Clinician's guide to exposure and habituation for panic disorder using the Fears Conquered protocol by The CBT Resource by Marie Chellingsworth

The Clinician’s guide to supporting the ‘Fears conquered with exposure and habituation’ protocol

Marie Chellingsworth Photography by Andy Poplar [Vinegar & Brown Paper] ®

© 2020 Marie Chellingsworth. The CBT Resource®. 3rd Edition. Last updated May 2020. The right to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. This work is provided under specific license as a read only document for The CBT Resource Annual CPD & Resources membership holders only. It may be used by the membership holder only for their own individual use in 2020/2021, in the original binding. It cannot be downloaded, photographed, sent electronically, hosted electronically or used by any other party under the conditions of membership. This condition must be imposed at all times and this work cannot be sold for profit, used for training others by the member or any other party, edited, copied in full or part, repackaged or amended in any other way without the express permission of the author. The work cannot be circulated for use outside of the individual license holder. The etched glass photography used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper]® and are used with kind permission (see the about the author section for more information about Andy’s work and his own experiences with anxiety and depression). All other images are used with permission from Unsplash in accordance with their policy. We would like to thank the focus groups and various service practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score of the associated patient protocol material is 13.4 and the Flesch reading ease is 80, calculated independently with Readability Studio©. This information booklet has been designed to meet NHS information Standard Principles and conform to good practice guidelines for self-help and patient information. It is designed to be combined with the patient workbook material and support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol alongside this guide. Disclaimer: This Clinician’s guide is to be read and used clinically alongside the patient workbook ‘Fears Conquered with Exposure and Habituation)’. It is provided for information purposes only, in conjunction with training in using the protocol from the author. It is not a substitute for CPD training and should only be used by those suitably qualified to support the protocol. While every reasonable effort has been made to ensure the accuracy of the information, no guarantees, representations or warranties can be given that the information is accurate, free from error or omission, complete or up to date. The assessment and treatment of mental health conditions requires the attention of a qualified medical or mental health professional. We shall accept no liability for any act or omission occurring in reliance on the information or for any consequences of any such act or omission. By using this information, you are agreeing to the provisions of this disclaimer and copyright notice.

Contents

1-2

Introduction

3-4

The ‘Fears Conquered’ with exposure and habituation protocol

5-6

Typical treatment outline

7-14

The physiology of the fear response

Panic and the defence cascade

The ABC maintenance cycle of panic

18-19

Introducing exposure and habituation

Creating the hierarchy

The essential conditions

22-23

The importance of homework

Manage endings

Useful references

About the author and Andy Poplar’s work

Introduction This guide presents an opportunity for practitioners and supervisors to review the clinical skills; competencies and knowledge needed to effectively and efficiently support the ‘Fears Conquered with Exposure and Habituation’ protocol (Chellingsworth, 2020). Panic disorder is a widely experienced anxiety disorder which affects about 7 in every 1000 people in the UK, approximately 1-2% of the population. Panic disorder is often misdiagnosed however, as panic attacks can be a discrete symptom of other anxiety disorders and occur in non clinical populations. At least 22.7% of the population experience panic attacks without panic disorder or another anxiety based disorder being present. A panic attack is a rapid rise in anxiety, usually reaching a peak within ten minutes. It is experienced as a rush of physical sensations. These sensations are the result of the arousal response in the body. In panic disorder, the patient will have experienced one or more panic attacks and their body catastrophically misinterpreted the physical symptoms as a sign of imminent threat at the time (e.g. I am having a heart attack/stroke/going to collapse/going mad). There should be at least one month of fear of having another attack and significant adaptations to behaviour to avoid having another attack. The panic attacks should not be experienced as a part of another anxiety disorder (known as a panic specifier, not panic disorder, see DSM-5 for more information on panic specifiers). The physical symptoms of panic can come on when the person is anxious, or when they are calm, as unexpected attacks ‘out of the blue’. Around 17-45% of patients experience nocturnal attacks. Four or more of the following symptoms should be experienced: • Palpitations, pounding heart, increased heart rate • Sweating • Trembling or shaking 1

• • • • • • •

Shortness of breath Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady or light-headed Chills or heat sensations Numbness or tingling sensations (paresthesias) • Feeling detached from what is going on around you (de-realization) • Fear of losing control, going crazy or of dying Agoraphobia is often experienced with panic disorder, although can be diagnosed in its own right. A commonly misinterpreted as merely a fear of wide open spaces. In Greek, the word Agora refers to public places of assembly. In agoraphobia busy, crowded places, as well as open spaces where getting help would be difficult are avoided. When they cannot be avoided they are endured with distress, leading to safety seeking behaviours to reduce the threat and often escape behaviours. Many therapists do not conceptualise that agoraphobia can be found in the absence of panic disorder, as they fear having a panic if their avoidance was not as high and they were in contact with the stimulus situations. Franklin (1985) identified that the largest © Marie Chellingsworth (2020). The CBT Resource.

recorded fears of agoraphobics if entirely alone in a situation, at the time were feelings of panic, collapse, losing control, causing a scene or disturbance or going mad, so these fears are shared with panic disorder and the agoraphobia may give high level avoidance for symptom management.

It can be difficult to engage patients into facing their fears, so a solid treatment rationale with accurate physiological explanation is required with good use of common factor skills to engage the patient and build expectancy of hope that symptoms can improve.

Exposure and habituation is a highly effective treatment for panic disorder, agoraphobia and specific phobias. It has a significant evidence base supporting its efficacy. The protocol targets the central maintenance role of negatively reinforced avoidance and the over-learning of the active fear cascade response to arousal. Exposure and habituation is a stand alone treatment, it is not combined with cognitive thought challenging work. CR added in unnecessarily dilutes the outcome, not enhances it. This is often a source of confusion as some step 3 protocols may do similar looking activities or experiments with the patient remaining in anxiety provoking situations, but for the scaffolding purpose of gathering cognitions and ratings, not to meet the criteria of exposure and habituation for extinction of fear as a change method. Both may look similar to a novice eye or those without specific training.

It is also important that any interfering beliefs or behaviours on the part of the practitioner (e.g. avoidance of using exposure, not tackling non-compliance, over grading to make it easier for the patient, or thoughts such as ‘I should not make my patient’s anxious’ or ‘I must be a nice practitioner and not make them do things that make them uncomfortable’ are addressed within clinical skills supervision, as high levels of practitioner drift have been found within exposure based methods (Waller, 2016).

