Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs

“The goal of this article is to study how individuals effectively cope with SCA, specifically with urges to withdraw during socially demanding situations such as closing sales (Verbeke and Bagozzi 2000, 2003; Wells et al. 1995).”

“reduce the therapeutic efficacy of exposure (Wells et al., 1995; Wells & Papageorgiou, 1998) but this is the first study to evaluate the effects of behavioral experiments that are designed to give patients an insight into the adverse effects of self-focus and safety behaviors and to measure the impact of these behavio…”

“Such “safety behaviours” (Salkovskis, 1996; Wells et al., 1995) can prevent reality testing, especially if such behaviours hinder engagement with the stimulus or experience (Goetz, Davine, Siwiec, & Lee, 2016; Helbig-Lang & Petermann, 2010).”

“, 1995), with less fear reduction (Garcia-Palacios & Botella, 2003; Kim, 2005; Morgan & Raffle, 1999; Salkovskis et al., 1999; Salkovskis et al., 2007; Wells et al., 1995) and with potentially less sustainable change at follow-up (Hood et al.”

“to positive feedback, possibly to subsequently hide autonomic symptoms from others (Wells et al., 1995).”

“Evidence suggests that people with high levels of SA engage in a variety of behaviors to avoid negative evaluation.([77]) For example, people with high SA have attentional biases for detecting social–evaluative threats.”

“Additionally, social anxiety is associated with avoidance and safety behaviours (McManus et al., 2008; Morgan & Raffle, 1999; Wells et al., 1996), so we will assess if the Internet is used as an avoidance strategy and if, while online, individuals with a high level of social anxiety engage in…”

“One could speculate that this might be the case because HSA persons are more likely to evaluate social interactions on the basis of their own subjective experience and not on the basis of social cues provided by their interaction partners (13).”

“Furthermore, social phobics use in-situation safety behaviors as coping strategies to reduce the risk of negative evaluation by others (see Wells et al., 1995).”

“Safety behavior manipulations in the style of Wells et al. (1995) and Salkovskis et al. (1999) are necessary to demonstrate the role of safety behaviors in the maintenance of insomnia.”

“Studies examining the incremental value of techniques aimed at reducing safety behavior and/or self-focused attention during exposure found an additional beneficial effect in comparison to exposure alone (Kim, 2005; McManus et al., 2009; Taylor & Alden, 2010; Wells et al., 1995).”

“Research has provided empirical support for the role of safety behaviours in maintaining dysfunctional cognitive appraisals and also for the impact of reducing or dropping safety behaviours on symptoms of social anxiety and related appraisals (Wells et al. 1995 ; Kim, 2005).”

“Also, a manipulation affecting safety behaviors was associated with greater reductions in anxiety and negative belief (Wells et al., 1995).”

“The efficacy of BEs as a component of CBT protocols has been demonstrated (McManus et al., 2009; Salkovskis, Hackmann, Wells, Gelder, & Clark, 2007; Wells et al., 1995) and it has been suggested that they may be a particularly powerful means of achieving belief change and symptom relief:…”

“…gangemia@unime.it (A. (F. Mancini), m.vandenhout@uu.nl (M. van den Hout) 0005-7916/$ e see front matter 2012 Elsevier Ltd. doi:10.1016/j.jbtep.2012.04.005 a b s t r a c t Background and objectives: Cognitive models of anxiety disorders view safety-seeking behaviors (i.e., avoidance, washing, etc.)…”

“2,3 Within sexual relationships, fears that one’s partner will react negatively to condoms is associated with less interest in using condoms.”

“Indeed, evidence indicates that therapeutic gains are greatly enhanced when these cognitive biases are explicitly modified during treatment (McManus et al. 2009, Wells and Papageorgiou 1995, Wells et al. 1995).”

