Universität zu Köln

Hilleke, Marina ORCID: 0000-0002-3557-2768 (2025). The Impact of Fear Prediction and Fear Experience in Exposure-Based Therapy for Panic Disorder With Agoraphobia. PhD thesis, Universität zu Köln.

PDF Dissertation_MarinaHilleke Veröffentlichung.pdf Download (481kB)

Abstract

While habituation is a potential mechanism of action in exposure therapy, its explanatory value is limited. Contemporary perspectives emphasize the importance of expectancy violations in the context of exposure. Since the early conceptualization of fear generation and maintenance, expectation violation has been a focus, as demonstrated by Rachman’s (1994) match-mismatch model. The match-mismatch model (Rachman, 1994) explores the discrepancy between expected fear and experienced fear, proposing that fearful individuals often overpredict the level of fear they expect to experience in a threatening situation. This overprediction bias might foster the development of anticipatory anxiety, avoidance behaviour, and safety behaviour, which in turn impedes the disconfirmation of feared outcomes (Hilleke et al., 2021). Despite the conceptual relevance of expectancies, there is a shortage of empirical studies examining their role within therapeutic treatments. Working within the framework of the match-mismatch model (Rachman, 1994), the first article of this dissertation presents a systematic review of research examining the impact of expectancies. An analysis of 50 studies predominantly affirms the core assumptions of the match-mismatch theory. Most studies validate the existence of an overprediction bias in subclinical fears and anxiety disorders, coupled with a trend of reduction in both expected and experienced anxiety levels through repeated exposures. Predictions of fear improved with repeated exposure. Some findings suggest that greater accuracy in fear prediction correlates with a concurrent reduction in experienced fear. This hypothesis was subsequently tested in the empirical study, which was conducted within a clinical population. Again within the framework of Rachman’s (1994) match-mismatch model, the second article of this dissertation examines the role of violating expected and experienced fear as well as the effects of safety behaviour during in vivo exposure to panic disorder with agoraphobia. A total of 268 patients meeting DSM-IV criteria for panic disorder with agoraphobia participated in a manual-based cognitive behaviour therapy within the framework of a randomized multicentre study. Our findings revealed a tendency among participants to overpredict fear during exposure. However, contrary to expectations, the accuracy of fear predictions did not improve with practice. Moreover, the accuracy of predictions was not related to therapy outcome. Interestingly, the presence of safety behaviours did not yield significant effects on fear assessments. This study’s result argues against the expectancy violation approach. Taken together, the systematic review demonstrated evidence of overprediction, reductions in both expected and experienced fear, and increasing accuracy in fear predictions. 5 The second study confirmed the overprediction bias but did not find a correlation between improvements in fear prediction and treatment outcomes. Implications for future research and clinical practice are presented in a general discussion.

Item Type:	Thesis (PhD thesis)
Creators:	Creators Email ORCID ORCID Put Code Hilleke, Marina mhilleke@uni-koeln.de https://orcid.org/0000-0002-3557-2768 UNSPECIFIED
URN:	urn:nbn:de:hbz:38-793597
Date:	July 2025
Language:	English
Faculty:	Faculty of Human Sciences
Divisions:	Faculty of Human Sciences > Department Psychologie
Subjects:	Psychology
Uncontrolled Keywords:	Keywords Language panic disorder and agoraphobia English mismatch English expectancy English
Date of oral exam:	28 November 2025
Referee:	Name Academic Title Gerlach, Alexander L. Professor, Doktor Helbig-Lang, Sylvia Dr. rer. nat. habil.
Refereed:	Yes
URI:	http://kups.ub.uni-koeln.de/id/eprint/79359