Increased use of safety-seeking behaviors in chronic back pain patients with high health anxiety
Abstract
Many patients with chronic pain also exhibit elevated levels of health anxiety. This study examined the effect of health anxiety on the use of safety-seeking behaviors (SSBs) in pain-provoking situations. Participants were 20 chronic back pain patients with high health anxiety (Group H), 20 with low health anxiety (Group L) and 20 pain-free controls (Group C). Two physical tasks were video recorded, and compared both for overt pain behavior (identified by blind observers following a standardized procedure) and for the occurrence of SSB (identified by showing the participants video playback and asking them to specify motivation for all actions/behaviors displayed during the tasks). While there were no differences in the display of overt pain behaviors, Group H deployed a greater number of SSBs than Groups L and C. This finding held true for both tasks and remained significant when concurrent pain and mood ratings were statistically controlled for. SSB was correlated with catastrophizing thoughts but not pain intensity; pain intensity was correlated with overt pain behavior but not catastrophizing. Taken together, these findings suggest that SSB is distinct from overt pain behavior and may be a defining characteristic of chronic pain patients reporting high levels of health anxiety.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Health-anxious individuals employ a range of maladaptive coping or safety-seeking behaviours, which reduce distress in the short-term but prevent the disconfirmation of incorrect health-anxious beliefs, thus maintaining the disorder.
“To manage anxiety and distress triggered by these dysfunctional beliefs and interpretations, health-anxious individuals employ a range of maladaptive coping or safety-seeking behaviours. Each of these behaviours is maladaptive in that although they reduce distress in the short-term, they prevent the disconfirmation of incorrect health-anxious beliefs, thus maintaining the disorder [56].”
From Illness Anxiety Disorder: A Review of the Current Research and Future Directions (2024) · cites this paper as [56]
The very concept of catastrophizing has been criticized, with some authors suggesting the need of new tools to assess it.
“The very concept of catastrophizing has also been criticized, with some authors suggesting the need of new tools to assess it [45].”
From Effectiveness of the psychological and pharmacological treatment of catastrophization in patients with fibromyalgia: a randomized controlled trial. (2009) · cites this paper as [45]
Cites
Diagnostic and Statistical Manual of Mental Disorders
Williams, J. B. W., & First, M. B. (2013) · Oxford University Press eBooks · doi:10.1093/acrefore/9780199975839.013.104 · Cited by 109,841 · see citing works
The Hospital Anxiety and Depression Scale
Zigmond, A. S., & Snaith, R. P. (1983) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.1983.tb09716.x · Cited by 47,139 · see citing works
Telling more than we can know: Verbal reports on mental processes.
Nisbett, R. E., & Wilson, T. D. (1977) · Psychological Review · doi:10.1037/0033-295x.84.3.231 · Cited by 11,317 · cited 1× · see citing works
“This can be regarded as a disadvantage ( Nisbett & Wilson, 1977 ) or a strength (Turk & Flor, 1987).”
BackgroundThe validity of the Hospital Anxiety and Depression Scale
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(01)00296-3 · Cited by 9,779 · see citing works
The McGill Pain Questionnaire: Major properties and scoring methods
Melzack, R. (1975) · Pain · doi:10.1016/0304-3959(75)90044-5 · Cited by 6,873 · see citing works
Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
Vlaeyen, J. W. S., & Linton, S. J. (2000) · Pain · doi:10.1016/s0304-3959(99)00242-0 · Cited by 4,931 · see citing works
The short-form McGill pain questionnaire
Melzack, R. (1987) · Pain · doi:10.1016/0304-3959(87)91074-8 · Cited by 4,368 · see citing works
Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance
Vlaeyen, J. W. S., Kole-Snijders, A. M. J., Boeren, R. G. B., & van Eek, H. (1995) · Pain · doi:10.1016/0304-3959(94)00279-n · Cited by 2,446 · see citing works
Benjamin, S. (1994) · Journal of Psychosomatic Research · doi:10.1016/0022-3999(94)90012-4 · Cited by 2,006 · see citing works
Williams, A. C. D. C. (1995) · Journal of Psychosomatic Research · doi:10.1016/0022-3999(95)90016-0 · Cited by 1,475 · see citing works
SALKOVSKIS, P. M., RIMES, K. A., WARWICK, H. M. C., & CLARK, D. M. (2002) · Psychological Medicine · doi:10.1017/s0033291702005822 · Cited by 1,351 · see citing works
Self-citationOutline of a fear-avoidance model of exaggerated pain perception--I.
