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An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia
Abstract
This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.
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“Our findings are consistent with this body of research, indicating that elements of treatment can be used as 'safety seeking behaviours' that reduce efficacy of exposure and maintain the disorder by preventing disconfirmatory experiences concerning fears of bodily sensations [42].”
From Helpful and hindering factors for remission in dysthymia and panic disorder at 9-year follow-up: A mixed methods study (2008) · cites this paper as [42]
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“Therefore, such safety behaviors play a key role in maintaining fear (Salkovskis, 1991; Salkovskis et al., 1999).”
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“Alleviating fear and anxiety through protective or safety behavior is supported by research (Rachman et al., 2008; Salkovskis et al., 1999).”
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“Research suggests that safety behaviors maintain clinical anxiety by preventing individuals from learning that their fears are unfounded (Salkovskis, 1991; Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999 ).”
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“Instructing clients to refrain from safety behaviors has been shown to improve exposure outcomes in PD/A (Salkovskis et al., 1999) and provides a simple method for therapists to discourage safety behaviors during exposure.”
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Translational research perspectives on maximizing the effectiveness of exposure therapy
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Selective attention to real phobic and safety stimuli
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“…behaviors on exposure to feared situations has been found, across anxiety diagnoses, to result in reduced belief in the probability of fearedoutcomes in future exposure to threat in anxiety difficulties such as panic disorder and claustrophobia (Salkovskis et al., 1999; Sloan and Telch, 2002).”
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Mechanisms of change in cognitive therapy for panic disorder with agoraphobia
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“In addition to being maintained by catastrophic beliefs, avoidant behavior is also assumed to maintain these beliefs by preventing patients from benefiting from disconfirmatory experiences (Salkovskis et al., 1999).”
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“Perseverance is commonly observed in safety-seeking behaviours that characterise anxiety disorders (Serpell et al., 2009; Salkovskis et al. 1999), which are typically used to prevent a perceived threat from appearing consciously.”
BackgroundWols, A., Lichtwarck‐Aschoff, A., Schoneveld, E. A., & Granic, I. (2018) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-018-9684-4 · Cited by 34
“…(Clark 1999; McManus et al. 2008; Salkovskis et al. 1999; Salkovskis et al. 1996), and that reducing avoidant and/or safety behaviours and increasing engagement with the treatment are predictive of better treatment outcomes (e.g., Glenn et al. 2013; Morgan and Raffle 1999; Salkovskis et al. 1999).”
Cooper, S. E., Grillon, C., & Lissek, S. M. (2018) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2018.07.001 · Cited by 30
“Additionally, and again in contrast to those with GAD, people with PD endorse experiencing anxiety reductions in identified safe situations such as being at home or when carrying a comforting item on their person when leaving the house [28, 29].”
Emotion Regulation and the Anxiety Disorders: Adopting a Self-Regulation Perspective
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“a feared catastrophe that might result from panic (e.g., clinging to objects in order to prevent oneself from fainting and falling), and reduction of such safety behaviors has been found to improve the effects of exposure treatment (e.g., Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999 ), indicating that such preve…”
BackgroundAn Integrative Cognitive Model of Internalized Stigma in Psychosis
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“Safety-seeking behaviours are utilized to prevent a feared catastrophe and are widely documented in cognitive models (Clark and Wells, 1995; Salkovskis et al., 1999).”
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The Reduction of Fear of Movement-related Pain: Does Motivational Context Matter?
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“Specifically, avoidance behavior is often discouraged during exposure as it is considered to prevent a violation of dysfunctional expectancies (34, 35), thereby interfering with fear reduction and consequently maintaining symptoms or resulting in a return of fear (98).”
BackgroundDissemination of Exposure Therapy in Clinical Practice: How to Handle the Barriers?
