Interoceptive Exposure: How To Use It To Manage Anxiety

I’m a big fan of exposure therapy, having used graded exposure on myself to treat my anxiety-induced psychosis. So when I heard about interoceptive exposure, I was keen to find out more, and when I did, I was keen to share what I learnt with you, my readers. Interoceptive exposure is another tool to help overcome certain anxieties and phobias, so I hope you enjoy learning about this method.

 

 

Graded Exposure

 

Some of you might be familiar with exposure techniques, such as the cue exposure method of cognitive behaviour therapies (CBT) graded exposure, but some of you might not be. A couple of years back, I created a graded exposure workbook which you can find in my Resources section (free version. A paid version can also be found in my shop) of my website. For those who aren’t familiar, exposure techniques all follow a similar concept. To get used to the things you fear through incremental exposure to those fears.

 

With graded exposure, you’d work out what your fears are and then work out a step-by-step plan to tackle them. For example, if you had a fear of spiders, you would create a spider exposure list, with the worst fear being the last step. This could look something like this:

 

• Step one – look at a drawing of a spider.
• Step two – look at a photo of a spider.
• Step three – look at a video of a spider.
• Step four – be in the same room as a spider that’s in a case.
• Step five – have someone handle a spider near you.
• Step six – have the spider physically touch you, such as having it placed on your arm or holding it in your hands.

 

You’d go through each step one at a time, only moving on when the fear caused by each step lessons so that you become comfortable at that step. Then, when that happens, you move to the next step and so on, until the graded exposure plan has been completed.

 

However, not all irrational fears can be tackled with a cue exposure method, such as graded exposure. For conditions such as emetophobia (a fear of vomiting, seeing vomit, seeing or hearing other people vomit, or even just feeling sick), you may find the problematic symptoms are internal body sensations, rather than anything external.

 

If you’re familiar with my anxiety disorders and how they cause me to have psychosis, then you’d also be familiar with the strange bodily sensations and the fear they cause that I have to deal with. My fear is centred around a fear of embarrassing myself by losing bladder or bowel control. Because of this, I became hypersensitive to my bodily sensations, and this is where interoceptive exposure can be useful.

 

 

Interoceptive Exposure

 

Exposure procedures come in two forms, according to Lee et al. (2006): exposure to environmental situations that evoke fear, termed in vivo exposure (graded exposure is an example of this); and exposure to exercises that mimic the physical sensations associated with their fears (e.g. hyperventilation, shaking head, and body tension), termed interoceptive exposure.

 

Interoceptive exposure is another CBT method that is used to bring out the physical sensations of your panic disorder or phobia, using exercises to break the conditioned response. A conditioned response is a learned response to a thing that evokes a reaction where there used to be none (ThoughtCo).

 

According to one theoretical perspective on panic disorders, the central component of it is hypersensitivity to physical sensations (Lee et al., 2006). I hadn’t thought about my anxieties disorders being a panic disorder, but if this perspective is used in a clinical practice, then I believe I would have been diagnosed as having it.

 

For me, the stories I heard of people being so wasted and thought they were in the bathroom going to the toilet, but really they weren’t. Instead, they were peeing into a cupboard or wetting themselves. I heard a lot of stories like this in my social circle at the time. This, coupled with my psychosis, created a fear that I wasn’t aware of my true reality, and boom, I could no longer trust my senses or bodily sensations.

 

Unlike me, who would experience these bodily sensations almost 24/7 for 15 years until they subsided, other people will have to find exercises to mimic the sensations. You then use these exercises to create the same sensations and feelings so that you can overcome them. The exercises allow you to gain experience of having the feared sensations in a safe environment and seeing that nothing bad follows (Barrera, Grubbs, Kunik, and Teng, 2014), thus breaking the conditioned response.

 

 

The Three Bs Of Interoceptive Exposure

 

The three Bs, body, belief, and behaviour is a simple way to show how someone might suffer and thus benefit from interoceptive exposure. I came across the three Bs at the Beck Institute, so all thanks go to them.

 

Body as expressed in physical sensations

For me, with my issues, it was:

• A tingling in the genitals, anus, and everywhere between my knees and my belly button.
• Gastrointestinal distress.
• Hot flashes.
• A crawling and scratching sensation between my knees and my belly button.
• A sense of feeling wet when I wasn’t.

 

Belief as expressed in thoughts

• Have I wet myself?
• Have I lost bowel control?
• Is that smell coming from me?
• Why do I feel wet when I’m not?
• It’s too much.
• What’s wrong with me?