“Indeed, prominent cognitive-behavioral models of social anxiety describe safety behaviors that people with social phobia may use to conceal characteristics they believe to be undesirable (such as their own anxiety; Clark & Wells, 1995; Rapee & Heimberg, 1997; Wells et al., 1995).”

“These postextinction phenomena highlight the importance of exposure to multiple contexts to facilitate generalization to other situations/contexts where safety signals (eg, a therapist) are absent or subtle safety behaviors cannot be performed (eg, postural adjustments) [38– 40,43,53].”

“assessing safety behaviors (e.g., McManus et al. 2008; Kim 2005; Wells et al. 1995), and even fewer available to assess”

“, 2004; Sloan & Telch, 2002; Telch, 2004) and that eliminating these strategies during exposure leads to a more favorable treatment outcome (Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999; Wells et al., 1995).”

“, cognitive rehearsal prior to a public speech) to active avoidance of social situations (Clark & Wells, 1995; Rapee & Heimberg, 1997; Wells et al., 1995).”

“Avoiding eye contact is a typical safety behaviour used by people who experience social anxiety (Clark & Wells, 1995; Horley et al., 2004; Huppert & Foa, 2004; Mansell, Clark, Ehlers, & Chen, 1999; Marks, 1969; Ohman, 1986; Wells et al., 1995).”

“…disconfirmation from occurring (allowing social phobics to attribute the non-occurrence of the feared catastrophes to the use of these behaviours), can increase their feared symptoms, and can contaminate the social situation (Clark & Wells, 1995; Wells et al., 1995; Clark, 1997; Wells, 1997).”

“, remaining quiet in social conversations may increase the likelihood of being ignored by others) [25, 26].”

“Yet in blood-injury-phobic patients who do not faint, applied tension may represent an avoidance or safety strategy and be thus counterproductive as its use may reduce the efficacy of exposure treatment (53,54).”

“However, as the fears of someone with SAD are excessive, it has been suggested that a major effect of safety behaviours is that they prevent patients from disconfirming some of their erroneous beliefs about this feared social situation [4].”

“…disconfirmation of catastrophic beliefs that GEXP tries to accomplish (Salkovskis, 1991, 1996; Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999; Wells et al., 1995) or because it redirects attention away from threat, thereby reducing the processing of corrective information (Sloan &…”

“Even more persuasively, it has been found in both agoraphobia (Salkovskis et al ., 1991; Salkovskis et al ., 1999) and in social phobia (Wells et al ., 1995) that exposure presented as behavioural experiments designed to disconfirm threat beliefs was very markedly superior to exposure alone.”

“Furthermore, a striking aspect of social phobia is the persistence of self-doubt about social performance, despite repeated exposures to social situations that do not go badly (Wells et al., 1995).”

“As a result, the person engages in avoidance or safety behaviors (Wells et al., 1995), followed by post-event rumination (Mellings & Alden, 2000; Rachman, Grüter-Andrew, & Shafran 2000).”

“We hypothesized that based on previous findings from single-session experiments (e.g., Kim, 2005; McManus et al., 2009; Wells et al., 1995), avoidance would affect subsequent fear (but not vice-versa).”

“…disorder has been shown to reduce anxiety and fear-related beliefs to a significantly greater extent than exposure therapy that does not include interventions designed to eliminate the use of safety behaviors (Kim, 2005; McManus, Sacadura, & Clark, 2008; Taylor & Alden, 2010; Wells et al., 1995).”

“Moreover, the presence of safety cues during situational and interoceptive exposure and drug-related attributions of improvement may have impaired adaptive cognitive reappraisal (Basoglu et al. 1994; Wells et al. 1995; Otto & Gould, 1996).”

“Specifically, MDD and SAD are associated with unique biases and patterns of behavior in both negative and positive emotional domains that are central in clinical manifestations of these disorders (Beck et al., 1979; Wells et al., 1995; Loas, 1996; Amir et al., 1998a).”

