Judith S. Beck, PhD and Norman Cotterell, PhD

Pam, a retired home health aide, asked her family to bring her to the emergency room when she experienced a panic attack, characterized by a racing heart, lightheadedness, and shortness of breath. She had experienced similar, though slightly less severe symptoms in the past, when she was in a situation or place where there was no easy exit. Her symptoms always decreased once she left. But this time, because she stayed in a supermarket for a longer period of time, the symptoms became more severe. This time she believed her symptoms meant that she was definitely having a heart attack.  She believed that had she not immediately left the supermarket when her symptoms became very strong, she would have died.

When a doctor at the emergency room reassured her that tests had shown her heart was healthy, Pam didn’t believe him. She thought the doctor must have missed something important when he evaluated her. She still maintained the belief that her symptoms were due to some medically pathological condition that he had failed to diagnose. Fortunately, despite her misgivings, Pam was willing to go for therapy.

Panic and intense anxiety can be terrifying and individuals can misinterpret their symptoms. They often fear they are losing control, going crazy, or about to faint or die. The last thing they want to do is to deliberately bring on their intense anxious symptoms. But just telling clients that their symptoms, while very uncomfortable and unpleasant, are not dangerous may not convince them—as indeed Pam was not convinced. They need to deliberately expose themselves to the symptoms without doing anything to reduce their severity, so they can see for themselves that no matter how intense their anxious symptoms get, their feared consequence does not happen. How do they do that? By engaging in exposure exercises and drawing conclusions about these experiences.

But the first step is asking clients about their values and aspirations, reminders of which can help motivate them to use exposure techniques to overcome their panic. The second step is to do psychoeducation. I asked Pam to describe the terrifying supermarket experience. She told me that shopping at supermarkets (and going to a number of other places as well) had become more and more difficult for her. While her anxiety was mild to moderate before she even arrived, it felt manageable. But the further she got from the exit, the more anxious she became. She coped by rushing through the aisles that were furthest from the door and always felt a strong sense of relief when she left the building. During her final trip to the supermarket (just before going to the ER), Pam noticed how long the check-out lines were. She had thoughts such as:

  • What if I get more anxious?
  • What if my heart starts racing?
  • What if I want to leave? But I can’t, I promised [my sister] that I would bring Mom’s birthday cake to dinner tonight.

Pam raced through the store, holding tight to the shopping cart, and buying only the essentials. She noticed how tight her chest felt and how fast her heart was beating. She got in the shortest check-out line but there were several people ahead of her. The lines to her right and left were long. She noticed that her symptoms had become more intense, and she had some additional thoughts:

  • I want to leave, but I can’t. I promised [my sister]!
  • I’m trapped! I can’t just leave the cart here. What will everyone think?”

Then her symptoms intensified. Her high anxiety had turned into a panic attack, and she fled the store without buying the groceries.

Next, I mapped out the sequence of events Pam had described, and I made sure I was correct.  I helped her see that her thoughts about being far from the exit had led to physiological symptoms of anxiety. Then her thoughts about these symptoms and being trapped led to an intense exacerbation of these symptoms. When the symptoms reached their peak, she made a catastrophic misinterpretation:

  • This [racing heart, tightness in chest, lightheadedness] means I’m having a heart attack!

This thought kept the symptoms at their most intense level. I explained the cycle of anxious thoughts and bodily reactions. This explanation helped Pam understand intellectually that she hadn’t been in danger, but she didn’t really believe that at an emotional or gut level. She needed the next step in treatment: exposure. Exposure techniques involve the deliberate decision by our clients to do what they fear, motivated by their desire to engage in valued actions to enrich their lives. (When clients are still reluctant, we might look at the advantages and disadvantages of engaging in the following exposure exercise and tying the exposure to their aspirations and values.)

I asked Pam if it was okay to have her breathe deeply and quickly to see if she could reproduce her panic symptoms so I could get a better idea of what she was dealing with. She agreed. We both breathed in and out at a deep level. Every ten seconds or so, I encouraged Pam to keep going: “That’s great. Keep it up!” I also asked her not to do anything to try to lessen her symptoms. After two minutes, I asked her to stop and to tell me how close that was to a panic attack. She said it was very much like the panic attack she had had in the supermarket, though somewhat less severe because I was in the room doing deep breathing along with her. She thought it would have been closer to an actual panic attack had I not been in the room with her. She drew the following conclusions:

  • Deep breathing brought on all the same symptoms as the panic attack.
  • The symptoms weren’t dangerous.
  • The symptoms must be happening because I’m anxious, not because I’m in danger of having a heart attack.
  • The symptoms feel scary, but they don’t mean I’m in any danger.
  • If I have these symptoms in the future, it’s very likely that they are happening because I’m experiencing high anxiety.
  • I don’t need to worry about these symptoms.
  • I should start doing things that I’ve been avoiding, especially when they’re important to me.

Next, I reviewed Pam’s values and aspirations with her. Then we discussed how panic and anxiety had led her to narrow her life. We listed places where Pam wanted to be able to go and linked these potential experiences to her values and aspirations. Each week, Pam chose steps she wanted to take in the coming week, in line with her aspirations and values. After six weeks of treatment, Pam had resumed all her prior activities with minimal anxiety.

Unfortunately, some therapists themselves fear doing exposure work with their clients, especially the interoceptive exposure that I had done with Pam. Blakey and Abramowitz (2016) reported on a survey of 66 therapists which assessed their fears of using interoceptive exposure with their clients. They predicted, on average:

  • 54.9% likelihood that their clients would prematurely stop the exposure.
  • 37.1% likelihood that they would drop out of therapy.
  • 22.2% likelihood that the client’s anxiety would become so high that they would de-compensate during the session.
  • 17.9% likelihood that the symptoms would worsen.

In actuality, the fears were not grounded. Out of 6,545 clients, only 1.4% found exposure too aversive and dropped out, and 99.4% had no negative outcome.

Panic had made Pam feel that the price of freedom was too high. CBT allowed her to test her beliefs, cut short the escalating cycle of anxious thoughts and related sensations, and resume her life.  

References:

Blakey, S. M. & Abramowitz, J. S. (2016). Interoceptive Exposure: An Underused Weapon in the Arsenal against OCD [PowerPoint Slides]. University of North Carolina at Chapel Hill.