PANIC STATIONSPANICSTATIONS

Panic Stations
Module 9
Coping with Physical Alarms:
Exposure Part 1
Introduction

2

Planning exposure to internal sensations

2

Internal Sensations Exercises

5

Exposure to Internal sensations

7

Module Summary

9

About This Module

10

The information provided in this document is for information purposes only. Please refer to the full
disclaimer and copyright statement available at http://www.cci.health.wa.gov.au regarding the informationon this website before making use of such information.

forCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 1PANIC STATIONSIntroduction
In the modules so far we've worked on changing some of the thoughts and behaviours that contribute toanxiety and panic. This includes changing your breathing patterns, reducing your general level of anxiety
through relaxation, and challenging your thoughts about panic.
The aim of this InfoPax is to give you information about how to challenge your beliefs about panic
symptoms by actually experiencing them. Research has shown that this is particularly important in being
able to successfully overcome panic symptoms and distress about panic symptoms.
In Module 1, we talked about some of the factors that are an important part of why panic is maintained.
1. Thinking styles, such as catastrophic thinking. Panic sensations are interpreted as signalling something
terrible, such as a medical emergency.
2. Focus on bodily sensations. Monitoring your body for symptoms of panic means that you areespecially sensitive to the sensations, even when those changes are normal.
3. Avoidance. As a result of this fear of experiencing a panic attack, you avoid certain situations andsensations similar to panic.
Of course, it does seem natural to try to avoid the sensations that are similar to panic attacks. It might also
seem natural to scan for the possibility of physical alarms, as this might help you to avoid them. After all,panic attacks can be quite frightening and uncomfortable, it's no wonder you would want to avoid it!
However, if you don’t experience these sensations, you won't give yourself any real evidence about one
important thing: panic sensations are not harmful. Only by facing your “fears” about panic attacks andrelated physiological sensations will you have enough evidence to challenge your beliefs about physicalalarms.
There are two ways to do this. One way is to experience the physical sensations that you are afraid of, or"exposure to internal sensations". The other way is to experience situations where you fear you might havea panic attack, or ”situational exposure”. In this module we will focus on learning how to cope with physicalalarms through exposure to internal sensations. We will talk about situational exposure in the Module 10.

HOW DOES "EXPOSURE TO INTERNAL SENSATIONS" WORK?
As mentioned, exposure helps by providing you with evidence that panic attacks are not harmful. It works
by challenging the three factors, discussed above, to break the cycle of panic and anxiety.
1. Thinking styles. Through physiological sensations exposure, you will have direct evidence that suchsensations are not catastrophic.
2. Focus on bodily sensations. If you do notice normal changes in your physiological sensations,
exposure tasks will give you direct evidence that physiological sensations are not catastrophic, and thiswill reduce your fear of them. Further, if you are not afraid of these sensations, then there will be lessreason to monitor your body for them.
3. Avoidance. Exposing yourself to physiological sensations is incompatible with avoiding them. By
repeatedly exposing yourself to such sensations, you will become used to them and you will be lesslikely to react with anxiety when you notice these sensations. By doing it over and over again, it
becomes easier to do.

forCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 2PANIC STATIONS

Planning exposure to internal sensations
Now that you have an idea of why exposure to physiological sensations is important, we can start talking
about how you can work through your fear of these sensations. Essentially, it will involve producing a
number of physiological sensations that are similar to panic, such as a rapid heart beat, breathlessness,dizziness and so forth, through some structured tasks.

PRECAUTIONSBefore you start, it is important to consider two things:
1. You must be in a healthy physical state before completing these exercises. If you have health issues thatmight be complicated by physical strain, you should not continue with this module. This includes:•

Epilepsy or seizures•

Pregnancy•

A heart condition•

History of fainting/low blood pressure•

Physical injuries eg neck problem•

Asthma or other lung problems

Check with your doctor, by presenting a list of the physiological exercises, to determine whether you
can proceed. Talk to your doctor if you have any concerns about the impact of these exercises.
2. Conducting these exposure tasks on your own is often the best way to challenge your beliefs about
physiological sensations because you can challenge the belief that you might need someone's help.
However, exposure tasks are usually designed with the guidance of a mental health professional. If you
are finding the tasks particularly difficult, or are concerned about your progress, please see your doctor
or a mental health practitioner who can more clearly guide you through the process.

