Elsevier

Behavior Therapy

Volume 47, Issue 5, September 2016, Pages 675-687
Behavior Therapy

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

https://doi.org/10.1016/j.beth.2015.11.005Get rights and content

Highlights

  • Safety behaviors (SBs) are actions deemed necessary to prevent a feared outcome.

  • SBs and related processes may maintain social anxiety disorder (SAD).

  • SBs negatively affect social performance and interactions for individuals with SAD.

  • Reduction of SB use during exposures results in greater symptom reduction for SAD.

  • Judicious use of SBs during early exposures may make SAD treatment more tolerable.

Abstract

Safety behaviors are considered an important factor in the maintenance of social anxiety disorder (SAD). Safety behaviors are typically employed by socially anxious individuals to reduce anxiety in feared social situations. However, by preventing individuals with social anxiety from gathering evidence that would disconfirm their maladaptive beliefs about social situations, the use of safety behaviors ultimately maintains social anxiety over time. Twenty years ago, Wells and colleagues (1995) demonstrated that use of safety behaviors diminishes the efficacy of exposure treatment for SAD, suggesting that reduction in the use of safety behaviors during exposure can enhance treatment response. Research on safety behaviors has expanded considerably since Wells et al.’s seminal publication, and our understanding of the role safety behaviors may play in the maintenance of social anxiety has grown in breadth and depth. In this paper, we present a detailed review of the published research on safety behaviors relevant to social anxiety and social-anxiety-related processes. Finally, we evaluate the impact of safety behaviors on the outcome of treatment for SAD, and we look to the literature on safety behaviors in other anxiety disorders to inform our understanding of use of safety behaviors during exposure and to facilitate future research in SAD.

Section snippets

Methods

Relevant studies for this systematic review were identified using PsycINFO (accessed via the EBSCOhost platform) and Google Scholar, as well as a backwards literature search that consisted of scanning references cited in identified articles to evaluate if these references might be relevant to our search criteria. Our search terms included, “safety behavior” and “anxiety,” as well as specific anxiety disorder terminology (e.g., “social anxiety disorder,” “social phobia”) when appropriate.

Defining and Measuring Safety Behaviors

Safety behaviors have long been defined as attempts to prevent or avoid feared outcomes that are viewed by the anxious individual as threatening or catastrophic (e.g., Salkovskis, 1991). For socially anxious individuals, the feared outcome typically involves social rejection, negative evaluation, or unbearable feelings of anxiety in social situations. Safety behavior use is strongly and positively related to these fears in social anxiety (Moscovitch et al., 2013, Okajima et al., 2009),

Safety Behaviors in Social Interactions

Cognitive-behavioral models of SAD assert that individuals with social anxiety employ safety behaviors to avoid feared social consequences without escaping the social situation completely (Clark, 2001, Heimberg et al., 2014, Hofmann, 2007). In fact, several studies indicate that individuals with high levels of social anxiety engage in more safety behaviors than individuals with low levels of social anxiety when participating in social interactions (e.g., McManus et al., 2008, Stangier et al.,

Safety Behaviors and Self-Imagery

Research on safety behaviors has expanded to incorporate the roles of attentional focus and self-imagery in social interactions. Self-imagery refers to the constructed (and often negative) self-impression that socially anxious individuals use to inform themselves on how others may view them in social situations. Research has suggested that self-imagery is critical in maintaining distorted cognitions and attentional biases in SAD. Spurr and Stopa (2003) manipulated perspective-taking in

Safety Behaviors and Post-Event Processing

After participating in a social situation, individuals with social anxiety engage in a maladaptive cognitive process that highlights the negative aspects of their performance, known as post-event processing (PEP). PEP often involves a detailed recounting of the social event, with a focus on negative self-appraisal and recounting of past social failures (Brozovich and Heimberg, 2008, Clark and Wells, 1995). Importantly, PEP is distinguishable from more adaptive forms of cognitive processing

Safety Behaviors and Treatment for SAD

Wells and colleagues’ (1995) study was the first to examine the role of safety behaviors in the treatment of social anxiety. Over the past 20 years, their results have been replicated in several studies. In a study involving intensive group CBT for SAD (Morgan & Raffle, 1999), half of the 30 participants received treatment as usual and the other half received psychoeducation about safety behaviors and were instructed to drop safety behaviors during exposure tasks. Participants in both

Conclusions

Research on the role of safety behaviors in the development, maintenance, and treatment of SAD has expanded in breadth and depth since the first published examination of safety behaviors in SAD (Wells et al., 1995). Safety behaviors were originally defined as actions perceived by an individual as necessary to prevent the occurrence of a feared outcome (e.g., Salkovskis, 1991). However, this broad definition requires further specification. Not all behaviors enacted in anxiety-provoking social

Conflict of Interest Statement

The authors have no conflicts of interest to report, nor was there any external funding for the preparation of this manuscript.

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