July 17, 2023

Dear Colleagues,

The National Social Anxiety Center (NSAC) provides information about relevant and current research in service of disseminating and promoting evidence-based treatment. This month’s summary is written by Julie DiMatteo, PhD, ABPP, representing NSAC North Jersey and examines the 2023 article by Rassaby, Smith, & Taylor: Examining Safety Behavior Subtypes across Distinct Social Contexts in Social Anxiety Disorder and Depression.”

Although safety behaviors have long been implicated as a maintaining factor in social anxiety disorder (SAD), little research has fully conceptualized safety behavior subtypes. Within the current literature, avoidance-based safety behaviors (reducing or eliminating engagement with others) and impression management safety behaviors (behaviors aimed at creating a positive self-image) have emerged as the two primary subtypes. However, little is understood regarding the use of these safety behaviors across contexts, within diagnostic presentations, and the impact of varying subtypes on outcomes across affective, behavioral, and social domains.

There are several gaps in regards to safety behaviors in the current literature. First, prior research recognizes that different social situations require different skills, and modification of skills, by the individual. However, there is not great understanding how utilization of safety behaviors differs across social interactions versus performance-based tasks. Second, there is an incomplete understanding of how safety behaviors relate to, and may be utilized within, other diagnostic presentations. For instance, it has been previously hypothesized, but not investigated, that the use of safety behaviors in those with major depressive disorder (MDD) may further socially disconnect and limit interpersonal rewards, thus maintaining both SAD and MDD. Finally, prior research does illustrate differentiating impacts of safety behavior subtype on affective and behavioral states within social interactions. However, it does not delineate how these impacts may differ in performance-based tasks, as well as if subtype presentation and context prompt different outcomes.

In the present article, Rassaby et al. (2023) aimed to address these gaps. They studied 69 individuals diagnosed with SAD, 30 individuals diagnosed with MDD, and 33 nonpatient controls with no prior history of psychiatric diagnosis. Participants completed questionnaires assessing social anxiety and major depression, and participated in social affiliation and performance-based tasks where their behaviors were rated by trained observers.

Results indicated that participants with both SAD and MDD used significantly more impression management and avoidance-based safety behaviors compared to controls. Those with SAD and MDD did not differ on use of impression management safety behaviors; however, those with SAD utilized more avoidance-based safety behaviors than those with MDD.

In differentiating context, those with SAD utilized more impression management safety behaviors during the social affiliation task, whereas those with MDD did not differ in use of impression management safety behaviors between social affiliation and social performance tasks. In the nonpatient controls group, greater impression management safety behaviors were seen during the social performance task.

Finally, results indicated that the greater one engaged in avoidance-based safety behaviors the more likely they were to experience negative affective states and state anxiety, and a reduction in positive affective states. For those that engaged in high impression management safety behaviors, there was a greater likelihood of increased negative affective states. Results were similar across social interaction and performance-based tasks with the one caveat of impression-management safety behaviors during performance-based tasks. The latter findings indicate that greater use of impression management safety behaviors was associated with less observer-rated anxious behaviors and more observer-rated approach behaviors, as well as more positive affect.

Findings from this study support assessment of safety behaviors across diagnostic presentations (not just SAD), as well as how co-occurring diagnoses may influence targets of treatment. Additionally, given the findings on impression management strategies during performance-based tasks, there are clinical implications of how and when safety behaviors should be addressed during the course of treatment.

For Clinicians:
What have your experiences been in differentiating safety behavior subtype across diagnostic profiles?
Do you tailor your treatment based on diagnostic profile and safety behavior subtype, and if so, how?

Rassaby, Madeline; Smith, Taylor; and Taylor, Charles T. Examining Safety Behavior Subtypes across Distinct Social Contexts in Social Anxiety Disorder and Major Depression. Behavior Therapy, vol. 54, issue 3, pp. 572-583, May 2023.

Julie DiMatteo, PhD, ABPP
Representing NSAC North Jersey
(CBT Specialists of New Jersey)