PREPARATION FOR THE TASKS
On page 5, there is a list of tasks that are designed to produce particular physiological sensations. To begin
with, try doing all of them. This will help to determine which exercises are particularly relevant to you, sothat you know which ones to focus on. Here are a few hints on preparing for the tasks.
• It may be useful to talk to a trusted, supportive, relative or friend about the tasks you are doing.
Perhaps you can talk with them regularly and discuss how you are going and if you are having any
difficulties. This can you acknowledge the positive steps you are taking and motivate you to continue.
• The tasks are not in any particular order. Try starting with exercises that seem less difficult for you.
That way you won't be too overwhelmed and decide it is too intense.

forCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 3

PANIC STATIONSPERFORMING THE TASKS
1. Try to experience the sensations as much as possible. Remember that there are many ways to subtly
avoid these sensations. Common methods of avoidance include•

Stopping the task early. For example thinking, "My heart's beating faster - that's enough, then".

•Not completing the tasks properly. For example, if you are trying to create the sensation ofsweating through heat, keeping a window partly open might be a form of subtle avoidance.

•

Distracting yourself from noticing the sensations rather than paying full attention to them.

2. While experiencing some sensation is better than nothing, try to complete the exercise in full as thiswill provide a more accurate assessment of your fear of the sensation.
3. In some tasks the sensations develop during the exercise, whereas in other tasks they occur shortly
after the exercise. So pay full awareness to the sensations that occur during and after the exercise.
4. After each task, make some notes about your experience• Use a scale of 0-100 (a Subjective Units of Distress Scale: SUDS) to rate your level ofanxiety/distress about the sensations, where 0 is the lowest.
0:

Relaxed:You feel absolutely no distress, you feel calm.

25-49

Mild.

You can still cope. You might feel like you’re more alert or nervous.

50-64

Moderate

Becoming difficult to cope. Distracted by anxiety, might use safety
behaviours.

65-84

High

Dfficult to cope. Difficulties concentrating, looking to escape85-100

Severe toextremeCannot cope. Your body response is so overwhelming that you think you
can’t possible stay in the situation any longer

•
•
•
•

Use a scale from 0-100 to rate the intensity and the similarity of the sensations.
Write down all of the internal sensations you experienced
Write down all of the anxious thoughts you experienced
You can use the Internal Sensations Exercises worksheet to make these notesforCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 4PANIC STATIONSINTERNAL SENSATIONS EXERCISES
If you have any physical problems, or any concerns about your physical health in relation tothese tasks, you should talk to your doctor before you proceed. These exercises are designed
to be uncomfortable, but they are not intended to be painful. You should use your common
sense at all times in regard to any physical limitations you may have.
Note: You should use a timer that you can set to sound an alarm after the specified time.
Exposure task

Duration

Notes/Comments

Hyperventilation. Breathe deeply and quickly
through your mouth, using as much force as you
can.

1 min

Try to breathe as loudly as possible andmaintain the breathing rate withoutslowing down too much.

Shaking head. Shake your head from side to side
while keeping your eyes open. After 30 seconds,
look straight ahead.

30 secBe careful with your neck in thisexercise – do not shake too vigorously.

Head between legs. While sitting in a chair, place
your head between your legs. After 30 seconds,
stand upright quickly.

30 secLower your head gently if you have hadback problems.

Running in place/run up steps. Run/Step up anddown quickly.

1 min

It may be tempting to slow down once
you notice physical sensations. Try tomaintain a quick pace.

Maintain muscle tension. While sitting in a chairtense/tighten all of your muscles or do a push-up
and hold that position.

1 min

You can use the methods of tensing we
discussed as part of the module on
PMR.

Hold your breath. Take a deep breath and hold it.

30 secIf you cannot hold it for 30 seconds,
hold it for as long as you can.

Spinning. Use a swivel chair to spin around as
quickly as possible by pushing against the floor as
you spin.

1 min

You can spin around while standing up,
but make sure you are not in danger of
injuring yourself.

Breathe through a straw. Use a narrow straw(eg cocktail straws) to breathe, whilst holding yournose closed.

1 min

Make sure that your lips are sealedaround the straw, so you breathe
ONLY through the straw.

Chest breathing. Take a deep breath until yourchest is “puffed up”, then take short, sharp breaths,
breathing just from your chest.

1 min

Try to maintain a quick, shallow pacethroughout.

Stare at a spot. Stare at spot on a blank wall, or atyour mirror image, without shifting your gaze.