The ‘Fears conquered with exposure and habituation’ protocol

The protocol should be delivered by a trained practitioner, supporting the ‘Fears Conquered’ selfhelp material, which has been tested to conform to good practice guidelines in self-help and have a suitable reading age. In line with NICE guidelines treatment for panic and agoraphobia should be exposure and habituation, integrated with use of an appropriate task based self-help material, with support session number dependant upon patient response and engagement to treatment homework (the treatment dose). Each session lasting 20-30 minutes for the homework review and subsequent weeks homework planning (subject to local variation for additional content needed in sessions). This should be delivered in weekly sessions, phased out as required as treatment progresses towards discharge. The protocol should end with relapse management using the relevant pages within the material. The change methods and scaffolding components of the protocol are:

Change Method/ Scaffolding Technique Explaining the fear response and maintenance cycle

Target A scaffolding technique to give the patient information about the adrenalin response, symptoms and how the body can learn to fear these symptoms and a cycle of panic, avoidance, escape and safety seeking can take hold, how exposure and habituation helps to break this cycle by helping the body to over-learn it does not need to produce fear on response to these triggers.

Duration/Dose A one off psycho-eduction task. At end of assessment/first treatment session depending on time available. This should be physiological in nature explaining the purpose of the symptoms of arousal, focused on accurately explaining the fear response and misinterpretation by the body of these symptoms relevant to the individual patient presentation, how the body has learnt to treat these normal physical symptoms inside of arousal and at other times as a sign of threat should be included, with normalisation of key individual patient symptoms of concern. It should be discussed how avoidance and safety seeking serves to maintain the disorder in a vicious cycle, but this learning can be reversed through the treatment. This should be reinforced through the reading in the patient self-help material.

Hierarchy creation

A scaffolding task to help patients to build a hierarchy of increasing levels of fear triggers: avoided situations and physical sensations. Enables exposure and habituation to be planned in a graded way that feels manageable whilst having enough symptoms for habituation to take place.

A brief exercise carried out as part of a session with the patient, with some activities in each level of difficulty added and either finished in the session or as homework if incomplete (alongside planning change method homework for completion after session 1, so the hierarchy requires an exercise in the easier section that produces enough fear to be effective (50-60%) to ensure this is possible). Ideally no safety behaviours are included on the hierarchy when completing it. Any steps with a safety behaviour included initially to make treatment possible, e.g. going out with someone, must still produce the required level of fear to be a suitable homework exercise and the same activity without the safety behaviour must be added to the hierarchy at a higher step to ensure it is dropped during treatment. The hierarchy should not include use of benzodiazepines or other prescribed or over the counter medicines or remedies that reduce affect and block habituation. Any such medication should always be discussed with a supervisor and the prescriber to see if a withdrawal programme is required prior to treatment taking place to.

Exposure and habituation exercises

Each week, the change method of exposure and habituation exercises to be completed over the following 7 days should be planned. These activities must be checked against the essential conditions as part of the planning process to ensure the patient is adhering to the conditions and has a working knowledge of how they operationalise. Homework each week should be drawn out on a blank graph to measure the habituation curve and give a visual illustration to the patient. Any difficulties or barriers should be problem solved.

Weekly exposure and habituation exercises should take place. An average of 4-5 exercises should take place each week. Initially, as it is unknown how long it will take for anxiety to drop by 50% for each individual (usually somewhere between 20-120 minutes) from the start of the exercise rating, sufficient time needs to be set aside by the patient in the first week at the top end of the possible amount of time it could take e.g. 5 exercises spread across the week x 20120 minutes each time = a time commitment of somewhere between 1 hour and 40 minutes to minutes to 10 hours in the first week. After the first exercises the time of each subsequent exposure should decrease, but its important the patient leaves enough time aside for 4-5 weekly repetitions and has enough time after the exercise for affect to reduce back to baseline. Each time they step up the hierarchy they should be reminded that the time may increase again for the first time they carry out that exercise. It is also important that the patient knows how and when to step up the hierarchy independently, and that repetitions of exercises are not carried out unnecessarily once a step has been habituated to, while waiting for a review session

Relapse management

A short exercise to target early warning signs of relapse, normalise mood fluctuations and anxiety as a helpful response to keep us safe, to help the patient to consolidate learning of the change method to assist if they need them it the future.

Used at the end of treatment, the patients learning of early warning signs of routine disruption, autonomic, cognitive and behavioural changes as well as reinforcing the change methods and learning from treatment.

Typical treatment outline Note: This is not a rigid, prescriptive list but an indicative treatment structure to enable the correct dose of the change method as homework during exposure and habituation within a Low Intensity CBT format. Exposure exercises should be front-loaded from the first session homework to ensure that a sufficient dose is provided, in line with the evidence. Session 1: 1. Agenda Setting 2. Socialisation to the maintenance model of fear, panic and agoraphobia and treatment rationale given for exposure and habituation 3. Hierarchy started and at least top, middle and bottom complete, with an exercise of at least 50-60% in the easier section to enable week 1 homework to be the change method task of exposure exercises 5. Homework task agreed, checked against the 4 essential conditions and the plan written down on a activity diary 6. Ending Session 1 Homework: 1. Completion of 4-5 exposure exercises as planned, meeting the 4 conditions 2. Completion of the hierarchy if not completed in session Session 2: 1. Agenda Setting 2. Review exposure and habituation exercise diary, drawing out each exercise ratings on the blank graphs as a visual learning tool for the patient. Any learning through using the intervention for the first week should be socratically discussed and consolidated, or any difficulties or misunderstandings in implementation reviewed in terms of internal or external barriers and managed accordingly. If hierarchy was completed as homework, review this and make any necessary changes. 3. Planning for week 2 homework based on week 1 progress. Discussion on how and when to step up independently using the information in the self-help material to guide the discussion. 4. Homework tasks agreed and plan written down on exercise diary, checked off against the conditions to check patient understanding 5. Ending Session 2 Homework: 1. Completion of 4-5 exposure exercises as planned, meeting the 4 conditions Session 3: 1. Agenda Setting 2. Review exposure and habituation exercise diary, drawing out each exercise ratings on the blank graphs as a visual learning tool for the patient. Any learning through using the 5

intervention for the first week should be socratically discussed and consolidated, or any difficulties or misunderstandings in implementation reviewed in terms of internal or external barriers and managed accordingly. 3. Planning for week 3 homework based on week 2 progress. Check understanding of when to step up the hierarchy. 4. Homework tasks agreed and plan written down on exercise diary, checked off against the conditions to check patient understanding 5. Ending Session 3 Homework: 1. Completion of 4-5 exposure exercises as planned, meeting the 4 conditions Session 4 onwards: Treatment is then continued as above, working up the hierarchy until progress towards goals is made, the patient is near recovery and relapse management can be initiated (usually 4-8 sessions of treatment).

