Core intervention: Interoceptive exposure

What is interoceptieve exposure?

Interoceptive exposure is a form of behavioural exposure used in the treatment of anxiety disorders such as panic disorder and illness anxiety disorder with cognitive-behavioural therapy. During interoceptive exposure, your client engages in a series of behavioural exercises that simulate physiological and psychological symptoms experienced during a panic attack. Anxious and often catastrophic beliefs about bodily sensations play a significant role in maintaining such issues. During exposure, the client will learn that their anxious expectations do not come true, creating the intended behavioural mismatch. By simulating an increased heart rate, a client learns that the elevated heart rate will not lead to a heart attack. Through repetition of these exercises, new behavioural beliefs gain credibility.

When and how to conduct interoceptieve exposure?
 

1. To prepare for the session, send the article on the panic vicious cycle and, if applicable, the articles on exposure and interoceptive exposure.
2. Begin by explaining the relationship between anxiety and avoidance, so that your client understands why they need to actively confront the fearful situation.
3. Thoroughly identify the bodily sensations that your client finds distressing. Also, establish the key "if-then" expectations. For example, "If I experience these feelings, I will have a heart attack."
4. Next, during the session, you will engage in interoceptive exposure exercises together. This serves as both motivational and supportive, and it is helpful for the client to observe your (healthy) response.
5. Reflect on the exercises and assess whether the "if-then" expectation has been realized. Then, make arrangements for the client to practice independently. It is preferable to practice as much as possible, with a guideline of three times a day.

Clients may have a tendency to avoid the exercises or even you and the therapy itself. Therefore, it can be beneficial to address this issue early on in the discussions.
 

How do you enhance the effectiveness of interoceptive exposure?

There are three important conditions for effective exposure: challenging anxious expectations, independence from context, and stress tolerance. The following strategies can be employed to optimize the effectiveness of exposure:

• Debunking the if-then expectation: It is important that the exposure exercise thoroughly debunks the feared if-then outcome, creating the largest possible discrepancy between the anxious expectation and the actual outcome. Formulate a logical and testable if-then expectation (e.g., not "I will have a panic attack," but "I will die").
• Deepened extinction: By combining different exercises, you can further decrease anxiety. For example, first perform an exercise for dizziness and immediately follow it with hyperventilation.
• Intermittent reinforced extinction: Encourage your client to seek out the feared consequences occasionally. Clients can learn a lot from experiencing a panic attack, such as realizing they can tolerate it even if it happens in public.
• Reduction of safety behaviors (response prevention): Safety behaviors limit inhibitory learning because they provide alternative explanations for the absence of the feared consequences. For instance, the absence of a panic attack in a supermarket can be attributed to carrying a water bottle.
• Variation in context and difficulty: Conduct exposure exercises in a wide range of internal and external contexts (e.g., practicing in different moods, locations, days, and times). A diversity of new experiences enhances the generalization of the learning effect. You can make interoceptive exposure more challenging by, for example, performing the exercises after having two cups of coffee or while on a train.
   

Sources:

1. Hofmann, S.G. & Smits, J.A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621-632. http://dx.doi.org/10.4088/JCP.v69n0415
2. Norton, P.J. & Price, E.C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease, 195, 521-531.
3. https://www.vgct.nl/vgct.nl/public/over-cgt/factsheets/factsheet-exposuretherapie-nieuwe-inzichten 
4. https://www.vgct.nl/themas/angststoornissen/de-nieuwe-inzichten-over-exposure-wat-moet-je-nu-anders-doen-als-cgter
5. Rijkeboer, M.M. & Van den Hout, M.A. (2014). Nieuwe inzichten over exposure. Gedragstherapie, 4(1), 2-19
6. Craske, M. G, Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B, (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy (58), 10-23.
7. https://www.psyxpert.nl/tijdschrift/editie/artikel/t/vermijdingsgedrag-veiligheidsgedrag-en-veilig-gedrag-bij-exposure-in-vivo#:~:text=Exposure%20in%20vivo%20en%20responspreventie,-Cognitieve%20gedragstherapie%20is&text=Exposure%20in%20vivo%20is%20de,ervaart%20dat%20het%20gevreesde%20uitblijft.
8. https://www.ggzstandaarden.nl/zorgstandaarden/angstklachten-en-angststoornissen