Safety Behaviours and Panic Disorder

Safety behaviours and panic disorder

Panic attacks usually occur unexpectedly and last for a few minutes. During a panic attack episode, one might misinterpret their bodily sensations as an indicator for an incoming heart attack and/or a similarly fatal medical emergency. As these panic attacks become more frequent, one might develop a full-blown panic disorder. The intrusive nature of panic disorders can greatly hinder one’s personal and professional life leading to further distress and anxiety (Doorn et al., 2019). In a previous review, we have also highlighted how panic attack are associated with certain medical conditions.

The current study: Examining the effects of different safety behaviours in panic attacks

Safety behaviours may be defined as steps taken to escape or lower the perceived level of threat in response to anxiety. Many employ a variety of safety behaviours to help manage their anxiety during a panic attack. Safety behaviours might include avoiding any activities that might increase one’s heart rate or constantly checking one’s heart rate for fear of it spiking. Admittedly, safety behaviours can help soothe one’s anxieties and make a panic attack episode less scary. However, unbeknownst to many, a lot of these safety behaviours might contribute to the continuation of panic attacks. One might be overly dependent on these safety behaviours and become even more anxious as they believe that they will not be able to survive a panic attack without these safety behaviours (Doorn et al., 2019).

Doorn and colleagues (2019) were interested in identifying the types of safety behaviours which people use to cope with panic disorders and how different safety behaviours would help or hinder the recovery of individuals suffering from panic disorders.


The research psychologists recruited 65 participants who were clinically diagnosed with panic disorder from Weill-Cornell Medical College and the University of Pennsylvania. These participants underwent cognitive-behavioural therapy (CBT) for panic disorders and gave the researchers consent to video-tape their therapy sessions. The researchers analysed these video tapes to explore the types of commonly employed safety behaviours. After 12 psychological therapy sessions, participants also answered several post-therapy questionnaires to assess their recovery from panic attacks.


The researchers found that the commonly used SBs could be classified into 5 distinct categories below. All the participants were assessed to have turned to more than one type of safety behaviour in coping with their panic attacks.

1. Avoidance

A significant majority of participants (52 out of 65 participants) had engaged in some form of avoidance by abstaining from anything that they felt might potentially trigger their panic attacks. For example, subjects reported avoiding caffeinated drinks for fear of it increasing their heart rate. Also, participants highlighted that they would escape to a place where they felt safe (e.g. going home) when they felt signs of anxiety creeping in.

2. Distraction

47 participants (72%) were found to cope by trying to distract themselves from any anxiety-inducing thoughts. For instance, when subjects felt overwhelmed in a crowded train, they might read a book to distract themselves from the situation. Participants also reported turning to alcohol to distract themselves from their anxiety.

3. Control

In the midst of a panic attack, one might feel a loss of control over their emotions and bodies as they struggle to stop the bodily symptoms that are causing them distress (eg. pulsing heart-rate, cold sweats). Safety behaviours, like having medication on hand and/or being close to the exit at all times, provided 36 individuals (55%) with a sense of security and control over the situations in the event they experience a panic attack.

4. People-focused

29 participants (45%) reported a reliance on other people to help them cope with their panic attacks. A subject who displayed people-focused safety behaviour might often talk to someone about the anxieties in hopes of preventing another panic attack. These individuals might also say something like, “I did not have a panic attack in that crowded room because my husband was with me”. Thus, they would often attribute their lack of panic attacks to the presence and support of the people around them even though they might, in reality, be actually ok without other people’s support.

5. Object-Focused

Object-focused safety behaviours are similar to people-focused safety behaviours, but there is a strong dependence on particular objects rather than on people. These participants may report carrying lucky charms with them thinking that it would prevent panic attacks. Over time, participants would begin to think that their lack of panic attacks is due to the presence of a particular item. The absence of these items could subsequently cause more distress and anxiety.

The influence of safety behaviours in recovery from panic attacks

Overall, the results found that avoidance were most commonly reported safety behaviour amongst the participants. Further analysis found that employing person-focused safety behaviours was associated with slower therapy progress for one of the treatment site (Penn), but not the other (Cornell). However, other types of safety behaviours did not affect therapy outcomes.


Experiencing panic attacks can be a very stressful and scary situation. The authors of the study highlighted that excessive use of safety behaviours may reduce the effectiveness of psychotherapy for panic attacks. People-focused safety behaviours may be more counter-productive compared to the other safety behaviours as their loved ones may further support their use of safety behaviours instead of encouraging effective coping strategies. You can find out more about how avoidance as a safety behaviour can be counter-productive here.

If you are experiencing panic attacks, being aware of the function of your safety behaviours. Although safety behaviours can be comforting, it would be good to reflect whether you are currently over-reliant on them, which may unnecessarily make you more anxious.


Doorn, K. A.-van, Zilcha-Mano, S., Graham, K., Caldari, A., Barber, J. P., Chambless, D. L., & Milrod, B. (2019). The Role of Safety Behaviors in Panic Disorder Treatment: Self‑Regulation or Self‑Defeat? Journal of Contemporary Psychotherapy, 49, 203–212. doi:

Article written with Charmaine Leong. Charmaine is a psychology undergraduate from the National University of Singapore (NUS). Charmaine is an aspiring clinical psychologist who is passionate about raising awareness of mental health issues in Singapore. She is currently on internship with ImPossible Psychological Services under the supervision of senior clinical psychologist, Haikal.

Categories: Mental Health
Muhammad Haikal Bin Jamil

About the Author

Haikal received his Master degree at the National University of Singapore (NUS), under a full scholarship awarded by the National Council of Social Service (NCSS). Before entering private practice, he has gained much experience in both hospital and social services settings.

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