Utilization of different types of safety behavior during exposure-based CBT for anxiety disorders and its correlates

Safety behavior is used to prevent or minimize perceived threats and contributes to the maintenance of anxiety disorders. Various types of safety behavior (e.g. cognitive, interoceptive strategies, aids, substances) are prevalent. Although assumed to be counterproductive during exposure-based CBT, little is known about its frequency and course across exposure exercises and its relation to treatment outcome. This study examined safety behavior during exposure-based CBT in a large multicenter outpatient sample and investigated its association with treatment outcome and clinical and exposure characteristic correlates. Safety behavior was dichotomously assessed after each exposure exercise using standardized worksheets (7,301) from 639 patients with panic disorder/agoraphobia, social anxiety disorder, or multiple specific phobia. Despite instructions to refrain from it, approximately half of patients reported safety behavior during their first exposure, most frequently cognitive strategies. It decreased significantly across exercises. More frequent safety behavior was associated with less symptom improvement and occurred more often with higher anticipatory and actual fear. Decline was steeper in therapist-guided than self-directed exposures, although therapist-guided exposures occurred first. Safety behavior is common early in exposure-based CBT and decreases across exposure exercises. Continuous monitoring appears important given its associations with clinical variables, exposure characteristics, and treatment outcome.Trial registration: NIMH Protocol Registration System (01EE1402A), German Register of Clinical Studies (DRKS00008743).