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This sandbox is in the article namespace. Either move this page into your userspace, or remove the {{User sandbox}} template. Safety behaviors are maladaptive coping behaviors that occur in order to reduce fear in a situation that contains little to no actual threat. However, the use of safety behaviors results in prolonged anxiety and fear of the nonthreatening situations.

History

The concept of safety behaviors was first related to a mental disorder when a “safety perspective” was used to explain how anxiety was maintained in agoraphobia in 1984.^[1] The “safety perspective” states that people with agoraphobia act to become and stay safe.^[1] Safety behaviors were later defined and connected to panic disorder in 1991.^[2] These safety behaviors were divided into three categories: avoidance of situations, escape, and subtle avoidance.^[2] The concept was later expanded to include other disorders such as social phobia,^[3] obsessive compulsive disorder,^[4] and posttraumatic stress disorder.^[5]

Currently, there are two possible theories about the use of safety behaviors.

Safety behaviors directly amplify fear and anxiety.^[6]
- Safety behaviors promote monitoring of anxiety symptoms so that these symptoms can be reduced. For example, people with panic disorder tend to monitor themselves for symptoms of anxiety and respond to these symptoms with avoidant behaviors.^[7] This attention towards anxiety symptoms results in detection of symptoms that may not lead to panic attacks but are perceived as panic-inducing symptoms.^[7]
- An example of a safety behavior amplifying anxiety occurs when people with social phobia withdraw themselves from social situations by quietly speaking, reducing body movement, and preventing eye contact with other people.^[3]^[8] These behaviors are meant to reduce the chances of receiving criticism from other people.^[3]^[8] Instead, these chances increase because other people view the person with social anxiety as an aloof and unwelcoming person.^[3]^[8]
Safety behaviors reduce anxiety in feared situations but retain anxiety in the long term.^[6]
- People believe that using safety behaviors will control their anxiety and reduce the chances of the threatening possibility from becoming reality.^[2] However, safety behaviors may reduce anxiety in the situation, but the person is unable to realize that the chances of the potentially threatening situation are low regardless of if safety behaviors were used.^[2] Also, the potentially threatening situation may not be as threatening as the afflicted person perceives the situation to be, but the use of safety behaviors prevents the person from experiencing the situation.^[2]

Classification

Safety behaviors can be grouped into two major categories: preventative and restorative safety behaviors.^[6]

Preventative safety behaviors

These behaviors are also known as emotional avoidance behaviors.^[9]^[10] These behaviors are aimed to reduce fear or anxiety in future situations. Examples include:

Completely avoiding situations in which the threat might occur^[6]
Relying on safety signals such as inviting companions to social events for support^[6]
Subtle avoidance behaviors such as avoiding physical contact^[6]
Compulsive behaviors such as checking doors before leaving^[6]
Preparations for potentially encountering these situations^[6]

Restorative safety behaviors

These behaviors are aimed to reduce fear or anxiety in a currently threatening situation. Examples include:

Escaping the situation^[6]
Using safety signals such as looking at cell phones to reduce social anxiety^[6]
Subtle avoidance behaviors such as breathing techniques^[6]
Compulsive behaviors such as repeatedly washing hands^[6]
Seeking reassurance from loved ones or professionals to ensure that the fears are unwarranted^[6]
Distracting attention from the threat or focusing attention on reducing the threat^[6]
Neutralizing the threat by praying or counting^[6]
Suppressing anxiety-provoking thoughts^[6]

Associated conditions

Generalized anxiety disorder

People with generalized anxiety disorder (GAD) view the world as a highly threatening environment.^[11] These people continuously search for safety and use safety behaviors to help themselves become safer.^[11] Common safety behaviors include seeking reassurance, avoiding all possible risks of danger, and overprotecting others.^[11] However, these safety behaviors are unlikely to reduce anxiety to a major extent because the affected person has multiple fears that are not clearly defined.^[11]

Insomnia

People with insomnia tend to excessively worry about getting enough sleep and the results of not getting enough sleep.^[12] These people then use safety behaviors to reduce the excessive anxiety.^[12] However, these safety behaviors increase the anxiety and reduce the chances that the affected person will disconfirm these anxiety-provoking thoughts.^[12] Common safety behaviors include attempting to control the anxiety-provoking thoughts, reducing the daytime workload, and taking naps to compensate for the lack of sleep.^[12]

