Abstract
Safety behaviors (SBs) are generally perceived as ‘dysfunctional’ emotion-regulation strategies that reduce physical symptoms and prevent unrealistic feared consequences of panic attacks. However, it is unclear whether all types of SBs are a hindrance or whether some may promote self-regulation in treatment. We propose that the type of SBs might explain some of the variability between panic disorder (PD) patients, and might help to predict why treatment is more successful for some than for others. In this secondary analysis of a subsample of 65 PD patients who received Cognitive Behavioral Therapy in a two-site randomized controlled trial, we examined the associations between type of SB and pre-treatment characteristics and their predictive value on trajectories of change in treatment process and outcome (panic symptoms, interpersonal problems, alliance). An observer-rating system for five types of SBs (avoidance/distraction/control-function and object/people-focus) was developed and applied to videotaped early treatment sessions, with high reliability. Patients with higher levels of people-focused SBs reported higher levels of panic symptoms pre-treatment at both treatment sites. These people-focused SBs predicted poorer treatment response on panic symptoms at one of two sites. Avoidance, control, or distraction-function and object-focused SBs were not associated with treatment process or outcomes. People-focused SBs may worsen PD symptoms, and possibly slow treatment progress, although this latter finding was not consistent across sites. This study differentiated between types of SBs and identified people-focused SBs as possible predictor of symptom change in CBT for PD—potentially relevant for efforts to improve treatment response.
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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders V. Washington, DC: American Psychiatric Association.
Amir, N., Freshman, M., & Foa, E. B. (2000). Family distress and involvement in relatives of obsessive-compulsive disorder patients. Journal of Anxiety Disorders, 14(3), 209–217.
Barlow, D. H., Craske, M. G., & Meadows, L. A. (2000). Mastery of your anxiety and panic: Workbook (4th ed.). Oxford: Oxford University Press.
Barrera, T. L., & Norton, P. J. (2009). Quality of life impairment in generalized anxiety disorder, social phobia, and panic disorder. Journal of Anxiety Disorders, 23(8), 1086–1090. https://doi.org/10.1016/j.janxdis.2009.07.011.
Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society. Series B (Methodological), 57(1), 289–300.
Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective. Clinical Psychology Review, 49, 1–15. https://doi.org/10.1016/j.cpr.2016.07.002.
Borden, J. W., Clum, G. A., Broyles, S. E., & Watkins, P. L. (1988). Coping strategies and panic. Journal of Anxiety Disorders, 2(4), 339–352. https://doi.org/10.1016/0887-6185(88)90029-1.
Chambless, S. F., Galst, J., Goldstein, A., Gordon, S., Holland, S., Levendusky, P., et al. (2010). Clinicians’ experiences in using an empirically support treatment (EST) for Panic Disorder: Results of a survey. The Clinical Psychologist: Special Feature, 63(4), 10–20. https://doi.org/10.1037/e740452011-001.
Craske, M. G., Antony, M. M., & Barlow, D. H. (2006). Mastering your fears and phobias: Therapist guide (2nd ed.). Oxford: Oxford University Press.
Craske, M. G., & Barlow, D. H. (2008). Panic disorder and agoraphobia. Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 1–64). New York: Guilford Press.
Deacon, B. J., Sy, J. T., Lickel, J. J., & Nelson, E. A. (2010). Does the judicious use of safety behaviors improve the efficacy and acceptability of exposure therapy for claustrophobic fear? Journal of Behavior Therapy and Experimental Psychiatry, 41(1), 71–80. https://doi.org/10.1016/j.jbtep.2009.10.004.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/10.1037/0033-2909.99.1.20.
Funayama, T., Furukawa, T. A., Nakano, Y., Noda, Y., Ogawa, S., Watanabe, N., et al. (2013). In-situation safety behaviors among patients with panic disorder: Descriptive and correlational study. Psychiatry and Clinical Neurosciences, 67(5), 332–339. https://doi.org/10.1111/pcn.12061.
Goodson, J. T., & Haeffel, G. J. (2018). Preventative and restorative safety behaviors: Effects on exposure treatment outcomes and risk for future anxious symptoms. Journal of Clinical Psychology (ePub ahead of print). https://doi.org/10.1002/jclp.22635.
Hamm, A. O., Richter, J., Pané-Farré, C., Westphal, D., Wittchen, H., Vossbeck-Elsebusch, A. N., et al. (2016). Panic disorder with agoraphobia from a behavioral neuroscience perspective: Applying the research principles formulated by the Research Domain Criteria (RDoC) initiative. Psychophysiology, 53(3), 312–322. https://doi.org/10.1111/psyp.12553.
