Clinical Psychology

incorporated breathing retraining instead of intero-
ceptive exposure. Although both forms of treatment
were effective, results indicated that panic disorder
patients who received the interoceptive exposure

component reported less impairment and fewer

panic attacks at posttreatment and at follow-up.

Thus, the addition of the interoceptive exposure

component had some beneficial effects.

BOX14-2 Focus on Clinical Applications: Rationale for Exposure Therapy Presented to a Client

with Panic Disorder

For many behavioral techniques, it is important that

the clinician provide a rationale to the client. This is

especially true for exposure-based therapies in which

the client is asked to engage in behaviors that will,

initially, increase levels of anxiety or fear. Barlow and

Cerny’s (1988) rationale for exposure treatment

appears below.

As you may recall from our earlier meetings, we

feel that panic attacks are essentially“false alarms”

issued by the body in response to a cue or signal that

you have learned to associate with danger or threat.

The problem, of course, is that these panic alarms are,

in fact, false. Nevertheless, the fear associated with the

panic attacks is quite real. Just as false alarms are

learned phenomena, the treatment for them also

involves planned relearning experiences. The term we

use to describe these corrective learning experiences is

exposure therapy.

The basic logic of exposure therapy is quite simple.

Exposing yourself to those situations and cues that have

been associated with anxiety and panic attacks provides

you with the opportunity to learn at least three things:

(1) You will learn that anxiety and panic symptoms can

be controlled using the relaxation and cognitive coping

techniques that you have been learning. In fact, you will

learn that you are able not only to reduce those trou-

blesome symptoms, but also actually to bring them on

at will. (2) You will learn that there is no basis for the

fear associated with your panic attacks. (3) And, finally,

you will learn to break the association between the cues

that signal your fears and panic attacks and teach

yourself new ways of responding during graduated

exposure to those panic-associated cues.

At the present time, we do not fully understand

the exact mechanisms that explain how this new

learning takes place, but we do know that exposure

therapy is highly effective in treating anxiety disorders.

Let me emphasize that it is the new learning that takes

place during exposure trials that is the critical element

in therapy. The exposure to panic-associated cues

merely provides the opportunity for that learning

to occur. Therefore, passive exposure to these same

cues—that is, unplanned exposures during which no

corrective learning takes place—is not sufficient to

bring about therapeutic changes in your behavior.

During the exposure trials we encourage you to deal

directly with your anxiety and fear and to take an

active part in the new learning process.

Because you will be exposing yourself to these

anxiety-provoking cues, you should anticipate that ini-

tially you may become more anxious and perhaps

notice an increase in panic attacks. However, as you

know, in most cases, anxiety and panic attacks are self-

limiting—that is, in most situations the anxiety and/or

panic symptoms will subside. The anxiety and fear

itself, of course, may be quite unpleasant.

In order to minimize the amount of unpleasant-

ness you will have to experience, we will develop

together a graduated hierarchy of anxiety-provoking

cues and work through that hierarchy from the least to

the most anxiety-provoking situations. Nevertheless, it

will be necessary for you to tolerate some anxiety, at

least initially. As you learn to deal more effectively

with anxiety and panic symptoms and to eliminate

“false alarms,”you should notice substantial reduc-

tions in the number and perhaps the intensity of your

panic attacks.

There are three ways that you can expose yourself

to panic-provoking cues. First, you can imagine yourself

experiencing the panic-provoking situation or cues.

Imaginal exposure provides not only an exposure trial

under controlled and low-arousal conditions, but it

also allows you rather easily to plan and practice your

management skills in imagination so that you will be

prepared to take advantage of in vivo exposures. Sec-

ond, you can expose yourself to certain panic-

provoking cues here in the office. We will explore ways

to induce those bodily sensations that have come to

signal the possibility of a false alarm. And, finally, you

will be exposing yourself to actual situations in your

daily life. Today, we will begin with imagery training

and hierarchy development.

SOURCE: From Barlow, D. H., & Cerny, J. A.,Psychological Treatment of

Panic(p. 155–156). Copyright © 1988 Guilford Publications, Inc. Reprinted

with permisison.

PSYCHOTHERAPY: BEHAVIORAL AND COGNITIVE-BEHAVIORAL PERSPECTIVES 407