“That is, avoidance promotes anxiety by reducing opportunities to disconfirm anxiety-related beliefs and to utilize adaptive coping strategies (Foa & Kozak, 1986; Thwaites & Freeston, 2005; Wells et al., 1995).”

“If the feared catastrophe does not occur, the nonoccurrence is attributed to the safety behavior, thus stabilizing the belief that social danger is evident (Wells et al., 1995).”

“In both conditions, the experimenter provided standardized rationales modeled after previous work (Kim, 2005; Wells et al., 1995).”

“Moreover, reductions in safety behaviors have been shown to reduce negative social judgments (e.g., Taylor & Alden, 2010; Wells et al., 1995).”

“Safety behaviours are strategies, many of which are mental operations, that are intended to prevent or minimise feared outcomes from occurring [15].”

“Moreover, peer rejection figures prominently in the development and/or maintenance of several forms of psychopathology, including externalizing behavior problems (e.g., Dodge et al., 2003), social anxiety disorder (e.g., Wells et al., 1995 ) and depression (e.g., French, Conrad, & Turner, 1995; Panak & Garber, 1992).”

“The concept of safety behavior has later been applied o social phobia (Wells et al., 1995), obsessive–compulsive disorer (Salkovskis, 1999), and posttraumatic stress disorder (Ehlers & lark, 2000).”

“Safety behaviours have been demonstrated to prevent shifts in cognitions about the probability and cost of catastrophe from occurring during exposure therapy (Wells et al., 1995).”

“It has been suggested that such biases enhance anxiety and lead to ineffective social behavior (Amir, Foa, & Coles, 1998; Rapee & Heimberg, 1997; Wells et al., 1995).”

“For example, people with social phobia may mentally rehearse a conversation and engage in excessive self-monitoring to avoid freezing up or babbling when making conversation (Wells et al., 1995).”

“This is of particular interest for patients with social anxiety disorder who show social withdrawal as a result of personal distress and fear of approaching others (52, 53).”

“In adults, safety behaviours in SAD have been show to have a range of unintended negative consequences such as increasing state anxiety (Gray et al., 2019); preventing disconfirmation of negative predictions (Wells et al., 1995; McManus et al., Behav Res Ther.”

“Safety behaviors that youth use to negate these negative outcomes can include keeping special objects with them, and can extend to elaborate belief systems about the ability of certain possessions or items to keep the child safe (Kim 2005; Sloan and Telch 2002; Wells et al. 1995).”

“…from peers figures prominently in the development and/or maintenance of several forms of psychopathology, including social anxiety disorder (e.g., Wells et al., 1995), externalizing behavior problems (e.g., Dodge et al., 2003), and depression (e.g., French, Conrad, & Turner, 1995; Nolan, Flynn,…”

“Most cognitive-behavioral models posit that safety behaviors, like other forms of avoidance, prevent individuals from habituating to anxiety and disconfirming their beliefs about the risk of socializing more freely (Clark & Wells, 1995; Rapee & Heimberg, 1997; Wells et al., 1995).”

“In most cases, people with SAD have problems to perform well in social situations (Wells et al., 1995) and have altered social cognitive abilities, such as dysregulated shyness (Nikolić, 2020) as well as selective attention and reporting bias for negative social stimuli (Amir et al.”

“Medication use may represent a safety behaviour that allows temporary relief of symptoms and the effort in having to manage them as commonly observed in anxiety disorders (Wells et al., 1995).”

“…elements, because Mulkens et al. (2001) have shown that TCT produced cognitive changes faster than exposure therapy and because on the other hand, studies have shown that the reduction of safety behaviors significantly improves therapy outcome in SAD (Morgan & Raffle, 1999; Wells et al., 1995).”

“Clearly, social phobia related thoughts decrease over the course of successful treatment (Wells et al., 1995; Wells and Papageorgiou, 1998; Hofmann, 2000; Mörtberg et al., 2007; McManus, Sacadurab and Clark, 2008).”