Exposure Therapy for Panic Disorder

Adults with panic disorder are typically sensitive to physical sensations such as increased heart rate, stomachache or chest pain. Although we know that these sensations are harmless and are in fact the body’s natural reaction to perceived threat or danger, over time, individuals with panic disorder become afraid of these sensations. They may misinterpret these sensations as indicating there is something very wrong with them, such as a heart attack or an underlying illness*. As a result, these individuals start to avoid locations or activities in which they believe they are at risk of experiencing their feared sensations, or purposely doing things they think will protect them, like never leaving home without a phone, or using slow breathing to prevent a panic attack. Consequently, life can become quite restrictive. In order to overcome panic, you must repeatedly generate these sensations in a safe setting to learn that your fears do not come true (for example, you don’t pass out, and you’re capable of coping with the sensations). In doing so, you will eventually discover that your physical sensations no longer make you anxious. For many, this plan sounds counterintuitive since the recommendation is to have you experience the very symptoms you fear more not less. However, this intervention is well supported by many scientific studies and is safe for children and adults of all ages.

*Note: it is important that you are sure you are healthy before you embark on anxiety sensitivity exposure exercises. There are a select few medical conditions that mimic the symptoms of a panic attack, and thus having a brief medical assessment may be indicated.

Engaging in Panic Attack Exposures in 3 Steps

Step 1

Using the following list of exercises, try each exercise to determine those that activate your feared sensations. All exercises should create some physical sensations such as increased heart rate, rapid breathing and dizziness, among others (see examples in parentheses after each exercise). With some exercises you will experience no fear, while others will produce significant fear. You can rate each exercise using a 0-10 scale, with 0 meaning no fear of the sensations at all, and 10 being the highest level of fear of the sensations.

Exposure exercises:

  • Running on the spot for 30 - 60 seconds (racing heart, breathlessness, chest discomfort).
  • Running up and down stairs for 30 - 60 seconds (racing heart, breathlessness, chest discomfort).
  • Rapid breathing. Agree ahead of time on a length of time that your child can repeatedly perform it with minimal anxiety. Then, try increasing it by 15 seconds, up to a maximum of 2 minutes for teens and 1 minute for children (dizziness, breathlessness, racing heart, numbness and tingling).
  • Breathe in and out through a small straw for 30 - 60 seconds while pinching nostrils (choking sensations, breathlessness, racing heart).
  • Shaking head from side to side, or moving head around by rotating our head in a circular motion for 30 seconds (dizziness).
  • Spinning around in place or spinning in a chair for 30 seconds (dizziness, nausea).
  • Hold breath for 15 - 30 seconds (breathlessness, dizziness).
  • Stare at your hand for 2 - 3 minutes (feelings of unreality – things looking and seeming weird).
  • Stare at a light on the ceiling for 1 minute and then try and read something (blurred vision).
  • Wear a tight turtleneck or scarf around your neck for a few minutes (tightness in the throat).  

Step 2

Once you have created a list of exercises that create anxiety, you will begin with the exercise that is the least scary, and build up to the more scary exercises. Each exercise can be broken up into smaller steps if necessary (e.g. start with running on the spot for 30 seconds, then 45 seconds, and finally 1 minute). Continue the exercise until you start to feel the feared sensations, and then stay with these sensations rather than escape. You can remind yourself that these sensations reflect the body’s natural reaction to reduced oxygen, or that these sensations are a normal part of the fight-flight-freeze response system. The goal is to “ride along” with these sensations rather than to eliminate them, and to learn to cope with and tolerate the sensations. While doing the exercises, rate your anxiety level using the 0-10 scale. Repeat the exercise until your anxiety drops by about half (for example, if your rating is a 6, repeat the exercise until you experience a 3), or is noticeably lower than it was at the start. Focus on one exercise at a time. Once you experience very little anxiety when completing that exercise on several different occasions, move onto the next one. It is optimal for practices to be planned in advance and done on a daily basis. The more you practice, the faster your fear will decrease.

Remember: The goal is to let yourself feel the feelings - Don’t fight them! These sensations are NOT dangerous. In fact, before you started having panic attacks, you may have even sought out activities that produced these sensations. For example, going jogging and having your heart rate and breathing increase, riding a roller coaster and feeling dizzy or nauseated, or sitting in a sauna and feeling warm and sweaty.

Step 3

Once you have become skilled in tolerating these physical sensations without fear or avoidance, it will be important for you to start entering situations that you have been avoiding due to fears of having panic attacks. First, identify feared situations or places (e.g. going places alone, entering crowded stores, riding the bus). Then, arrange the list from the least scary to the most scary.  Starting with the situation that causes the least anxiety, repeatedly enter the situation and remain there until your anxiety decreases. Once you can enter that situation without experiencing much anxiety (on numerous occasions), move on to the next thing on the list. Remember, you will experience anxiety when facing fears -this is normal. For more information, see Facing Your Fears – Exposure.

It will also be important to start eliminating various “safety behaviours” and subtle ways you avoid. These behaviours include carrying safety objects (e.g. medication, water, cell phone), sitting near exits, using distraction (as a means to avoid feeling anxious), avoiding certain foods (spicy dishes) or beverages (caffeine or alcohol), constantly seeking reassurance from others, or being accompanied by a trusted companion.  First, make a list of your safety behaviours.  Second, try to gradually reduce these behaviours, starting with the ones that are easiest to drop.