The physiology of the fear response To diagnose panic disorder from other differential diagnoses and be able use exposure and habituation effectively, a thorough understanding of the physiology of the fear response is essential. Being able to explain to patients what is actually happening within the body and the function of each arousal symptom is a critical success factor for engaging patients in treatment. Often however time given to this information is limited in training due to time constraints, the condensing of curricula into shorter time frames, or a lack of physiology background and expertise that has developed over time. Worryingly, out of date, poor quality or lazy explanations of anxiety and the fear response exist in many self-help materials in circulation; even those from seemingly reputable sources and those newly published can have these problems. Many encourage safety seeking behaviours, such as distraction or do not adhere to the essential conditions. Some are also interpreted as patronising under focus group review for containing cartoons and illustrations, or being too basic in their approach. Practitioners can fall into the trap of not accurately explaining why a symptom happens, only that it occurs as a result (and let’s face it, most patients with panic disorder are acutely aware of that, but are misinterpreting their cause and consequences and unsure why their body responds in this way). Most patients have already heard of arousal and fight and flight and they know that as previous hunter gathers, this response was helpful to us then. The response however is not a legacy from that time, we still very much need it. We share the arousal response with all other vertebrates and evolution has not removed it since Palaeolithic times, because of its important function to this day. We also never stepped out of our cave and saw dinosaurs, we were not on the planet at the same time and the great majority of 7

hominis did not even live in caves, they were nomadic. It also tells the patient nothing about their symptoms in particular and what their purpose is in a way that informs treatment appropriately. We also do not have a steady stream of adrenalin in our bodies all the time as some materials reviewed state - or habituation simply wouldn’t work!, We have the ability to produce it on response to a perceived threat trigger. Our blood also does not ‘divert’ from its usual route around the body to the arms and legs, flow is prioritised there, on its normal course through vasodialation and vasoconstriction. To aid with this, we have provided a thorough overview of the physiology of the fear response in the following pages and how this then applies to panic disorder. Whilst this information is not required to be relayed to the patient in full, we would strongly argue that it is a necessary level of physiological awareness for a clinician working in a CBT way to have, to ensure that assessments, information giving, selection of suitable resources and rationales given are improved. The physiology of the fear response © Marie Chellingsworth (2020). The CBT Resource.

As humans, we share the physiology of the fear response with other vertebrates. We are certainly not unique in our responses as humans. The fear response evolved to keep species safe. It enables us to avert danger quickly by reflexes such as jumping out of the way of an oncoming car, before we have even begun to experience the anxiety affects of the emotion of fear. In fact, the word emotion in Latin literally means emotus/emovere - to act, to move away, remove, agitate. Therefore it implies a verb, an action being implicit. In the case of fear, the action being to quickly move to respond to the threat in one of the fear cascade defences: freeze, flight, fight, flop or faint. The nervous system in the body is divided into the central nervous system (the brain and the spine) and the peripheral nervous system. The nervous systems are in constant communication with each other through afferent (sensory) and efferent (motor) neuron activity and respond to what is happening across each area of the body. The peripheral nervous system is sub-divided © Marie Chellingsworth (2020). The CBT Resource.

into the somatic nervous system (which carries sensory information and controls skeletal muscle contractions, voluntary movement), the enteric nervous system (the gut, which has over 100 million nerve cells and is often described as the second brain. It is there that serotonin is produced. It also plays a key role in mediating the body’s immune system) and finally, the autonomic nervous system (which provides involuntary regulation of processes that lie outside of conscious control and require no conscious awareness such as breathing and heartbeat regulation, blinking, blood flow, stomach acid secretion etc.). The autonomic nervous system is the nervous system that most clinicians are aware of as having responsibility for the adrenalin response. It is composed of the sympathetic and parasympathetic systems, which have to work together in balance with each other to maintain a stable environment in the body. The parasympathetic system is responsible for ‘rest, digest, feeding and breeding’ and is active most of the time when there is no threat to respond to. It conserves resources and helps to maintain normal body functions. It is this system that steps back in to slow the 8

The defensive fear cascade: freeze, flight, fight, faint and flop heart, breathing and blood flow as well as our pupil constriction when a threat has passed. The sympathetic system is involuntary by nature, it is the system that is activated when there is a stress, threat or danger trigger. It tells the body to produce adrenalin on response to the trigger, arousal occurs and then sets of a chain of autonomic, involuntary changes in the body to prepare to respond to the specific situation of the threat (also known as the ‘fear defence cascade’ within the anatomy and physiology literature. The arousal enables the individual to prepare to either actively respond by flight (run to safety), fight (attack to defend life), or more passive responses, freeze (put defence on hold to assess or hide), flop (tonic immobility when there is significant threat to life and escape or fight is not possible, where consciousness is maintained), or faint (where consciousness is lost, termed collapsed immobility by Kozlowska et al, 2015). These changes are mediated by the neural circuits (the amygdala, hypothalamus, spinal cord, periaqueductal gray - the nucleus that plays a critical role in autonomic function, the ventral and dorsal medulla - part of the brain stem that deals with autonomic function and the ventral pontine tegmentum). The important thing to remember is that they are autonomic changes on response to a perceived threat, not choices made under voluntary conscious control. They happen within approximately 1/300 of a second to move the body to prepare for action and set of chain reactions of physical changes to meet the relevant cascade demands. A way I developed within teaching to explain the physiology of fear cascade responses is to use a rabbit and a fox. The fox, rabbit and the defence cascades: Imagine a rabbit in a field sitting happily alone in the grass. There is no sign of any threat or 9

danger, the field is otherwise empty. There is food to eat there and he is near his warren, where his female pair and a social group of other rabbits reside in the next field. The rabbit would not have adrenalin currently in its bloodstream. Its parasympathetic nervous system would be activated and things in the body in balance, the rabbit would be in the rest, digest, feeding and breeding’ state. Now, imagine scenario 1. The rabbit looks up and a fox is in the distance. Sensory information processing sends a signal to the amygdala in the limbic system where the arousal response begins, this is area of the brain that deals with emotional processing. It interprets the sensory data and sounds the alarm via a signal to the hypothalamus. The hypothalamus is control centre of the brain which will communicate with the rest of the body through the autonomic nervous system. It will trigger the adrenal glands above the kidneys to produce the adrenal medulla hormones - epinephrine (adrenalin) and norepinephrine (noradrenalin). Arousal has now begun and is the first step needed for the defence cascade to be activated. A series of autonomic physical, behavioural and cognitive © Marie Chellingsworth (2020). The CBT Resource.

