The role of safety behaviors in exposure-based treatment for panic disorder and agoraphobia: associations to symptom severity, treatment course, and outcome

Sylvia Helbig-Lang; Jan Richter; Thomas Lang; Alexander L Gerlach; Lydia Fehm; Georg W Alpers; Andreas Ströhle; Tilo Kircher; Jürgen Deckert; Andrew T Gloster; Hans-Ulrich Wittchen

doi:10.1016/j.janxdis.2014.09.010

The role of safety behaviors in exposure-based treatment for panic disorder and agoraphobia: associations to symptom severity, treatment course, and outcome

J Anxiety Disord. 2014 Dec;28(8):836-44. doi: 10.1016/j.janxdis.2014.09.010. Epub 2014 Oct 5.

Authors

Affiliations

¹ Clinical Psychology and Psychotherapy, University of Hamburg, Hamburg, Germany; Department of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany. Electronic address: Sylvia.Helbig-Lang@uni-hamburg.de.
² Department of Biological and Clinical Psychology, Ernst-Moritz-Arndt University of Greifswald, Greifswald, Germany.
³ Department of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany; Christoph-Dornier-Foundation for Clinical Psychology, Bremen, Germany.
⁴ Department of Clinical Psychology and Psychotherapy, University of Cologne, Cologne, Germany.
⁵ Department of Psychology, Humboldt University of Berlin, Berlin, Germany.
⁶ Department of Clinical and Biological Psychology, University of Mannheim, Mannheim, Germany.
⁷ Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin, Campus Charité Mitte, Berlin, Germany.
⁸ Department of Psychiatry und Psychotherapy, Philipps-University of Marburg, Marburg, Germany.
⁹ Department of Psychiatry, Psychosomatics & Psychotherapy, University of Würzburg, Würzburg, Germany.
¹⁰ Department of Psychology, University of Basel, Basel, Switzerland.
¹¹ Department of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany.

PMID: 25445073
DOI: 10.1016/j.janxdis.2014.09.010

Abstract

The potentially detrimental effects of safety behaviors during exposure therapy are still subject to debate. Empirical findings are inconsistent, and few studies have investigated effects of idiosyncratic safety behavior manifestations during exposure or in everyday life. These limitations might be due to a lack of appropriate measures that address individual safety behaviors. We examined psychometric properties and predictive value of the Texas Safety Maneuver Scale (TSMS), a questionnaire specifically targeting safety behaviors in panic disorder and agoraphobia. Effects of safety behavior use, both during everyday life and during therapy, were examined using data from a multicenter RCT of N=268 patients that aimed at evaluating efficacy and mechanisms of action of two variants of an exposure-based therapy. The TSMS total score demonstrated good internal consistency (α=0.89), and it showed significant correlations with selected measures of baseline anxiety and impairment. The proposed factor structure could not be replicated. Frequent safety behavior use at baseline was associated with actual safety behavior during exposure exercises. Pronounced in-situ safety behavior, but not baseline safety behavior was associated to detrimental treatment outcome. The results underline the relevance of a rigorous safety behavior assessment in therapy. The actual relationship between safety behavior use and treatment outcome is yet to determine.

Keywords: Agoraphobia; Behavioral assessment; Exposure; Panic disorder; Safety behaviors.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Activities of Daily Living
Adult
Agoraphobia / psychology
Agoraphobia / therapy*
Anxiety / psychology
Anxiety / therapy
Anxiety Disorders / therapy
Discriminant Analysis
Female
Humans
Implosive Therapy / methods*
Male
Middle Aged
Panic Disorder / psychology
Panic Disorder / therapy*
Psychometrics
Reproducibility of Results
Safety*
Surveys and Questionnaires*
Treatment Outcome