The Role of Safety Behaviors in Panic Disorder Treatment: Self-Regulation or Self-Defeat?

Katie Aafjes-van Doorn, Sigal Zilcha-Mano, Kathryn Graham, Alyson Caldari, Jacques P. Barber, Dianne L. Chambless, Barbara Milrod

Research output: Contribution to journalArticlepeer-review


Safety behaviors (SBs) are generally perceived as ‘dysfunctional’ emotion-regulation strategies that reduce physical symptoms and prevent unrealistic feared consequences of panic attacks. However, it is unclear whether all types of SBs are a hindrance or whether some may promote self-regulation in treatment. We propose that the type of SBs might explain some of the variability between panic disorder (PD) patients, and might help to predict why treatment is more successful for some than for others. In this secondary analysis of a subsample of 65 PD patients who received Cognitive Behavioral Therapy in a two-site randomized controlled trial, we examined the associations between type of SB and pre-treatment characteristics and their predictive value on trajectories of change in treatment process and outcome (panic symptoms, interpersonal problems, alliance). An observer-rating system for five types of SBs (avoidance/distraction/control-function and object/people-focus) was developed and applied to videotaped early treatment sessions, with high reliability. Patients with higher levels of people-focused SBs reported higher levels of panic symptoms pre-treatment at both treatment sites. These people-focused SBs predicted poorer treatment response on panic symptoms at one of two sites. Avoidance, control, or distraction-function and object-focused SBs were not associated with treatment process or outcomes. People-focused SBs may worsen PD symptoms, and possibly slow treatment progress, although this latter finding was not consistent across sites. This study differentiated between types of SBs and identified people-focused SBs as possible predictor of symptom change in CBT for PD—potentially relevant for efforts to improve treatment response.

Original languageEnglish
Pages (from-to)203-212
Number of pages10
JournalJournal of Contemporary Psychotherapy
Issue number4
StatePublished - 1 Dec 2019

Bibliographical note

Publisher Copyright:
© 2019, Springer Science+Business Media, LLC, part of Springer Nature.


  • Alliance
  • Panic disorder treatment
  • Safety behaviors
  • Self-regulation

ASJC Scopus subject areas

  • Clinical Psychology
  • Psychiatry and Mental health


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