Neudeck, P., & Einsle, F. (2012) · Exposure Therapy · doi:10.1007/978-1-4614-3342-2_3 · Cited by 24
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“Cognitive-behavioral models of health anxiety emphasize the role of avoidance and safety behaviors in the development and maintenance of anxiety (Helbig-Lang & Petermann, 2010; Rachman et al., 2008; Salkovskis et al., 1999) including in older adults (Boston & Merrick, 2010).”
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“a variety of anxiety disorders (Wells, 1997; Salkovskis et al., 1999), including PTSD (Blake & Sonnenberg, 1998; Richards, Lovell, & Marks, 1994), yet there is little in the literature to document its use with survivors of torture,”
BackgroundSelective effects of excessive engagement in health-related behaviours on disgust propensity
Olatunji, B. O. (2014) · Cognition & Emotion · doi:10.1080/02699931.2014.951314 · Cited by 21
The Safety Behavior Assessment Form: Development and Validation.
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“For instance, Salkovskis et al. (1999) suggested that SBs which are employed in order to avoid imagined disastrous consequences may be classified as maladaptive coping strategies that will interfere with disconfirmation.”
BackgroundSafety Behaviours, Rumination and Trait Paranoia in a Non-Clinical Sample
Simpson, J. M., MacGregor, B., Cavanagh, K., & Dudley, R. E. J. (2012) · Journal of Experimental Psychopathology · doi:10.5127/jep.027212 · Cited by 19
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For-Profit Higher Education Sees Booming Enrollments and Revenues.
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Cognitive behavior therapy in the treatment of panic disorder
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“As evidenced in the literature, unless specific instructions for stopping safety behaviors are provided, patients with panic continue such safety-seeking behaviors.[41] In the present study, the CBI group received cognitive restructuring which elaborated on safety behaviors and specific instructions not to involve in…”
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Goodwin, G. M., Holmes, E. A., Andersson, E., Browning, M. D., Jones, A., Lass‐Hennemann, J., Månsson, K. N. T., Moessnang, C., Salemink, E., Sánchez-López, Á., et al. (2018) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2017.10.036 · Cited by 18
“…mental or behavioural operations) in which patients engage to prevent imagined catastrophes from occurring (OCD; Deacon and Maack, 2008; PTSD: Dunmore et al., 1999; Social phobia: Kim, 2005; Wells et al., 1995; Salkovskis et al., 1999; Salkovskis et al., 2000; GAD: Woody and Rachman, 1994).”
BackgroundThe cognitive theory of panic disorder: A systematic narrative review.
Aslam, S. Y., Zortea, T., & Salkovskis, P. M. (2024) · Clinical Psychology Review · doi:10.1016/j.cpr.2024.102483 · Cited by 15
Self-citationIt’s the who not the when: An investigation of safety behavior fading in exposure to contamination
Levy, H. C., & Radomsky, A. S. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2016.02.006 · Cited by 16
The effect of information seeking behaviors in fear control
Restrepo-Castro, J. C., Labrador, F. J., Gantiva, C., Camacho, K., & Castro-Camacho, L. (2022) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2022.101797 · Cited by 16
Jamani, N., & Clyde, Z. (2008) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x08000032 · Cited by 16
“1996; Thwaites & Freeston, 2005) and social phobia (Clark & Wells, 1995; Thwaites & Freeston, 2005), and empirical evidence supports the central role of safety-seeking behaviour in these disorders (Wells et al. 1995; Salkovskis et al. 1999).”
BackgroundGender Differences In Anxiety, Depression And Metacognition
Lenzo, V., Toffle, M. E., Tripodi, F., & Quattropani, M. (2016) · The European Proceedings of Social & Behavioural Sciences · doi:10.15405/epsbs.2016.05.02.1 · Cited by 16
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“Our findings are consistent with this body of research, indicating that elements of treatment can be used as 'safety seeking behaviours' that reduce efficacy of exposure and maintain the disorder by preventing disconfirmatory experiences concerning fears of bodily sensations [42].”
ResultThe Role of Safety Behaviors in Panic Disorder Treatment: Self-Regulation or Self-Defeat?
