The Behavior Analyst Today Volume 7, Number 3, 2006

In Vivo Exposure Treatment for Agoraphobia

Katherine Porter, Carole Porcari, Ellen I. Koch1 , Courtney Fons
Eastern Michigan University
&
C. Richard Spates
Western Michigan University

Agoraphobia is a condition that most often occurs in the context of panic disorder and is characterized by
intense fear or anxiety of places or situations in which escape might be difficult or help might not be available in the
event of a panic attack or panic-like symptoms (APA, 2000). The purpose of this paper is to examine the behavioral
mechanisms that may be responsible for the development and maintenance of the disorder, as well as how the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

disorder can be treated. In particular, the effective use in vivo exposure is described.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Key words: In Vivo Exposure, Agoraphobia, Behavioral Treatments, Anxiety Disorders.

Agoraphobia is characterized by intense anxiety or fear of places or situations in which escape

might be difficult or help might not be available in the event of a panic attack or panic -like symptoms
(APA, 2000). These symptoms may include increased heart rate, sweating, trembling or shaking,
shortness of breath, a feeling of choking, chest pain, nausea, dizziness, feelings of derealization or
depersonalization, fear of going crazy, fear of dying, numbness or tingling sensations, or chills. The
individual develops a fear of dying, losing control, or embarrassing themselves during these panic -like
symptoms in a variety of situations such as driving, shopping, being in crowded places, traveling,
standing in line, being alone, or attendance of meetings or social gatherings.

Mowrers two-factor theory (1960) proposes to explain the anxiety response based on the
principles of both respondent and operant conditioning. Respondent conditioning is believed to have
occurred with the pairing of a stimulus that evokes a fear response with stimulus by-products arising from
strong bodily somatic sensations. Therefore, bodily sensations become conditioned responses triggered
by high levels of private stimulation generated by anxiety and fear. When the individual is confronted
with these triggers and the associated aversive emotions, the individual attempts to escape or avoid these
triggers. The result may be a reduction in fear and distress and the individual learns through negative
reinforcement that escape or avoidance of these cues reduces distress. Some debate exists on the
completeness of the respondent conditioning mechanisms involved in the development of panic disorder
(Bouton, Mineka, & Barlow, 2001). The debate in part centers on the role of selected cognitive appraisal
processes in relation to fear conditioning. Nonetheless, behavioral researchers seem clear on the operant
conditioning mechanism in the development of the agoraphobic response.

Agoraphobia most often occurs in the context of panic disorder; however, it can become
relatively independent of panic attacks (Craske & Barlow, 2001). An individual may not have had a panic
response for some time, although the avoidance behaviors associated with agoraphobia remain. Not all
persons who have experienced panic attacks or develop panic disorder go on to experience agoraphobia.
There has been no evidence that age of onset or frequency of panic predic ts an agoraphobic response,
however, agoraphobia tends to develop in younger individuals. In a study by Bourden, Boyd, Rae, and
Burns, (1988), 74% of the participants had developed agoraphobia before the age of 25. In addition, the
likelihood that agoraphobia will develop increases as the length of panic increases (Craske & Barlow,
1988). Panic disorder with agoraphobia is diagnosed three times more often in women than in men (APA,
2000) and this gender difference increases as the severity of the agoraphobic response increases (Craske
& Barlow, 1988).

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It can be challenging to differentiate agoraphobia from a specific phobia. A diagnosis of specific

phobia must be considered if the avoidance is limited to one or only a few specific places or situations.
Social phobia should be considered if the avoidance behaviors are limited to only social situations and
fear of negative evaluation from others. The primary fear in agoraphobia is that the individual will be
trapped or unable to get help in the event of a panic attack. In agoraphobia, stimulus generalization
typically occurs where multiple contexts and diverse situations (e.g., shopping malls, elevators, airplanes,
etc.) come to elicit the anxiety response.

Panic Control Treatment

As stated previously, agoraphobia typically occurs in the context of panic disorder, therefore, a
brief description of this treatment is provided. Both cognitive-behavioral treatment (CBT) and exposure
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

therapy are empirically validated procedures for panic disorder with and without agoraphobia (Chambless
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& Ollendick, 2001). Of these procedures, Panic Control Treatment (PCT) is the most widely utilized and
researched. PCT includes psychoeducation, cognitive strategies, and exposure-based procedures designed
to reduce fear of somatic sensations and agoraphobic situations. In addition, the protocol includes
relaxation strategies such as breathing retraining; however, a recent dismantling study suggests that the
relaxation component is unnecessary (Schmidt et al., 2000).

