Live exposure to agoraphobic situations (if applicable)

When Panic Disorder is accompanied by agoraphobia—the fear and avoidance of situations where escape might be difficult or help would not be available in the event of a panic attack—in vivo exposure to these feared situations becomes an essential component of treatment.

Agoraphobia as Conditioned Avoidance

People with agoraphobia often avoid a variety of situations such as public transport, open spaces (car parks, bridges), enclosed places (shops, cinemas), queuing or being in crowds, or even being out and about alone.

This avoidance is due to the fear of experiencing a panic attack or disabling symptoms in those places and being unable to escape or get help.

Avoidance, although it reduces anxiety in the short term, maintains and reinforces the agoraphobic fear in the long term, as the person never has the opportunity to prove that they can handle the situation or that their fears are unfounded.

In Vivo Exposure Hierarchy Design

As with other forms of exposure, treatment for agoraphobia using in vivo exposure begins with creating a hierarchy of feared and avoided situations.

Specific situations that the person avoids (e.g., going to the grocery store alone, riding a bus, being in a movie theater) are identified and ordered from least to most anxiety-provoking (using the SUDS scale).

Graded, Systematic Coping

Exposure occurs gradually, starting with situations in the hierarchy that generate low to moderate anxiety.

The person confronts these situations in a planned and systematic way, remaining in them until their anxiety decreases significantly.

For example, if going to the grocery store alone is very feared, one might start by bringing someone with them, then go alone for a short time, then stay longer, and so on, until the situation is does not cause significant discomfort.

It is crucial during in vivo exposure to eliminate safety behaviors (such as always carrying your phone to call someone, constantly checking the exits, or only going during certain low-traffic hours), since these prevent the person from learning