changes take place to prepare the rabbit for respond to the threat, even before he has begun to feel the physical effects of fear or fully process what is happening. Adrenalin will increase heart rate and flow to the brain and muscles. It will spike blood sugar by converting glycogen stores to glucose in the liver to enable it to be used as fuel. It will bind to receptors in the lung muscle cells, resulting in faster breathing. The lungs open additional pockets to enable more oxygen to be taken in with each breath.

narrowing of the blood vessels to increase blood pressure. The autonomic nervous system will then initiate one of the fear defence cascades. All of this will occur before the rabbit has even had time to consciously process the threat.

The fox in this scenario is at least two fields away in the distance and doesn’t yet seem to be moving in the rabbits direction. Does it make sense to flight, fight, faint, flop or freeze? What do you think you would you do if you were the rabbit? Remember that the Blood vessels are triggered to respond. The response here is involuntary and autonomic. route blood takes within the body does not The rabbit (like other mammals, including divert its usual course. Blood pumps up from humans) would ordinarily freeze first. Freezing the heart, through the brain and down and occurs in the context of a predatory threat, around the body, then back up to the heart. context or discrete cues (Kozlowska et al, To aid the oxygenated blood reaching the 2015). The purpose of this is to stay as still arms and legs, vasodialation of blood vessels as possible and assess if it has been seen to these key areas takes place enabling the or not, be attentive to the threat, scan the blood to get there faster, with vasoconstriction environment and further prepare to respond. of non essential pathways minimising flow It also makes sense to not move and expend there to the level needed to maintain the area. energy if it is not needed yet. Movement may Muscle cells contract to enable perspiration make the situation worse, making the fox to keep the body cool, if active defence is notice it and take chase, so freezing decreases required and insulin production is inhibited. the likelihood of being detected. The noradrenalin will enable vasoconstriction, In a freeze based response, sympathetic and © Marie Chellingsworth (2020). The CBT Resource.

parasympathetic components are co-activated. Vagal inhibition opposes the sympathetic activation to enable the freezing response and make covert the effects of arousal. This prevents external expression of arousal symptoms. The primary autonomic changes are aimed to assist the rabbit to stay as still as possible, the muscles tense further with a heightened muscle tone specific to a freeze response. Focus of attention is now on the threat (the fox). When the threat is further away, a freeze based response makes sense, it enables time to further prepare or assess when you cannot flee to safety (without making it worse) and you cannot fight it, as the threat is in the distance/future and not imminent. The main anxiety disorder where the threat is located in the future is obviously GAD which has a primary autonomic arousal response of freeze with the threat. Some other anxiety disorders also show situational specific freeze based responses along with fight or flight in other situations, due to the proximity of the threat when it is not imminent, compared with alternating times of active defence responses (fight/flight) when the threat is more imminent. This includes social anxiety disorder and health anxiety disorder for example. So the purpose of funnelling in the assessment is to gather specific recent examples and look at the autonomic, behavioural and cognitive symptom cluster at key time points to see if the response differs according to the situation and proximity of the threat the patient is in. Now, imagine scenario 2. The rabbit is happily in the field, looks up and this time, the fox is only one field away and appears to be looking in the rabbits direction. Arousal will be initiated again as before, this time followed by an active defence response appropriate for the situation rather than freeze. The rabbit is in imminent risk of harm as the threat is closer and higher, it will need to take aversive action to try to escape, to flee to a place of 11

safety. When faced with an imminent threat, it makes sense that escaping the threat, fleeing to a place of safety when able to do so, is the better option to fighting. Sympathetic arousal activation is maintained and further amplified in an active defence response, motor networks remain activated, heart rate and respiration increase, sympathetic efferents inhibit digestive function in the gut, vasoconstriction of blood vessels that supply the salivary glands takes place (this can lead to a dry mouth, as in turn can the switch made to breathing through the mouth to take in more oxygen). The body will prepare for the rabbit to run, it wants to maintain the increased cardiac activation and energy to escape. The vasodialation and increased blood flow can make the person feel unsteady as it takes the route up and through the brain and can also lead to feelings of pins and needles or tingling sensations. Interestingly, fight or flight active responses have been shown to also initiate analgesia to block pain signals in the spinal cord in case of injury. Sweating can be initiated from the contract muscles under the skin to reduce body temperature as it increases through exertion © Marie Chellingsworth (2020). The CBT Resource.

of running. The focus of the rabbits attention will be widened as its pupils dilate, it needs to focus on the exit from the field and also on the threat, the fox. A good way of thinking about this focus of attention is like watching the lead cyclist in a velodrome race. He needs to look at the finish line (his exit) but also spends a large part of the race looking back at his competitor behind him to ensure he has not caught up or will overtake him). An example of a flight response in panic disorder is any time the patient undertakes a behaviour to escape from their feelings of fear, for example physically leaving a situation before they planned, such as dropping their shopping and running out of a supermarket, or by adapting behaviour to leave a situation more quickly, for example by taking the shortest queue. Panic patients often report that they look and plan for exits and escape strategies, in case they need them. It is important to ask about these adaptations within assessment by asking for examples of situations and what they do to manage their symptoms. .