Individuals learn through PCT the nature of their panic and that the somatic sensations they
experience are not dangerous. Cognitive restructuring is then used to help the individual identify
maladaptive cognitions and replace these cognitions with ones that are more realistic and balanced.
Interoceptive exposure is employed to address the conditioned fear response to somatic experiences. It
involves systematic, repeated evocation and then exposure to the somatic sensations that are most
problematic for the individual. The feared sensations may be produced using idiosyncratic methods such
as spinning (to produce dizziness) or physical exertion (to increase heart rate). Through this process,
habituation is believed to take place, producing progressively weaker fear arousal and the individual
learns to be less afraid of their bodily sensations. In-vivo exposure is included in the PCT protocol to
target agoraphobia and is described in more detail in the following sections. For details of the entire PCT
protocol, please refer to the Mastery of Your Anxiety and Panic, 3 rd Edition workbook (Craske, Barlow, &
Meadows, 2000).
Treatment of Agoraphobia

Several meta-analyses and reviews have examined the efficacy of CBT and exposure treatments
for agoraphobic symptoms. An early revie w of the literature compared outcomes for treatments that were
classified as direct exposure (e.g. in vivo exposure), indirect exposure (e.g. systematic desensitization),
and treatments that were not exposure based (Jansson & st, 1982). The results demonstrated that 60 to
70% of people treated with in vivo exposure showed significant reductions in agoraphobic symptoms and
these reductions were maintained through a 6-month follow-up. Also, while this study was not a meta-
analysis, and as such, did not compare effect sizes, the authors noted that there was more empirical
evidence supporting the use of direct exposure compared to indirect exposure (Jansson & st, 1982).

A later meta-analysis examined the differences in behavior therapies on agoraphobic symptoms

(Trull, Nietzel, & Main, 1988). The results of this analysis showed that behavior therapy, as a whole,
produced a reduction in symptoms, but treatments that included exposure produced better outcomes.

In another meta-analysis, Chambless and Gillis (1993) explored whether or not the addition of
cognitive components increased the efficacy of exposure treatments. The results showed that in all but
one study, the effect sizes of the combined cognitive plus exposure conditions were no larger than
exposure alone. More recent studies also demonstrated no additional improvement in terms of
agoraphobia when cognitive components were added (van den Hout, Arntz, & Hoekstra, 1994; Williams

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& Falbo, 1996). The results of these studies indicated that cognitive treatment components did not appear
to add any effect beyond that of in vivo exposure in the treatment of agoraphobia.

This fact was most recently confirmed in a study by st, Thulin, and Ramnero (2004) whose
results indicated that the cognitive treatment components might not add to the effect of exposure for the
treatment of panic disorder as a whole. In this study, in vivo exposure was compared with a CBT
treatment that included in vivo exposure and cognitive techniques. The cognitive aspect focused on
challenging the participants misinterpretations and catastrophic thoughts regarding their bodily
sensations. The results showed that on the majority of outcome measures (31 out of 32 measures) there
was no significant difference between the two treatments. Overall, the addition of the cognitive
component did not lead to significant improvements in outcome. As a result of these findings, the present
paper will focus only on in vivo exposure for agoraphobic symptoms.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

In Vivo Exposure

In vivo exposure is a technique that draws directly from the concepts of respondent conditioning,
respondent extinction, and learning theory and it has shown efficacy in treating a wide range of anxiety
disorders. The essential aspect of the treatment involves arranging for the clie nt to confront the feared
situation repeatedly, in a methodical and systematic way. Two principles form the foundation of in vivo
exposure and underscore the importance of this systematic exposure to the feared situation: habituation
and extinction. The principle of habituation suggests that when a response is elicited repeatedly, the
strength of the response decreases. In the context of exposure, as the person engages in the assignments,
the anxious response is repeatedly elicited and it begins to decrease in strength.

The principle of extinction suggests that as the conditioned stimulus is presented repeatedly
without the presentation of the unconditioned stimulus, the conditioned response will decrease. In the
context of agoraphobia, as the person is exposed to the avoided situation (conditioned stimulus) and does
not encounter the feared arousal (e.g. they do not experience a panic attack and are not trapped), the
avoidant responses that are based on this arousal should decrease.

Before beginning the actual procedure, time must be spent evaluating which situations the client
avoids, as well as how much distress these situations cause the person. In order to do this, the client and
therapist develop a hierarchy of feared and avoided situations, which are ranked based upon level of
distress. Distress is measured on a 0 (no distress/anxiety) to 8 (extreme distress/anxiety) scale (White &
Barlow, 2002; Craske & Barlow, 2001). The Subjective Units of Distress Scale (SUDS) is also commonly
used to represent the individuals level of anxiety/distress on a 0 (no distress/anxiety) to 100 (extreme
distress/anxiety) scale (Wolpe, 1969).

