Safety behaviors (anxiety)

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Safety behaviors (also known as safety-seeking behaviors) are coping behaviors used to reduce anxiety and fear when the user feels threatened. [1] An example of a safety behavior in social anxiety is to think of excuses to escape a potentially uncomfortable situation. [2] These safety behaviors, although useful for reducing anxiety in the short term, might become maladaptive over the long term by prolonging anxiety and fear of nonthreatening situations. [1] [3] This problem is commonly experienced in anxiety disorders. [4] Treatments such as exposure and response prevention focus on eliminating safety behaviors due to the detrimental role safety behaviors have in mental disorders. [5] [6] There is a disputed claim that safety behaviors can be beneficial to use during the early stages of treatment. [7]

Contents

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. [1] 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]

Theories about effects

Safety behaviors directly amplify fear and anxiety. [4]

  • 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]

Safety behaviors reduce anxiety in feared situations but retain anxiety in the long term. [4]

  • When a person uses safety behaviors to reduce anxiety and fear in a threatening situation, the anxiety and fear may subside. [4] The user will then believe that the safety behaviors caused the emotional decrease and continue to use safety behaviors in future situations. [1] However, the decrease in anxiety and fear may be due to other factors such as time. [1]
  • The decrease in anxiety and fear may also be due to the situation itself. [1] Situations that seem severely threatening, such as giving a presentation, are not actually very harmful. [1] By avoiding the situation through the use of safety behaviors, the user is unable to realize that the situation is harmless, allowing the cycle of anxiety and behavior to continue. [1]

Classification

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

Preventative

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:

Restorative

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

Associated conditions

Agoraphobia

People may increase their risk for agoraphobia when they use safety behaviors to avoid potentially dangerous environments even though the danger may not be as severe as perceived. [15] A common safety behavior is when a person with agoraphobia attempts to entirely avoid a crowded place such as a mall or a public bus. [16] If the affected person does end up in a crowded area, then the person may tense his or her legs to prevent collapsing in the area. [15] The affected person may also attempt to escape these crowded situations. [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

People with generalized anxiety disorder (GAD) view the world as a highly threatening environment. [17] These people continuously search for safety and use safety behaviors. [17] A common safety behavior used by GAD sufferers is seeking reassurance from a loved one to reduce the excessive worry. [17] The affected person may also attempt to avoid all possible risks of danger and protect others from that danger. [17] However, these behaviors are unlikely to significantly reduce anxiety because the affected person often has multiple fears that are not clearly defined. [17]

Insomnia

People with insomnia tend to excessively worry about getting enough sleep and the consequences of not getting enough sleep. [18] These people use safety behaviors in an attempt to reduce their excessive anxiety. [18] However, the use of safety behaviors serves to increase anxiety and reduce the chances that the affected person will disconfirm these anxiety-provoking thoughts. [18] A common safety behavior used by affected people is attempting to control the anxiety-provoking thoughts by distracting themselves with other thoughts. [18] The affected person may also cancel appointments and decide not to work because the person believes that he or she will not function properly. [18] The affected person may take naps to compensate for the lack of sleep. [18]

Obsessive-compulsive disorder

People with obsessive-compulsive disorder (OCD) use safety behaviors to reduce their anxiety when obsessions arise. [19] Common safety behaviors include washing hands more times than needed and avoiding potential contaminants by not shaking hands. [19] However, when people with OCD use safety behaviors to reduce the chance of contamination, their awareness of potential contamination increases. [19] This heightened awareness then leads to an increased fear of being contaminated. [19]

Checking rituals, such as checking several times to determine if all of the doors to a house are locked, are also common safety behaviors. [20] People with OCD often believe that if they do not perform their checking rituals, others will be in danger. [20] Consequentially, people with OCD often perceive themselves as more responsible for the wellbeing of others than people without the disorder. [20] Therefore, people with OCD use safety behaviors when they believe that other people will be in danger if these behaviors are not used. [20] 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

People with posttraumatic stress disorder (PTSD) believe that their general safety has been compromised after a trauma has occurred. [21] These people use safety behaviors to restore their general sense of safety and to prevent the trauma from happening again. [21] A common safety behavior used by affected people is staying awake for long periods of time to make sure that potential intruders do not attempt to break into their homes. [21] The person may also attempt to avoid potential reminders of the trauma such as moving away from the place where the trauma occurred. [21] These behaviors may lead to persistent fears because the behaviors prevent the affected person from disconfirming the threatening beliefs. [21]

Schizophrenia

People with schizophrenia may have persecutory delusions. [22] These people use safety behaviors to prevent the potential threats that arise from their persecutory delusions. [23] Common safety behaviors include avoiding locations where perceived persecutors can be found and physically escaping from the perceived persecutors. [23] These behaviors may increase the amount of persecutory delusions the person experiences because the safety behaviors prevent the affected person from disconfirming the threatening beliefs. [23]