Now, imagine scenario 3. This time when the rabbit looks up, the fox it is within a few meters distance and can cause imminent harm. The rabbit cannot run away quickly enough, it wouldn’t make it on time and is cornered. This time, a fight response will be used. A fight response is an active fight for its survival. From a physiological perspective, it shares the same symptoms as flight, an active defence. One noticeable change is focus of attention, now locked onto the threat (the fox). An example of a fight response within humans would be either attacking or lashing out or in an anxiety provoking situation a patient cannot escape from, a resulting peak of symptoms within a few minutes, leading to a full panic attack. Now imagine scenario 4, this time, when the rabbit looks up, the fox is right there, it cannot escape and it is not able to fight to defend itself (imagine in this situation the fox has it cornered, is far bigger a threat to the rabbit and the rabbit cannot fight back and likely survive). The flop response, tonic immobility, is a last ditched attempt to preserve life. It occurs when fight or flight is switched off and has a different physiological presentation. Sympathetic activity is withdrawn. In a flop 12

response, the animal or person loses control of its muscles initially and involuntarily ‘flops’ to the floor, but unlike faint, remains conscious. After the initial loss of muscle control, rigidity is present, Paralysis of the muscles occurs, meaning movement becomes temporarily suspended, which mimics rigor mortis. Rigor mortis is a post-mortem stiffening of the muscles due to chemical changes in their myofibrils. The function of a flop response is to deactivate the predators natural instinct to kill it. If the rabbit is already dead, the fox will (like most predators) carry the prey to a place of safety to eat it - or bury it for later, where he too is not at risk from a predator of his own. In a flop response, the rabbit will appear dead, it will not be responsive to touch, as such, it offers no resistance to the fox and will not scratch or bite, meaning he can carry it away to his den without much resistance. When able, the rabbit can then make one last escape attempt when the fox releases control of it and run. There are numerous examples of this within the animal world, across mammals, insects, fish, reptiles and birds. Many can be seen on videos posted to You Tube of lucky animals appearing dead, but escaping from the jaws of a predator at the last moment. This state used to be (cruelly) often invoked in pet rabbits by well meaning owners, by turning them on their backs and tickling their tummies. They would go rigid and people would think it was cute and the rabbit was happy. The rabbit however thought its life was in imminent danger from their owner, was immobilised and trying to prevent being killed. Luckily, these days the majority of rabbit owners know this is not ethical! In humans, this response is seen only in extreme situations where there is significant imminent risk to life and fight or flight is either not possible or would significantly increase risk of mortality. It comes with disassociation and de-realisation from the situation as cognitive 13

processing is interrupted. Patients usually report feeling numb, with little or no memory of specifics of what happened. The flop response enables the person to get through the incident with the chance of least injury or resistance. The collapse and immobility protect from injury to vital organs and maintain blood flow to the brain. The flop defence response is seen with traumatic incidents in PTSD cases, such as situations experienced in war and conflict, terrorist or other violent attacks or in cases of sexual assault. Often the person describes feeling guilt or shame, that their ‘body let them down’ for not fighting back, but report not being able to move or being ‘paralysed with fear. In our final scenario, there is no fox, but our rabbit has traumatically injured itself and is bleeding. The faint response is seen particularly in humans, although is shared with some animals. It is a passive immobility response, sometimes referred to as collapsed immobility or vasovagal syncope. Fainting is a consequence of fear response leading to a temporary loss of consciousness. This © Marie Chellingsworth (2020). The CBT Resource.

response occurs specifically in blood, injection and injury phobia. Physiologically it is a variant of tonic immobility with greater loss of blood flow to the brain. It has been seen as part of the fear cascade for some time and reports of fainting responses can be found going back across history (Bracha, 2004). The faint is caused by bradycardia-induced hypoxia. After the initial arousal response increases heart rate and blood pressure, a sudden drop in blood pressure from this initial spike level occurs, due to a rapid surge of parasympathetic response. This causes a temporary decrease in blood flow to the brain, resulting in fainting and loss of consciousness (known as syncope). Regulated blood flow to the brain is required constantly, the sudden drop in blood pressure from the physiological response to the fear is a shock response. This defence response is believed to be to protective against high levels of blood loss. Major injury and trauma resulting in blood loss can be quickly fatal and lead to haemorrhagic shock.

The fear defence cascades, along with the cognitive themes of each disorder (such as catastrophic misinterpretation of bodily sensations of arousal as a sign of imminent harm in panic disorder) are essential to have in mind in an assessment. To gather specific situational examples of the patients fear, clustering the autonomic, behavioural and cognitive changes that take place for the patient. Think when funnelling, what is the fox/ threat they fear and when it is present, how doe the autonomic, behavioural and cognitive symptoms cluster?, Where is the fox/threat they fear, in the distance/future or up close there and then?, Does it remain one defence cascade or change depending on situational variables? Is it future focused threat like in GAD, or imminent fear of harm, like in panic disorder? Does it vary in autonomic response depending on the situation, for example the difference between worrying about a future event in social anxiety and the lead up to it, versus being at a social event like a party or work presentation.

Panic and the defence cascade In panic disorder, the involuntary autonomic physical sensations of the adrenalin response have been misinterpreted by the body as being a sign of imminent threat. From a physiological perspective, the amygdala in the limbic system has learned, through conditioning, that these physical sensations of arousal are a threat that needs an active fear cascade defence. Therefore, the amygdala sends the alarm to the hypothalamus (just like an over-sensitive smoke alarm going off when classical there is no real fire, just burning toast or dust!) whenever internal (body sensations/ thoughts) or external (situations/places) triggers occur. As a learned response, this can be over-learned, through exposure and habituation, which teaches the body the alarm is not required for these symptoms. As these triggers cause arousal, the threat is always imminent and an active defence response initiated (fight or flight). Right at the time they are experiencing the trigger, be it a place, a physical sensation, a thought - even about something in the future - the threat (arousal symptoms) is right there when the fear response is initiated by the amygdala. In literal terms, panic disorder is a fear of fear. These triggers can be any situations that bring on the physical symptoms of the arousal response. These could be busy, crowded places; of previous panic attacks, or also neutral activities and situations that bring on physical sensations that are also part of the arousal response symptoms, like exercise, sex or even walking up stairs, as these increase heart rate, or other physical body changes that happen in arousal such as sweating or a dry mouth. Understandably, the person begins to avoid things that trigger feeling this way as much as possible. They may also try to escape from these situations if they begin to have symptoms and cannot avoid them, or may do things to make them go down more 15

