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Safety behaviors (anxiety)

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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 coping behaviors used for protection in threatening situations.[1] These safety behaviors become maladaptive when used in situations, such as those experienced in anxiety disorders, that seem threatening but contain little to no actual threat.[2] The maladaptive use of safety behaviors results in prolonged anxiety and fear of nonthreatening situations.[3][4] Treatments such as exposure and response prevention focus on eliminating safety behaviors,[5][6] but some researchers argue that safety behaviors can be beneficial to use during treatment.[7]

History

The concept of safety behaviors was first related to a mental disorder in 1984 when the “safety perspective” hypothesis was proposed to explain how agoraphobia is maintained over time.[3] The “safety perspective” hypothesis states that people with agoraphobia act in ways they believe will increase or maintain their level of safety.[3] In 1991, the use of safety behaviors was observed in people with panic disorders.[4] Later studies observed the use of safety behaviors in people with other disorders such as social phobia,[5] obsessive compulsive disorder,[8] and posttraumatic stress disorder.[9]

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

  1. Safety behaviors directly amplify fear and anxiety.[2]
    • The use of safety behaviors promotes the monitoring of anxiety symptoms. For example, people with panic disorders tend to monitor themselves for symptoms of anxiety and respond to these symptoms with avoidant behaviors.[10] This over analysis of physical sensations results in detection of symptoms that may not lead to panic attacks but are perceived as panic-inducing symptoms.[10]
    • People with social phobia withdraw themselves from social situations by quietly speaking, reducing body movement, and preventing eye contact with other people.[5][11] These behaviors are meant to reduce the chances of receiving criticism from other people.[5][11] Instead, safety behaviors result in more criticism because people with social phobia are seen as aloof and unwelcoming people.[5][11]
  2. Safety behaviors reduce anxiety in feared situations but retain anxiety in the long term.[2]
    • Safety behaviors may reduce anxiety in nonthreatening situations.[2] This phenomena strengthens the person’s faith in their safety behaviors and makes the person unable to see the reality of the situation: that the chance of actual danger occurring in that situation was low regardless of whether or not safety behaviors were used.[4]
    • The use of safety behaviors also prevents the person from experiencing the nonthreatening situation.[4] By not experiencing the situation, the affected person was unable to falsify the perception of danger, allowing the cycle of anxiety and behavior to continue.[4]

Classification

Safety behaviors can be grouped into two major categories: preventative and restorative safety behaviors.[12]

Preventative safety behaviors

These behaviors are also known as emotional avoidance behaviors.[13][14] These behaviors are aimed to reduce fear or anxiety in future situations.[12] Examples include:

  • Completely avoiding situations in which the threat might occur[2]
  • Relying on safety signals such as inviting companions to social events for support[2]
  • Subtle avoidance behaviors such as avoiding physical contact[2]
  • Compulsive behaviors such as checking doors before leaving[2]
  • Preparations for potentially encountering these situations[2]

Restorative safety behaviors

These behaviors are aimed to reduce fear or anxiety in a currently threatening situation.[12] Examples include:

  • Escaping the situation[2]
  • Using safety signals such as looking at cell phones to reduce social anxiety[2]
  • Subtle avoidance behaviors such as breathing techniques[2]
  • Compulsive behaviors such as repeatedly washing hands[2]
  • Seeking reassurance from loved ones or professionals to ensure that the fears are unwarranted[2]
  • Distracting attention from the threat or focusing attention on reducing the threat[2]
  • Neutralizing the threat by praying or counting[2]
  • Suppressing anxiety-provoking thoughts[2]

Associated conditions

Agoraphobia

Main article: Agoraphobia

People develop agoraphobia when they use safety behaviors to avoid potentially dangerous environments even though the danger may not be as severe as perceived.[15] Common safety behaviors include avoiding crowded places entirely, tensing legs to prevent collapse, and escaping situations that become potentially dangerous.[15] People with agoraphobia then attribute the lack of feared symptoms to the safety behaviors instead of to the lack of danger itself.[15] This incorrect attribution may lead to persisting fears and symptoms.[15]

Generalized anxiety disorder

Main article: Generalized anxiety disorder

People with generalized anxiety disorder (GAD) view the world as a highly threatening environment.[16] These people continuously search for safety and use safety behaviors to accomplish safety.[16] Common safety behaviors include seeking reassurance, avoiding all possible risks of danger, and overprotecting others.[16] However, these safety behaviors are unlikely to significantly reduce anxiety because the affected person has multiple fears that are not clearly defined.[16]

Insomnia

Main article: Insomnia

People with insomnia tend to excessively worry about getting enough sleep and the consequences of not getting enough sleep.[[17] These people use safety behaviors in an attempt to reduce their excessive anxiety.[17] However, the use of safety behaviors serves to increase anxiety and reduce the chances that the affected person will disconfirm these anxiety-provoking thoughts.[17] 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.[17]

