Breaking Free: Managing Panic Attacks Triggered by Avoidance Behaviors
Story-at-a-Glance
• Avoidance behaviors and panic attacks create a self-reinforcing cycle where each strengthens the other, trapping individuals in patterns that seem protective but ultimately intensify fear
• Research reveals that anticipation of panic, rather than the severity of panic attacks themselves, drives most avoidance behaviors and determines their impact on daily life
• The observer-experimenter mindset offers a powerful alternative to self-diagnosis, encouraging individuals to notice patterns without judgment and test new responses
• COVID-19 has created a natural laboratory for understanding avoidance-panic cycles, with pandemic-related health anxiety demonstrating how external threats can trigger familiar internal patterns
• Evidence-based techniques like interoceptive exposure and mindful observation help individuals reclaim agency by transforming their relationship with both physical sensations and feared situations
• Breaking the cycle requires understanding that avoidance provides only temporary relief while preventing the brain from learning that many feared situations are actually manageable
Dave’s story began on an ordinary Tuesday morning when he experienced what felt like a heart attack while driving to work.
The crushing chest pain, racing heart, and overwhelming sense of impending doom lasted only minutes, but the emergency room visit that followed changed everything. When doctors found nothing physically wrong, Dave felt relief—followed immediately by a new kind of terror. What if it happened again?
Over the following months, Dave’s world gradually contracted.
First, he avoided the highway where the attack occurred. Then unfamiliar routes. Eventually, he was making excuses to work from home, turning down social invitations, and relying on his wife to handle school pickups for their children. What had started as a single frightening experience evolved into a pattern that was “significantly impacting Dave’s life” and straining his marriage.
Dave’s experience illustrates a phenomenon that researchers have been studying for decades.
This is the anxiety-avoidance cycle, where people with anxiety disorders avoid situations that trigger their anxiety, leading to a pattern where “avoidance is a natural and necessary behavior” that becomes problematic when it “may each strengthen and maintain the other.”
The Hidden Architecture of Avoidance
What makes avoidance so seductive—and so problematic—is that it works.
In the short term, that is. When someone avoids a situation that causes anxiety, “they may experience temporary relief that they did not have to encounter their stressor or trigger. This may lead to a habit of avoidance.” The brain’s reward system reinforces this pattern, creating what feels like a logical solution: avoid the trigger, avoid the panic.
Yet research reveals a crucial insight that transforms how we understand this cycle.
Studies examining the relationship between panic frequency, severity, and avoidance behavior show that “avoidance is not a simple function of panic ‘severity.'” Instead, “anticipated panic emerged as the most potent correlate of agoraphobic avoidance.”
This finding challenges a common assumption.
It’s not the intensity of past panic attacks that drives avoidance—it’s the fear of future ones. Dr. David Barlow, whose research at Boston University’s Center for Anxiety and Related Disorders has shaped our understanding of anxiety disorders for over three decades, has consistently found that “perceived control” plays a crucial role. Laboratory studies show that “individuals with PD report less fear and fewer panic attacks during laboratory panic provocations when they perceive the procedures as controllable.”
When External Threats Meet Internal Patterns
The COVID-19 pandemic provided an unprecedented natural experiment in understanding avoidance behaviors.
The World Health Organization reported that “in the first year of the COVID-19 pandemic, global prevalence of anxiety and depression increased by a massive 25%.”
What emerged was fascinating.
Researchers found that “worries about COVID-19 were related to disease avoidance, safety behaviors (e.g., wearing personal protective equipment), and compulsive checking and reassurance-seeking.” The pandemic created conditions where avoidance behaviors that might normally seem excessive suddenly appeared rational and socially sanctioned.
For individuals with pre-existing social anxiety, the pandemic created a particularly complex dynamic.
Research showed that “individuals with social anxiety tend to dwell on negative thoughts, promoting the avoidance of stressful situations and reminders of them (e.g., COVID-19).”
Interestingly, some individuals who had been successfully managing anxiety disorders before the pandemic found their coping strategies served them well.