Within the hierarchy, a range should be represented. In other words, activities or situations that
represent minimal or moderate distress should be included, as well as situations or activities that represent
a severe amount of distress. Once the person is in the in vivo situation, standard protocols suggest they
should remain in that situation until their distress decreases by at least half. Additionally, it is important
that the person does not end the in vivo assignment when they are at their peak anxiety level or while they
are experiencing a panic attack. Ending at these points, it is believed, will only serve to reinforce the
avoidant behavior. Furthermore, recent research suggests that the treatment context itself may come to
elicit aversive arousal and thus could become the basis for escape behaviors on the part of the patient
(Garcia -Palacios, & Botella 2003; Morgan, & Raffle 1999; Powers, Smits, Telch 2004; Sloan & Telch
2002; Salkovskis Clark, Hackmann, Wells, & Gelder 1999). These behaviors, when evoked, interfered
with treatment by reducing its impact on primary targets, lengthening the duration of treatment, or leading
to premature termination from treatment. See the discussion below in reference to safety behaviors and
their effects.

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Considerations for In Vivo Exposure

Along with the basic guidelines outlined above, diverse in vivo exposure procedures have been
studied. Specifically, Craske and Barlow (2001) identify five variations of in vivo exposure including, (1)
therapist-directed versus self-directed, (2) massed versus spaced, (3) graduated versus intense, (4)
endurance versus controlled escape, and (5) attention versus distraction.

There are advantages and disadvantages to utilizing a therapist-directed or a self-directed

exposure procedure. For individuals with more severe agoraphobia, or for individuals who are less
motivated or educated, therapist-directed exposure has been found to be more effective than self-directed
exposure (Holden, OBrien, Barlow, Stetson, & Infantino, 1983). However, self-directed exposure has its
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

advantages in that it encourages independence and generalization. It is generally recommended that

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treatment be initiated in a therapist-directed approach and proceed to a self-directed procedure (Craske &
Barlow, 2001).

Exposure can be conducted in long, continuous sessions (massed) or shorter interrupted sessions
(spaced). No optimal exposure rate has yet been determined in terms of overall efficacy, or dropout and
relapse rates (Craske & Barlow, 2001). In one study, 10 weekly sessions of in vivo exposure were
compared to 10 daily sessions of exposure for patients with agoraphobia (Foa, Jameson, Turner, & Payne,
1980). Results of the study indicated that the massed exposure treatment was more effective. However, in
another study, a similar protocol was used with 36 participants, half of which had agoraphobia
(Chambless, 1990). The massed and spaced exposure conditions were found to be equally effective
immediately following treatment and at 6-month follow-up. The therapist and client together should
determine the appropriate rate of exposure taking into consideration the clients current level of distress
and possible impact on their social and occupational functioning.

Another consideration for the in vivo protocol is the approach to the items on the hierarchy. Each
item on the hierarchy is ranked as to the expected level of distress when confronted with the situation.
The in vivo hierarchy may be approached gradually, starting with the least difficult item or intensely,
starting with the most difficult item. Feigenbaum (1988) compared gradual to intense in vivo exposure
and found both conditions were equally effective at posttest and 8-month follow-up. However, intense
exposure was found to be superior at a five-year follow-up assessment. It should be noted that the intense
exposure was conducted in a massed format and it is not known whether intense exposure could produce
similar results in a spaced format.
Consistent with an extinction model in the reduction of anxiety, exposure is typically continued
with no escape until anxiety is reduced. However, some studies suggest that controlled escape, allowing
the individual to leave the feared situation before completion of the exposure task, can also be effective
when the individual immediately returns to the situation (DeSilva & Rachman, 1984; Rachman, Craske,
Tallman, & Solyom, 1986). In the studies cited, one group of individuals was allowed to escape their
exposure task after reporting a SUDS of 70 and then was instructed to immediately return to the exposure
task. The other group was instructed to remain in the feared situation until their anxiety peaked and then
was reduced by at least half. Both conditions were found to be equally effective, although more perceived
control was reported in the escape group. If controlled escape is to be implemented, the therapist and
client must operationalize and plan for inclusion of this strategy.

Finally, one study has examined instructions to focus on feared somatic sensations or a distraction
task during in vivo exposure for agoraphobia (Craske, Street, & Barlow, 1989). At posttest 54% of the
distraction group demonstrated high end-state functioning compared to 25% of the focused group.
However, the focused exposure group significantly improved from posttest to 6-month follow-up with
63% (versus 42% of the distraction group) meeting high end-state functioning. Additional studies

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examining the impact of various instructions during in vivo exposure are needed. It may be the case that
individuals naturally utilize distraction more frequently than realized through safety signals or safety
behaviors.

