Learning theory applied to panic and avoidance (MEQ)

(i) Classical and operant / two-factor. Classically, interoceptive and situational cues (crowd, heart racing) have become CSs that elicit fear/panic CRs after pairing with intense panic (US-like event).^[9] Operantly, leaving the shop negatively reinforces escape by terminating aversive arousal; partner presence and carrying diazepam act as safety signals. Two-factor theory: classical fear to cues + operant avoidance/escape maintained by anxiety reduction, preventing extinction of the CS.^[3][4]

(ii) Extinction (Bouton). Extinction is new inhibitory CS–noUS learning, not erasure of the original CS–US memory; retrieval is context- and time-dependent.^[3][4] Relevant relapse phenomena: renewal if she only practices in clinic then returns to the mall alone; spontaneous recovery after a gap in practice; reinstatement after an unexpected panic or stressor US-like event; (bonus) rapid reacquisition if a full panic re-pairs cues quickly.

(iii) Inhibitory-learning exposure plan. Assess risk/medical exclusion; build hierarchy; rate specific expectancies (e.g. probability of collapse/heart attack). Design trials that violate expectancies (stay with heart racing without leaving). Fade safety behaviours: partner distance graded, no talisman benzodiazepine, no pulse-checking. Use variability and multiple contexts (different shops, times, alone). Process learning after trials; add retrieval cues; plan boosters against renewal.^[5][6][9]

(iv) Vs habituation-only. Habituation model ends trials when SUDS falls and may keep identical graded steps. Inhibitory learning prioritises expectancy violation and retrieval of safety learning; SUDS drop is neither necessary nor sufficient; variability and context diversity are deliberate.^[5][6]

(v) Defer elective exposure. Examples: acute suicide plan/intent needing crisis care; medical instability or uncontrolled arrhythmia concerns requiring medical review; severe intoxication; acute psychosis/mania; inability to consent to the plan. MI-style engagement and stabilisation can proceed, but intense interoceptive/mall exposure waits.^[6]