1.5 min

It is easy to be distracted and shift yourgaze, but try to hold it as long as you
can. Also, try not to blink for too long.

On the next page is a worksheet where you can record the types of sensations you felt, the level ofintensity of the sensations, the degree of similarity to your typical panic sensations, and the thought andsensations you experiencedforCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 5PANIC STATIONSINTERNAL SENSATIONS EXERCISES: WORKSHEET
Exposure task

Time

Hyperventilation

1 min

Shaking head

30 secHead between legs

30 secRunning in place/steps

1 min

Muscle tension

1 min

Hold your breath

30 secSpinning

1 min

Breathe through straw

1 min

Chest breathing

1 min

Stare at a spot

1.5 min

SUDS
0-100

Similarity
0-100

Intensity
0-100

Physical Sensations

Thoughts

PANIC STATIONSEXPOSURE TO INTERNAL SENSATIONSNOTE: You should complete the previous exercises before continuing with this module.
Now that you have conducted the tasks you can determine which exercises are most relevant to you.
1. Similarity ratings. Look at the similarity rating for each task. If the similarity rating is over 35, thenthis exercise should be part of your ongoing exposure tasks. Circle them now. If none, or very few, ofthem are similar, then you may want to create extra tasks that might be more relevant to you.
2. SUDS ratings. Sometimes it is easier to work through exposure tasks in order of increasing difficulty,
in the same way that you might walk up a series of steps. Using the SUDS ratings from the previous
exercises, list the similar exposure tasks that you circled in increasing order starting from the lowest.
There is a worksheet on the next page where you can do this.

BEFORE YOU BEGIN AN EXPOSURE SESSION.
•
•
•

•

Thought diaries. While sometimes thinking, “Just Do It!” is enough to get you working through yourexposure exercises, at other times it might seem like a struggle to get into it. If you have unhelpful
thoughts about doing your exposure exercises, use a thought diary to challenge them.
Social support. As mentioned before, you might want to talk things over with a friend or relative
who will help you to “stick it out”.
Make an appointment to do the exercises.
• Mark blocks of time in your diary or on your calendar to complete the exercises. This helps toformalise your commitment to doing it.
• Set aside enough time to complete 2 different exercises each day. Write down which exercises you
will complete.
Materials. Make sure you have everything you need to complete the tasks for that day.

DURING THE EXPOSURE SESSION••

Try to experience the sensations fully.
• Pay attention to the sensations and notice what you are feeling• Try to engage in the task for the time indicated• Try to complete the task fully rather than using any safety behaviours
Disputation. During the exercises, you can use disputation to challenge any catastrophic thoughts
about the sensations you are experiencing. Perhaps make a flash card and keep it close by.

ONGOING EXPOSURE
Working through an exposure session is critical to getting used to the feared sensations. So how do you
keep moving onwards and upwards? Here are some hints on how to help keep you moving through all of
your feared sensations.
• Repetition. It is important to repeat each task until your SUDS rating has decreased to less than 30.
This might be later on the same day, or schedule it for the next day. If you do need to repeat it, try tocomplete the exercise to the same level of intensity to experience the sensations as fully as before.
• Acknowledge your achievements. When you have completed an exposure session, make sure you
acknowledge your efforts. You might want to do something that you find positive and rewarding inrecognition of this.
• Use your resources. Talk to a friend about how you are going, and work through any unhelpful
thoughts you might have about completing the tasks.
• Exposure extension. When you have a SUDS rating of less than 30 on a particular task you can
extend it to further develop your coping. For example, you might try• Increasing the duration of the task by 30-60 seconds• Performing seated tasks whilst standing up• Performing the tasks in unfamiliar places, or away from easy sources of help
forCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 7PANIC STATIONSINTERNAL SENSATIONS EXERCISES: DIARY
Instructions: Write down the exposure tasks from the previous exercise that have a similarity rating over 35. List
these in order of SUDS rating, starting with the lowest. Use the following rows when repeating exposures until the
SUDS rating drops below 30. Record the physical sensations you experience.
SUDS
0-100

Similarity
0-100

Intensity
0-100

Physical Sensations

Task:
Date:
Date:
Date:
Date:
Date:

Task:
Date:
Date:
Date:
Date:
Date:

Task:
Date:
Date:
Date:
Date:
Date:

Task:
Date:
Date:
Date:
Date:
Date:

for
Centrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 8PANIC STATIONSModule Summary•

One way to help you cope with physical alarms is by actually experiencing the physical sensations. This
will help you get used to them and gives you the evidence you need that panic sensations are notharmful.