 

Behaviour as expressed in urges

I was constantly distracted by urges to:

• Check myself by touching my jeans around the groin to see if I’d wet myself.
• I’d seek reassurance by asking my partner if they can smell anything nasty and got a referral to a urologist.
• I avoided going outside unless I had to, or I was intoxicated.
• I engaged in safety behaviours, such as constantly checking to see if I was wet, going to the bathroom a lot to empty my bladder as much as possible, avoiding drinking liquids, and challenging my thoughts.

 

Once you know your three Bs, this will help you create alternative exercises to mimic your bodily sensations so you can beat your beliefs and stop engaging in your safety behaviours. Once you can do that, it is truly life-changing.

 

 

Support For Interoceptive Exposure

 

A study by Craske et al. (2011) sort to see if interoceptive exposure could help people with irritable bowel syndrome (IBS). Previous approaches were based on the assumption that stress or anxiety played a key role in IBS, increasing the symptoms. Therefore, they wanted to test an interoceptive exposure treatment against stress management and attention control treatments in managing IBS symptoms. 110 participants took part in the study and were randomly assigned to 10 sessions of one of the three treatments.

 

The results of Craske et al. (2011) study showed that the interoceptive exposure treatment outperformed both stress management and attention control treatments in several domains. Thus, showing that interoceptive exposure can be an effective treatment for IBS.

 

A study by Lee et al. (2006) used nine interoceptive exposure exercises (hyperventilation, shaking your head, putting the head between the legs, step-ups, holding breath, body tension, spinning, breathing through a straw, and chest breathing) to reproduce various fears. The study found that of the nine exercises, ‘hyperventilation’, ‘holding breath’, ‘spinning’, and ‘chest breathing’ were found to have a significant effect in reducing the fears of physical sensations experienced by participants with panic disorders.

 

Originally, interoceptive exposure was thought to be a method exclusively used for the treatment of panic disorders. However, according to Boswell el al. (2013), recent research has shown that interoceptive exposure can be a useful intervention for people with and without panic. Their own study of 54 participants also supports this broadening of uses for interoceptive exposure.

 

 

Interoceptive Exposure Exercises

 

By using interoceptive exposure exercises, we can trigger the physiological sensations systematically and mimic the sensations experienced during anxiety or a panic attack, allowing us to reduce the fear associated with those sensations (Barrera, Grubbs, Kunik, and Teng, 2014).

 

Step-by-step guide

If you were going to a therapist to do this, then you’d go through a sequence of steps similar to the one outlined by Psych Central.

 

• A therapist would start off by encouraging you to talk about how your anxiety affects you and how it makes you feel.
• You’d then discuss what physical sensations you experience that is triggered by your anxiety or can cause your anxiety to be triggered. For example, someone with emetophobia might be triggered by strange feelings in their digestive system, like butterflies in their stomach.
• Then you’d work on recreating the physical sensations by devising interoceptive exposure exercises.
• Your therapist would then guide you through these interoceptive exposure exercises.
• Eventually, in your mind, the link between the physical sensations and your anxiety/fear will become undone. But to do this, prolonged exposure to the sensations is important. In short, you won’t overcome this by doing the interoceptive exposure exercises twice.
• It’s also important to note that if you stop the exercises before they’re finished, then you’re engaging in avoidance. If an exercise is too hard, then tweak it so it’s a more realistic exercise, just don’t give up on it.
• When ready, you can then shift to situational exposure. This will mean doing the interoceptive exposure exercises in a real-world setting.

 

 

Exercises

According to Psych Central, if your anxiety causes you shortness of breath, causing you to associate fast breathing with fear and losing control, then a rapid breathing exercise would help. Thus, breathing rapidly for one minute could be one of your interoceptive exposure exercises. The Beck Institute also states that this can help with mimicking derealization and tingling appendages.

 

Barrera, Grubbs, Kunik, and Teng (2014) provided us with a couple of interoceptive exposure exercises which are to run on the spot to create a rapid heartbeat. The other one was to breathe through a straw to mimic laboured breathing. According to the Beck Institute, this can also mimic a tight chest, breathlessness, and hot flashes.

 

Another example of an interoceptive exposure exercise by Psych Central and Barrera, Grubbs, Kunik, and Teng (2014) could be to spin in an office chair for a minute to mimic sensations of dizziness. You could use this exercise if you had concerns about losing your balance and falling.

 

There are also the following exercise examples that the Beck Institute listed which you can do for between 30-60 seconds:

 

• Sharking your head from side to side mimics dizziness and headaches.
• Swallowing 10 times quickly to mimic a tight throat, breathlessness, and a dry mouth.
• Placing your head between your legs creates a feeling of disorientation and nausea.
• Hold your breath to create a feeling of light-headedness.