Haug, T., Nordgreen, T., Öst, L.-G., Tangen, T., Kvale, G., Hovland, O. J., et al. (2016). Working alliance and competence as predictors of outcome in cognitive behavioral therapy for social anxiety and panic disorder in adults. Behaviour Research and Therapy, 77, 40–51. https://doi.org/10.1016/j.brat.2015.12.004.
Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders. Clinical Psychology: Science and Practice, 17(3), 218–233. https://doi.org/10.1111/j.1468-2850.2010.01213.x.
Helbig-Lang, S., Richter, J., Lang, T., Gerlach, A. L., Fehm, L., Alpers, G. W., et al. (2014). The role of safety behaviors in exposure-based treatment for panic disorder and agoraphobia: Associations to symptom severity, treatment course, and outcome. Journal of Anxiety Disorders, 28(8), 836–844. https://doi.org/10.1016/j.janxdis.2014.09.010.
Hill, C. E. (2012). Consensual qualitative research: A practical resource for investigating social science phenomena. Washington, DC: American Psychological Association.
Hofmann, S. G., & Hay, A. C. (2018). Rethinking avoidance: Toward a balanced approach to avoidance in treating anxiety disorders. Journal of Anxiety Disorders, 55, 14–21. https://doi.org/10.1016/j.janxdis.2018.03.004.
Hood, H. K., Antony, M. M., Koerner, N., & Monson, C. M. (2010). Effects of safety behaviors on fear reduction during exposure. Behaviour Research and Therapy, 48(12), 1161–1169. https://doi.org/10.1016/j.brat.2010.08.006.
Horowitz, L. M., Alden, L. E., Wiggins, J. S., & Pincus, A. L. (2000). IIP: Inventory of interpersonal problems. San Antonio, TX: The Psychological Corporation.
Houck, P. R., Spiegel, D. A., Shear, M. K., & Rucci, P. (2002). Reliability of the self-report version of the panic disorder severity scale. Depression and Anxiety, 15(4), 183–185. https://doi.org/10.1002/da.10049.
IBM Corp. (2016). IBM SPSS statistics for Windows, version 24.0. Armonk, NY: IBM Corp.
Kamphuis, J. H., & Telch, M. J. (1998). Assessment of strategies to manage or avoid perceived threats among panic disorder patients: The Texas Safety Maneuver Scale (TSMS). Clinical Psychology & Psychotherapy, 5(3), 177–186. https://doi.org/10.1002/(SICI)1099-0879(199809)5:3%3c177:AID-CPP166%3e3.0.CO;2-%23.
Kessler, R. C., Chiu, W. T., Jin, R., Ruscio, A. M., Shear, K., & Walters, E. E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of general psychiatry, 63(4), 415–424.
Korte, K. J., Norr, A. M., & Schmidt, N. B. (2018). Targeting safety behaviors in the treatment of anxiety disorders: A case study of false safety behavior elimination treatment. American Journal of Psychotherapy, 71(1), 9–20. https://doi.org/10.1176/appi.psychotherapy.20180001.
Levy, H. C., & Radomsky, A. S. (2014). Safety behaviour enhances the acceptability of exposure. Cognitive Behaviour Therapy, 43(1), 83–92. https://doi.org/10.1080/16506073.2013.819376.
Littell, R. C., Milliken, G. A., Stroup, W. W., Wolfinger, R. D., & Schabenberger, O. (2007). SAS for mixed models (2nd ed.). Cary, NC: SAS Institute.
Little, R. J. A. (1988). A test of missing completely at random for multivariate data with missing values. Journal of the American Statistical Association, 83, 1198–1202.
Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., & Craske, M. G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria. Clinical Psychology Review, 42, 72–82. https://doi.org/10.1016/j.cpr.2015.08.004.
Manjula, M., Kumariah, V., Prasadarao, P. S. D. V., & Raguram, R. (2009). Cognitive behavior therapy in the treatment of panic disorder. Indian Journal of Psychiatry, 51(2), 108–116. https://doi.org/10.4103/0019-5545.49450.
Meulders, A., Van Daele, T., Volders, S., & Vlaeyen, J. W. S. (2016). The use of safety-seeking behavior in exposure-based treatments for fear and anxiety: Benefit or burden? A meta-analytic review. Clinical Psychology Review, 45, 144–156. https://doi.org/10.1016/j.cpr.2016.02.002.
Milosevic, I., & Radomsky, A. S. (2008). Safety behaviour does not necessarily interfere with exposure therapy. Behaviour Research and Therapy, 46(10), 1111–1118. https://doi.org/10.1016/j.brat.2008.05.011.
Milrod, B. (1997). Manual of panic-focused psychodynamic psychotherapy. Washington, D.C.: American Psychiatric Publications.
Milrod, B., Chambless, D. L., Gallop, R., Busch, F. N., Schwalberg, M., McCarthy, K. S., et al. (2016). Psychotherapies for panic disorder: A tale of two sites. The Journal of Clinical Psychiatry, 77(7), 927–935. https://doi.org/10.4088/jcp.14m09507.
