Complex PTSD Symptoms:

Avoidance

Sections:

• Common Psychological Defenses
• Avoidance Behaviors
• Agoraphobia

COMPLEX PTSD - SHAME - HYPERVIGILANCE - DYSREGULATION - INTERPERSONAL DIFFICULTIES - DISSOCIATION - IMPULSIVITY - DEPRESSION -TRIGGERS - OBSESSIVE BEHAVIOR - PHYSICAL - TREATMENT

Common Psychological Defenses

Symptoms of complex PTSD can leave you feeling trapped. Avoidance behaviors include denial, repressing feelings, minimizing distress, dissociating, or using substances to numb pain.

Avoidance behaviors come in many forms and are upheld by psychological defenses. 

You may have developed strong walls around your most vulnerable feelings. Maybe you use emotional eating, drinking, or excessive exercising. Perhaps you resist going out places or seeing people.

These protective maneuvers come with unwanted consequences, such as physical health impairments or loss of relationships that leave you feeling isolated.

It can be understandable to avoid dangerous situations or avoid peer pressure, but avoidance is more than just feeling uncomfortable.

Avoiding something can make you feel in control; however, depending on what you are avoiding, it doesn't always signify true control. Long-term, these behaviors can exacerbate other issues going on in your life.

If you identify your defenses you can create changes that will address the underlying issues and resolve the need for such defenses.

REPRESSION & DENIAL

REGRESSION

IDEALIZATION

FANTASY

INTELLECTUALIZATION

DISSOCIATION

ADDICTIONS

It can be hard to see your own defenses clearly or to be fully honest with yourself about behaviors that are no longer serving you. The truth is, we all employ defenses at some point in our lives.

See if you can bring self-compassion to this process. Take a few minutes to look over the previous list of avoidance defenses.. Do you relate to any of these ways of pushing painful emotions or memories away.
 
 Defenses as Self-Protection

Where or when might you have learned to stop allowing yourself to feel vulnerable?

When did you learn to push away pain, or turn toward addictive substances?

Do you recall a time when perhaps you decided to stop talking to people about your emotions, thoughts, hopes, or dreams?

When did you learn, perhaps, that focusing on work helped to push your feelings away?

If you can identify with any of these issues, recognize that you were doing the best you could to survive with the resources that you had at the time—and now, with self-awareness, you can change the way you handle these things.

Avoidance Behavior
Examples, Impacts, & How to Overcome

Avoidance refers to specific behaviors that people use to ensure they're not involved in a specific situation, or that they can leave a situation they've already entered. These behaviors also refer to individuals who actively avoid difficult feelings. Avoidance behaviors can be a sign of underlying mental health issues.
 

What Is Avoidance Behavior?

Avoidance behaviors are any behavior people use to escape or distract themselves from difficult thoughts, feelings, and situations. This can look like avoiding new job opportunities, career advancements, relationships, social situations, recreational activities, and family get-togethers. People use avoidance as a natural coping mechanism for pain, trauma, and other mental health issues.
 

Avoidant behavior can be a symptom of the following mental health issues:

• Social anxiety disorder
• Panic disorder
• Avoidant personality disorder
• PTSD
• Avoidant attachment
• Abandonment issues
• Toxic shame
• Depression
• Anxiety
• Toxic relationships
• Disorganized attachment

13 Examples of Avoidance Behavior

Avoidance behaviors can present in several different ways, including escapism, drug and alcohol use, day-dreaming, and burying your emotions.

Here are thirteen examples of avoidance behaviors:

1. Escapism
2. Drug/alcohol use
3. Wishful thinking/day dreaming
4. Burying one's emotions
5. Self-isolation
6. Avoiding eye contact
7. Lowering voice when speaking
8. Leaving gatherings early
9. Making up excuses to avoid attending a party/social gathering
10. Procrastination
11. Cancelling plans last minute
12. Not answering calls or texts
13. Avoiding certain places and at certain times

Impacts of Avoidance Behavior

When you try to prevent stress instead of allowing yourself to feel the emotions that come up for you, you give yourself a false sense of control. In reality, you hand over control to the thing you are trying to avoid, which does more long-term harm than good, even if it feels better in that moment. This can become a cycle that's hard to break, leaving you more anxious, triggered, and/or depressed.
 

Avoidance behaviors can also wreak havoc on your day-to-day life, forcing you to engage in other negative or maladaptive behaviors.
  

Here are examples of impacts from avoidance behavior:

• If you're avoiding a route in your car, it may make you late or cause you to spend more money
• Anxiety-related avoidance may make you lose professional opportunities
• If you're avoiding certain feelings or conversations, it could hurt your personal relationships
    
  

Ways to Overcome Avoidance Behavior 

Journaling

Try writing things down to get them out of your head, so to speak. Sometimes, when we write down our feelings and read them aloud, it helps us process differently. This can help us identify negative thought patterns and explore where they come from and why. Once we're able to sort through some of that, we can start to do the work to heal.
 

