Testing Judicious Use of Safety Behaviors During Exposure: A Randomized Controlled Trial Examining when and for whom Safety Behaviors Improve Fear Reduction

Safety behaviours are ubiquitous across anxiety disorders and are associated with the aetiology, maintenance and exacerbation of anxiety. Cognitive behavioural models posit that beliefs about safety behaviours directly influence their use. Therefore, beliefs about safety behaviours may be an important component in decreasing safety behaviour use. Unfortunately, little empirical research has evaluated this theorized relationship. The present study aimed to examine the predictive relationship between beliefs about safety behaviours and safety behaviour use while controlling for anxiety severity. Adults with clinically elevated levels of social anxiety (n = 145) and anxiety sensitivity (n = 109) completed an online survey that included established measures of safety behaviour use, quality of life, and anxiety severity. Participants also completed the Safety Behaviour Scale (SBS), a measure created for the current study which includes a transdiagnostic checklist of safety behaviours, as well as questions related to safety behaviour use and beliefs about safety behaviours. Within both the social anxiety and anxiety sensitivity groups, positive beliefs about safety behaviours predicted greater safety behaviour use, even when controlling for anxiety severity. Certain beliefs were particularly relevant in predicting safety behaviour use within each of the clinical analogue groups. Findings suggest that efforts to decrease safety behaviour use during anxiety treatment may benefit from identifying and modifying positive beliefs about safety behaviours.

An investigation of monitoring for sleep-related threat in primary insomnia

Those who are socially anxious may use safety behaviors during feared social interactions to prevent negative outcomes. Safety behaviors are associated with anxiety maintenance and poorer treatment outcomes because they prevent fear extinction. Social anxiety disorder is often comorbid with stuttering. Speech pathologists reported in a recent publication (Helgadottir, Menzies, Onslow, Packman, & O'Brian, 2014a) that they often recommended procedures for clients that could be safety behaviors. This study investigated the self-reported use of safety behaviors by adults who stutter. Participants were 133 adults who stutter enrolled in an online cognitive-behavior therapy program. Participants completed a questionnaire about their use of potential safety behaviors when anxious during social encounters. Correlations were computed between safety behaviors and pretreatment scores on measures of fear of negative evaluation and negative cognitions. Of 133 participants, 132 reported that they used safety behaviors. Many of the safety behaviors correlated with higher scores for fear of negative evaluation and negative cognitions. Adults who stutter report using safety behaviors, and their use is associated with pretreatment fear of negative evaluation and unhelpful thoughts about stuttering. These results suggest that the negative effects of safety behaviors may extend to those who stutter, and further research is needed.

Paranoia is a common experience in adolescence that may entail the use of safety behaviours (e.g. avoidance), which are assumed to maintain paranoia in the long run. As the development of paranoia and related safety behaviours in youth may be influenced by their caregivers, we aimed to investigate the associations of paranoia and safety behaviours in adolescents and their parents. Adolescents from the general population aged 14–17 and one of their parents (N = 142 dyads) were recruited via Qualtrics to complete online surveys including measures of paranoia, safety behaviour use, anxiety, and demographics. We fitted an Actor-Partner-Interdependence Model (APIM) for testing dyadic parent–child interaction by using structural equation modelling and controlled for adolescents’ and parents’ anxiety. Results indicated that paranoia positively predicted safety behaviour use in adolescents and in parents. There were significant positive intra-dyad (i.e. parent-adolescent) correlations for both paranoia and safety behaviour use. One partner effect was significant: parental paranoia positively predicted the safety behaviour use of their adolescent child. Conversely, adolescents’ paranoia did not predict their parents’ safety behaviour use. Our findings corroborate prior research demonstrating an association between paranoia and safety behaviours among adults, and extend this association to adolescents. Children of parents experiencing paranoia are at increased risk of developing paranoia and safety behaviours, which indicates the need for interventions that target paranoia and safety behaviours in family systems.

Safety Behaviors in Adults With Social Anxiety: Review and Future Directions

Safety behaviors are common in anxiety and have been thought to reduce the efficacy of exposure therapy, although some investigations have indicated that safety behaviors may have a non-significant or beneficial impact on exposure efficacy. There have been few investigations of the characteristics and impact of safety behavior use in youth compared to adults, and no known validated, transdiagnostic youth measure of safety behaviors exists. In Study 1, we investigated the psychometric properties of a transdiagnostic measure of adolescent safety behavior use. In Study 2, we examined the relationship between safety behavior use and treatment outcome in 51 anxious and depressed adolescents. Results of Study 1 supported the measure's psychometric properties, while results of Study 2 revealed that decreased safety behavior use is associated with better treatment outcomes. This investigation supports the importance of safety behavior reduction and provides a tool for further investigating adolescent safety behavior use.