Obsessive-compulsive disorder

People with obsessive-compulsive disorder (OCD) use safety behaviors to reduce the anxiety that arises when obsessions arise.^[13] Common safety behaviors include excessive hand washing and avoidance of potential contaminants.^[13] When people with OCD use safety behaviors to reduce the chance of contamination, their awareness of potential contamination increases.^[13] This heightened awareness then leads to an increased fear of being contaminated.^[13]

Checking rituals are also common examples of safety behaviors in OCD.^[14] People with OCD perceive more responsibility for others’ safety than people without the disorder.^[14] Therefore, people with OCD use safety behaviors when they believe that other people will be in danger if these behaviors are not used.^[14] Continuous checking results in uncertainty about previous actions and details in memory, but not memory itself.^[15] Exposure and response prevention therapy is effective in treating OCD.^[15]

Panic disorder and agoraphobia

People with panic disorder are affected by panic attacks.^[16] These people develop agoraphobia when they use safety behaviors to reduce the possibility of experiencing another panic attack.^[16] Common safety behaviors include avoiding crowded places that may trigger panic attacks, tensing legs to prevent collapse, and escaping situations in which a panic attack might occur.^[16] People with panic disorder and agoraphobia then attribute the lack of feared symptoms to the safety behaviors instead of to the panic attacks themselves.^[16] This incorrect attribution may lead to persisting fears and symptoms.^[16]

Posttraumatic stress disorder

People with posttraumatic stress disorder (PTSD) believe that their general safety has been compromised after the trauma has occurred.^[17] These people use safety behaviors to restore their general safety and prevent the trauma from happening again.^[17] Common safety behaviors include staying awake to make sure that intruders do not attack and avoiding potential reminders of the trauma.^[17] These behaviors may lead to persisting fears because the behaviors prevent the affected person from disconfirming the threatening beliefs.^[17]

Schizophrenia

People with schizophrenia may have persecutory delusions. These people use safety behaviors to prevent the potential threats that arise from the persecutory delusions.^[18] Common safety behaviors include avoiding the threatening situation, escaping the threatening situation, and seeking help from others to reduce the threat.^[18] These behaviors may increase the amount of persecutory delusions because people who use safety behaviors are not focused on discrediting the delusions.^[18]

Social anxiety

Generally, people use social behaviors to either seek approval from others or avoid disapproval from others. People without social anxiety tend to use behaviors that are aimed to gain approval from others, while people with social anxiety prefer to use behaviors that help avoid disapproval from others.^[19]^[20]^[21]

In social anxiety, people use safety behaviors to reduce the chances of being seen negatively by other people. People with social anxiety therefore attempt to draw less attention to themselves. Common safety behaviors include avoiding eye contact, focusing on saying the correct words, and doing other self-controlling behaviors.^[8]

Exposure therapy alone is mildly effective in treating social anxiety. There are larger decreases in anxiety and fear when people are also told to stop themselves from using safety behaviors during therapy than when people were allowed to use safety behaviors.^[3] These decreases are largest when people are told to stop using safety behaviors and disconfirm the thoughts that the threatening situation will most likely not happen even if the safety behaviors are stopped.^[8] This combination of techniques is used in exposure and response prevention therapy for social anxiety.^[3]

Assessment measures

Several assessments have been developed to measure the amount of safety behaviors used by people with specific psychological conditions. Two examples of assessments developed to measure safety behaviors performed by people with social anxiety are the Social Behavior Questionnaire and the Subtle Avoidance Frequency Examination.

The Social Behavior Questionnaire is an assessment that was developed in 1994.^[22] The frequency of each behavior measured in this assessment would be rated from “never” to “always.”^[22] Examples of safety behaviors recorded in this assessment include “avoiding asking questions” and “controlling shaking.”^[22] This measure has been shown to distinguish people with strong fears of being negatively evaluated by others from people who have low levels of fear of negative evaluation.^[23]

The Subtle Avoidance Frequency Examination is an assessment developed in 2009.^[24] This assessment uses a scale from 0 ("never") to 5 ("always") to measure the amount and frequency of safety behaviors used by people with social anxiety.^[24] Examples of safety behaviors recorded in this assessment include “speaking softly” and “avoiding eye contact.”^[24] This measure has been shown to distinguish people with clinical levels of social anxiety from people without clinical social anxiety.^[24]^[25] This measure has also been shown to support assessments of social anxiety.^[24]^[26]