Aafjes-van Doorn, K., Zilcha-Mano, S., Graham, K., Caldari, A., Barber, J. P., Chambless, D. L., & Milrod, B. (2019) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-019-09432-9 · Cited by 15
“People with PD might use combinations of different types of idiosyncratic SBs that match their catastrophic cognitions (Salkovskis et al. 1999).”
BackgroundResultLang, T., Helbig-Lang, S., Gloster, A. T., Richter, J., Hamm, A. O., Fehm, L., Fydrich, T., Gerlach, A. L., Ströhle, A., Alpers, G. W., et al. (2012) · Zeitschrift für Klinische Psychologie und Psychotherapie · doi:10.1026/1616-3443/a000139 · Cited by 15
Dental clinicians recognizing signs of dental anxiety: a grounded theory study
Höglund, M., Wårdh, I., Shahnavaz, S., & Berterö, C. (2022) · Acta Odontologica Scandinavica · doi:10.1080/00016357.2022.2154263 · Cited by 15
“The category of Controlling behaviours, fits well into the established and wellknown concept of safety-seeking behaviours [29].”
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“To fully overcome such problems, we have recently adapted an acute CBT paradigm (Salkovskis et al., 1999) to measure the effects of treatment on cognitive bias prior to changes in subjective symptoms (Reinecke, Waldenmaier, Cooper, & Harmer, 2013), analogue to research investigating acute effects…”
BackgroundMethodInfluentialAdding Cognitive-Behavioral Therapy to Pharmacotherapy for Panic Disorder: Issues and Strategies
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Ethical Issues When Considering Exposure
Wolitzky-Taylor, K. B., Viar-Paxton, M. A., & Olatunji, B. O. (2012) · Autism and child psychopathology series · doi:10.1007/978-1-4614-3253-1_10 · Cited by 12
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Do safety behaviors preserve threat expectancy?
van Uijen, S. L., Dalmaijer, E., van den Hout, M., & Engelhard, I. (2018) · Journal of Experimental Psychopathology · doi:10.1177/2043808718804430 · Cited by 10
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Combining Cognitive-Behavioral Therapy and Pharmacotherapy for the Treatment of Panic Disorder
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“Just as there is evidence that fading of maladaptive safety behaviors during cognitivebehavioral therapy facilitates fear reduction (Salkovskis et al., 1999), there is evidence that tapering and discontinuing medications during a program of cognitive-behavioral therapy helps patients maintain and…”
BackgroundThe Role of Fear of Fatness and Avoidance of Fatness in Predicting Eating Restraint
MacLeod, J., MacLeod, C., Dondzilo, L., & Bell, J. (2019) · Cognitive Therapy and Research · doi:10.1007/s10608-019-10052-9 · Cited by 11
“Similarly, it has been found that fear of crowded environments is more strongly linked to maladaptive agoraphobic symptoms in individuals who exhibit greater avoidance of crowded environments (Salkovskis et al. 1999).”
BackgroundImagery rescripting of traumatic memories for panic disorder: an exploratory study
Shibuya, T., Seki, Y., Nagata, S., Murata, T., Hiramatsu, Y., Yamada, F., Yokoo, M., Ibuki, H., Minamitani, N., Tanaka, M., et al. (2018) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x18000028 · Cited by 12
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Why Use Cannabis? Examining Motives for Cannabis Use in Individuals with Anxiety Disorders
Ouellette, M. J., Rowa, K., Cameron, D. H., Elcock, A., Soreni, N., Pawluk, E. J., & McCabe, R. E. (2022) · Behaviour Change · doi:10.1017/bec.2022.21 · Cited by 11
“…disorders, where the majority of individuals ’ symptoms do not meet criteria for CUD (Ouellette et al., 2019) and where cannabis use may be clinically relevant despite not meeting CUD criteria (e.g., using cannabis as a subtle avoidance strategy; Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999).”