Milrod, B., Markowitz, J. C., Gerber, A. J., Cyranowski, J., Altemus, M., Shapiro, T., et al. (2014). Childhood separation anxiety and the pathogenesis and treatment of adult anxiety. American Journal of Psychiatry, 171(1), 34–43.
Pompoli, A., Furukawa, T. A., Imai, H., Tajika, A., Efthimiou, O., & Salanti, G. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: A network meta-analysis. The Cochrane Database of Systematic Reviews, 4, CD011004. https://doi.org/10.1002/14651858.cd011004.pub2.
Porter, E., & Chambless, D. L. (2015). A systematic review of predictors and moderators of improvement in cognitive-behavioral therapy for panic disorder and agoraphobia. Clinical Psychology Review, 42, 179–192. https://doi.org/10.1016/j.cpr.2015.09.004.
Rachman, S., Radomsky, A. S., & Shafran, R. (2008). Safety behaviour: A reconsideration. Behaviour Research and Therapy, 46(2), 163–173. https://doi.org/10.1016/j.brat.2007.11.008.
Richards, H. J., Benson, V., Donnelly, N., & Hadwin, J. A. (2014). Exploring the function of selective attention and hypervigilance for threat in anxiety. Clinical Psychology Review, 34(1), 1–13. https://doi.org/10.1016/j.cpr.2013.10.006.
Ruiz, M. A., Pincus, A. L., Borkovec, T. D., Echemendia, R. J., Castonguay, L. G., & Ragusea, S. A. (2004). Validity of the Inventory of Interpersonal Problems for predicting treatment outcome: An investigation with the Pennsylvania Practice Research Network. Journal of Personality Assessment, 83(3), 213–222. https://doi.org/10.1207/s15327752jpa8303_05.
Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition-behaviour links in the persistence of panic. Behaviour Research and Therapy, 34(5–6), 453–458. https://doi.org/10.1016/0005-7967(95)00083-6.
Salkovskis, P. M., Clark, D. M., Hackmann, A., Wells, A., & Gelder, M. G. (1999). An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37(6), 559–574. https://doi.org/10.1016/S0005-7967(98)00153-3.
Scocco, P., Barbieri, I., & Frank, E. (2007). Interpersonal problem areas and onset of panic disorder. Psychopathology, 40(1), 8–13. https://doi.org/10.1159/000096384.
Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., et al. (1997). Multicenter collaborative panic disorder severity scale. The American Journal of Psychiatry, 154(11), 1571–1575. https://doi.org/10.1176/ajp.154.11.1571.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin, 86(2), 420–428. https://doi.org/10.1037/0033-2909.86.2.420.
Stein, M. B., Pesale, F. P., Slavin, J. M., & Hilsenroth, M. J. (2010). A training outline for conducting psychotherapy process ratings: An example using therapist technique. Counselling & Psychotherapy Research, 10(1), 50–59. https://doi.org/10.1080/14733140903229457.
Sy, J. T., Dixon, L. J., Lickel, J. J., Nelson, E. A., & Deacon, B. J. (2011). Failure to replicate the deleterious effects of safety behaviors in exposure therapy. Behaviour Research and Therapy, 49(5), 305–314. https://doi.org/10.1016/j.brat.2011.02.005.
Telch, M. J., & Lancaster, C. L. (2012). Is there room for safety behaviors in exposure therapy for anxiety disorders? In P. Neudeck & H.-U. Wittchen (Eds.), Exposure therapy: Rethinking the mode—Refining the method (pp. 313–334). New York: Springer. https://doi.org/10.1007/978-1-4614-3342-2_18.
Thwaites, R., & Freeston, M. H. (2005). Safety-seeking behaviours: Fact or function? How can we clinically differentiate between safety behaviours and adaptive coping strategies across anxiety disorders? Behavioural and Cognitive Psychotherapy, 33(2), 177–188. https://doi.org/10.1017/S1352465804001985.
Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Psychological Assessment, 1(3), 207–210. https://doi.org/10.1037/1040-3590.1.3.207.
Wolf, A. W., & Goldfried, M. R. (2014). Clinical experiences in using cognitive-behavior therapy to treat panic disorder. Behavior Therapy, 45(1), 36–46. https://doi.org/10.1016/j.beth.2013.10.002.
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Aafjes-van Doorn, K., Zilcha-Mano, S., Graham, K. et al. The Role of Safety Behaviors in Panic Disorder Treatment: Self-Regulation or Self-Defeat?. J Contemp Psychother 49, 203–212 (2019). https://doi.org/10.1007/s10879-019-09432-9
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DOI: https://doi.org/10.1007/s10879-019-09432-9