For many people with panic disorder and agoraphobia, facing anxiety-provoking situations like taking public transport or entering crowded spaces can feel overwhelming.
Exposure therapy—where patients gradually confront these feared situations—is a cornerstone of treatment.
But a common experience during these sessions is fear overprediction: patients often expect their anxiety will be worse than it turns out to be. A new study investigated whether correcting these inflated predictions might be a key driver of treatment success.
This study by Marina Hilleke and colleagues, published in Depression and Anxiety (2025), explores the role of fear prediction and experience during exposure-based therapy for panic disorder with agoraphobia.
The researchers found that while patients consistently overestimated their fear at the beginning of therapy, improvements in the accuracy of these predictions did not appear to influence treatment outcomes. Instead, reductions in overall fear—regardless of whether they were expected or not—were more closely linked to symptom improvement.
Panic disorder with agoraphobia involves recurrent panic attacks and the avoidance of situations where escape might be difficult.
Exposure therapy, a type of cognitive-behavioral treatment, helps patients gradually face these feared scenarios.
Traditionally, one proposed mechanism of improvement has been expectancy violation—the idea that when patients experience less fear than they predicted, this mismatch corrects irrational fears and leads to recovery.
However, the evidence supporting this theory is mixed, and researchers are now exploring how different aspects of fear expectations contribute to therapeutic change.
This study, conducted as part of a large German multicenter clinical trial, included 268 participants diagnosed with panic disorder with agoraphobia.
Participants received a structured, manualized course of exposure-based cognitive behavioral therapy over 12 sessions. Each exposure involved predicting their level of fear beforehand and rating the actual fear experienced afterward, using a 0–10 scale.
Researchers then analyzed the discrepancy between expected and experienced fear over time, along with its relationship to treatment outcomes.
On average, patients began therapy by significantly overestimating the fear they would feel during exposure.
In nearly half of the first exposure trials, predicted fear was notably higher than what was actually experienced. Despite repeated sessions, the accuracy of these predictions did not reliably improve across treatment.
While both predicted and experienced fear declined, the gap between them—the prediction inaccuracy—remained relatively stable.
Importantly, what did change—and what mattered—was the overall reduction in both predicted and experienced fear levels.
The more patients’ fear expectations decreased over time, the better their scores on standardized measures of panic symptoms and avoidance at post-treatment and follow-up assessments.
This suggests that while overestimating fear is common, simply becoming more accurate at predicting fear may not be necessary for recovery.
For individuals undergoing exposure therapy, this finding highlights a key point: progress may not depend on perfectly aligning expectations with reality, but rather on repeated, emotionally engaging exposures that gradually reduce fear intensity.
In practical terms, even if patients continue to overpredict how afraid they’ll feel, they can still benefit significantly from exposure exercises.
Interestingly, the study also examined the potential influence of safety behaviors—actions like distraction or carrying a phone that people use to feel more secure during exposure.
Although these behaviors are often thought to hinder therapy, this study found no clear link between their use and the accuracy of fear predictions.
However, the researchers note that their measure of safety behavior was broad and may not have captured important distinctions between types of safety strategies.
The study’s findings have implications for how therapists structure exposure-based treatment.
Rather than focusing on correcting fear prediction biases, therapists might emphasize helping patients tolerate and observe their fear decrease across repeated exposures. Encouraging patients to reflect on fear reduction, rather than prediction accuracy, could help reinforce progress and reduce dropout rates.
There are limitations to consider. The study relied on self-reported fear ratings, which may be subject to bias.
Also, because exposure tasks were partially standardized, some may not have elicited strong fear responses, potentially influencing prediction accuracy.
Future research could benefit from including physiological or behavioral measures of fear, as well as examining different types of fear expectancies—such as expecting physical danger versus emotional distress.
Ultimately, the findings suggest that while overestimating fear is a common hurdle in exposure therapy, it is not necessarily a barrier to recovery.
What appears more critical is helping individuals reduce their fear responses over time, regardless of how well they anticipate them.
As exposure therapy continues to evolve, a better understanding of how expectations shape outcomes may refine how clinicians guide patients through anxiety treatment.
Citation
Hilleke, M., Lang, T., Helbig-Lang, S., Alpers, G. W., Arolt, V., Deckert, J., Fydrich, T., Hamm, A. O., Kircher, T., Richter, J., Ströhle, A., Wittchen, U., & Gerlach, A. L. (2025). How Do Patients’ Fear Prediction and Fear Experience Impact Exposure-Based Therapy for Panic Disorder With Agoraphobia? A Comprehensive Analysis of Fear Prediction. Depression and Anxiety, 2025(1), 6963860. https://doi.org/10.1155/da/6963860
