et al., 2006; McCabe & Milosevic, 2015):

• “Habituation of anxiety in patients with panic disorder” (Lee et al., 2006, p. 2).
• The practice provides evidence against the belief that physical sensations associated with fear and panic are dangerous.
• Repeatedly practicing interoceptive exposure leads clients to become familiar and even accustomed to their sensations.
• Therapy can be planned, repeated, and is largely predictable.
• The treatments are controllable; the degree of exposure can be managed and reduced as needed, especially when the client is reluctant.
• Exercises can be repeated at home without the need for specialist treatment.

In the future, interoceptive exposure therapy may prove successful in treating other conditions, including depression, eating disorders, and low self-esteem (Boettcher et al., 2016).

How to Do Interoceptive Exposure: A Guide

There are many different exercises to bring on the physical sensations feared by the client; it is, therefore, crucial to understand the client and their experience of their phobia or the nature of their panic (McCabe & Milosevic, 2015).

Treatment process

• Step one:
  The therapist must identify which interoceptive exposures will be most helpful in treatment.

Often the treatment begins by inducing a series of different physical sensations and noticing which ones produce the most significant fear or are most similar to those that result from the phobic situation.

• Step two:
  Build a hierarchy of interoceptive exposure practices; they should be ranked from least to most anxiety provoking and discussed with the client. Then work through the list in the order agreed.
• Step three:
  The client needs to practice interoceptive exposure exercises, beginning with practices that invoke a minor reaction. Once these have been mastered, the client will work their way up, finishing with the most reactive techniques.

A gradual, increasingly challenging approach appears most successful with clients, especially those who are reluctant to engage in more impactful practices and are at risk of dropping out (McCabe & Milosevic, 2015).

McCabe and Milosevic (2015) also offer some valuable guidelines that should be reflected in both the design and performance of interoceptive exposure therapy practices.

Exposures should:

• Be planned and predictable (the client retains control)
• Be performed frequently (most likely, daily)
• Lead the client to experience anxiety
• Encourage clients to refrain from avoidance strategies (using distraction, alcohol, etc.)
• Enable clients to stay in the anxiety-provoking space until it decreases
• Be practiced in multiple situations to generalize its effect
• Set the client up for success, not failure

“Through repeated practice, people eventually become accustomed to their sensations” (McCabe & Milosevic, 2015, p. 139).

Typical treatments

Interoceptive exposure procedures began by tackling phobias and panic anxiety using biochemical substances, including caffeine, lactate infusions, and even carbon dioxide inhalation; now, more typically, therapists use a selection of the following methods (Boettcher et al., 2016):

Breathing

• Overbreathing, involving fast and deep breathing
• Breathing through a straw while holding your nose
• Holding your breath

Shaking and spinning

• Spinning on a swivel chair with eyes open or closed
• Shaking the head from side to side, then focusing on something straight ahead

Physical exercise

• Running in place, up the stairs, or stepping up onto a low bench
• Muscle tensing – one muscle group at a time or the whole body

Head rush

• Placing your head between your legs then sitting up quickly

All of these exercises can be used by the therapist and practiced by the client to provoke or induce feelings associated with panic or anxiety (Boettcher et al., 2016).

6 Worksheets & Exercises for Your Sessions

Interoceptive techniques often focus on “reproducing sensations from one of the four somatic domains typically reported by patients having panic attacks” (Boettcher et al., 2016, p. 5), including the following:

• Cardiovascular sensations, including racing heart
• Audiovestibular sensations, including dizziness
• Respiratory sensations, including shortness of breath
• Dissociative sensations, including depersonalization and derealization

Therapists and researchers continue to explore other techniques and practices to provoke the sensations clients experience during panic or in connection with phobias.

The following therapy worksheets can help identify and focus on helpful interoceptive exposure techniques.

Understanding Your Anxiety and Triggers

Anxiety, panic, and the fear of the sensations accompanying them can lead people to avoid the situations they believe will trigger those feelings.

The Understanding Your Anxiety and Triggers worksheet helps clients identify which anxiety triggers lead to avoidance and require focus during interoceptive exposure therapy.

The client is asked to identify five triggers and ask themselves the following questions:

Am I avoiding any of these triggers because of my anxiety?
Are there occasions when I experience the triggers and react in ways I don’t want?

Therapy provides an opportunity to work on these triggers, reduce their impact, and allow the client to continue their life as they wish.

Understanding the Severity of the Panic Disorder

While planning to use interoceptive exposure to treat panic disorder, it is essential to understand its severity and frequency.

The Understanding the Severity of the Panic Disorder worksheet can track the impact of the client’s panic disorder between sessions.

The following is a typical list of symptoms often experienced during a panic attack (Ehrenreich, Mattis, & Pincus, 2008).

• Rapid heart rate
• Feeling of choking
• Numbness or tingling of muscles or skin
• Sweating
• Trembling
• Breathlessness
• Nausea
• Dizziness
• Feelings of unreality or “going crazy”
• Fear of dying

Experiencing two or more of these symptoms may indicate a panic attack.

