It may be helpful to read through these different conditions and the common safety behaviors associated with them to identify what you are going through. Each condition includes a description of the symptoms, the safety behaviors, and then a fictional example of a person suffering from the condition.
GAD is characterized by worry, tension, a sense of looming apprehension, and difficulty tolerating uncertainty. The core feature of GAD is worry, which is a sense of looming apprehension about something (future catastrophe) that may or may not happen. The sense of apprehension is associated with attempts to prevent the catastrophe through problem solving. While everyone worries, in GAD the worry is excessive and uncontrollable. GAD also includes several physical symptoms such as: muscle tension, fatigue, feeling keyed up or on edge, difficulty concentrating, sleep problems, and irritability. Worry in GAD can revolve around several themes, including future, health, mental health, relationships, safety, finances, and everyday life activities. GAD also involves thinking patterns that perpetuate anxiety, including expecting the worst and catastrophizing. Thus, future catastrophes are perceived to be likely and severe in nature. Simultaneously, a person’s perceived ability to handle potential threats and related anxiety is diminished. This results in a state of perceived vulnerability and sense of danger, which is where safety behaviors come into play.
GENERALIZED ANXIETY DISORDER (GAD) AND SAFETY BEHAVIORS
When a person feels anxious and vulnerable, they begin to engage in safety behaviors, which are designed to reduce anxiety and/or the likelihood that a feared outcome will occur. These often include: over-planning, reassurance, checking behaviors monitoring the clock, control strategies, and of course, and worry itself. These safety behaviors may decrease anxiety in the short run (and increase a person’s sense of control in the moment), but over time they maintain (and usually increase) anxiety. This occurs because new learning about the likelihood of the feared outcome does not occur (most things we worry about never happen). Neither does a person learn that they are able to cope with anxiety around the possibility of the feared outcome occurring. This in part, is because individuals attribute the lack of the feared occurrence to the safety behaviors and come to rely on them to manage their anxiety. Finally, individuals are likely to view their safety behaviors as valuable and helpful, it increases the likelihood they rely on these strategies and thereby maintaining their anxiety. Let’s look at a clinical example of safety behavior use in generalized anxiety disorder.
Don suffers from generalized anxiety and persistent and chronic worry. One of his primary worries is that that he will get fired from work, eventually leading to being homeless and alone on the streets. This worry persists despite mountains of evidence of the contrary. The actual facts are that he has been at his job for several years, he has always gotten good performance ratings, he is well-respected, and he has even gotten raises and promotions. His work history is completely devoid of any formal disciplinary actions. Also, the company he works for has a lengthy procedural process to go through when they terminate an employee that includes numerous written and verbal warnings and remediation planning.
So, what keeps Don worry about losing his job despite all of the evidence? Of course, the answer is safety behaviors. Specifically, Don has a habit of seeking reassurance from supervisors and co-workers. He seeks reassurance about decisions he makes, about the possibility of mistakes, and how others perceive his performance. He is also vigilant to any signs that his supervisors or co-workers y may be dissatisfied with any aspect of his work. He recounts conversations with others for any clues that he may have done or said something wrong or incorrect. He also checks and rechecks his work for any mistakes in content, grammatical, or appearance. Even casual emails are re-read several times. He also makes extensive lists of all the tasks he has to complete and spends considerable time reorganizing, and reprioritizing tasks on this list. He also extensively plans around deadlines attempting to figure out exactly how each task will be completed in time. All these safety behaviors leave Don feeling tense, worn-down, overwhelmed, and irritable and focused on the worst possible outcome despite the fact that he is highly successful in his career.