One final issue to consider prior to the actual implementation of in vivo exposure is that of safety
signals. It is important that any safety signals that the person utilizes are identified. Safety signals are
typically people or items that make the person feel more safe or comfortable in the avoided situation
(White & Barlow, 2002). In other words, they are things that the person brings with them to the situation
(or does in the situation), that makes them believe they are safe (e.g., carrying a water bottle, gum, or
medication bottle at all times, entering situations only with a friend present, attempting to distract
themselves in some way, etc.). The problem with safety signals is that the person may attribute their
safety and their ability to cope during the in vivo assignments to the presence of the safe object or activity.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

This means that the person may not learn that they can remain in those situations and tolerate the anxiety
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until it reduces, but instead learn that they can only survive if they bring object X or person Y with them.
As a result, it is important that safety signals be identified prior to beginning exposure, and that these
signals are systematically eliminated before concluding treatment. One particularly difficult behavior to
extinguish is carrying anxiolytic medication just in case it is needed. If this is the case, prior to
terminating treatment an in vivo hierarchy could be created to address this specifically. This may include
leaving the medication bottle in the car while the person enters the shopping mall briefly and eventually
keeping it at home during a short trip.

This issue is related though not necessarily identical with another problem that emerges in the
context of in vivo exposure. It is referred to as safety behaviors. These constitute behaviors displayed by
the clients, which function to reduce fear relevant arousal in the treatment context. An example of a safety
behavior would be tensing legs, holding on to nearby objects, and seeking a seat when experiencing
weakness in the legs and a fear of collapse (Salkovskis et al., 1999). These are essentially escape
behaviors, which in effect reduce contact with the target stimuli designed by the treatment plan, to
undergo extinction. With this reduced contact, comes reduced impact and efficacy. The client might
succeed on the one hand in reducing momentary discomfort, but the treatment plan fails in the final
analysis or is seriously impeded in efficacy.

Of the five recent studies to investigate this phenomenon, four measured changes between groups
and one study involved a single subject design with alternating treatment conditions. All of the studies
examined pre to post changes across treatment conditions with regard to the effect of safety behaviors on
treatment gains. All studies found that the use of safety behaviors significantly impacted exposure
treatments in a negative manner (Garcia -Palacios, & Botella 2003; Morgan, & Raffle 1999; Powers et al.,
2004; Sloan & Telch 2002; Salkovskis et al., 1999). Attention must therefore be given to identifying and
addressing safety behaviors as part of the assessment in the early stages of treatment. If treatment is to
have greatest impact, the safety behaviors must be significantly reduced or eliminated.

Summary

Agoraphobia is a disorder that most often occurs in the context of panic disorder and is
characterized by fear and avoidance of certain places and situations (APA, 2000). Previous research has
demonstrated the efficacy of in vivo exposure in treating agoraphobia and has suggested that the addition
of cognitive or relaxation components do not lead to improved outcomes. As a result, the purpose of this
paper was to briefly outline the theory behind in vivo exposure and describe how it can be used to treat
people who are suffering from agoraphobia.

References

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Author Contact Information:

Katherine Porter, Doctoral Student, Eastern Michigan University, Department of Psychology, 537 Mark
Jefferson, Ypsilanti, MI 48197, TEL: (734) 487-0394, FAX: (734) 487-6553, e-mail:
katherine_e_porter@hotmail.com.

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Carole Porcari, Doctoral Student, Eastern Michigan University, Department of Psychology, 537 Mark
Jefferson, Ypsilanti, MI 48197, TEL: (734) 487-0394, FAX: (734) 487-6553, e-mail:
caroleporcari@yahoo.com.

Ellen I. Koch, Assistant Professor, Eastern Michigan University, Department of Psychology, 537D Mark
Jefferson, Ypsilanti, MI 48197, TEL: (734) 487-0189, FAX: (734) 487-6553, e-mail:
ellen.koch@emich.edu.

Courtney Fons, Doctoral Student, Eastern Michigan University, Department of Psychology, 537 Mark
Jefferson, Ypsilanti, MI 48197, TEL: (734) 487-0394, FAX: (734) 487-6553, e-mail: cfons@emich.edu.

C. Richard Spates, Professor and Director of Clinical Training, Western Michigan University, Department
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

of Psychology, Kalamazoo, MI 49008, TEL: (269) 387-4329, FAX: (269) 387-4550, e-mail:
This document is copyrighted by the American Psychological Association or one of its allied publishers.

CRSpates@aol.com.

1
Corresponding Author: Ellen I. Koch, Eastern Michigan University Department of Psychology, 537D
Mark Jefferson, Ypsilanti, MI 48197. Tel: 734-487-0189, e-mail: ellen.koch@emich.edu.

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