•

The first thing you need to do is to work out which sensations are most similar to those that you
experience. You can do this by working through a list of exercises or tasks.

••

Before completing the tasks you need to take necessary precautions in regard to yourphysical health. Talk to your doctor if you have any concerns, or you need to consider any
physical limitations.

•

Sometimes it helps to prepare for the tasks by talking to a trusted, supportive friend or
relative.

•

When performing the tasks, remember to experience them fully, paying attention to yoursensations both during and after the exercise. It is important to note what sensations you
experienced, the SUDS rating, the intensity and the similarity of the sensations, along withany associated thoughts.

Once you have determined which exercises/tasks are similar to your own panic, you can start towork through the exposure exercises on a daily basis, staring with the one with the lowest SUDS
rating.
•Remember to use thought diaries, social support, and scheduling to maximise your continued
commitment to working through the exposure exercises.

•

During the exposure sessions, try to experience the sensations fully by paying close attention
what sensation you are feeling. Dispute any unhelpful thoughts that might stop you fromcompleting the exercise.

•Work through the tasks in increasing order of SUDS ratings. You will need to repeat theexercise until you have a SUDS rating of less than 30. Once you have done this, you mightwant to try extending the exposure task to expose yourself to more intense sensations. Be
sure to acknowledge your achievements and use your resources to help you to continue
with exposure on a daily basis.

In the next module wewill look at exposure toactivities and situations
where you are worried
that panic sensations
might occur.

forCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 9PANIC STATIONS

About This Module
CONTRIBUTORSPaula Nathan (MPsych*)Director, Centre for Clinical Interventions
Adjunct Senior Lecturer, School of Psychiatry and Clinical
Neuroscience, The University of Western Australia

Dr Helen Correia (MApp Psych*; PhD)
Centre for Clinical Interventions*MPych/MApp Psych: Masters of Psychology (Clinical Psychology)

BACKGROUND
The concepts and strategies in this module have been developed from evidence based psychologicalpractice, in this case, Cognitive-Behaviour Therapy (CBT). CBT for panic disorder is a type of
psychotherapy that is based on the theory that panic disorder is a result of problematic cognitions(thoughts) and behaviours. There is strong scientific evidence to support that cognitions and behaviours canplay an important role in panic disorder, and that targeting cognitions and behaviours in therapy can help
many people to overcome panic disorder. Examples of this evidence have been reported in the following:
Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic
Disorder and Agoraphobia. (2003). Australian and New Zealand clinical practice guidelines for thetreatment of panic disorder and agoraphobia. Aust N Z J Psychiatry, 37(6), 641-56.

REFERENCES
These are some of the professional references used to create this module.
Craske, M.G., & Barlow, D.H. (2001). Panic disorder and agoraphobia. In D.H. Barlow (Ed.), ClinicalHandbook Of Psychological Disorders, Third Edition. New York: Guilford Press.
White, K.S. & Barlow, D.H. (2002). Panic Disorder and Agoraphobia. In D.H. Barlow (Ed.), Anxiety and Its
Disorders. Second Edition. New York: Guilford Press.

FURTHER READING
There have been many other information resources written for people with panic attacks and panic
disorder.
Barlow, D. H., & Craske, M. G. (2000). Mastery of your anxiety and panic (3rd edition). San Antonio, TX:
The Psychological Corporation. (ISBN: 0127850783)
Royal Australian and New Zealand College of Psychiatrists. (2003). Panic Disorder and Agoraphobia:
Treatment Guide for Consumers and Carers. Available: http://www.ranzcp.org/publicarea/cpg.asp (click on“Panic Disorder and Agoraphobia”). Accessed Feb. 2004.
Zuercher-White, E. (1998). An End To Panic: Breakthrough Techniques For Overcoming Panic Disorder (2nd
Edition). Oakland, CA: New Harbinger Publications. (ISBN: 1567313760)“PANIC STATIONS”
We would like to thank Uta Juniper for the title of the InfoPax that this module forms part of:Nathan, P., Correia, H., & Lim, L. (2004). Panic Stations! Coping with Panic Attacks. Perth, Australia: Centre
for Clinical Interventions.
ISBN: 0-9751985-8-0 Created: June, 2004.
forCentrelinical
C Interventions• Psychotherapy • Research • Training

Module 9: Coping with Physical Alarms – Exposure Part 1

Page 10