In this case, many of Don’s safety behaviors may actually contribute to positive job performance. Additionally, many of Don’s safety behaviors may be congruent with his values of hard-work and responsibility. Also, some of these safety behaviors are needed to complete his job. These are some of the most difficult safety behaviors to address as they appear to be adaptive (at least on the surface). However, at the same time, Don’s anxiety is overwhelming and his has a very low level of job satisfaction. Don will need to make a decision about his willingness to try to reduce some of his safety behaviors. IF he is able to do so, Don and his therapist will have to identify “normal” levels of checking, planning, reviewing and preparing and begin to practice. For example, it may be normal to review an email one time before sending. However, it may also be important to learn that a catastrophe will not happen if Don does not check at all. Thus, Don may then be encouraged to send an email without any checking. Don may also have to learn that mistakes are not the end of the world. As such, Don may then be encouraged to purposefully make a minor mistake in an email. Mistake making exposures are powerful learning tools. This is the typical progression of safety behavior elimination. Other of Don’s safety behaviors can be eliminated completely, such as reassurance seeking. With this safety behavior, be prepared to identify and counter very subtle (often automatic) ways of seeking reassurance.
SOCIAL ANXIETY DISORDER AND SAFETY BEHAVIORS
Social anxiety is characterized by fears of negative judgment, evaluation, or embarrassment. Concerns about negative judgment are often fueled by fears such as, being perceived as stupid, boring, awkward, offensive, generally unattractive, unappealing, etc. To avoid such judgments, individuals with social anxiety avoid social situations and engage in a host of different safety behaviors. Common safety behaviors include: impression management, monitoring of self and others, attempting to hiding anxiety, avoiding eye contact, leaving events early, and pretending not to recognize or see people. Of course, these safety behaviors prevent a person from learning that their fears are unlikely and/or overblown. Additionally, social anxiety related safety behaviors often result in negative judgment and evaluation from others, even though this is what they are designed to prevent. Additionally, social anxiety safety behaviors increase anxiety in the moment often through monitoring of self and others. Below is a clinical description of social anxiety and safety behaviors.
Adam suffers from social anxiety. He struggles with fears or embarrassment and anxiety about being negatively judged or evaluated in many social situations. In general, he fears awkwardness in conversations and believes he is not well-liked by others. He also avoids situations that trigger his social anxiety. As indicated above, safety behaviors play an integral role in maintaining social anxiety. In Adam’s case, his safety behaviors begin long before he actually enters a social situation. Prior to social events, Adam experiences high levels of anticipatory anxiety. During these periods he often has images of mishaps, embarrassments, and rejections. IN response to these, he prepares a head of time by identifying and rehearsing things he will talk about. For example, Adam practices how he will introduce himself and different topics he can discuss. Since he feels more anxious alone, he often reaches out to friends to try to attend social gatherings with them. Unfortunately, despite these anticipatory safety behaviors (or better stated, because of his anticipatory safety behaviors) his anxiety continues to increase as the social event approaches.
Then when he gets to the social event his anxiety spikes and he often experiences strong physical symptoms of arousal. He feels hot, his face flushes, his chest is beating hard, and he starts sweating. He attempts to lessen these symptoms by positioning himself right next to a window or a cooling vent and somewhat away from the main crowd of people. He also tries to stay where the lights are dim and wears clothes that hide sweat. When friends attempt to call him over, he often declines because of his concern about his physical symptoms and others noticing them. At the first opportunity possible, Adam consumes alcohol to bring down his anxiety. After he feels the effect of the alcohol, he starts to engage in conversation and move around the party more freely. However, he continues to engage in safety behaviors. Since he does not want to come across as self-involved, he shares very little information about himself. When asked directly about himself he gives short answers and quickly asks about the other person. Adam also has difficulty maintaining eye contact and whenever there is a lull in the conversation he ends the conversation to avoid any awkwardness. Adam also monitors his conversations carefully and remains vigilant for cues to disapproval. This results in less fluent conversation and gives the perception that he not very interested in the conversation. Of course, all these behaviors have the opposite of their intended effect. That is, they leave others feeling as if Adam is not genuinely interested in talking with them, that he is somewhat disinterested and aloof. After more time passes with Adam continuing to feel anxiety, he usually decides to leave early. Adams early departure (along with his other safety behaviors) is also interpreted by others as him not being interested or motivated to spend time with them. As a result, the next time Adam runs into some of the partygoers they may act a bit more distant and uninterested, which of course will reinforce Adam’s belief that he was negatively judged and not well-liked by others.
