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.