quickly. People with panic disorder have a range of safety seeking behaviours that they add to their behaviour feel ‘safer’ in these situations. These are done initially to help with the unpleasant physical symptoms they experience, such as carrying water for a dry mouth, taking someone out with them, adapting when they go, listen to music on headphones, walk at the edge of busy streets, use a stick to walk or a trolley in supermarkets to manage feeling unsteady or carrying emergency numbers as just some examples. They may use alcohol to feel able to face situations, or carry around herbal or prescribed medications ‘just in case’. Other patients may avoid alcohol, coffee or similar substances as they bring on their symptoms. People may also use more covert and subtle safety seeking behaviours to divert their attention away from their symptoms and distract themselves, for example humming or trying to think about other things. Asking about what they do and gathering specific examples is very important as these things may otherwise negatively impact on exposure exercises or can be contra-indicated with exposure and habituation (such as use of benzodiazepines or beta-blockers). It also helps with hierarchy creation. For every safety behaviour gathered, the associated autonomic symptom that it brings relief from should be linked and checked and what they think would happen if they did not do the safety behaviour asked. These adaptations to behaviour serve to maintain the panic disorder, with the reason for not panicking attributed to this. They backfire as then become part of the pattern and also block over learning that the fear response was not required from taking place.

The ABC maintenance cycle of Panic

Physical symptoms

Palpitations, Increased heart rate, Sweating, Trembling or shaking, Shortness of breath, Dry mouth, Chest pain, Nausea, Feeling dizzy, Unsteady or light-headed, Chills or heat sensations, Numbness or tingling sensations (paresthesias) Feeling detached (de-realization)

Behaviours Avoidance of internal and external triggers Escape behaviours to get through situations more quickly or to leave if symptoms become to high Safety seeking behaviours to reduce fear artificially

Altered thoughts “I am having a stroke” “I am having a heart attack” “I am choking” “I am going crazy” “I am going to collapse” “I have to get out of here” “I must avoid triggers for feeling anxious” “People will stare at me”

Introducing Exposure and Habituation Practitioner: “You may have noticed that I asked you about three main areas today, how your anxiety has affected how you are feeling physically, how it has affected what you are doing or not doing and how it has affected your thinking, as on the diagram here. That is because in a CBT model, these three areas are interlinked and can have a knock on effect on each other. For example, when people are feeling anxious, under some kind of stress or threat, their body produces a rapid rise in the physical symptoms of the adrenalin response. This is to prepare you to manage the threat your body feels it is under. The symptoms can feel very unpleasant and scary and seem like something catastrophic is going to happen” Patient: “Yes, they do” Practitioner: ‘These symptoms happen very quickly on response to a trigger and are involuntarily controlled by the body. They include things an increase in heart rate and blood pressure to pump blood around the body to the arms and legs to help you to act quickly, breathing changes to help you take in more oxygen, which can make the mouth feel dry, you may feel dizzy or like you are going to faint as the oxygen rich blood flows to your arms and legs. As they feel so unpleasant it can feel like something more catastrophic is going to happen at the time. The body then learns that these symptoms themselves are a source of threat and begins to trigger the adrenalin response any time they occur, sometimes it can seem like they can even come on out of the blue. Understandably, you begin to try to avoid things that bring these symptoms on. This gives some short term relief, but in the long term, it maintains the anxiety and the body does not learn it does not need to produce these symptoms on response, so the adrenalin response system keeps going off. It is a bit like an over-sensitive fire alarm that is going off for something it doesn’t need to. Your body has learned to fear the symptoms of the fear response themselves” Patient: “OK, yes, that makes sense” Practitioner: “Avoiding and adapting what you do to manage these symptoms places a lot of restrictions on your life, and it is hard to avoid these triggers altogether as they are physical symptoms that can happen at other times too, such as your heart rate increasing when you exercise, which you have mentioned is difficult now and brings on your attacks. So, just to check your understanding and that I have explained it well enough, could you perhaps explain back an example of how your symptoms we discussed are affecting you in the cycle?” Patient: “So my heart beats out of my chest and I think I am having a heart attack, so I try to avoid places that trigger my attacks, but because my body has learned to fear the physical symptoms of adrenalin, anytime my body notices a similar symptom, like when my heart rate goes up if I take the stairs for example, it brings on an attack...and on it goes....” Practitioner: “Yes absolutely, it seems you have a really good understanding. The good news is we can do things that will break into the cycle to help to reverse it the other way, and reverse this learning in the body, to switch down the sensitivity of the alarm. I can explain more about treatment method that is recommended and shown to help with this called Exposure and Habituation next, if you would like me to and there is also more information in this guide, I have marked the pages for you……..”

Building hope is an important aspect in engaging a patient into facing their fears. Explaining how exposure and habituation works is essential to that engagement. The aim is to increase expectancy of exposure and response prevention being beneficial for their individual symptom profile and that change is possible. Although treatment will be challenging, it is graded and supported and those who do it, see incredible benefits on the impact of their symptoms on their daily life. To do this, it can be beneficial to ask the patient to visualise their symptoms have improved and consider what they would be doing, where they would be going and who they would be spending time with in their daily life. What things would they want to do more of, what do they feel they have missed out on that this could open up for them? This is a great way to set targets and lead to automatically smart focused goals to aid motivation. It is also beneficial to let the patient know that they can begin working on these symptoms from today and that improvements usually begin to happen in just a few weeks. This of course needs to be balanced with being realistic about the amount of work and commitment involved in the short term, alongside these longer term benefits and everything they will gain from it. Be specific about how much time they may need to set aside in week one and then subsequent weeks to aid homework compliance and ensure the patient is aware of this from the start and how it will reduce as habituation takes place. It is also important to prepare the patient that they will initially have more symptoms, but in a managed, graded way that feels realistic and achievable. It is important to normalise this before it occurs, so the patient does not disengage. The patient needs to understand that during exposure feeling the symptoms and not avoiding them is the way in which the body learns to no longer fear them, and doing anything that brings these down artificially, or makes the fear too low will mean they feel fear but without the benefit of the treatment working, so the conditions are an important part to meet. If the patient is reluctant to try the treatment, an agreement with the patient to give it a try as a treatment for 2-4 weeks, then review it together can often be enough to engage less motivated patients alongside the motivational techniques provided in the patient material.