An assessment developed to measure safety behaviors performed by people with panic disorder is the Texas Safety Maneuver Scale.^[27] The frequency of each measured behavior was measured on a five-point scale from “never” to “always.”^[27] Examples of safety behaviors recorded in this assessment include “checking pulse” and “avoiding stressful encounters.”^[27] This assessment has been shown to correlate with agoraphobia and anxiety in the framework of panic disorder.^[27]

Objections to treatment

There is a claim that safety behaviors can be helpful in therapy when the behaviors are only used during the early stages of treatment.^[28] Exposure therapy will appear to be less threatening if patients are able to use safety behaviors during the therapy.^[28] Patients will also feel more control in the threatening situations by being able to use safety behaviors to reduce anxiety.^[28] The studies testing this claim have shown mixed results.^[6]

References

^ ^a ^b Rachman, S. (1984). Agoraphobia—A safety-signal perspective. Behaviour Research and Therapy, 22(1), 59-70.
^ ^a ^b ^c ^d ^e Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy, 19(1), 6-19.
^ ^a ^b ^c ^d ^e ^f Wells, A., Clark, D.M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26(1), 153-161.
^ Salkovskis, P. M. (1999). Understanding and treating obsessive—compulsive disorder. Behaviour Research and Therapy, 37, S29-S52.
^ Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders. Clinical Psychology: Science and Practice, 17(3), 218-233.
^ ^a ^b Ehlers, A., & Breuer, P. (1992). Increased cardiac awareness in panic disorder. Journal Of Abnormal Psychology, 101(3), 371-382.
^ ^a ^b ^c ^d ^e Kim, E. J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders, 19(1), 69-86.
^ Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioural disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.
^ Salters-Pedneault, K., Tull, M. T., & Roemer, E. (2004). The role of avoidance of emotional material in the anxiety disorders. Applied and Preventive Psychology, 11, 95–114.
^ ^a ^b ^c ^d Woody, S., & Rachman, S. (1994). Generalized anxiety disorder (GAD) as an unsuccessful search for safety. Clinical Psychology Review, 14, 743–753.
^ ^a ^b ^c ^d Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869-893.
^ ^a ^b ^c ^d Deacon, B., & Maack, D. J. (2008). The effects of safety behaviors on the fear of contamination: An experimental investigation. Behaviour Research and Therapy, 46(4), 537-547.
^ ^a ^b ^c Salkovskis, P.M., Wroe, A.L., Gledhill, A., Morrison, N., Forrester, E., Richards, C., Reynolds, M., & Thorpe, S. (2000). Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder. Behaviour Research and Therapy, 38, 347–372.
^ ^a ^b van den Hout, M., & Kindt, M. (2004). Obsessive–compulsive disorder and the paradoxical effects of perseverative behaviour on experienced uncertainty. Journal of Behavior Therapy and Experimental Psychiatry, 35(2), 165-181.
^ ^a ^b ^c ^d ^e Salkovskis, P.M., Clark, D.M., Hackman, A., Wells, A., & Gelder, M.G. (1999). An experimental investigation of the role of safety behaviors in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559–574.
^ ^a ^b ^c ^d Dunmore, E., Clark, D. M., & Ehlers, A. (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, 37(9), 809-829.
^ ^a ^b ^c Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., Bebbington, P. E., & Dunn, G. (2007). Acting on persecutory delusions: The importance of safety seeking. Behaviour Research and Therapy, 45(1), 89-99.
^ Arkin, R. M. (1981). Self-presentation styles. In J. T. Tedeschi (Eds.), Impression management theory and social psychological research (pp. 311–333). New York: Academic Press.
^ Arkin, R. M., Lake, E. A., & Baumgarder, A. H. (1986). Shyness and self-presentation. In W. H. Jones, J. M. Cheek, & S. R. Briggs (Eds.), Shyness: perspectives on research and treatment (pp. 189–204). New York: Plenum Press.
^ Schlenker, B.R., & Leary, M.R. (1982). Social anxiety and self-presentation: A conceptualization and model. Psychological Bulletin, 92, 641–669.
^ ^a ^b ^c Clark, D. M., Wells, A., Hackmann, A., Butler, G., & Fennell, M. J. U. (1994). Social behaviour questionnaire. Unpublished. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford.
^ Spurr, J. M., & Stopa, L. (2003). The observer perspective: Effects on social anxiety and performance. Behaviour Research and Therapy, 41(9), 1009-1028.
^ ^a ^b ^c ^d ^e Cuming, S., Rapee, R. M., Kemp, N., Abbott, M. J., Peters, L., & Gaston, J. E. (2009). A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties. Journal of Anxiety Disorders, 23(7), 879-883.
^ Moscovitch, D. A., Rowa, K., Paulitzki, J. R., Ierullo, M. D., Chiang, B., Antony, M. M., & McCabe, R. E. (2013). Self-portrayal concerns and their relation to safety behaviors and negative affect in social anxiety disorder. Behaviour Research and Therapy, 51(8), 476-486
^ Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77(2), 317.
^ ^a ^b ^c ^d Kamphuis, J. H., & Telch, M. J. (1998). Assessment of strategies to manage or avoid perceived threats among panic disorder patients: The Texas Safety Maneuver Scale (TSMS). Clinical Psychology & Psychotherapy, 5(3), 177-186.
^ ^a ^b ^c Rachman, S., Radomsky, A. S., & Shafran, R. (2008). Safety behaviour: A reconsideration. Behaviour Research and Therapy, 46, 143–173.