Lethem, J., Slade, P. D., Troup, J. D. G., & Bentley, G. (1983) · Behaviour Research and Therapy · doi:10.1016/0005-7967(83)90009-8 · Cited by 1,327 · see citing works
The pain anxiety symptoms scale: development and validation of a scale to measure fear of pain
McCracken, L. M., Zayfert, C., & Gross, R. T. (1992) · Pain · doi:10.1016/0304-3959(92)90113-p · Cited by 950 · see citing works
The importance of behaviour in the maintenance of anxiety and panic: A cognitive account
Salkovskis, P. M. (1991) · Behavioural Psychotherapy · doi:10.1017/s0141347300011472 · Cited by 780 · see citing works
Self-citationInternational Classification of Diseases 10th Revision (ICD-10)
DiSantostefano, J. (2009) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2008.09.020 · Cited by 659 · see citing works
Warwick, H. M. C., & Salkovskis, P. M. (1990) · Behaviour Research and Therapy · doi:10.1016/0005-7967(90)90023-c · Cited by 587 · cited 1× · see citing works
“The cognitive theory of health anxiety (Salkovskis & Bass, 1997; Salkovskis & Warwick, 1986; Warwick & Salkovskis, 1990) suggests that people with persistent and severe health anxiety have a relatively enduring tendency to misinterpret bodily symptoms and health-relevant information as evidence…”
BackgroundSelf-citationAnxiety disorders: Why they persist and how to treat them
Clark, D. M. (1999) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(99)00048-0 · Cited by 556 · cited 2× · see citing works
“Though not intended, such reactions increase the sufferer’s preoccupation with health and may worsen hypochondriacal symptoms in the longer term ( Clark, 1999; Salkovskis, 1996b; Salkovskis, Clark, & Gelder, 1996).”
BackgroundSocial phobia: the role of in-situation safety behaviors in maintaining anxiety and negative beliefs
Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995) · Behavior Therapy · doi:10.1016/s0005-7894(05)80088-7 · Cited by 548 · cited 1× · see citing works
“The introduction of the concept of SSB has led to significant advances in the theoretical understanding and clinical management of a range of anxiety disorders (e.g., Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999; Wells, Clark, Salkovskis, & Ludgate, 1995 ); its specific application to the study of chronic pain u…”
BackgroundSelf-citationSalkovskis, P. M., & Warwick, H. M. C. (1986) · Behaviour Research and Therapy · doi:10.1016/0005-7967(86)90041-0 · Cited by 475 · cited 2× · see citing works
“The cognitive theory of health anxiety (Salkovskis & Bass, 1997; Salkovskis & Warwick, 1986; Warwick &”
BackgroundSelf-citationDevelopment of an observation method for assessing pain behavior in chronic low back pain patients
Keefe, F. J., & Block, A. R. (1982) · Behavior Therapy · doi:10.1016/s0005-7894(82)80001-4 · Cited by 451 · see citing works
The Science and Practice of Cognitive Behaviour Therapy
Clark, D. M., Fairburn, C. G., & Jones, J. V. (1997) · Journal of Cognitive Psychotherapy · doi:10.1891/0889-8391.11.2.141 · Cited by 448 · see citing works
Avoidance behaviour and its role in sustaining chronic pain
Philips, H. C. (1987) · Behaviour Research and Therapy · doi:10.1016/0005-7967(87)90005-2 · Cited by 434 · see citing works
Cognitive-Behavioral Treatments for Chronic Pain: What Works for Whom?
Vlaeyen, J. W. S., & Morley, S. (2005) · The Clinical Journal of Pain · doi:10.1097/00002508-200501000-00001 · Cited by 350 · see citing works
The McGill Pain Questionnaire: Appraisal and current status.
Melzack, R., & Katz, J. D. (2001) · Cited by 350 · see citing works
Understanding and Treating Fear of Pain
Asmundson, G. J. G., Vlaeyen, J. W. S., & Crombez, G. (2004) · doi:10.1093/oso/9780198525141.001.0001 · Cited by 332 · see citing works
Salkovskis, P. M., Clark, D. M., Hackmann, A., Wells, A., & Gelder, M. G. (1999) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(98)00153-3 · Cited by 310 · cited 1× · see citing works
“The introduction of the concept of SSB has led to significant advances in the theoretical understanding and clinical management of a range of anxiety disorders (e.g., Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999; Wells, Clark, Salkovskis, & Ludgate, 1995); its specific application to the study of chronic pain un…”
BackgroundSelf-citationThe role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients
Flor, H., Kerns, R. D., & Turk, D. C. (1987) · Journal of Psychosomatic Research · doi:10.1016/0022-3999(87)90082-1 · Cited by 281 · see citing works
Handbook of pain assessment, 2nd ed.