Creating the hierarchy It is unrealistic that the hierarchy will be fully completed within a first session and easier exercises for a change method to be completed in week 1 is planned sufficiently. Completion of the hierarchy should never be prioritised over enabling the patient to start the active dose of the exposure and habituation change method from the first sessions homework. Therefore, in session one, aim to complete some of the hierarchy in the most difficult, easier and more difficult sections, ensuring that there is an exercise that gives sufficient predicted anxiety (50-60%) . This ensures enough time is left to ensure the patient is clear on the 4 essential conditions and how they operationalise, when to stop the exercise and how to record each exercise on the diary. The hierarchy gaps between these items put in can then be finished for homework or at the next session.

When creating the hierarchy, it should always be remembered that the aim of the hierarchy is increasing levels of fear, not decreasing levels of avoidance. The aim of the hierarchy is to enable sufficient physiological arousal to take place, using the exercises as a way of bringing autonomic arousal symptoms on. The hierarchy may include both interoceptive situations that bring on these physical symptoms, as well as confrontation of places they currently avoid or find trigger them. For example, a patient who thinks they are having a heart attack when their heart races, may avoid places they find triggers their panic, such as busy, crowded places. Similarly, they may also avoid exercise, as this increases the heart rate and brings the response on. They can do things that bring on an increase in heart rate, such as going up and down stairs, or jogging on the spot as well as going into situations. Often these options can be less daunting for initial steps if the patient is struggling to identify easier steps, as they can be done in the home and still bring on symptoms to a sufficient level. The patient is being exposed to physiological arousal, bringing on symptoms for them to habituate to them. The hierarchy should never be graded in the amount of time or amount of an activity that will be done, e.g. if going to the supermarket is an exercise, they would need to remain there until arousal drops by 50% to end the exercise. We don’t know how long that will take for each individual. The other important factor is the patient needs to be made aware this is treatment for the sake of treatment, they work to the plan at the planned times, not go out only when they need some shopping and combine this with an exercise. They need to complete the homework for the purpose of the exposure and habituation treatment and pay full focused attention on their arousal level, not be distracted by getting shopping or speaking to others.

The 4 essential conditions of exposure and habituation As a practitioner, being able to spot any essential condition problems on planned and completed homework diary visually is important, as well as assisting the patient to draw out the habituation curve for each step as a visual indicator in review.

Graded: The first condition is that exercises are graded. This needs to be so there is enough

anxiety to habituate, but it is not too overwhelming and feels manageable. 50-60% is a good starting exercise, any lower and symptoms are not high enough for the fear cascade response and over learning and habituation to take place, any higher and the response is more likely to lead to a panic attack and disengagement.

Prolonged: The second condition is that each time the patient completes an exercise, that they

need to stay in the situation until their anxiety drops by 50% from the start of the exercise rating. They should complete the duration on the diary at the end of the exercise, once it is known how long this took. This is a measure of progress towards habituation and highlights any instances where it has not come down as quickly as expected, or may have come own too quickly, suggesting a problem with the way the exercise has been carried out.

Repeated: The third condition is that each step of the hierarchy needs to be repeated until it

no longer triggers a high level of fear. 4-5 exercises of exposure a week on average is needed to achieve over learning of the conditioned response. Some weeks the patient will need to a mix of steps if they habituate to one mid way through before their next session. They repeat each step of the hierarchy as an exercise until your anxiety drops to 40% or less before and at the start of the exercise at least once. Then habituation to that step has taken place and they can move to the next exercise. Remember each step will produce an increased level of fear as they work up the hierarchy and take more time to drop, although it often gets easier than predicted.

Without distraction: The final condition is that they need to be aware of any internal or external

distractions, even subtle things that can distract them while doing the exercise. These must be discussed with the patient and a clear rationale given for how they must experience the anxiety without any safety behaviours or anything to bring anxiety down artificially, including subtle internal and external avoidances.

The importance of homework

Change method homework is the focus of CBT, with the sessions to guide and support use of the techniques between sessions. Change methods are needed from the first session for the correct dose of the intervention to be possible and get recovery rates up. A change method from the first session has been shown to be a strong factor in patient engagement and reliable improvement in IAPT (Ewbank et al, 2019). As Laidlaw, (2015) states homework is not an optional extra to be used as and when it suits, but must form the start and end of every session. Research tells us that patients who are compliant with homework get the best outcomes (Coon & Gallagher-Thompson, 2002; Kazantzis et al., 2005) and that reviewing homework on the part of the practitioner increases patient compliance (Tompkins, 2002). Unlike high intensity CBT approaches, where  the session time is longer and somewhat more flexible; due to the time and evidence of Low Intensity CBT and the way in which it brings about change, the focus should always be on the change method tasks that the patient does between sessions. Effective Low Intensity CBT © Marie Chellingsworth (2020). The CBT Resource.

treatment sessions, whether delivered on the telephone or face to face should always use a Plan It, Do It and Review it cycle structure. This means the focus of the first treatment session should be on making an effective plan for the change method inter-session task that the patient is to carry out between your sessions. Whether you use the term homework or inter-session task is entirely down to you and what your patient would prefer. Some patients with negative experiences of school may prefer the latter. Any potential internal things that may get in the way of their plan (things within them like confidence or understanding for example) or external things (like neighbours popping round or a friend calling on the telephone) that are outside of their control should be considered and problem solved in advance when homework setting, not resolved after the event, to maximise the potential of the patient carrying it out and having a good experience of the task. The homework plan on the diary for completion in the following week should be routinely checked off against the 4 essential conditions at the end of the session to reinforce their importance.

Review change method h/w learning

Plan next change method h/w

Patient will do change method h/w plan between sessions The patient should then go off and carry out their plan. The focus of subsequent sessions should be to review the change method tasks completed, problem solve any difficulties that have arisen and then make a new plan for the patient to go off and do more of the change methods of the protocol (and so on....). This structure does not and should not change in the context of working with someone with an LTC or an older adult. At times, the person we work with may not be used to a structured approach or may find it difficult to work within it. They may present challenges. When this occurs sessions can easily drift away from change method homework planning and reviewing into eclectic and nonevidence based support. If drifting from the agenda becomes problematic in a session, having already outlined the structure and way of working in the approach from the outset allows a gentle but clinically important reminder to be made such as: 23

“As I mentioned when we first met, this is a time limited and active approach. To get the most from the sessions it is important we keep to the structure of reviewing how your change method tasks went this week, the tasks that work to improve your symptoms and meet your goals and us have time to make a new plan for next week. With that in mind, can I bring us back to......” OR “It is important to me that you get the most from the sessions and time that we have together. To do that we need to keep focused upon the tasks you did between session and make a new plan. I would like us to look at your homework next to make sure that we have time to complete the agenda, can we move back to your worksheets and then if there is some time left at the end we can pick up this discussion if you would like to.”