A cognitive dissonance perspective on threats to self-concept in obsessive-compulsive disorder
Wright, E. C., & Riskind, J. H. (2020) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2020.100619 · Cited by 10
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A qualitative examination and theoretical model of anxiety in adults with epilepsy
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Novel Treatment Approaches for Refractory Anxiety Disorders
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The effects of dropping in‐situation safety behaviors in the treatment of social phobia
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Hypochondriacal Concerns in Panic Disorder and Major Depressive Disorder: A Comparison
Noyes, R., WOODMAN, C. L., Bodkin, J. A., & Yagla, S. J. (2004) · The International Journal of Psychiatry in Medicine · doi:10.2190/lme3-97gj-68cg-h6aq · Cited by 10
“[48] confirmed the specificity of such cognitive and behavioral features in a comparison of panic and hypochondriacal patients.”
BackgroundAvoidance Behavior Prevents Modification of Fear Memory During Reconsolidation
Nitta, Y., Takahashi, T., Haitani, T., Sugimori, E., & Kumano, H. (2018) · Psychological Reports · doi:10.1177/0033294118811116 · Cited by 10
Why are Mindfulness and Acceptance Central Elements for Therapeutic Change in Schema Therapy Too?
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The Development of Safety Behavior: A 30-Year Review
Rusyda, H. M., & Aziz, S. F. A. (2021) · International Journal of Academic Research in Economics and Management Sciences · doi:10.6007/ijarems/v10-i1/9212 · Cited by 13
“Clinical psychology refers to explicit or implicit safety behaviors, under exact circumstances, to make efforts to prevent formidable results (Salkovskis et al., 1999; Salkovskis, 1991).”
BackgroundDelgado-Rodríguez, R., Madroñal, R. C., Villalba, C. V., Martos, R., & Ordóñez-Pérez, D. (2022) · Journal of Veterinary Behavior · doi:10.1016/j.jveb.2022.07.005 · Cited by 9
Planert, J., Machulska, A., Hildebrand, A. S., Roesmann, K., Otto, E., & Klucken, T. (2022) · Trials · doi:10.1186/s13063-022-06366-x · Cited by 10
In-situation safety behaviours as a factor in the maintenance and treatment of sexual dysfunctions
Frank, E., Noyon, A., Höfling, V., & Heidenreich, T. (2010) · Sexual & Relationship Therapy · doi:10.1080/14681990903433703 · Cited by 9
“Further negative consequences of safety behaviours include the maintenance of inappropriate and dysfunctional beliefs (Salkovskis et al., 1999; Sloan & Telch, 2002), for example a patient who uses excessive preparation for a public speech will tend to assume that only this preparation will prevent…”
BackgroundInfluentialKnoll, R. W., Valentiner, D. P., & Holzman, J. B. W. (2016) · Assessment · doi:10.1177/1073191116686685 · Cited by 12
Cognitive Processes in Panic Disorder: An Extension of Current Models
Goldberg, C. (2001) · Psychological Reports · doi:10.2466/pr0.2001.88.1.139 · Cited by 9
“&OST, L. G. (1999) Preattentive bias for emo- tional information in panic disorder with agoraphobia.”
BackgroundInfluentialSchumacher, S., Schopka, N. M., Heinrich, M., & Knaevelsrud, C. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000371 · Cited by 6
Exposure therapy for specific phobias in children and adolescents
Mobach, L., Oar, E. L., & Hudson, J. L. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-815915-6.00008-1 · Cited by 8
Tutino, J. S., Ouimet, A. J., & Ferguson, R. J. (2020) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s135246582000017x · Cited by 8
“Indeed, researchers have found equivalent levels of fear reduction, belief change and ability to gather disconfirmatory evidence between SB and no SB conditions (Milosevic and Radomsky, 2008; Salkovskis et al., 1999).”