Utilize Stress Management Techniques

Stress management techniques can help people manage and move on from avoidance behaviors. Given that stress can sometimes mask itself as anxiety or depression, identifying the root cause of an issue or feeling is the first step towards recovery. Stress management provides many ways to deal with stress, no matter its cause, instead of avoiding the issues.
 

Develop Coping Skills

It's important to develop healthy, positive coping strategies. Think about your day-to-day routine and imagine what a life without avoidance would look like. Ask yourself this: How do I feel? Can I get past this feeling? Could this have been prevented? Is there something I can do to fix this now? These questions will allow you to tap into your emotion-focused and problem-focused coping mechanisms.
 

Seek Professional Help

If you're avoiding situations or people and not really able to cope well or consistently, seek professional help. Due to the complex nature of how avoidance behaviors impact and trigger other mental health issues, it's safer to find help at the first sign of struggle and get the support right away.

Agoraphobia

Agoraphobia is a anxiety disorder that involves an extreme and irrational fear of being unable to escape a difficult or embarrassing situation. People fear they will experience panic or other incapacitating symptoms when trapped in a public and inescapable setting.
  

Agoraphobia is sometimes mistaken as a fear of leaving the house, but it is more complex. The disorder is marked by anxiety that causes people to avoid situations where they might feel panicked, trapped, helpless, or embarrassed. It can occur on its own or alongside another mental health condition, such as panic disorder.
 

This fear often leads to persistent avoidance behaviors, in which the person begins to stay away from the places and situations in which they fear panic may occur. For example, a person with agoraphobia may avoid driving a car, leaving the comfort of home, shopping in a mall, traveling by airplane, or simply being in a crowded area.
 

Due to these avoidance behaviors, the life of a person with agoraphobia can become very restrictive and isolated—greatly affecting their personal and professional life. For example, heightened fears and avoidance behaviors can make it difficult for a person with agoraphobia to travel for work or to visit with family and friends. Even small tasks, such as going to the store, can become extremely difficult.
 

Fear and avoidance can become so severe with agoraphobia that the person with the phobia becomes confined to their home. Fortunately, agoraphobic symptoms can be treated.
 

Symptoms of Agoraphobia:

• Being afraid of leaving home
• Being afraid of open spaces, bridges, or shopping centers
• Fear of enclosed spaces or buildings
• Fear of leaving home or being in social situations alone
• Fear of losing control in a public place
• Fear of places where escape might be difficult
• Fear of public transportation

These situations almost always trigger an anxiety response that is out of proportion to the actual danger presented by the situation.

Panic attacks often precede the onset of agoraphobia. When forced to endure a feared situation, a person may experience a panic attack that causes symptoms including:

• Chest pain
• Chills
• Diarrhea
• Dizziness
• Feelings of choking
• Feelings of unreality
• Nausea
• Numbness
• Rapid heartbeat
• Shortness of breath
• Sweating
• Trembling

Types of Agoraphobia

Although many people with agoraphobia will also have panic disorder, it is possible to be diagnosed with agoraphobia without having a history of panic disorder.

When this occurs, the person still has a fear of being stuck in a situation where escape would be difficult or humiliating. However, they generally do not fear having full-blown panic attacks.  

Rather, they may be afraid of having some other type of distressing anxiety symptom or other intense physical issues, such as vomiting or having a severe migraine. For instance, the person may be afraid that they will lose control of their bladder in public or faint without any help being available.

Approximately one-third to half of those diagnosed with panic disorder will also develop agoraphobia. The National Institute of Mental Health (NIMH) reports that agoraphobia occurs to approximately 0.9% of adults in the U.S. population in any given year. This condition typically develops in adulthood, though it can emerge earlier in adolescence.

The avoidance behaviors present in agoraphobia differ from the diagnostic criteria of a specific phobia. 

For instance:

• A person with agoraphobia may avoid traveling by airplane due to a fear of having a panic attack on a plane and not necessarily due to aerophobia, or the fear of flying.
   
• A person with agoraphobia may avoid crowds, fearing the embarrassment of having a panic attack in front of a lot of people. Such a fear is not the same as social anxiety disorder, which is a separate mental health condition that involves anxiety about being negatively evaluated by others.

Causes of Agoraphobia

The exact causes of agoraphobia are not known, but there are a number of risk factors that may increase your risk of developing this condition. These include:

• Having another anxiety disorder, such as generalized anxiety disorder or social anxiety disorder
   
• A family history of agoraphobia
   
• A history of abuse or trauma 
    
• Brain chemistry
   
• Low self-esteem or depression
   

Learned associations can also play a role in the development of agoraphobia. Experiencing a panic attack in a certain situation or setting can lead to a fear that such a reaction will occur again in the future.
 

In some cases, post-traumatic stress disorder (PTSD) can contribute to the development of agoraphobia. PTSD can occur following a traumatic event and lead to hypervigilance and anxiety symptoms, which can lead to the onset of agoraphobia.
 