Turk, D. C., & Melzack, R. (2001) · Cited by 259 · see citing works
(1996) · Cited by 206 · see citing works
Cognition-behaviour links in the persistence of panic
Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996) · Behaviour Research and Therapy · doi:10.1016/0005-7967(95)00083-6 · Cited by 204 · see citing works
Self-citationSalkovskis, P. M., Hackmann, A., Adrian Wells, A., Gelder, M., & Clark, D. M. (2007) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.02.008 · Cited by 143 · see citing works
Self-citationAmending the fear-avoidance model of chronci pain: What is the role of physiological arousal?
Norton, P. J., & Asmundson, G. J. G. (2003) · Behavior Therapy · doi:10.1016/s0005-7894(03)80019-9 · Cited by 141 · see citing works
Pain > pain behaviors: The utility and limitations of the pain behavior construct
Turk, D. C., & Flor, H. (1987) · Pain · doi:10.1016/0304-3959(87)90158-8 · Cited by 140 · see citing works
The modification of avoidance learning pain behaviors
Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982) · Journal of Behavioral Medicine · doi:10.1007/bf00845370 · Cited by 138 · see citing works
Hypochondriacal concerns in a community population
Looper, K. J., & Kirmayer, L. J. (2001) · Psychological Medicine · doi:10.1017/s0033291701003737 · Cited by 135 · see citing works
Cognitive‐Behavioral Treatment for Severe and Persistent Health Anxiety (Hypochondriasis)
Salkovskis, P. M., Warwick, H. M. C., & Deale, A. C. (2003) · Brief Treatment and Crisis Intervention · doi:10.1093/brief-treatment/mhg026 · Cited by 132 · see citing works
Self-citationTrends in Cognitive and Behavioural Therapies.
Salkovskis, P. M. (1996) · Behaviour Research and Therapy · Cited by 119 · see citing works
Self-citationBehavioral assessment and treatment of chronic pain: Current status and future directions.
Keefe, F. J. (1982) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.50.6.896 · Cited by 115 · see citing works
The influence of communication goals and physical demands on different dimensions of pain behavior
Sullivan, M. J. L., Thibault, P., Savard, A., Catchlove, R. F. H., Kozey, J. W., & Stanish, W. D. (2006) · Pain · doi:10.1016/j.pain.2006.06.019 · Cited by 112 · see citing works
Behavioral assessment and treatment of chronic pain: Current status and future directions.
Keefe, F. J. (1982) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.50.6.896 · Cited by 110 · see citing works
Health anxiety levels in chronic pain clinic attenders
Rode, S., Salkovskis, P., Dowd, H., & Hanna, M. (2006) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2005.07.005 · Cited by 103 · see citing works
Self-citationMethodological Issues in the Effects of Attrition: Simple Solutions for Social Scientists
Ahern, K., & Brocque, R. M. L. (2004) · Field Methods · doi:10.1177/1525822x04271006 · Cited by 93 · see citing works
An experimental study of attention, labelling and memory in people suffering from chronic pain
Rode, S., Salkovskis, P. M., & Jack, T. (2001) · Pain · doi:10.1016/s0304-3959(01)00356-6 · Cited by 85 · see citing works
Self-citationA behavioural perspective on chronic pain
Fordyce, W. E. (1982) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.1982.tb00569.x · Cited by 55 · see citing works
Keefe, F. J., & Smith, S. J. (2002) · Applied Psychophysiology and Biofeedback · doi:10.1023/a:1016240126437 · Cited by 33 · see citing works
Hadjistavropoulos, H. D., & Hadjistavropoulos, T. (2003) · Current Pain and Headache Reports · doi:10.1007/s11916-003-0019-z · Cited by 30 · see citing works
THE “SAFETY SEEKING BEHAVIOURS” CONSTRUCT AND ITS APPLICATION TO CHRONIC PAIN
Sharp, T. J. (2001) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465801002107 · Cited by 20 · see citing works
Pain behavior observation: Current status and future directions
Keefe, F. J. (2000) · Current Review of Pain · doi:10.1007/s11916-000-0004-8 · Cited by 9 · see citing works
Cognitive-behavioural factors in pain and health anxiety.