The final stage occurs after he has left the party. While driving home, Adam rehashes conversations, comments, facial expressions, body language etc. Adam attempts to identify things that may have upset or offended others or times when others may have felt awkward. This is called post-event rehashing. Adam believes that post-event rehashing will help him to not have such problems again in the future. However, the more he rehashes the worse he feels about the evening. He becomes more convinced that others may have misinterpreted some of the things he said as offensive and that he made them feel uncomfortable and awkward. This rehashing lasts through the night and much of the next day and causes high levels of distress and anxiety. Later in the week, Adam may see some of the partygoers on the street. However, he pretends to not recognize them which greatly limits the likelihood to future positive interactions with these individuals. Overall, these behaviors serve to reinforce Adams belief that he is not well liked and catastrophize feelings of awkwardness in a conversation (which are actually quite normal). These behaviors also cause others to view Adam in a less favorable light, which becomes a self-fulfilling prophecy bringing to pass the very things he was trying to prevent.
SAFETY BEHAVIORS AND PANIC DISORDER
Panic disorder is characterized by recurrent panic attacks, catastrophic interpretations of physical symptoms, and avoidance of situations where panic attacks may occur. Common fears in panic attacks include fears of physical catastrophe, fears of losing control, fears of going crazy, fears of dying, and fears of fear. Common safety behaviors in panic disorder include: body vigilance/scanning for physical symptoms, arousal control strategies, checking pulse or HR, reassurance seeking, traveling with companions, carry medication, carry water bottles, stay on the outside of crowds, take it easy when exercising, avoiding stimulants or alcohol, etc. Below is a clinical description of safety behaviors in panic disorder.
Anne suffers from panic attacks. She is fearful of unusually bodily symptoms as well as situations that may trigger such symptoms and subsequent panic attacks. While she has entered into these situations many times, she continues to feel anxious and panicky. Likewise, while no physical catastrophe has occurred, she continues to be fearful of the symptoms. Why does this continue even when she has entered the situations repeatedly? Again, because of safety behaviors. For instance, Anne always carries a water bottle and anxiety medication. Additionally, when she starts to feel the physical symptoms, she slows down and takes care to not exert herself any more than necessary. As such, when Anne has gotten through the situation without incident, she attributes her safety (i.e., the absence of a catastrophe) to her safety behaviors, as opposed to reevaluating symptoms/situations and her ability to handle them. With the passage of time, Anne monitors her body more and more and becomes more sensitive to her internal experiences. Her vigilance becomes automatic and nearly constant. As soon as she senses a physical symptom she immediately attempts to reduce it through medication, leaving the situation, or taking it easy. She begins to avoid more and more situations and activities (e.g., alcohol, caffeine, heavy meals, exercise, etc.). Additionally, she regularly checks her pulse, looks up symptoms of the internet, and attempts to reassure herself that she is not in danger. Unfortunately, the more she does so the less safe she feels. As Anne continues to engage in safety behaviors, her anxiety around physical symptoms increases, while her life activities become more restricted.
PTSD AND SAFETY BEHAVIORS
PTSD is characterized by a sense of ongoing threat. This sense of threat stems from traumatic events that involved extreme danger to one’s physical or emotional self. Following exposure to a trauma, a constellation of symptoms develops, including intrusive recollections, avoidance, changes in beliefs about the world and others, changes in emotional functioning, and arousal. Most fears in PTSD revolve around fears of physical safety. PTSD is characterized by two types of safety behaviors: 1) vigilance; 2) thought suppression Common vigilance related safety behaviors include scanning, contingency planning, monitoring, checking for danger, locating exits, etc. Thought suppression usually takes the form of trying not to think about the traumatic event and pushing out memories and negative feelings. Below is a clinical description of PTSD related safety behaviors.
