Exposure When the Last Therapist Said Not To
Mr. T., 41, is an accountant who has had panic attacks for six months. He stopped driving more than five miles from home after an attack on the highway, has a coworker do his grocery shopping, and took leave from work three weeks ago. He carries a water bottle and a bottle of lorazepam tablets 'just in case' at all times, though he has taken only two tablets. His previous therapist, whom he saw for ten sessions, taught him progressive muscle relaxation and explored his childhood; he says he improved at first and then plateaued. He has hypertension managed with lisinopril and drinks two cups of coffee each morning. He asks you, 'Can we do relaxation and figure out why I'm like this? My old therapist said exposure would make me worse.'
1. Provide a formulation and explain how you would present the rationale for treatment to Mr. T.
Read the worked answer
Formulation: panic disorder with agoraphobia. The maintaining cycle is the fear of fear. A benign sensation (heartbeat, dizziness, breathlessness) is appraised catastrophically ('I'm having a heart attack,' 'I'll lose control on the highway'), which produces anxiety and more sensations, which strengthens the appraisal. Avoidance and safety behaviors - the water bottle, the lorazepam in his pocket, letting a coworker shop - short-circuit the test that would disconfirm the prediction. He never learns that the sensations are harmless because he never stays in the situation without his escape hatch.
Why the previous treatment stalled: relaxation reduced baseline arousal, which felt better, but it did not alter his catastrophic appraisals and it may have become another safety behavior (a way of controlling sensations). Psychodynamic exploration addressed origins, not maintenance.
Presenting the rationale honestly:
- Name the cycle and have him map a recent attack onto it.
- Explain that the goal is not to eliminate anxiety but to find out whether his predictions are true - exposure is a series of experiments, not a tolerance test.
- Address the prior therapist's warning directly: exposure that is gradual, collaborative, and under his control does not make panic disorder worse; dropout and premature, unbounded 'flooding' are what give exposure a bad name.
- Be explicit that he is in charge of the pace and can stop any exercise.
2. What do you do about the lorazepam, the water bottle, and the coffee?
Read the worked answer
All three are interoceptive or safety signals, and all three need to be addressed as part of the treatment rather than as side issues.
- Lorazepam PRN. He has taken two tablets in six months, which tells you its function is reassurance, not sedation. As-needed benzodiazepines can function as a safety behavior and, when actually taken before or during exposure, can interfere with the learning that drives extinction. Do not tell him to stop unilaterally - coordinate with the prescriber, agree that he carries it but does not use it during exposure, and revisit whether he still needs the prescription at all. Never direct an abrupt discontinuation.
- The water bottle. A portable escape route. It gets faded on a schedule: first carried but not used, then left in the car, then left at home for short trips. This is a graded behavioral task, not a rule imposed by you.
- Caffeine. Two cups daily is modest, but caffeine produces exactly the sensations he fears and raises baseline arousal. Suggest a two-week taper to decaf and frame it as removing noise from the signal, not as a prohibition.
Also confirm that his medical workup covered thyroid and cardiac causes; new-onset panic in a 41-year-old with hypertension warrants a basic medical rule-out before you attribute everything to the anxiety cycle.
3. How would you design the first two exposure exercises, and how would you measure change?
Read the worked answer
Session one: interoceptive exposure as a behavioral experiment. Build the hierarchy with him, then pick a symptom he fears most (likely cardiorespiratory). Have him rate the catastrophic prediction and his belief in it (0-100) before the exercise, then do 60 seconds of voluntary hyperventilation or stair climbing, then re-rate. Ask him directly: 'Did the thing you predicted happen?' The learning target is disconfirmation of the prediction, not a drop in anxiety during the exercise. Anxiety often rises and stays high; that is expected and should be predicted in advance.
Session two: a small in-vivo test. Driving a familiar route with the water bottle left at home, with a written prediction ('I will panic and have to pull over; I will be unable to continue'), a defined duration, and a planned debrief. Increase distance only when the prediction has been weakened, not when his anxiety score has fallen.
Measurement:
- Panic Disorder Severity Scale at intake and every four sessions.
- Weekly self-monitoring of panic frequency, anticipatory anxiety, and avoidance.
- A safety-behavior checklist tallied each week - fading these is the mechanism, so it deserves its own measure.
- Behavioral markers: distance driven, whether he returns to work, who does the shopping.
Judgment points: if he refuses an exercise, treat that as information about the prediction rather than noncompliance; if anxiety does not decrease across trials, look for a hidden safety behavior rather than concluding exposure has failed.