Chapter 10 - Intervention to Reduce Use of Safety Behaviors

BackgroundIntimate partner violence (IPV) during pregnancy is a global health problem with adverse consequences for mothers, infants and families. We hypothesise that information about IPV and safety behaviours during pregnancy has the potential to increase quality of life and the use of safety behaviours and prevent IPV.MethodsA multicentre randomised controlled trial among culturally diverse pregnant women in Norway, to test the effect of a tablet-based video intervention about IPV and safety behaviours. Women attending routine antenatal check-ups alone (baseline) were screened for violence (Abuse Assessment Screen) by responding to questions on a tablet, and randomised (1:1) by computer to receive an intervention or a control video. The intervention video presented information about IPV and safety behaviours. The controls viewed a video promoting healthy pregnancy in general. Outcome measures were assessed three months post-partum: The World Health Organization Quality of Life-BREF, the Composite Abuse Scale on violence during the last 12 months and use of safety behaviours based on a 15-item checklist. A general linear model for repeated measures was used to examine the intervention’s effect. The analyses were conducted by intention to treat.ResultsAmong 1818 eligible women, 317 reported IPV and were randomised to an intervention (157) or a control group (160). A total of 251 (79.2%) women completed the follow-up questionnaire: 120 (76.4%) in the intervention group and 131 (81.9%) in the control group. At follow-up, 115 (45.8%) women reported a history of IPV. Few women (n = 39) reported IPV during the last 12 months. No differences in quality-of-life domains and overall quality of life and health were found between the intervention and the control groups. We detected no differences between the use of safety behaviours or IPV frequency and severity during the last 12 months.ConclusionOur intervention did not improve women’s quality of life, use of safety behaviours or exposure to violence. Nevertheless, a tablet-based tool may motivate women experiencing IPV to seek help and support. More research is needed regarding tablet-based interventions for women experiencing IPV, particularly culturally sensitive interventions.Trial registrationNCT03397277 registered in clinicaltrials.gov on 11/01/2018.

The role of safety behaviors in exposure-based treatment for panic disorder and agoraphobia: Associations to symptom severity, treatment course, and outcome

The functional value of preventive and restorative safety behaviors: A systematic review of the literature

Research has shown threat overestimation is significantly associated with intolerance of uncertainty (IU), and both processes predict higher anxiety and safety behavior usage. However, the extent to which threat overestimation predicts subsequent COVID-19-related distress may vary as a function of IU. The present study examined IU as a moderator of the relationship between COVID-19 threat estimation and subsequent COVID-19 fear and safety behavior use. Between February 27 and March 26, 2020, participants (N = 57) completed a self-report measure of IU and estimated the number of people they believed had died from COVID-19. Four weeks later, participants completed measures of COVID-19 fear and safety behavior use. Results revealed IU significantly predicted subsequent COVID-19 fear and safety behavior use. IU also moderated the effect of threat estimation on COVID-19 fear such that those who underestimated threat and experienced low to moderate levels of IU reported experiencing lower levels of COVID-19 fear 1 month later.

Effects of text message reminders of safety behavior reduction on health anxiety: A randomized control trial.

An experimental manipulation was conducted to test the hypothesis that monitoring for sleep-related threat during the day triggers a cycle of cognitive processes that includes increased negative thinking, increased use of safety behaviours, increased perceived impairment in functioning, and increased self-reported sleepiness. Forty-seven individuals with primary insomnia were randomly assigned to a monitoring group (instructed to monitor their body sensations), a no-monitoring group (instructed to distract from their body sensations), or a no-instruction group. The manipulations to monitor or not monitor were administered immediately on waking and participants were asked to continue the manipulation throughout the experimental day. The monitoring group reported more negative thoughts, the use of more safety behaviours, and more sleepiness during the day relative to the no-instruction group. These findings offer support to a recent cognitive model, which identifies daytime monitoring for sleep-related threat as a key factor in the maintenance of the daytime distress and difficulty functioning in chronic insomnia.

Efficacy of a novel safety behavior elimination intervention for posttraumatic stress symptoms: Results from a randomized controlled trial

With the exception of one self-report questionnaire assessing storm fear severity (Nelson et al. Journal of Psychopathology and Behavioral Assessment, 36(1), 105–114, 2014), there are few brief published assessment tools to measure the cognitive, behavioral, and physical manifestations of storm fear. A principal feature of phobic disorders is the use of safety behaviors to alleviate distress. Safety behaviors are believed to perpetuate anxiety by preventing the disconfirmation of feared outcomes (Salkovskis Behavioural Psychotherapy, 19(1), 6–19, 1991). To date, no studies have examined the use of safety behaviors in storm fear. The purpose of the current research was to develop and validate the Storm-Related Safety Behavior Scale (SRSBS; Vorstenbosch and Antony 2017), a 24-item self-report scale that measures safety behavior use in adults with a fear of storms. Two studies examined the (1) factor structure, internal consistency, validity, and test-retest reliability of the SRSBS, as well as the frequency with which specific safety behaviors were endorsed; and (2) ability of the SRSBS to differentiate between a group of adults with low and high fear of storms after exposure to a virtual thunderstorm. Factor analysis revealed that the SRSBS is best captured by one factor. Results provided preliminary evidence of convergent and discriminant validity, as well as test-retest reliability. Finally, significant group differences were found between participants with high versus low fear of storms following a virtual thunderstorm. These findings demonstrate the value of the SRSBS for assessing safety behavior use.