1. Interoceptive Exposure
Welcome to our 6th session of group CBT for PD
So far, everyone has filled out BSQ and understands SUDS hierarchy
Everyone has agoraphobia and has indicated fear of having panic attack in public

2. Introduction Today will be interoceptive exposure
First, I will explain what this is and why it is helpful
Then I will demonstrate to you how to do interoceptive exposure
Based on BSQ each person will pick out one to try
Each person will try their chosen exercise with help from therapist: must induce anxiety, if not, choose a different one
Then each person will rate SUDS prior to, during, and after exercise
Symptoms will be discussed afterwards
Homework
Helpful tips
Exposure intervention:
Provide rationale for confronting feared situation
Establish hierarchy of feared situations
Provide accurate expectations
Repeat exposure until fear diminishes
Attend to disconfirmation of fears
(what was learned from exposure)

3. Education Conditioning; Avoidance; Habituation
Interoceptive is bodily sensations
Anxiety Sensitivity; Attention to physical sensations; Threat-related cognitions
Exposure leads to Cognitive Restructuring
Goal is to view physical sensations as uncomfortable nuisance-not warning sign of impending physical catastrophe
Increased sensitivity DOES NOT EQUAL INCREASED ACCURACY
Does anyone have any safety behaviors?
Escape, avoidance, and safety behaviors maintain fears through negative reinforcement
Conditioning to anxiety-associated stimuli, avoiding situations means that there are fewer
opportunities to learn about how dangerous they really are, same as safety behaviors.
Can do SUDS with and without use of safety behaviors.
What occurs: bodily sensation->anxiety->physical arousal->VICIOUS CYCLE
3 factors that maintain) Thinking style, focus on bodily sensations, avoidance
People with anxiety sensitivity are more prone to panic attacks and
those with panic attacks have increased sensitivity to bodily sensations
Anxiety sensitivity is a fear of arousal sensations.
People with anxiety sensitivity pay more attention to physical sensations
and interpret them as harmful.
Increased sensitivity does not correspond with increased accuracy.
Threat related cognitions including catastrophic thoughts, expectancies of danger,
information processing biases and underlying beliefs about personal control.
Catastrophic misinterpretations increases level of panic
Cognitive restructuring allows people to test thoughts as hypotheses:
over-estimating probability of negative outcomes, understanding thoughts=emotions,

4. Exercises Breathing through straw Clipping nose
Head b/w legs (30 sec), rapidly lift head
Spinning (1 min)
Jogging-in-place
Hyperventilation
Shaking head side-to-side
SUDS prior to/during/after
People with panic disorder over predict their fear level for anticipated exposure intervention
Does anyone have any safety behaviors?
What does your panic attack feel like?
Dizziness, palpitations, shortness of breath
What cues to you that you might be getting a panic attack?
Does anyone have any worries or questions about doing exercises?
First I will demonstrate these exercises to you
According to what you have seen, and your BSQ which exercises:
do you think would induce fear the most?
Which exercises most similarly induce bodily sensations that cause fear for you?
Pick exercise, perform, does it cause anxiety?
Continued until intense physical sensations occur
and anxiety sets in, people repeat exercises that are
most powerful for them in triggering physical
sensations similar to panic
THESE EXERCISES MUST INDUCE ANXIETY (ANXIETY NETWORK)
Try to complete each task for the allotted time-stopping early is avoidance
Focus on sensations-distraction is avoidance
Carry out exercise multiple times
Do on own rather than with other people
Try in different places
Try for longer periods of time

5. Discussion Test symptoms for which induce anxiety How did SUDS change?
Fill out Internal Sensations Worksheet
Bodily symptoms
Symptom intensity
Fear intensity
Similarity to panic attack
Did you over predict?

6. Homework
Go to places you have been working for agoraphobia and practice interoceptive exercise
Waiting in line, heavy traffic, airplanes, public transportation,
crowds, being home alone, being away from home,
shopping mall/grocery store
-anywhere it is difficult to leave unnoticed.
Pick three exercises to do every day, do internal sensations exercise, see Etc slide for things to consider when doing Interoceptive exposure

7. Etc …. Breathing retraining Relaxation Mindfulness Support system
These are good coping strategies for doing interoceptive exposure. Do not avoid exposure by trying to relax during exercise, but these are helpful for afterwards when trying to get SUDS back down to normal.