BackgroundCognitive–behavioural treatment for panic
Salkovskis, P. M. (2007) · Psychiatry · doi:10.1016/j.mppsy.2007.03.002 · Cited by 8
Self-citationThe Role of Anxiety Control Strategies in Imaginal Exposure
Koerner, N., & Fracalanza, K. (2012) · Springer eBooks · doi:10.1007/978-1-4614-3342-2_12 · Cited by 8
Ouellette, M. J., Rowa, K., Cameron, D. H., Elcock, A., Soreni, N., Pawluk, E. J., & McCabe, R. E. (2022) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2022.10.054 · Cited by 7
Raines, A. M., Chambliss, J. L., Norr, A. M., Sanders, N., Smith, S., Walton, J. L., True, G., Franklin, C. L., & Schmidt, N. B. (2022) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2022.2130819 · Cited by 7
“…it is well documented that repeated use of these behaviors in the long-term contributes to the development and maintenance of various anxiety and related disorders (Deacon & Maack, 2008; Ehring et al., 2006; Olatunji et al., 2011; Salkovskis et al., 1999; Wells et al., 1996; Woody & Rachman, 1994).”
BackgroundSimons, M., & Herpertz‐Dahlmann, B. (2008) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917.36.5.345 · Cited by 6
Kannis‐Dymand, L., Grace, E., McDonald, L., & Chambers, R. (2022) · Clinical Psychologist · doi:10.1080/13284207.2022.2035651 · Cited by 7
김헌영, Ebesutani, C. K., & Kim, M. (2017) · Korean Journal of Health Psychology · doi:10.17315/kjhp.2017.22.4.002 · Cited by 6
Senn, J. M., & Radomsky, A. S. (2015) · Cognitive Therapy and Research · doi:10.1007/s10608-015-9703-7 · Cited by 6
Kemp, J. J., Blakey, S. M., Wolitzky-Taylor, K. B., Sy, J. T., & Deacon, B. J. (2019) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2019.1574312 · Cited by 6
“Those who oppose the use of safety behaviors during exposure caution that these behaviors may interfere with learning during exposure (e.g. Craske et al., 2014; Salkovskis, 1991; Salkovskis et al., 1999).”
BackgroundZaccari, V., Gragnani, A., Pellegrini, V., Caiazzo, T., D’Arienzo, M. C., Magno, A., Femia, G., & Mancini, F. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.755744 · Cited by 6
“It is well-known that those who suffer from psychopathological anxiety engage in a series of safety-seeking, protective, and avoidance behaviors, or prudential reasoning, in order to avoid a threat, aspects that have a role in the maintenance of psychopathological symptoms (28, 29).”
BackgroundCarmassi, C., Dell’Oste, V., Cordone, A., Pedrinelli, V., Cappelli, A., Ceresoli, D., Massimetti, G., Nisita, C., & Dell’Osso, L. (2020) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001163 · Cited by 5
“According to this observation, FAs may express the attitude for “explanation-seeking” rather than for “treatment seeking” (Neal et al., 2000; Salkovskis et al., 1999) due to typical drugsphobia and increased substances sensitivity.”
Background
Metadata
- Authors
- Salkovskis, P. M., Clark, D. M., Hackmann, A., Wells, A., & Gelder, M. G.
- Affiliations
- Warneford Hospital (GB)
- Corresponding author
- Salkovskis, Paul M.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 1999-06
- Volume
- 37
- Issue
- 6
- Pages
- 559-574
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2064286008
- Cited by
- 310
- References
- 31
- Citations by year
- 2026: 10 · 2025: 11 · 2024: 8 · 2023: 5 · 2022: 20 · 2021: 19 · 2020: 15 · 2019: 9 · 2018: 14 · 2017: 13 · 2016: 20 · 2015: 11 · 2014: 11 · 2013: 12 · 2012: 17
- FWCI
- 7.46
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- safety-seeking behavior, panic disorder with agoraphobia, anxiety maintenance, exposure therapy, anxiety reduction
- MeSH terms
- Adult, Agoraphobia, Anxiety, Attitude, Avoidance Learning, Desensitization, Psychologic, Female, Humans, Male, Middle Aged, Panic, Psychiatric Status Rating Scales, Panic Disorder
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