Anatomy of Anxiety: Mastery by Avoidance
Learn how the vicious cycle of anxiety evolves through "mastery by avoidance."
Posted January 31, 2020
As we look at anxiety, consider the following case.
Ann was an elementary school teacher. For Ann, the sensations she experienced were feelings of unreality, shortness of breath, and stomach upset. These would occur on an average of three times per week, lasting from a few seconds to ten minutes. Most of these were expected but occasionally they came “out of the blue.” They mainly occurred in public situations where she felt there was no escape—like in cars if she wasn’t driving, movies or plays, or in her classroom. Her internal triggers tended to revolve around stomach distress accompanied by thoughts of vomiting and never being able to control this again. Her reactions to a panic attack invariably involved escaping from wherever she was, seeking help from therapists and a boyfriend, and being sure she had her medication bottle. She thus constantly avoided being out of control through speaking in public, driving with others, or being at restaurants. Her mood had deteriorated to hopelessness, with frequent crying spells and greater isolation in her apartment. She was in a classic downward spiral when she reluctantly sought help from a therapist just one more time.
This case and others like it—including social anxiety, generalized anxiety, and agoraphobia (or growing difficulty tolerating being away from a safe place like home)—are all variations of one of the most common problems seen in clinical practice: anxiety.
Anxiety is the paradigm case of vicious cycles. Anxiety comes down to mastery by avoidance, and resolution comes down to reversing peoples’ solutions.
Fear Has Big Eyes (Russian Proverb)
Anxiety in the best of situations can alert us to a potential challenge or danger. Once we identify the source of danger, we may become afraid and take action to resolve the threat. However, if the source of potential danger remains vague and thus irresolvable, or if our solutions not only fail to resolve the perceived danger but actually maintain and perpetuate it; we become part of a vicious cycle. Our perceptions of danger and attempts to resolve it maintain anxiety and make it worse. Panic attacks, for example, often begin by some chance occurrence that causes us to react with symptoms of anxiety. The initial “kick point” or trigger for the first attack can be almost anything that causes us to feel widely out of control, unsure if we can handle the situation, and worried that the situation is dangerous.
Fight or Flight
Innate “fight or flight” mechanisms set in. If we are aware of the cause of our physical discomfort and the innate nature of these physiological responses, we may be able to categorize our reaction as unpleasant but natural. In so doing, we can often move beyond the incident. We might act directly on the situation that made us anxious. We might learn new skills to master it. We might decide that we misinterpreted the situation or find that our view was correct, yet there was no cause for worry. In these instances, we will move beyond the incident with few, if any, residual effects.
Becoming Anxious About Being Anxious
On the other hand, we may become very alarmed and worried about the panic attack itself. How did we get that out of control? What happened to us? Is there something physically wrong? Are we having heart problems? How can we avoid ever having that happen again? We get anxious about having gotten anxious.
This can be the inception of a vicious cycle. Once panic attacks have occurred, they tend to be maintained by selective internal attention to bodily events, safety behaviors to bolster the person against the traumatic situation, and avoidance or escape (Craske & Barlow, 2014; Barlow, Conklin & Bentley, 2015). Our resulting solutions become the very things that produce the syndrome of escalating anxiety and ongoing recurrent panic attacks. Our solutions exacerbate the anxiety we seek to quell. Our solutions become the problem.
Some people may be more prone to respond to bodily distress with anxiety or panic due to factors they uniquely “bring to the table.” Craske and Barlow (2014) review the contributions of genetics and temperament, anxiety sensitivity, history of medical illness and/or abuse, and interoceptive awareness. They describe these potential vulnerabilities as:
- an increased potential to experience negative emotions in response to stressors as a biological vulnerability of some individuals,
- a potential for anxiety sensitivity as a fairly well-documented tendency to respond with fear to physical symptoms of anxiety, viewing them as signals of harm or danger,
- a history of medical illnesses such as heart problems or asthma, for example, may generalize to future similar sensations as signs of pending illness, and,
- interoceptive awareness, based upon research supporting the tendency of some individuals to have a heightened awareness of or ability to detect bodily sensations of arousal.
Taken together, combinations of many of these predisposing vulnerabilities may increase some individuals’ potential to respond with anxiety or particularly panic to heightened body sensations. This was the situation in our case above.
Ann had a history of gall bladder problems, and she had recently had an operation to help. Nevertheless, the vicious cycle of escalation, once begun, and for whatever reason, remains remarkably similar. Ann's solution to become hyper-vigilant for anxiety cues and avoiding situations that might prevent escape is classic mastery by avoidance.
Mastery by Avoidance
The paradox of anxiety is that the more we try to control it, the worse it gets. We try to master anxiety through avoidance. This includes acute attention to anxiety cues, avoiding all situations that may bring on anxiety, enlisting others to help us stay safe, escaping anxiety-provoking situations, and gradually reducing the times we go out in public. Ann, in the case above, had all of these classic traits including:
- Ann was hyper-aware of any body sensations that might signal anxiety.
- Sometimes panic would simply come on "out of the blue" with no identifiable cause.
- Ann quickly escaped and avoided all anxiety-provoking situations.
- She avoided all situations not allowing escape.
- She enlisted others for support and reassurance to buffer against anxiety.
- Ann kept an empty pill bottle in her pocket to hold when in new situations.
- She was avoiding all situations for speaking in public, including in her classroom.
- Ann was beginning to avoid going outside and staying instead where she felt safe.
All of these classic elements of anxiety problems amount to mastery by avoidance. What we will find in my next related post, is that all treatments that work to master anxiety problems include, in a word, exposure.
*Abstracted from Fraser, J. S. (2018). Unifying Effective Psychotherapies: Tracing the Process of Change, Chapter 6, Anxiety. Washington DC: APA Books.
Barlow, D. H., Conklin, L. R., & Bentley, K. H. (2015). Psychological treatments for panic disorders, phobias, and social and generalized anxiety disorders. In P. E. Nathan, & J. M. Gorman (Eds.), A Guide to Treatments that Work. (pp. 409-461). New York: Oxford Press.
Craske, M. G., & Barlow, D. H. (2014). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual. (5th ed., pp. 1-61). New York: The Oxford Press.