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 • 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

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).