Obsessive-compulsive disorder

Main article: Obsessive-compulsive disorder

People with obsessive-compulsive disorder (OCD) use safety behaviors to reduce their anxiety when obsessions arise.[18] Common safety behaviors include excessive hand washing and avoidance of potential contaminants.[18] However, when people with OCD use safety behaviors to reduce the chance of contamination, their awareness of potential contamination increases.[18] This heightened awareness then leads to an increased fear of being contaminated.[18]

Checking rituals are also common safety behaviors.[19] People with OCD often believe that if they do not perform their checking rituals, others will be in danger.[19] Consequentially, people with OCD perceive themselves as more responsible for the wellbeing of others than people without the disorder.[19] Therefore, people with OCD use safety behaviors when they believe that other people will be in danger if these behaviors are not used.[19] Continuous checking reduces the certainty and vividness of memories related to checking.[6] Exposure and response prevention therapy is effective in treating OCD.[6]

Posttraumatic stress disorder

Main article: Posttraumatic stress disorder

People with posttraumatic stress disorder (PTSD) believe that their general safety has been compromised after the trauma has occurred.[20] These people use safety behaviors to restore their general safety and prevent the trauma from happening again.[20] Common safety behaviors include staying awake to make sure that intruders do not attack and avoiding potential reminders of the trauma.[20] These behaviors may lead to persistent fears because the behaviors prevent the affected person from disconfirming the threatening beliefs.[20]

Schizophrenia

Main article: Schizophrenia

People with schizophrenia may have persecutory delusions. These people use safety behaviors to prevent the potential threats that arise from the persecutory delusions.[21] Common safety behaviors include avoiding the threatening situation, escaping the threatening situation, and seeking help from others to reduce the threat.[21] These behaviors may increase the amount of persecutory delusions because people who use safety behaviors are not focused on discrediting the delusions.[21]

Social anxiety

Main article: Social anxiety disorder

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.[22][23][24]

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.[11]

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.[5] 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.[11] This combination of techniques is used in exposure and response prevention therapy for social anxiety.[5]

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.[25] The frequency of each behavior measured in this assessment would be rated from “never” to “always.”[25] Examples of safety behaviors recorded in this assessment include “avoiding asking questions” and “controlling shaking.”[25] 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.[26]

The Subtle Avoidance Frequency Examination is an assessment developed in 2009.[27] 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.[27] Examples of safety behaviors recorded in this assessment include “speaking softly” and “avoiding eye contact.”[27] This measure has been shown to distinguish people with clinical levels of social anxiety from people without clinical social anxiety.[27][28] This measure has also been shown to support assessments of social anxiety.[27][29]

An assessment developed to measure safety behaviors performed by people with panic disorder is the Texas Safety Maneuver Scale.[30] The frequency of each measured behavior was measured on a five-point scale from “never” to “always.”[30] Examples of safety behaviors recorded in this assessment include “checking pulse” and “avoiding stressful encounters.”[30] This assessment has been shown to correlate with agoraphobia and anxiety in the framework of panic disorder.[30]

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.[7] Exposure therapy will appear to be less threatening if patients are able to use safety behaviors during the therapy.[7] Patients will also feel more control in the threatening situations by being able to use safety behaviors to reduce anxiety.[7] The studies testing this claim have shown mixed results.[2]

See also

References

  1. ^ Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, 55(11), 1247-1263.
  2. ^ a b c d e f g h i j k l m n o p q r 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.
  3. ^ a b c Rachman, S. (1984). Agoraphobia—A safety-signal perspective. Behaviour Research and Therapy, 22(1), 59-70.
  4. ^ 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.
  5. ^ a b c d e f g 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.
  6. ^ a b c 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.
  7. ^ a b c d Rachman, S., Radomsky, A. S., & Shafran, R. (2008). Safety behaviour: A reconsideration. Behaviour Research and Therapy, 46, 143–173.
  8. ^ Salkovskis, P. M. (1999). Understanding and treating obsessive—compulsive disorder. Behaviour Research and Therapy, 37, S29-S52.
  9. ^ Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345.
  10. ^ a b Ehlers, A., & Breuer, P. (1992). Increased cardiac awareness in panic disorder. Journal Of Abnormal Psychology, 101(3), 371-382.
  11. ^ 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.
  12. ^ a b c Rachman, S., & Hodgson, R. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice Hall.
  13. ^ 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.
  14. ^ 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.
  15. ^ a b c d 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.
  16. ^ 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.
  17. ^ a b c d Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869-893.
  18. ^ 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.
  19. ^ a b c d 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.
  20. ^ 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.
  21. ^ 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.
  22. ^ 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.
  23. ^ 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.
  24. ^ Schlenker, B.R., & Leary, M.R. (1982). Social anxiety and self-presentation: A conceptualization and model. Psychological Bulletin, 92, 641–669.
  25. ^ 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.
  26. ^ Spurr, J. M., & Stopa, L. (2003). The observer perspective: Effects on social anxiety and performance. Behaviour Research and Therapy, 41(9), 1009-1028.
  27. ^ 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.
  28. ^ 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
  29. ^ 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.
  30. ^ 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.
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