Avoidance is the engine that keeps anxiety and trauma going: in PTSD, avoiding distressing emotion and trauma memories is what makes symptoms persist. Treatment means avoiding avoidance, which shapes how we explain symptoms to patients, how we use tools like mindfulness, and what paperwork we sign.
What it is
The crux of the psychology of PTSD is that the patient develops cognitive and behavioral strategies to avoid distressing emotional reactions.
“the crux of the psychology of PTSD is that a patient develops cognitive and behavioral avoidance strategies to avoid distressing emotional reactions”
23:23PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 Panic disorder is not having panic attacks, it is fearing and avoiding them. In the same way, PTSD that persists with or without treatment often comes down to avoidance of trauma memories.
“Panic disorder isn't having the panic attacks. It's having fear and avoidance of the panic attacks. I find that in many cases of persistent PTSD that persists with treatment or without treatment, it's that there's an avoidance of trauma memories”
15:17Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026
How we diagnose it
In PTSD, criterion C is avoidance, in two parts: efforts to avoid internal trauma reminders (memories, thoughts, feelings) and efforts to avoid external ones (people, places, activities).
“avoidance or efforts to avoid distressing internal trauma reminders, memories, thoughts, or feelings. And then the second part is avoidance or efforts to avoid distressing external trauma reminders, people, places, activities”
18:36Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 Also said in 1 more episode
“So C is avoidance. And then the two that I mentioned are avoidance or efforts to avoid distressing internal trauma reminders, memories, thoughts, or feelings. And then the second part is avoidance or efforts to avoid distressing external trauma reminders, people, places, activities”
18:24Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025
Talking to patients
Make it clear that where they are now comes both from the traumas and from their response to them: avoiding danger is a rational response, but one that keeps the problem going.
“I try to make it fairly clear that this is something that has happened to them both because of the traumas that they've had and also because of the response. That it's a rational but also perpetuating response to keep avoiding danger”
21:31PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025
Pitfalls and myths
A huge part of treating anxiety and trauma is avoiding avoidance. Signing paperwork that lets a patient stay away from what they fear promotes the avoidance.
“a huge part of that is avoiding avoidance. And by signing that paperwork, you're promoting the avoidance”
1:03:58Disability Claims 101 for Psychiatrists: Programs, Pitfalls, and Practical StepsDec 2025 Mindfulness used as an escape from fear stops being mindfulness and becomes one more avoidance behavior, which perpetuates the problem.
“If you use mindfulness practice as an escape from fear, it will make it not mindfulness practice and we'll make it another avoidance behavior which just perpetuates the problem”
43:18Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
It also comes up on
- Panic disorderIt is the avoidance of panic attacks that produces panic disorder, not so much the attacks themselves. In agoraphobia, too, anxious avoidance worsens the fear response.
- AnxietyAnother grouping by clinical type: GAD proper, dead-loop avoidance problems like panic disorder and agoraphobia, specific fear problems like phobias, and developmental-relational problems.
- Childhood traumaAvoidance of discussing, thinking about and feeling about trauma is part of the psychopathology. Do not force anyone, but do not let the way you approach things imply that talking about it is dangerous or hurtful.
- Complex PTSDA mnemonic: PTSD is FEAR (fright, exposure, avoidance, re-experiencing). Complex PTSD is BAD FEAR, adding betrayal, affect regulation and developmental impact.
- Exposure therapyWith just a specific phobia, a little avoidance is sometimes fine if it keeps the person running their life the way they want to.
- Exposure therapyThe treatment for anxiety is avoiding avoidance. Benzodiazepines decrease the efficacy of therapy because they reduce the ability to learn new information.
- PTSDA mnemonic: PTSD is FEAR (fright, exposure, avoidance, re-experiencing), and complex PTSD is BAD FEAR, adding betrayal, affect regulation and developmental impact.
- Psychiatric intakeDo ask about trauma within a standard frame. Avoidance is part of trauma psychopathology, and you do not want your frame to imply that talking about it is dangerous or hurtful, though you should not force anyone.
From these episodes
- Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 · 2 points
- Disability Claims 101 for Psychiatrists: Programs, Pitfalls, and Practical StepsDec 2025 · 1 point
- Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 · 1 point
- PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 · 2 points
- Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.