[Rachman_(1984)-1] Rachman, S. (1984). Agoraphobia—A safety-signal perspective. Behaviour Research and Therapy, 22(1), 59-70.

[Salkovskis_(1991)-2] Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy, 19(1), 6-19.

[Wells_(1995)-3] ^ ^a ^b ^c ^d ^e ^f Wells, A., Clark, D.M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26(1), 153-161.

[4] Salkovskis, P. M. (1999). Understanding and treating obsessive—compulsive disorder. Behaviour Research and Therapy, 37, S29-S52.

[5] Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345.

[Helbig-Lang_(2010)-6] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders. Clinical Psychology: Science and Practice, 17(3), 218-233.

[Ehlers_(1992)-7] Ehlers, A., & Breuer, P. (1992). Increased cardiac awareness in panic disorder. Journal Of Abnormal Psychology, 101(3), 371-382.

[Kim_(2005)-8] Kim, E. J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders, 19(1), 69-86.

[9] Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioural disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.

[10] Salters-Pedneault, K., Tull, M. T., & Roemer, E. (2004). The role of avoidance of emotional material in the anxiety disorders. Applied and Preventive Psychology, 11, 95–114.

[Woody_(1994)-11] Woody, S., & Rachman, S. (1994). Generalized anxiety disorder (GAD) as an unsuccessful search for safety. Clinical Psychology Review, 14, 743–753.

[Harvey_(2002)-12] Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869-893.

[Deacon_(2008)-13] Deacon, B., & Maack, D. J. (2008). The effects of safety behaviors on the fear of contamination: An experimental investigation. Behaviour Research and Therapy, 46(4), 537-547.

[Salkovskis_(2000)-14] Salkovskis, P.M., Wroe, A.L., Gledhill, A., Morrison, N., Forrester, E., Richards, C., Reynolds, M., & Thorpe, S. (2000). Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder. Behaviour Research and Therapy, 38, 347–372.

[van_den_Hout_(2004)-15] van den Hout, M., & Kindt, M. (2004). Obsessive–compulsive disorder and the paradoxical effects of perseverative behaviour on experienced uncertainty. Journal of Behavior Therapy and Experimental Psychiatry, 35(2), 165-181.

[Salkovskis_(1999)-16] Salkovskis, P.M., Clark, D.M., Hackman, A., Wells, A., & Gelder, M.G. (1999). An experimental investigation of the role of safety behaviors in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559–574.

[Dunmore_(1999)-17] Dunmore, E., Clark, D. M., & Ehlers, A. (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, 37(9), 809-829.

[Freeman_(2007)-18] Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., Bebbington, P. E., & Dunn, G. (2007). Acting on persecutory delusions: The importance of safety seeking. Behaviour Research and Therapy, 45(1), 89-99.