 

If I was to apply this to the physical symptoms of my anxiety disorders and psychosis, I could try wearing wet underwear or spraying my clothes with water. I could also try making myself hot and sweaty or lightly scratching my legs with something. All three exercises would mimic my physical symptoms that can cause my anxiety disorders to escalate and thus trigger my psychosis.

 

As many of you might know, I have IBS, and if you didn’t know before, you do now. Anxiety disorders, such as how mine affect me, can come with hypersensitivity and hypervigilance to bodily sensations. People with panic disorders and other forms of anxiety can also develop this annoying quirk. In extreme cases, the hypersensitivity and hypervigilance problem can cause IBS or vice versa (IBS cause anxiety about bodily sensations).

 

Craske et al. (2011) study into how interoceptive exposure treatment could help with IBS, created several exercises that could mimic the bodily sensations. These exercises were:

 

• Tightening the stomach to produce gut sensations. So you’d suck your gut in and out or hold your stomach sucked in.
• Wearing tight clothing.
• Delaying entrance to the toilet.
• Eating feared/avoided foods.

 

Taking these exercises to a real-world setting could mean going on a long road trip, eating at restaurants, and going places where you don’t know where the toilets are.

 

Unfortunately, my IBS doesn’t really work like that. My IBS flares up in response to drinking too much acidic drinks, alcohol, or spicy foods. So, although the above exercises might work for some people with IBS, they won’t work for me. Which sucks.

 

Obviously, not every exercise will have the desired effect, but with some trial and error, you’ll be able to find the ones that mimic your symptoms. Then you’ll be able to tackle your fears and anxieties that have connections to physical symptoms.

 

 

Summary

 

When I first came across the concept of interoceptive exposure, I was at a loss for what exercises you could do to mimic bodily sensations. But after reading more about it, especially after seeing some exercises others had created, it made a lot more sense, and I could create my list of exercises.

 

Working in much the same way graded exposure does for external triggers, interoceptive exposure allows you to apply a similar method to tackle internal triggers. Interoceptive exposure offers an exciting internal way to manage some aspects of anxiety and panic disorders, even IBS and psychosis. This makes it a great new tool to add to your treatment toolbox.

 

Before you try out any of these exercises, discuss any potential health issues that might make doing the exercises a bad idea. You might not want to do any of the breathing exercises if you have a condition like asthma or want to spin around if you’re heavily pregnant.

 

As always, leave your feedback in the comments section below. Also, please share your experiences of interoceptive exposure, anxiety, and phobias in the comments section below as well. Don’t forget, if you want to stay up-to-date with my blog, then sign up for my newsletter below. Alternatively, get push notifications for new articles by clicking the red bell icon in the bottom right corner.

 

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References

Barrera, T. L., Grubbs, K. M., Kunik, M. E., & Teng, E. J. (2014). A review of cognitive behavioral therapy for panic disorder in patients with chronic obstructive pulmonary disease: the rationale for interoceptive exposure. Journal of Clinical Psychology in Medical Settings, 21(2), 144-154. Retrieved from https://www.researchgate.net/profile/Terri-Fletcher-2/publication/261373560_A_Review_of_Cognitive_Behavioral_Therapy_for_Panic_Disorder_in_Patients_with_Chronic_Obstructive_Pulmonary_Disease_The_Rationale_for_Interoceptive_Exposure/links/55818a7f08ae6cf036c168e1/A-Review-of-Cognitive-Behavioral-Therapy-for-Panic-Disorder-in-Patients-with-Chronic-Obstructive-Pulmonary-Disease-The-Rationale-for-Interoceptive-Exposure.pdf and https://link.springer.com/article/10.1007/s10880-014-9393-4.

Boswell, J. F., Farchione, T. J., Sauer-Zavala, S., Murray, H. W., Fortune, M. R., & Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A transdiagnostic construct and change strategy. Behavior therapy, 44(3), 417-431. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3727659 and https://dx.doi.org/10.1016%2Fj.beth.2013.03.006.

Craske, M. G., Wolitzky-Taylor, K. B., Labus, J., Wu, S., Frese, M., Mayer, E. A., & Naliboff, B. D. (2011). A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations. Behaviour research and therapy, 49(6-7), 413-421. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100429, https://www.sciencedirect.com/science/article/abs/pii/S0005796711000854, and https://doi.org/10.1016/j.brat.2011.04.001.

Lee, K., Noda, Y., Nakano, Y., Ogawa, S., Kinoshita, Y., Funayama, T., & Furukawa, T. A. (2006). Interoceptive hypersensitivity and interoceptive exposure in patients with panic disorder: specificity and effectiveness. BMC Psychiatry, 6(1), 1-9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1559685, https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-6-32, and https://dx.doi.org/10.1186%2F1471-244X-6-32.