Extended periods of isolation may increase the risk of developing agoraphobia. For example, fear caused by the COVID-19 pandemic combined with isolation caused by social distancing and quarantines has increased anxiety for many Americans. Mental health experts believe that the repercussions of these events may have a lasting effect on the well-being of adults and children for years to come. 

Diagnosis of Agoraphobia

To receive a diagnosis of agoraphobia, a healthcare provider will assess your symptoms and check for any underlying medical conditions that might be causing those symptoms. You may be asked about your medical history and you will be asked about the nature, duration, and severity of your anxiety symptoms. 

Mental health conditions such as agoraphobia are diagnosed using criteria in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5-TR). The book categorizes different mental disorders and is published by the American Psychiatric Association.

In order to be diagnosed with agoraphobia, you must:

• Have marked fear in at least two different situations, such as open spaces, crowded areas, or public transportation
    
• Have the agoraphobic situation almost always provoke an anxiety response
   
• Have fear that is out of proportion to the threat
   
• Exhibit avoidance behaviors or distress that disrupts your normal routines, work, school, and relationships
   
• Experience these symptoms for at least six months

The symptoms must also not be better explained by another medical or mental condition.

Treatment for Agoraphobia

If a person does develop agoraphobia with panic disorder, symptoms typically begin to occur within the first year that the person starts having recurring and persistent panic attacks. Agoraphobia can get worse if left untreated. 

For the best outcomes in managing agoraphobia and panic symptoms, it is important to seek treatment as soon as symptoms arise. Treatment options typically include a combination of both medication and psychotherapy.

The therapeutic approach may include some systematic desensitization, in which the person gradually confronts avoided situations with the support and guidance of their therapist. Some research has shown that integrating exposure therapy with psychodynamic treatment has been beneficial in panic disorder with agoraphobia. Many times, the person will fare better in facing their fears if accompanied by a trusted friend.

Medications may also be prescribed to help manage certain symptoms of agoraphobia. 

These medications include:

• Antidepressants, including selective serotonin reuptake inhibitors (SSRIs) such as Prozac (fluoxetine) and Zoloft (sertraline); selective serotonin-norepinephrine inhibitors (SNRIs) such as Effexor (venlafaxine); and tricyclic antidepressants (TCAs) such as Tofranil (imipramine) and Anafranil (clomipramine)
   
• Anti-anxiety medications, such as Klonopin (clonazepam) and Xanax (alprazolam)

Coping With Agoraphobia

In addition to seeking help from a mental health professional, there are also lifestyle changes that can help you to better manage the symptoms of agoraphobia. These include:

• Practicing stress management techniques, such as deep breathing, visualization, and progressive muscle relaxation to help reduce anxiety
   
• Eating a healthy and nutritious diet
   
• Getting regular physical exercise
   
• Avoiding drugs and alcohol
   
• Limiting caffeine intake
   

Through the support of family and friends and professional help, a person with agoraphobia can manage their condition. With medication and psychotherapy, a person with agoraphobia can expect to eventually experience fewer panic attacks, fewer avoidance behaviors, and a return to a more independent and active life.

If you or a loved one are struggling with agoraphobia, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

SOURCES:

CPTSD Workbook, Arielle Schwartz PhD/ CPTSD Treatment Manual__CPTSD: From Surviving to Thriving, Pete Walker__www.verywellmind.com/what-is-complex-ptsd__psychcentral.com/ptsd/complex-posttraumatic-stress-disorder-symptoms#common-triggers__goodtherapy.org/dissociation-c-ptsd-role-of-detachment-in-complex-trauma___crappychilhoodfairy.com/cptsd-behaviors-like-narcissism__Crittenden, P. M., Heller, M. B. (2017). The roots of chronic posttraumatic stress disorder: Childhood trauma, information processing, and self-protective strategies. Chronic Stress, 1, 1-13 https://journals.sagepub.com/doi/10.1177/2470547016682965__Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119–138. https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031912-114409__Lawson, D. M. Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, https://onlinelibrary.wiley.com/doi/abs/10.1002/jcad.12143 Sar, V. (2011, March 7)__Developmental trauma, complex PTSD, and the current proposal of DSM-5__European Journal of Psychotraumatology, https://www.tandfonline.com/doi/full/10.3402/ejpt.v2i0.5622__Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12, 228–245. https://journals.sagepub.com/doi/10.1177/1534650113479442__https://www.verywellmind.com/agoraphobia-101-2584235__Avoidance Behavior, Written by Silvi Saxena MBA, MSW, LSW, CCTP, OSW-C/Reviewed by Raiy Abulhosn MD__ https://psychcentral.com/pro/complex-ptsd-and-the-realm-of-dissociation

COMPLEX PTSD 

SHAME

HYPERVIGILANCE

DYSREGULATION

INTERPERSONAL DIFFICULTIES

DISSOCIATION

IMPULSIVITY

DEPRESSION

TRIGGERS

OBSESSIVE BEHAVIOR

PHYSICAL

*TREATMENT*

PERSONAL EXAMPLES