Manage endings When working briefly, practitioners can find it challenging to raise the issue of discharge, particularly if the patient is socially isolated or lonely as a result of their difficulties. Patients may wrongly assume that treatment will go on for longer than the short-term nature of Low Intensity CBT. A clear discussion at the start of treatment about the structure and short term nature of the approach can stop this from feeling abrupt when it arises. Practitioners may also find it helpful to remind patients at each subsequent contact about the number of sessions before a review will take place (usually at session 4 of treatment for exposure and habituation). In an active CBT based intervention, if a patient is not engaging in exposure and habituation exercises, despite solid rationales and motivational support, this should be taken to case management supervision and an honest discussion with the patient take place about the focus and structure of the approach. If the patient continues to not engage with the change method, but is attending sessions looking for a more informal discussion or supportive approach, this needs to be flagged to supervisors and a decision made to either step the patient up if this will likely increase engagement with CBT or, discharge them with signposting advice or services who may be better able to meet their needs. If a patient is discharged for this reason, a discussion about the right time for engaging in treatment and being able to refer themselves back when they are ready should take place.

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Useful references American Psychiatric Association (Eds.) (2013) Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. Bracha, H.S., Ralston, T.C., Matsukawa, J.M., Williams, A.E., Bracha, A.S. (2004) Does “fight or flight” need updating? Psychosomatics. London. Bracha, H.S. (2004) Freeze, flight, fright, faint: adaptionist prespectives on the acute stress response spectrum. CNS Spectr. Chellingsworth, M. (2020) Fears conquered with exposure and habituation. The CBT Resource. Chellingsworth, M., Laidlaw, K. and Davies, S. (2016) Low Intensity CBT with Older People. National curriculum for the IAPT Programme. Department of Health. Chellingsworth, M. (2017) Improve your mood with Behavioural Activation (BA). The CBT Resource. Gozza, A., Jain, A., Giovanelli, A. (2010) A neural switch for active and passive fear. Neuron 67:656-666. Kozlowska, K., Walker, P., McLean, L., Carrive, P. (2015) Fear and the defence cascade: clinical managament and implications. Harvard Rev Psychiatry. 2015. Jul: 23(4): 263-287. Fanselow, M.S. (1989) The adaptive function of conditioned defensive behaviour: an ecological approach to Pavlovian stimulus substitution theory in Blanchard et al (1989) Experimental approaches to the study of behaviour. Kluwer Academic. Boston. Farrand, P., Chellingsworth M. (2015). How to beat panic disorder one step at a time: Using evidence based low intensity CBT. Robinson. London. Lang, P.J., Simons, R.F., Balaban, M.T. (2013) Attention and orientating: sensory and motivational processes. Psychology Press. London. Marks, I.M (1987) Fears, Phobias and Rituals: Panic, Anxiety and Their Disorders. Oxford University Press. Mobbs, D., Marchant, J.L., Hassabis, D. (2009) From threat to fear: the neural organization of defensive fear systems in humans. Journal of Neuroscience. 29: 12236-43. National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: recognition and management. [CG113] (2011, last updated 26th July 2019). London. Porges, S.W. (2011) Polyvagal theory: neurophysiological foundations of emotions, attachment, communication, self regulation. Norton. London. Richards, D., Chellingsworth, M., Farrand, P. (2015) National curriculum for the education of psychological wellbeing practitioners. The Department of Health. London.

Marie Chellingsworth The CBT Resource® Marie is a renowned CBT and IAPT consultant, academic and author. She is the Founder of The CBT Resource and an invited Subject Matter Expert (SME) for a number of digital therapeutic and mental health services. She is a co-author of the IAPT PWP curriculum and high and low intensity CBT with older people curricula as well as a wide range of published resources for patients with anxiety and depression used internationally. Her work via The CBT Resource aims to help more people with anxiety and depression to be able to access evidence based treatments and ensure practitioners are supported to get optimal outcomes through CPD training and supervision. Run in a social enterprise approach, all profits are invested back into the creation of more resources and the work of the organisation. She has worked with UK national bodies and the IAPT workforce and training groups within the Department Of Health to maintain standards for CBT and IAPT based approaches and was Consultant to the successful implementation of the Australian IAPT programme. Prior to developing The CBT Resource, she was Executive Director of Evidence Based Programmes at UEA and Senior Lecturer and Director of Training at the Universities of Nottingham and Exeter. Her passion for CBT and working in this field first came after hearing a song called Howard Hughes (a B side of a band called Ride in 1992!). Outside of work she loves music, interior design, gardening and spending time on the local beaches and forests with her Irish Setters and with family and friends. www.thecbtresource.co.uk

Andy Poplar [Vinegar & Brown Paper]® The photographs of etched glass and objects throughout this programme are the work of Andy Poplar from [vinegar & brown paper]® ideas etched in glass. Special thanks and credit goes to him for enabling us to use these images. An award winning advertising creative, he set out to mend his head with [Vinegar & Brown paper] after his own anxiety and depression. At the heart of Andy’s work are his reflections upon his own experiences that led to his career change into etching glass. As [vinegar & brown paper], Andy has spent the last 8 years taking vintage or iconic items of glassware and bringing them to life with the tools of typography, wit, word-play and a slightly askew way of looking at the world. You can now find pieces of [vinegar & brown paper] on bookshelves everywhere, from York to New York (and a much happier man too). You can find more of Andy’s work on his website and his Facebook and Instagram pages on the links below. Website: www.vinegarandbrownpaper.co.uk Instagram: instagram.com/mendyourhead Facebook: facebook.com/mendyourhead

Clinician's guide to exposure and habituation for panic disorder using the Fears Conquered protocol

Articles inside

Useful references

Manage endings

About the author and Andy Poplar’s work

The essential conditions

The importance of homework

The ABC maintenance cycle of panic

Introducing exposure and habituation

The physiology of the fear response

Panic and the defence cascade

Typical treatment outline

Creating the hierarchy

Introduction

The ‘Fears Conquered’ with exposure and habituation