Social anxiety

Generally, people use social behaviors to either seek approval or avoid disapproval from others. [24] People without social anxiety tend to use behaviors that are designed to gain approval from others, while people with social anxiety prefer to use behaviors that help to avoid disapproval from others. [24] [25] [26]

Safety behaviors seem to reduce the chances of obtaining criticism by drawing less attention to the affected person. [11] Common safety behaviors include avoiding eye contact with other people, focusing on saying the proper words, and other self-controlling behaviors. [11]

Exposure therapy alone is mildly effective in treating social anxiety. [5] 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 are encouraged 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. [2] [27] An assessment developed to measure safety behaviors performed by people with panic disorder is the Texas Safety Maneuver Scale. [28]

Social Behavior Questionnaire

The Social Behavior Questionnaire (SBQ) is an assessment of safety behaviors in social anxiety that was developed in 1994. [27] The frequency at which a behavior is performed is rated from “never” to “always.” [27] Examples of safety behaviors recorded in this assessment include “avoiding asking questions” and “controlling shaking.” [27] The SBQ has been shown to distinguish between people with strong from people with weak fears of being negatively evaluated by others. [29]

Subtle Avoidance Frequency Examination

The Subtle Avoidance Frequency Examination (SAFE) is an assessment of safety behaviors in social anxiety that was developed in 2009. [2] The frequency at which a behavior is performed and the total number of safety behaviors utilized is rated from “never” to “always.” [2] Examples of safety behaviors recorded in this assessment include “speaking softly” and “avoiding eye contact.” [2] This measure has been shown to distinguish between people with clinical levels of social anxiety and those without. [2] [30] This assessment has also been shown to support other measures of social anxiety such as the Social Phobia Scale. [2] [31]

Texas Safety Maneuver Scale

The Texas Safety Maneuver Scale (TSMS) is an assessment of safety behaviors in panic disorder that was developed in 1998. [28] The frequency at which each behavior is performed is measured on a five-point scale from “never” to “always.” [28] Examples of safety behaviors recorded in this assessment include “checking pulse” and “avoiding stressful encounters.” [28] This assessment has also been shown to correlate with agoraphobia measures such as the Fear Questionnaire. [28]

Objections to treatment

Some researchers have claimed that safety behaviors can be helpful in therapy but only when the behaviors are used during the early stages of treatment. [7] For example, exposure therapy will appear less threatening if patients are able to use safety behaviors during the treatment. [7] Patients will also feel more in control in the threatening situations if they are able to use their safety behaviors to reduce anxiety. [7] The studies testing this claim have shown mixed results. [4]

See also

Related Research Articles

Phobia Anxiety disorder defined by a persistent and excessive fear of an object or situation

A phobia is a type of anxiety disorder defined by a persistent and excessive fear of an object or situation. Phobias typically, result in a rapid onset of fear and are present for more than six months. Those affected will go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, which are often found in agoraphobia. Around 75% of those with phobias have multiple phobias.

Anxiety disorder Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatiguability, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

Agoraphobia Anxiety disorder

Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can include open spaces, public transit, shopping centers, or simply being outside their home. Being in these situations may result in a panic attack. Those affected will go to great lengths to avoid these situations. In severe cases people may become completely unable to leave their homes.

Panic attack Period of intense fear

Panic attacks are sudden periods of intense fear and discomfort that may include palpitations, sweating, chest pain, shaking, shortness of breath, numbness, or a feeling of impending doom or of losing control. Typically, symptoms reach a peak within ten minutes of onset, and last for roughly 30 minutes, but the duration can vary from seconds to hours. Though distressing, panic attacks themselves are not physically dangerous.

Acrophobia Extreme or irrational fear of heights

Acrophobia is an extreme or irrational fear or phobia of heights, especially when one is not particularly high up. It belongs to a category of specific phobias, called space and motion discomfort, that share both similar causes and options for treatment.

Cognitive restructuring Type of psychological therapy

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, over-generalization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

The Liebowitz Social Anxiety Scale (LSAS) is a short questionnaire developed in 1987 by Michael Liebowitz, a psychiatrist and researcher at Columbia University and the New York State Psychiatric Institute. Its purpose is to assess the range of social interaction and performance situations feared by a patient in order to assist in the diagnosis of social anxiety disorder. It is commonly used to study outcomes in clinical trials and, more recently, to evaluate the effectiveness of cognitive-behavioral treatments. The scale features 24 items, which are divided into two subscales. 13 questions relate to performance anxiety and 11 concern social situations. The LSAS was originally conceptualized as a clinician-administered rating scale, but has since been validated as a self-report scale.