Joe has posttraumatic stress disorder (PTSD) which is characterized by vigilance related safety behaviors. One Saturday afternoon, Joe and his wife decide to go to Wall Mart. As the time to leave approaches, Joe starts to feel more uneasy and has some images of things that could go wrong while shopping and what he could do about each situation should it occur…. his sense of unease begins to grow. It’s time to leave, and he and his wife lock the front door and jump in the car. Before leaving, Joe jumps out of the car and checks the door to make sure it is locked. While he’s at it, he checks a couple of the windows just to make sure. Back in the car and Joe is driving. On the back streets he is scanning for debris and trash along the side of the road and when he sees some he swerves to miss it. He also notices cars that look out of place or may be driving erratically. His anxiety has increased a good bit by this point.
The couple arrive at the freeway and have to merge into fast moving traffic. Joe is continually scanning, looking for beat-up cars, trucks, or cars without license plates. When a car gets too close, he believes the driver may have hostile intent and he moves defensively to let the car pass. He feels a mixture of anxiety and rage at the car while it passes and has some fantasies about chasing him down. Joe also continues to scan the side of the road for debris and keeps away from the outside lanes. He also notices cars going too fast as well as those going to slow…but there are so many cars that it is difficult to track all of them. Joe is constantly looking in his rearview and side view mirrors and continues to formulate plans in case he is attacked or other cars lose control. He approaches a bridge and feels his heart begin to race and suddenly feels vulnerable and open to attack. He is sweating and feels like his head is on a swivel. There are so many cars to pay attention to and so much that could possibly go wrong. By the time Joe and his wife reach Walmart his anxiety is very high, he’s feeling tense, his breathing is rapid, and mind is racing.
The couple pull into the parking lot, but it is pretty full and he does not want to park close to other cars. Joe decides on parking near the far corner, which irritates his wife because she does not want to walk that far. Joe feels irritated that his wife does not understand how potentially dangerous this parking lot could be. While walking across the parking lot, he notices cars parked but with their engines idling, he notices cars with tinted windows, he notices cars with passengers sitting waiting in them and for each he forms a plan for what he would do if someone jumps out and attacks him. He feels vulnerable in the parking lot. By the time he gets into the store his anxiety is even higher.
Of course the store is packed. As Joe walks in he has a sinking feeling that quickly turns into anxiety and near-panic. There is no way he can keep eyes on all of these people. HE is scanning their faces, their hands, their clothes, shoes, and looking for people that just seem to be out of place. He continues to formulate contingency plans in case he is attacked. He takes note of the exits and places he could use for cover if something went down. As he begins to walk the isles he continues to scan and notice all kinds of potential danger. He uses the shopping cart to keep a safe distance between he and other people. He takes wide turn when he turns into a new isle. He is bothered by people talking too loud. He is fully on guard and aware and expecting something to jump off any minute. He feels panicked and just wants to get out as soon as possible. His wife does not share this concern. IN fact, not only is she not in a hurry, but she decides this is a good opportunity to have a nice chat about their relationship and how great things are going. But Joe does not feel like talking. He is on guard and believes it will take his attention away from the potential danger. He also feels that his wife does not understand how dangerous this situation could be. His gives short, quick answers and does not look at his wife. This quickly irritates his wife and she asks him what is wrong with him. Joe can’t really explain what is going on so he remains quiet and focused on getting out of there as soon as possible. By the time the shopping trip is over, joe is wired, anxious, exhausted, and angry. Joe’s wife is somewhat confused and angry as well. The couple don’t talk much for the rest of the day.
That evening, joe has several intrusive memories about his combat experiences and the friends that he lost. The memories come and he feels anger, guilt, shame, anxiety, and rage. It completely throws him off. He does not want to talk with anyone, but rather wants to be alone. As the memories come, Joe tries to push them out of his mind, but he still feels terrible and the memories continue to linger. Joe then watches TV in attempts to distract himself. This does not really work and he is having a hard time concentrating. He tries getting up and going for a run, which works somewhat, but when he is still having memories. Joe feels desperate. He worries he may be going crazy or will never get over what he saw and experienced. He worries he will not be able to function and does not understand why these memories keep plaguing him. After 2 or 3 hours of this struggle, Joe starts drinking. He quickly feels better and so he keeps drinking. Finally, after a couple hours of drinking, Joe gets tired and goes to bed.