Interoceptive Exposure for Panic Disorder

Interoceptive Exposure (IE) is a component of Cognitive Behavioral Therapy (CBT) used to treat panic disorder by intentionally exposing the individual to the somatic symptoms or internal cues.

Interoceptive exposure is the strategic introduction of exercises that mimic somatic symptoms that trigger panic attacks to gain tolerance for stressors that individuals with panic disorder misappraise as dangerous and anxiously avoid. The avoidance of these somatic symptoms provide relief for individuals; however, long-term avoidance patterns can perpetuate the feelings of anxiety and increase the severity and frequency of panic attacks.

Somatic symptoms that are most commonly associated with panic attacks include hyperventilation, tachycardia (i.e., increased heart rate), shaking, chills, shortness of breath, sweating, palpitations, and dizziness.

These physical sensations trigger psychological and emotional reactions in individuals with panic disorder by activating the amygdala and creating a fight or flight response. The overwhelming fear of feeling these sensations motivates individuals to avoid activities that cause them to feel any of these stressors. These interceptive avoidances result in individuals with anxiety to irrationally become hypervigilant of their bodily sensations and increase the fear they will have a panic attack. For example, consider an individual with generalized anxiety and panic disorder. Let’s assume this individual misappraises their increased heart rate as a precursor to a panic attack. Anytime this person increases their heart rate through physical exertion they might become anxious and thus more likely to avoid exercise in the future.

Interoceptive exposure works to develop a distress tolerance against symptoms that could trigger a panic attack while also testing the threat threshold patients can tolerate in a clinical setting with a licensed provider. This allows patients with anxiety to learn that their condition is safe and manageable and that the stimuli they fear will not hurt them.

Before providers introduce exercises that target somatic symptoms, it is imperative that the individual not have any underlying health conditions that would cause interoceptive exposure to be unsafe. Patients that have heart or lung conditions, epilepsy, are pregnant, or have other physical conditions could experience difficulties with interoceptive exposure. After Individuals are cleared by their physicians and deemed good candidates for interoceptive exposure therapy, providers will work with patients to identify specific interoceptive triggers that increase their levels of anxiety and validate the patient’s anxiety with these symptoms.

The provider and patient will work together to create a hierarchy of fear by listing triggers that make an individual anxious and then rank these triggers in order of least anxiety-inducing to most anxiety-inducing. Each of the identified triggers will be given a Subjective Unit of Discomfort Scale (S.U.D.S) score by the patient. S.U.D.S. is a self-assessment tool used by clinicians to gauge the level of discomfort a person would feel with each internal cue/somatic symptom. The scale ranges from 1-100 (no discomfort to intolerable discomfort). A person who experiences anxiety and breaks down any time they feel dizzy might rate their distress as a 100; whereas, a person who experiences dizziness and is uncomfortable but still functional might rate their distress as a 50. After triggers and levels of discomfort are identified, the therapist would provide the patient with a list of exercises and instructions that would increase exposure and trigger the anxiety to help the individual increase tolerance. After each exercise, the individual would continue to give each trigger a S.U.D.S score.

Interoceptive exposure exercises for commonly misappraised symptoms

Somatic symptom (internal cue) Interoceptive Exposure Exercise
Shortness of breath Individuals are asked to hyperventilate by taking deep breaths rapidly for approximately 1 minute, 8 times.

This effect can also be achieved by breathing through a straw for 2 minutes while closing the nasal passageway or by holding the breath for 30 seconds, 5 times.

Physical exertion Running in place while lifting the knees close to the chest for 2 minutes, or by tensing body muscles for 1 minute, taking a break for 1 minute, and repeating 8 times.
Dizziness Spinning in an office chair for 1 minute as quickly as possible or spinning in a single direction while standing for 1 minute, 8 times.
Head-rush While sitting, place head between the legs and sitting up quickly after 1 minute, repeat 15 times.
Sweating Sitting in a small room with a space heater or sitting in a sauna.
Gag reflex Placing a tongue depressor or utensil in the back of the tongue until gag reflex is induced, repeat 15 times.


Subsequent S.U.D.S scores help providers and patients track progress as the anxiety to each symptom becomes more tolerable. For example, an individual may misappraise and assign their dizziness a S.U.D.S score of 50 at their initial session; after a single exposure, this individual might rate their dizziness as a S.U.D.S score of 45. A decrease in the patient’s S.U.D.S score for each exercise is considered progress since the individual feels less discomfort. Repeated exposure to these internal stimuli will help patients create neuropathways that are not associated with anxiety. Over time, individuals become less anxious or completely remove their anxiety towards the somatic symptom.

Therapy is individualized and the recreation and repetition of these symptoms are based on the level of discomfort produced after each exercise. Patients are encouraged to complete the exercises for the entirety of the allotted time. Failure to complete the exercise is a common avoidance mechanism and can render interoceptive exposure ineffective. Patients must avoid using safety behaviors during the exercises (i.e., using benzodiazepines, wearing an Apple Watch or Fitbit to monitor heart rate); instead, patients should focus on the anxiety and discomfort occurring during each exercise.  Patients must ‘activate to generate’. To maximize the efficacy of interoceptive exposure, the patient must induce as much anxiety as possible for the amygdala to be activated and to more efficiently generate neuropathways that are calm when exposed to a previously anxiety-inducing trigger. After patients become more tolerant of these stimuli and give S.U.D.S ratings that are significantly lower, each exercise can be increased in duration, frequency, or recreated in different environments.

Interoceptive exposure should be supervised by a licensed provider in a clinical setting until the provider deems it safe for patients to continue with the exercises in an alternate environment.





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