Dr. David Rosmarin at Harvard Medical School discovered that patients already receiving cognitive behavioral therapy “weren’t reporting the worsening symptoms he expected” during the pandemic. Learning to face uncertainty had prepared them for this unprecedented global stressor.
The Observer-Experimenter Alternative
Rather than asking “Do I have panic disorder?” or “How severe is my avoidance?”—questions that often increase anxiety—leading researchers suggest a different approach entirely.
Dr. Michelle Craske, whose work at UCLA’s Anxiety and Depression Research Center has revolutionized exposure therapy, emphasizes that “fear and anxiety as separable constructs” can be approached through “fear extinction through exposure therapy as treatment.” But her most recent research focuses on something more fundamental: changing how people relate to their own experiences.
Craske’s current work involves helping people become observers of their own patterns.
This observer stance transforms the relationship with both panic and avoidance.
Instead of “I’m having a panic attack and must escape,” the internal dialogue becomes “I notice my heart racing and thoughts about danger. What happens if I stay curious about this experience?”
The experimenter mindset takes this further.
Craske and her colleagues are “studying how to integrate virtual reality into treatment for anxiety and depression” not just to expose people to feared situations, but to help them “anticipate and savor rewarding events and then transfer that to real life.”
Understanding the Avoidance Spectrum
Recent research reveals that “avoidance is typically considered a maladaptive behavioral response to excessive fear and anxiety, leading to the maintenance of anxiety disorders.”
However, researchers are developing “a balanced approach to avoidance in treating anxiety disorders” that recognizes “there are occasions when avoidance behaviors can serve as effective coping strategies to enhance the person’s perception of control over the environment and the potential threat.”
This nuanced understanding helps explain why simple exposure—just facing your fears—isn’t always sufficient.
The brain needs to learn new information, not just endure distressing experiences. Consider interoceptive avoidance—the tendency to avoid internal bodily sensations that might trigger panic.
Dr. Barlow’s research shows common patterns:
- Someone who experienced a racing heart during a panic attack might avoid exercise or caffeine
- Someone who experienced choking sensations might avoid wearing high-necked sweaters or necklaces
- Someone who felt dizzy might avoid standing up quickly or looking up at tall buildings
- Someone who experienced shortness of breath might avoid physical exertion or crowded spaces
These behaviors make perfect sense from the brain’s perspective.
If racing heart equals danger, avoid anything that causes racing heart. The problem is that this logic prevents the brain from learning that racing heart during exercise is completely different from racing heart during panic.
The Science of Breaking Patterns
Modern neuroscience reveals why traditional approaches to breaking avoidance cycles often fall short.
Dr. Stefan Hofmann, whose research has been cited over 90,000 times, has shown that “d-cycloserine, a partial agonist of the glutamate receptor can augment extinction learning and speed up exposure therapy of anxiety disorders.” But his more recent work focuses on something more accessible: process-based therapy.
Rather than treating diagnostic labels, Hofmann advocates for “an idiographic approach where we treat the individual” by identifying “the processes that are involved in turning these networks from maladaptive to adaptive.”
This means looking beyond specific fears to understand the underlying patterns.
Someone might avoid social situations, medical appointments, and driving—seemingly unrelated behaviors that share a common thread of uncertainty intolerance.
Practical Pathways Forward
Research suggests several evidence-based approaches for individuals ready to experiment with their avoidance patterns.
Mindful Observation: Craske’s research on “focused breathing to promote mindfulness” found that “participants who practiced focused breathing responded less negatively to aversive stimuli whereas participants who practiced unfocused breathing reported more distress.”
Graduated Exposure: Barlow’s landmark studies show that “exposure to somatic cues combined with cognitive therapy” resulted in “85% or more of clients were panic free at posttreatment” and remained effective long-term.
Behavioral Experiments: Rather than avoiding situations entirely, individuals can design small experiments.
What happens if I stay in the grocery store for two extra minutes? What do I notice if I allow my heart rate to increase slightly during a brief walk?