[19] Arkin, R. M. (1981). Self-presentation styles. In J. T. Tedeschi (Eds.), Impression management theory and social psychological research (pp. 311–333). New York: Academic Press.

[20] Arkin, R. M., Lake, E. A., & Baumgarder, A. H. (1986). Shyness and self-presentation. In W. H. Jones, J. M. Cheek, & S. R. Briggs (Eds.), Shyness: perspectives on research and treatment (pp. 189–204). New York: Plenum Press.

[21] Schlenker, B.R., & Leary, M.R. (1982). Social anxiety and self-presentation: A conceptualization and model. Psychological Bulletin, 92, 641–669.

[Clark_(1994)-22] Clark, D. M., Wells, A., Hackmann, A., Butler, G., & Fennell, M. J. U. (1994). Social behaviour questionnaire. Unpublished. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford.

[23] Spurr, J. M., & Stopa, L. (2003). The observer perspective: Effects on social anxiety and performance. Behaviour Research and Therapy, 41(9), 1009-1028.

[Cuming_(2009)-24] Cuming, S., Rapee, R. M., Kemp, N., Abbott, M. J., Peters, L., & Gaston, J. E. (2009). A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties. Journal of Anxiety Disorders, 23(7), 879-883.

[Moscovitch_(2013)-25] Moscovitch, D. A., Rowa, K., Paulitzki, J. R., Ierullo, M. D., Chiang, B., Antony, M. M., & McCabe, R. E. (2013). Self-portrayal concerns and their relation to safety behaviors and negative affect in social anxiety disorder. Behaviour Research and Therapy, 51(8), 476-486

[26] Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77(2), 317.

[Kamphuis_(1998)-27] Kamphuis, J. H., & Telch, M. J. (1998). Assessment of strategies to manage or avoid perceived threats among panic disorder patients: The Texas Safety Maneuver Scale (TSMS). Clinical Psychology & Psychotherapy, 5(3), 177-186.

[Rachman_(2008)-28] Rachman, S., Radomsky, A. S., & Shafran, R. (2008). Safety behaviour: A reconsideration. Behaviour Research and Therapy, 46, 143–173.

