The Role of Safety Behaviors

            Psychotherapeutic success with individuals with Panic Disorder (PD) involves identification of irrational cognitions, fears, and safety behaviors, so as to facilitate conscious testing of underlying catastrophic hypotheses. This becomes possible when alexithymic traits are adequately mitigated to facilitate this conscious process. In the event that underlying cognitive and affective processes do not become conscious, hundreds of further unreinforced trials may continue without significant increase in the likelihood of spontaneous extinction. In my clinical experience with panic disordered individuals, it appears that remission of panic attacks proceeds from amelioration of the cognitive and affective deficits of alexithymia.

Examples of Safety Behaviors

            The degree to which safety behaviors contribute to the perpetuation of panic level anxiety is considerable and widely recognized. They are similar to the avoidance behaviors of simple phobia or agoraphobia and can be explained by operant or classical conditioning models. An operant model suggests that safety behaviors can best be understood as freely emitted behaviors that increase or decrease relative to their consequence or value. If any behavior reduces anxiety and seems to prevent a panic attack, heart attack or other catastrophe, it is reinforced and likely to be repeated. A classical conditioning model suggests that anxiety has become associated with certain stimuli and the avoidance of these stimuli is reinforced by the termination of the anxiety state.

             In simple phobias or agoraphobia, avoidance behavior reinforces fear of the avoided object or situation by precluding desensitization via exposure to the feared stimuli. Similarly, safety behaviors reinforce fear of external or interoceptive cues by avoiding a test of the catastrophic hypothesis associated with those cues. Safety behaviors are reinforced by their capacity to terminate aversive anxiety states but contribute to the continuation of an anxiety disorder. This study found no significant difference in alexithymia prevalence between the PD with agoraphobia individuals, and the PD without agoraphobia individuals. I suggest this is the result of their difference without a difference. That is, both these groups employ avoidance behaviors with identical function and consequence but with apparently insignificant surface distinctions.

                                    Avoidance:

            One type of safety behavior is avoidance. This includes the set of behaviors that constitute agoraphobia, but also include more subtle avoidance behaviors manifested by individuals with PD either with or without agoraphobia. Often the difference in the avoidant behaviors demonstrated by individuals within these two different diagnostic categories is the degree of subtlety, or symbolization, of the behavior. It is not accurate to consider only the individual with PD and agoraphobia as a phobic avoider, and one with PD without agoraphobia as a non-avoider. Each group generally manifests some degree or variant of avoidant safety behaviors, blurring the clear distinction between the two diagnostic categories.

             Panic disordered individuals with agoraphobia manifest classic symptoms and behaviors that constitute agoraphobia. Anxiety over situations and places of limited escape, or unavailability of assistance in the event of panic, cause them to avoid going far from home or leaving home altogether. Their anxiety can prompt them to avoid crowds, certain modes of transportation, or standing in line. These and similar situations are avoided or are endured with marked anxiety (American Psychiatric Association, 1994).

            But there are other avoidance behaviors that do not qualify as classic agoraphobic manifestations as they constitute subtler forms of avoidance. They are more subtle as they are selective, discriminating forms of avoidance as compared to the more generalized agoraphobic forms of avoidance. Specific aspects of anxiogenic situations may be avoided such as avoiding one particular stretch of road as opposed to avoiding all driving situations. Specific bridges, tunnels, roads, or driving conditions may be avoided, while others are not. Anxiogenic physiological sensations such as dizziness, breathlessness, or accelerated heart rate may be avoided by avoiding substances or activities that produce them. These may include avoidance of: caffeine; sugar; amusement park or playground rides; physiological exertion such as sports activities or exercise; or even the witnessing of others participating in these behaviors.

            A significant variant of avoidant-type safety behavior employed in the presence or absence of agoraphobia, is the avoidance of being alone via the use of a safe person. The safe person is an external comforting source, typically a spouse or first degree relative such as a parent. The overt reliance on a comforting individual suggests delay in the development of internalized, comforting parental introjects and the continuation of proximity-maintaining behavior (Bowlby, 1973). The dependence on a safe person also represents significant lack of “differentiation of the self” - what Bowen (1978) considered the highest level of maturational development.

            The agoraphobic individual may be obvious about their resistance or refusal to leave home without a safe person. The non-agoraphobic individual may manifest this behavior in symbolized form involving the use of an object representation or transitional object. Instead of requiring the presence of a safe person, there may be reliance on a cell phone that represents immediate connection with a comforting source. A transitional object can be any object imbued with comforting value – a picture, a ‘good luck charm’, or any object with representational or talisman value. This transitional object can be similar to a child’s but tends to have more symbolic meaning as opposed to comforting sensory properties like a child’s security blanket or stuffed animal.

            Closely related to the safe person is the concept of a safe place. The agoraphobic is unwilling to leave their only true safe place – their home, but may do so with a safe person or alone but with considerable anxiety. For non-agoraphobics, a safe place is a place with representational value - places away from home wherein the person is in proximity to a source of perceived safety or assistance. Examples are a hospital, a restroom or freeway rest area, or a friend or relative’s home.

                                     Distraction:

            Another form of safety behavior is distraction. An individual experiencing an internal or external anxiety cue while driving a car may turn up the radio, open a window, sing aloud, or force conversation with anyone else in the car in an attempt to distract their attention from the cue and incipient catastrophic cognitions. Physiological maneuvers such as shifting in one’s seat, muscle clenching, or moving about can be attempts to distract one’s attention from incipient cues for panic.

                                      Escape:

            Another type of safety behavior is the use of escape, or taking flight from an anxiogenic situation. These behaviors constitute fleeing from a store or mall, leaving the line at a cash register, or pulling off a road or freeway. Often the flight is from a situation that represents suffocation or restriction of breathing, to one that represents a capacity for unrestricted breathing. Examples are: leaving an enclosed or crowded room, escaping a traffic jam or backup, going to an open door or window or going outside for fresh air.

                                     Relaxation:

            Another set of safety behaviors involve the use of relaxation techniques to avoid a panic attack. These responses include deep breathing, progressive relaxation techniques, and meditation. While there is a very legitimate use of these methods during the early phase of treatment of PD, they become potentially counterproductive measures when they become the solution to panic.

            Most of these safety behaviors have preliminary value for the panic disordered individual in their attempts to find ways to abort the fear of fear cycle. Behaviors that constitute mastery of relaxation techniques have an inherent generalized value that can contribute to a legitimate sense of self-control and affect regulation. But relaxation techniques, like other safety behaviors, become counterproductive and self-limiting if they interfere with identification and resolution of the underlying process of panic. These behaviors can interfere with the identification of internal and external anxiogenic cues, and the amplification and catastrophic misinterpretation that follow. These safety behaviors not only support the alexithymic deficits that impede the awareness of and challenge of false catastrophic hypotheses, they also promote the alexithymic tendency to consider a problem as physiological that can be ameliorated with palliative physiological interventions.