Uncertainty Training: As one researcher noted, “Uncertainty does not cause anxiety. It is intolerance of uncertainty that causes anxiety.”
Learning to be comfortable with not knowing what will happen next becomes a transferable skill.
When Professional Support Becomes Essential
Research shows that structured approaches like Panic Control Treatment achieve impressive results.
Studies demonstrate that “87% of patients in the PCT group were panic free by the end of treatment.” Professional support becomes particularly valuable when avoidance behaviors significantly impact work, relationships, or daily functioning.
Modern treatment approaches recognize that “the relationship between symptoms and quality of life was indirectly accounted for by use of preventive safety behaviors.”
This means addressing not just the panic attacks themselves, but the elaborate safety systems people construct around them.
The Long View
Long-term follow-up studies of behavioral treatment for panic disorder show remarkable durability.
“81% of the patients remained panic free after the 2 year assessment.” These results suggest that learning to change one’s relationship with panic and avoidance creates lasting change—not because people never feel anxious again, but because they develop confidence in their ability to navigate uncertainty.
The COVID-19 pandemic, despite its challenges, offered an unexpected gift.
A global reminder that uncertainty is the human condition, not a personal failing. Factors like “loneliness, fear of infection, suffering and death for oneself and for loved ones, grief after bereavement and financial worries” affected entire populations, normalizing the experience of anxiety while highlighting the importance of adaptive coping strategies.
A Different Relationship with Fear
The most profound insight from decades of research on panic and avoidance is that the goal isn’t to eliminate fear or anxiety.
These emotions serve important functions and will always be part of human experience. The goal is to develop a different relationship with these states—one characterized by curiosity rather than dread, experimentation rather than rigid control.
As researchers note, “anxiety is more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidance behaviors.”
But when this natural protective mechanism becomes overactive, “excessive avoidance is the hallmark of many emotional disorders, especially anxiety disorders.”
The path forward involves learning to distinguish between helpful caution and problematic avoidance.
This skill develops through practice, patience, and often professional guidance. For individuals ready to begin this journey, the observer-experimenter approach offers a compassionate starting point: notice patterns without judgment, design small experiments, and remain curious about what emerges.
The cycle of panic and avoidance feels unbreakable from the inside.
Research consistently shows that change is possible when we’re willing to approach our own experience with both courage and scientific curiosity. The question isn’t whether you can eliminate panic and avoidance entirely—it’s whether you’re ready to discover what becomes possible when these experiences no longer define the boundaries of your life.
FAQ
Q: What’s the difference between normal caution and problematic avoidance?
A: Normal caution helps us navigate genuine risks appropriately—like avoiding a dangerous neighborhood at night or preparing for a job interview. Problematic avoidance involves restricting activities based on feared internal experiences (like panic attacks) rather than actual external dangers. When avoidance begins significantly limiting your work, relationships, or daily activities, it may have crossed into problematic territory.
Q: What is a panic attack exactly?
A: A panic attack is a sudden episode of intense fear that reaches peak intensity within minutes. It includes physical symptoms like racing heart, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, and feelings of unreality. People often fear they’re having a heart attack, dying, or losing control. While extremely distressing, panic attacks are not physically dangerous and typically last only a few minutes.
Q: What does “anxiety-avoidance cycle” mean?
A: This refers to a pattern where anxiety leads to avoiding certain situations, which then reinforces the anxiety. For example, if you have a panic attack in a store, you might avoid stores to prevent future attacks. But avoiding stores makes them seem more dangerous, increasing anxiety about them. This creates a loop where avoidance and anxiety feed off each other.
Q: Can avoidance behaviors actually make panic attacks worse?
A: Yes, research shows that avoidance prevents your brain from learning that many situations you fear are actually manageable. Each time you avoid a situation where you might feel anxious, you reinforce the belief that anxiety is dangerous and unmanageable. This maintains the fear cycle and can make future panic attacks more likely when you eventually encounter similar situations.
Q: What does “interoceptive avoidance” mean?