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@@ Line 5: / Line 5: @@
 ==History==
 The concept of safety behaviors was first related to a mental disorder when a “safety perspective” was used to explain how anxiety was maintained in agoraphobia in 1984.<ref name="Rachman (1984)">Rachman, S. (1984). Agoraphobia—A safety-signal perspective. ''Behaviour Research and Therapy'', ''22''(1), 59-70.</ref> The “safety perspective” states that people with agoraphobia act to become and stay safe.<ref name="Rachman (1984)" /> Safety behaviors were later defined and connected to panic disorder in 1991.<ref name="Salkovskis (1991)">Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. ''Behavioural Psychotherapy'', ''19''(1), 6-19.</ref> These safety behaviors were divided into three categories: avoidance of situations, escape, and subtle avoidance.<ref name="Salkovskis (1991)" /> The concept was later expanded to include other disorders such as social phobia,<ref name="Wells (1995)">Wells, A., Clark, D.M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. ''Behavior Therapy'', ''26''(1), 153-161.</ref> obsessive compulsive disorder,<ref>Salkovskis, P. M. (1999). Understanding and treating obsessive—compulsive disorder. ''Behaviour Research and Therapy'', ''37'', S29-S52.</ref> and posttraumatic stress disorder.<ref>Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. ''Behaviour Research and Therapy'', ''38''(4), 319-345.</ref>
-Currently, there are three possible theories about the use of safety behaviors.<ref name= "Helbig-Lang (2010)">Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders. ''Clinical Psychology: Science and Practice'', ''17''(3), 218-233.</ref>
+Currently, there are two possible theories about the use of safety behaviors.
-# Safety behaviors directly amplify fear and anxiety.
+#Safety behaviors directly amplify fear and anxiety.<ref name= "Helbig-Lang (2010)">Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders. ''Clinical Psychology: Science and Practice'', ''17''(3), 218-233.</ref>
-#*This theory was taken from the models describing panic disorder and social phobia.<ref name="Rachman (1984)" />
+#*Safety behaviors promote monitoring of anxiety symptoms so that these symptoms can be reduced. For example, people with panic disorder tend to monitor themselves for symptoms of anxiety and respond to these symptoms with avoidant behaviors.<ref name= "Ehlers (1992)">Ehlers, A., & Breuer, P. (1992). Increased cardiac awareness in panic disorder. ''Journal Of Abnormal Psychology'', ''101''(3), 371-382.</ref> This attention towards anxiety symptoms results in detection of symptoms that may not lead to panic attacks but are perceived as panic-inducing symptoms.<ref name= "Ehlers (1992)" />
-#*An example of a safety behavior amplifying anxiety occurs when people with social phobia withdraw themselves from social situations by quietly speaking, reducing body movement, and preventing eye contact with other people. These behaviors are meant to reduce the chances of receiving criticism from other people. Instead, these chances increase because other people view the person with social anxiety as an aloof and unwelcoming person.<ref name="Wells (1995)" /><ref name="Kim (2005)">Kim, E. J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. ''Journal of Anxiety Disorders'', ''19''(1), 69-86.</ref>
+#*An example of a safety behavior amplifying anxiety occurs when people with social phobia withdraw themselves from social situations by quietly speaking, reducing body movement, and preventing eye contact with other people.<ref name="Wells (1995)" /><ref name="Kim (2005)">Kim, E. J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. ''Journal of Anxiety Disorders'', ''19''(1), 69-86.</ref> These behaviors are meant to reduce the chances of receiving criticism from other people.<ref name="Wells (1995)" /><ref name="Kim (2005)" /> Instead, these chances increase because other people view the person with social anxiety as an aloof and unwelcoming person.<ref name="Wells (1995)" /><ref name="Kim (2005)" />
-# Safety behaviors reduce anxiety in feared situations but exacerbate anxiety over time.
-#*This theory was taken from learning theories and attributional processes.<ref name="Salkovskis (1991)" />
+#Safety behaviors reduce anxiety in feared situations but retain anxiety in the long term.<ref name= "Helbig-Lang (2010)" />
+#*People believe that using safety behaviors will control their anxiety and reduce the chances of the threatening possibility from becoming reality.<ref name="Salkovskis (1991)" /> However, safety behaviors may reduce anxiety in the situation, but the person is unable to realize that the chances of the potentially threatening situation are low regardless of if safety behaviors were used.<ref name="Salkovskis (1991)" /> Also, the potentially threatening situation may not be as threatening as the afflicted person perceives the situation to be, but the use of safety behaviors prevents the person from experiencing the situation.<ref name="Salkovskis (1991)" />
-# Safety behaviors directly develop clinical anxiety.
-#*This theory was also taken from learning theories.<ref>Lohr, J. M., Olatunji, B. O., & Sawchuk, C. N. (2007). A functional analysis of danger and safety signals in anxiety disorders. ''Clinical Psychology Review'', ''27''(1), 114-126.</ref><ref>Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition-behaviour links in the persistence of panic. ''Behaviour Research and Therapy'', ''34'', 453–458.</ref>