Cynophobia is the fear of dogs and canines in general. Cynophobia is classified as a specific phobia, under the subtype "animal phobias". According to Timothy O. Rentz of the Laboratory for the Study of Anxiety Disorders at the University of Texas, animal phobias are among the most common of the specific phobias and 36% of patients who seek treatment report being afraid of dogs or afraid of cats. Although ophidiophobia or arachnophobia are more common animal phobias, cynophobia is especially debilitating because of the high prevalence of dogs and the general ignorance of dog owners to the phobia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) reports that only 12% to 30% of those suffering from a specific phobia will seek treatment.

Exposure hierarchy

In exposure therapy, an exposure hierarchy is developed to help clients confront their feared objects and situations in a manner that is systematic and controlled for the purpose of systematic desensitization. Exposure hierarchies are included in the treatment of a wide range of anxiety disorders.

In psychology, desensitization is a treatment or process that diminishes emotional responsiveness to a negative, aversive or positive stimulus after repeated exposure to it. Desensitization also occurs when an emotional response is repeatedly evoked in situations in which the action tendency that is associated with the emotion proves irrelevant or unnecessary. The process of desensitization was developed by psychologist Mary Cover Jones, and is primarily used to assist individuals in unlearning phobias and anxieties. Joseph Wolpe (1958) developed a method of a hierarchal list of anxiety evoking stimuli in order of intensity, which allows individuals to undergo adaption. Although medication is available for individuals suffering from anxiety, fear or phobias, empirical evidence supports desensitization with high rates of cure, particularly in clients suffering from depression or schizophrenia.

Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger. Doing so is thought to help them overcome their anxiety or distress. Procedurally, it is similar to the fear extinction paradigm developed studying laboratory rodents. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and specific phobias.

Social anxiety is the anxiety and fear specifically linked to being in social settings. Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autistic spectrum disorders, eating disorders, and substance use disorders. Individuals with higher levels of social anxiety often avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. Social anxiety commonly manifests itself in the teenage years and can be persistent throughout life, however, people who experience problems in their daily functioning for an extended period of time can develop social anxiety disorder. Trait social anxiety, the stable tendency to experience this anxiety, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

Interoceptive exposure

Interoceptive exposure is a cognitive behavioral therapy technique used in the treatment of panic disorder. It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension, and in the process removing the patient's conditioned response that the physical sensations will cause an attack to happen.

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.

Panic disorder Anxiety disorder characterized by reoccurring unexpected panic attacks

Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

A driving phobia is a pathological fear of driving. It is also referred to as amaxophobia or vehophobia. Amaxophobia is an intense, persistent fear of participating in car traffic that affects a person's lifestyle, including aspects such as an inability to participate in certain jobs due to the pathological avoidance of driving. The fear of driving may be triggered by specific driving situations, such as expressway driving or dense traffic. Driving anxiety can range from a mild cautious concern to a phobia.

Anxiety sensitivity (AS) refers to the fear of behaviours or sensations associated with the experience of anxiety, and a misinterpretation of such sensations as dangerous. Bodily sensations related to anxiety, such as nausea and palpitations, are mistaken as harmful experiences, causing anxiety or fear to intensify. For example, a person with high anxiety sensitivity may fear the shakes as impending neurological disorder, or may suspect lightheadedness is the result of a brain tumour; conversely, a person with low anxiety sensitivity is likely to identify these as harmless and attach no significance to them. The Anxiety Sensitivity Index attempts to assess anxiety sensitivity.

In psychology, relationship obsessive–compulsive disorder (ROCD) is a form of obsessive–compulsive disorder focusing on close or intimate relationships. Such obsessions can become extremely distressing and debilitating, having negative impacts on relationships functioning.

Fear of negative evaluation (FNE), also atychiphobia, is a psychological construct reflecting "apprehension about others' evaluations, distress over negative evaluations by others, and the expectation that others would evaluate one negatively". The construct and a psychological test to measure it were defined by David Watson and Ronald Friend in 1969. FNE is related to specific personality dimensions, such as anxiousness, submissiveness, and social avoidance. People who score high on the FNE scale are highly concerned with seeking social approval or avoiding disapproval by others, and may tend to avoid situations where they have to undergo evaluations. High FNE subjects are also more responsive to situational factors. This has been associated with conformity, pro-social behavior, and social anxiety.

Social Interaction Anxiety Scale Self-report scale that measures distress when meeting and talking with others

The Social Interaction Anxiety Scale (SIAS) is a self-report scale that measures distress when meeting and talking with others that is widely used in clinical settings and among social anxiety researchers. The measure assesses social anxiety disorder, which is fear or anxiety about one or more social situations where the individual is subject to possible scrutiny.

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