Fear Hierarchy

Understanding the activities that cause fear, anxiety, and panic helps target appropriate interoceptive exposure therapy treatment.

The Fear Hierarchy worksheet considers several situations or activities that may induce fear.

For example:

• Going on vacation
• Going shopping
• Going to work
• Giving a presentation
• Going on a date
• Meeting friends
• Meeting new people
• Walking into a busy room

The negative sensations you experience are the ones you will need to focus on as part of interoceptive exposure therapy (Lee et al., 2006; McCabe & Milosevic, 2015).

Developing Interoceptive Exposure Therapy Interventions

As several interoceptive exposure techniques are available, therapists must first identify the sensations they need to recreate (McCabe & Milosevic, 2015).

The Developing Interoceptive Exposure Therapy Interventions worksheet considers the phobia or panic attack and explores the sensations that the therapist needs to address.

Work through the questions with the client. You may revisit the worksheet several times as understandings grow and you identify helpful practices.

Consider using the following techniques and record those that recreate the targeted sensations:

• Hyperventilating
• Breathing through a straw
• Running in place and stepping up onto a low bench
• Muscle tensing
• Spinning
• Head shaking

Create a plan to try out these techniques, starting with the least reactive practices. Only once the client has mastered them should you move on to more difficult ones.

Interoceptive Exposure Therapy Practices

“Interoceptive exposures involve using different types of exercises to bring on feared physical sensations” (McCabe & Milosevic, 2015, p. 138).

The Interoceptive Exposure Therapy Practices worksheet introduces the client to three simple practices that they can try in the session or at home:

• Breathing:
  Shallow breathing at a rate of 100–130 breaths per minute.
• Dizziness:
  Spinning around on a swivel chair (eyes closed if it helps).
• Too much warmth:
  Wearing multiple layers of clothing in a warm house, sitting in a car that’s too hot, or spending time in a sauna.

Each practice tests the client’s ability to deal with discomfort regarding the sensations they may experience when panicking or reacting to a phobia.

Therapist Interoceptive Exposure Record

It is essential to keep track of the outcome of interoceptive exposure treatments to identify what is appropriate and understand their effectiveness (Ehrenreich et al., 2008).

The Therapist Interoceptive Exposure Record helps the therapist log and track interoceptive exposure interventions.

Resources From PositivePsychology.com

Interoceptive exposure techniques bring on internal physical sensations to help clients learn how to manage fear, anxiety, and phobias.

We also have plenty of other techniques available to help clients cope with stress, anxiety, and panic.

Why not download our free stress and burnout prevention exercises pack and try out the powerful tools contained within? Here are some examples:

• Energy Management Audit
  This checklist is designed to provide insights into the individual’s energy strengths and deficits that can leave the client ready for the day ahead or stressed, respectively.
• The Stress-Related Growth Scale
  This powerful questionnaire was built to assess and reveal the individual’s perceived positive outcomes from a stressful or traumatic event.

Other free resources include:

• Interoceptive Exposure
  Learn the steps involved in multiple interoceptive exposure therapy exercises and become aware of the thoughts and physical symptoms that accompany each.
• STOP the Panic
  The STOP acronym offers a useful way to manage feelings and thoughts in the moment and regain a state of calm.

More extensive versions of the following tools are available with a subscription to the Positive Psychology Toolkit©, but they are described briefly below:

• The Acceptance or Avoidance Route
  Acceptance and Commitment Therapy helps clients live in line with their values. This exercise promotes acceptance of emotions by comparing acceptance-based coping and avoidance-based coping.

Use the tool to remind yourself how it is possible to take action despite the fear you are experiencing.

• Leaving the Comfort Zone
  Entering discomfort can be scary and yet can be a way to experience new things and develop resilience.
  • Step one – Start by considering the difference between comfort, fear, learning, and growth zones.
  • Step two – Work through an example to see how entering each zone can shape how you think and behave.
  • Step three – Think of an existing situation in which you are firmly in your comfort zone.
  • Step four – Consider how you would feel if you moved out of your comfort zone into the learning and growth zones.
• 17 Positive Psychology Exercises
  If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

A Take-Home Message

Experiencing panic and phobias can be distressing, limiting our ability and capacity to interact with our environment and friends and set appropriate goals. And yet, the fear they generate may not be focused on the events or activities themselves, but on the sensations accompanying them.

Interoceptive exposure therapy takes a unique approach, bringing on internal physical sensations to help clients learn how to manage fear, anxiety, or phobia. This unique method tackles the senses directly, rather than targeting thoughts and beliefs regarding the event or activity.

It may not be the fear of starting a new job or concerns regarding social occasions that need to be addressed, but rather the physical sensations experienced.

Interoceptive exposure engages the client directly in the overwhelming sensations that appear when they experience phobia or panic. Therapists can use these techniques on their own or with other therapeutic approaches to help the client handle situations that keep them from living a full and happy life.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.