-#*People participate in safety behaviors to reduce the chances of a threatening situation from occurring. Since the threatening situations are usually unlikely to happen, people then attribute the lack of threatening situations to the use of safety behaviors.<ref name="Salkovskis (1991)" /><ref name="Wells (1995)" /> Therefore, people will not be motivated to figure out that these threatening situations will most likely not occur or are not severe because they just need to use safety behaviors to prevent the situations from happening at all.<ref name="Kim (2005)" />
 ==Classification==
@@ Line 70: / Line 68: @@
 Several assessments have been developed to measure the amount of safety behaviors used by people with specific psychological conditions. Two examples of assessments developed to measure safety behaviors performed by people with social anxiety are the Social Behavior Questionnaire and the Subtle Avoidance Frequency Examination.
-The Social Behavior Questionnaire is an assessment that was developed in 1994.<ref name= "Clark (1994)">Clark, D. M., Wells, A., Hackmann, A., Butler, G., & Fennell, M. J. U. (1994). ''Social behaviour questionnaire''. Unpublished. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford.</ref> The frequency of each behavior measured in this assessment would be rated from “never” to “always”.<ref name= "Clark (1994)" /> Examples of safety behaviors recorded in this assessment include “avoiding asking questions” and “controlling shaking.” <ref name= "Clark (1994)" /> This measure has been shown to distinguish people with strong fears of being negatively evaluated by others from people who have low levels of fear of negative evaluation.<ref>Spurr, J. M., & Stopa, L. (2003). The observer perspective: Effects on social anxiety and performance. ''Behaviour Research and Therapy'', ''41''(9), 1009-1028.</ref>
+The Social Behavior Questionnaire is an assessment that was developed in 1994.<ref name= "Clark (1994)">Clark, D. M., Wells, A., Hackmann, A., Butler, G., & Fennell, M. J. U. (1994). ''Social behaviour questionnaire''. Unpublished. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford.</ref> The frequency of each behavior measured in this assessment would be rated from “never” to “always.”<ref name= "Clark (1994)" /> Examples of safety behaviors recorded in this assessment include “avoiding asking questions” and “controlling shaking.”<ref name= "Clark (1994)" /> This measure has been shown to distinguish people with strong fears of being negatively evaluated by others from people who have low levels of fear of negative evaluation.<ref>Spurr, J. M., & Stopa, L. (2003). The observer perspective: Effects on social anxiety and performance. ''Behaviour Research and Therapy'', ''41''(9), 1009-1028.</ref>
 The Subtle Avoidance Frequency Examination is an assessment developed in 2009.<ref name= "Cuming (2009)">Cuming, S., Rapee, R. M., Kemp, N., Abbott, M. J., Peters, L., & Gaston, J. E. (2009). A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties. ''Journal of Anxiety Disorders'', ''23''(7), 879-883.</ref> This assessment uses a scale from 0 ("never") to 5 ("always") to measure the amount and frequency of safety behaviors used by people with social anxiety.<ref name= "Cuming (2009)" /> Examples of safety behaviors recorded in this assessment include “speaking softly” and “avoiding eye contact.”<ref name= "Cuming (2009)" /> This measure has been shown to distinguish people with clinical levels of social anxiety from people without clinical social anxiety.<ref name= "Cuming (2009)" /><ref name= "Moscovitch (2013)">Moscovitch, D. A., Rowa, K., Paulitzki, J. R., Ierullo, M. D., Chiang, B., Antony, M. M., & McCabe, R. E. (2013). Self-portrayal concerns and their relation to safety behaviors and negative affect in social anxiety disorder. ''Behaviour Research and Therapy'', ''51''(8), 476-486</ref>  This measure has also been shown to support assessments of social anxiety.<ref name= "Cuming (2009)" /><ref>Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. ''Journal of Consulting and Clinical Psychology'', ''77''(2), 317.</ref>
+An assessment developed to measure safety behaviors performed by people with panic disorder is the Texas Safety Maneuver Scale.<ref name= "Kamphuis (1998)">Kamphuis, J. H., & Telch, M. J. (1998). Assessment of strategies to manage or avoid perceived threats among panic disorder patients: The Texas Safety Maneuver Scale (TSMS). ''Clinical Psychology & Psychotherapy'', ''5''(3), 177-186.</ref> The frequency of each measured behavior was measured on a five-point scale from “never” to “always.”<ref name= "Kamphuis (1998)" /> Examples of safety behaviors recorded in this assessment include “checking pulse” and “avoiding stressful encounters.”<ref name= "Kamphuis (1998)" /> This assessment has been shown to correlate with agoraphobia and anxiety in the framework of panic disorder.<ref name= "Kamphuis (1998)" />
 ==Objections to treatment==
 There is a claim that safety behaviors can be helpful in therapy when the behaviors are only used during the early stages of treatment.<ref name= "Rachman (2008)">Rachman, S., Radomsky, A. S., & Shafran, R. (2008). Safety behaviour: A reconsideration. ''Behaviour Research and Therapy'', ''46'', 143–173.</ref> Exposure therapy will appear to be less threatening if patients are able to use safety behaviors during the therapy.<ref name= "Rachman (2008)" /> Patients will also feel more control in the threatening situations by being able to use safety behaviors to reduce anxiety.<ref name= "Rachman (2008)" /> The studies testing this claim have shown mixed results.<ref name= "Helbig-Lang (2010)" />
-An experiment was conducted in 1984 that showed the effectiveness in safety signals in therapy.<ref name="Rachman (1984)" /> Another experiment was conducted in 2008 that showed how safety behaviors could be used to help patients respond with greater efficacy to exposure therapy.<ref name= "Rachman (2008)" />
 ==See also==