A: Interoceptive avoidance means avoiding activities that produce the physical sensations associated with panic attacks. “Interoceptive” refers to awareness of internal body signals like heartbeat, breathing, or dizziness. For example, someone might avoid exercise, caffeine, or even climbing stairs because these activities cause a racing heart—one of the sensations they experienced during a panic attack. This prevents them from learning that a racing heart from exercise is completely different from a racing heart during panic.
Q: What is “fear extinction” and “exposure therapy”?
A: Fear extinction is the brain’s natural process of learning that something previously feared is actually safe. Exposure therapy uses this process by gradually and repeatedly exposing someone to feared situations or sensations in a controlled way. Over time, the brain learns that the feared situation isn’t actually dangerous, reducing the fear response. It’s like learning to ride a bike—the fear goes away through safe, repeated practice.
Q: What is Cognitive Behavioral Therapy (CBT)?
A: CBT is a type of talk therapy that focuses on the connection between thoughts, feelings, and behaviors. It teaches practical skills to identify unhelpful thought patterns (like “I’m going to die” during a panic attack) and change behaviors that maintain problems (like avoiding feared situations). CBT is considered the gold standard treatment for anxiety disorders because extensive research shows it works effectively.
Q: What is Panic Control Treatment (PCT)?
A: PCT is a specific type of CBT designed specifically for panic disorder. It typically involves 12-15 sessions and includes education about panic, breathing techniques, cognitive restructuring (changing anxious thoughts), and interoceptive exposure (deliberately triggering mild panic sensations in a safe environment to reduce fear of them). Research shows 85-87% of people completing PCT become panic-free.
Q: What does “agoraphobia” mean?
A: Agoraphobia is the fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs. Contrary to popular belief, it’s not just fear of open spaces. People with agoraphobia might avoid crowded places, public transportation, being alone outside their home, or any situation where they feel “trapped.” It often develops after experiencing panic attacks in specific locations.
Q: How long does it typically take to break the avoidance-panic cycle?
A: Research on evidence-based treatments like Panic Control Treatment shows that many people experience significant improvement within 10-15 sessions, with studies showing 85-87% of participants becoming panic-free. However, everyone’s timeline is different, and long-term success often depends on practicing new skills consistently and gradually expanding comfort zones over time.
Q: What’s the “observer-experimenter” approach mentioned in the article?
A: Instead of trying to diagnose yourself or rate the severity of your symptoms, the observer-experimenter approach involves noticing your patterns with curiosity (“I notice my heart racing when I think about going to the store”) and then designing small experiments (“What happens if I go to the store for just five minutes?”). This reduces the anxiety that comes with self-diagnosis while building confidence through direct experience.
Q: What are “safety behaviors” in the context of anxiety?
A: Safety behaviors are actions people take to prevent or reduce anxiety in feared situations, like always carrying a water bottle in case of dry mouth during panic, sitting near exits, or bringing a trusted person everywhere. While these provide short-term relief, they prevent learning that the situation is actually safe, maintaining the fear long-term.
Q: What does “uncertainty intolerance” mean?
A: Uncertainty intolerance is difficulty coping with not knowing what will happen in ambiguous or unpredictable situations. People with high uncertainty intolerance often worry excessively about “what if” scenarios and try to control or avoid uncertain situations. Learning to become more comfortable with uncertainty is a key skill in managing anxiety disorders.
Q: When should someone seek professional help for panic and avoidance?
A: Consider professional support when avoidance behaviors are significantly impacting your work, relationships, or quality of life, or when you’re avoiding multiple important activities. Also seek help if you’re having frequent panic attacks, using substances to cope, or if family members are expressing concern about changes in your behavior.
Q: How did the COVID-19 pandemic affect people with existing anxiety and avoidance issues?
A: The pandemic had mixed effects. While anxiety and depression increased 25% globally, people already receiving treatment for anxiety disorders often coped better than expected. This suggests that skills learned for managing uncertainty and avoiding avoidance behaviors served as protective factors during this unprecedented global stressor.