Rode, S. A. (2004) · OpenGrey (Institut de l'Information Scientifique et Technique) · Cited by 3 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
The Short Health Anxiety Inventory: A systematic review and meta-analysis
Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., & Sharpe, D. (2013) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2012.10.009 · Cited by 267 · see citing works
The effects of safety behaviors on health anxiety: An experimental investigation
Olatunji, B. O., Etzel, E. N., Tomarken, A. J., Ciesielski, B. G., & Deacon, B. (2011) · Behaviour Research and Therapy · doi:10.1016/j.brat.2011.07.008 · Cited by 192 · see citing works
Bailey, K. M., Carleton, R. N., Vlaeyen, J. W. S., & Asmundson, G. J. G. (2010) · Cognitive Behaviour Therapy · doi:10.1080/16506070902980711 · Cited by 181 · see citing works
Health anxiety disorders: A cognitive construal
Rachman, S. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.05.001 · Cited by 161 · see citing works
Learning to predict and control harmful events: chronic pain and conditioning
Vlaeyen, J. W. S. (2015) · Pain · doi:10.1097/j.pain.0000000000000107 · Cited by 159 · see citing works
Brief cognitive-behavioral internet therapy for irritable bowel syndrome
Hunt, M. G., Moshier, S., & Milonova, M. (2009) · Behaviour Research and Therapy · doi:10.1016/j.brat.2009.05.002 · Cited by 139 · see citing works
Vlaeyen, J. W. S., Morley, S., & Crombez, G. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.08.016 · Cited by 117 · see citing works
Singh, K., & Brown, R. J. (2016) · Journal of Health Psychology · doi:10.1177/1359105315569620 · Cited by 78 · see citing works
Increasing intolerance of uncertainty over time: the potential influence of increasing connectivity
Carleton, R. N., Desgagné, G., Krakauer, R., & Hong, R. Y. (2019) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1476580 · Cited by 64 · see citing works
Meulders, A., & Vlaeyen, J. W. S. (2012) · Pain · doi:10.1016/j.pain.2012.04.013 · Cited by 59 · see citing works
The role of pain catastrophizing in cyberchondria among emerging adults
Gibler, R. C., Jastrowski Mano, K. E., O’Bryan, E. M., Beadel, J. R., & McLeish, A. C. (2019) · Psychology, Health & Medicine · doi:10.1080/13548506.2019.1605087 · Cited by 39 · see citing works
Leonidou, C., & Panayiotou, G. (2018) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2018.06.001 · Cited by 38 · see citing works
Illness Anxiety Disorder: A Review of the Current Research and Future Directions
Kikas, K., Werner-Seidler, A., Upton, E., & Newby, J. (2024) · Current Psychiatry Reports · doi:10.1007/s11920-024-01507-2 · Cited by 31 · see citing works
“Each of these behaviours is maladaptive in that although they reduce distress in the short-term, they prevent the disconfirmation of incorrect health-anxious beliefs, thus maintaining the disorder [56].”
BackgroundGarcía-Campayo, J., Serrano-Blanco, A., Rodero, B., Magallón, R., Alda, M., Andrés, E., Luciano, J. V., & del Hoyo, Y. L. (2009) · Trials · doi:10.1186/1745-6215-10-24 · Cited by 30 · see citing works
“The very concept of catastrophizing has also been criticized, with some authors suggesting the need of new tools to assess it [ 45 ].”
BackgroundPanjwani, A. A., Applebaum, A. J., Revenson, T. A., Erblich, J., & Rosenfeld, B. (2024) · Journal of Behavioral Medicine · doi:10.1007/s10865-023-00419-5 · Cited by 17 · see citing works
- Authors
- Tang, N. K. Y., Salkovskis, P. M., Poplavskaya, E., Wright, K. J., Hanna, M., & Hester, J.
- Affiliations
- King's College London (GB)
- King's College Hospital (GB)
- Corresponding author
- Tang, Nicole K.Y.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2007-12
- Volume
- 45
- Issue
- 12
- Pages
- 2821-2835
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2063706980
- Cited by
- 89
- References
- 50
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 4 · 2023: 5 · 2022: 8 · 2021: 6 · 2020: 1 · 2019: 5 · 2018: 5 · 2017: 3 · 2016: 5 · 2015: 6 · 2014: 5 · 2013: 6 · 2012: 6
- FWCI
- 3.10
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion)
- Funders
- Croucher Foundation
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- safety-seeking behavior, health anxiety, chronic back pain, pain catastrophizing, pain intensity, pain behavior, chronic pain
- MeSH terms
- Adaptation, Psychological, Adult, Anxiety Disorders, Back Pain, Chronic Disease, Female, Humans, Male, Middle Aged, Health Behavior, Case-Control Studies
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
