Within the study and treatment of clinical anxiety, “safety behaviors” refer to overt or covert actions performed to prevent the occurrence of a feared outcome and/or reduce associated distress (Telch & Lancaster, 2012). Safety behaviors are a hallmark feature of anxiety disorders, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD; American Psychiatric Association, 2013). For example, someone afraid of accidentally hitting a pedestrian while driving might excessively scan for people walking nearby or turn their car around to make sure they did not hit a pedestrian without realizing it. Yet, not all safety-seeking actions are indicative of psychopathology; engaging in some precautionary behavior (e.g., looking both ways before crossing an intersection) ensures human welfare and survival. The degree to which a certain coping strategy might be considered a maladaptive safety behavior versus adaptive survival mechanism, therefore, depends more on its intended function than its topographic form (Thwaites & Freeston, 2005).
Although the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) includes avoidance of trauma reminders as a diagnostic criterion for PTSD, experts have long noted that trauma survivors typically engage in additional strategies-which are often subtle and generalized-to minimize aversive internal states that do not obviously map onto PTSD symptom clusters. According to the cognitive-behavioral theory, these posttraumatic safety behaviors observed in clinical practice counterintuitively maintain PTSD symptoms because they perpetuate maladaptive beliefs and circumvent the natural reduction of distress (Clark, 1999; Ehlers & Clark, 2000; Foa, Hembree, & Rothbaum, 2007). In his misattribution of safety hypothesis, Salkovskis (1991) argued that when an anxious patient performs a safety behavior and their feared catastrophe does not occur, the patient will consider the situation a “near miss” and credit their safety behavior for the noncatastrophic outcome. The patient’s exaggerated beliefs about the likelihood and/or severity of negative events in feared situations therefore remain intact (Salkovskis, 1991; Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999; Salkovskis, Hackmann, Wells, Gelder, & Clark, 2007). Moreover, patients will not learn that their distress would have declined over time anyway (a process sometimes referred to as habituation; Cooper, Clifton, & Feeny, 2017). Thus, in highlighting how idiosyncratic safety behaviors are both temporarily “effective” and functionally related to threat-related cognitions, the cognitive-behavioral theory provides a nuanced framework for understanding how these behaviors are negatively reinforced and maintain PTSD in the long term.
Consider someone who was assaulted with a weapon in a high-crime area at night and consequently holds trauma-related beliefs such as “people want to harm me” and “I must always remain alert.” They justifiably avoid walking in objectively dangerous areas at night but also begin to experience strong emotional and physiological reactions to approaching strangers during the daytime in acceptably safe areas (e.g., the workplace). They consequently insist on sitting near exits and carrying pepper spray at all times to defend against an attacker, even in situations in which the probability of an attack is extremely low. If unable to position themselves near an exit route or keep access to their pepper spray, they experience intense panic and urges to escape. Eventually, they stop attending social gatherings altogether if there is no guarantee of being able to engage in these safety behaviors. In addition to demonstrating the functional link between trauma-related beliefs and safety behaviors, this example illustrates how (a) safety behaviors are unnecessary to prevent harm, given the actual degree of threat, and (b) individuals tend to hold overvalued beliefs about their safety behaviors, given their actual ability to cope (e.g., “I could never get through this situation without doing this behavior”).
Substantial research implicates safety behaviors in the development and maintenance of clinical anxiety (Helbig-Lang & Petermann, 2010). Accordingly, safety behaviors are traditionally eliminated as soon as possible during cognitive-behavioral therapy (CBT) for anxiety and related disorders (Abramowitz & Jacoby, 2015; Antony, Craske, & Barlow, 1995; Craske & Barlow, 2007; Foa et al., 2007). Although experts have offered multiple explanations for safety behaviors’ deleterious effects on CBT outcome (for a review, see Blakey & Abramowitz, 2016), safety behaviors are primarily thought to prevent the correction of mistaken/maladaptive beliefs. That is, if an individual is engaging in safety behaviors, they cannot learn through direct experience that their feared outcomes are less likely and/or catastrophic than anticipated. Furthermore, individuals might misattribute the nonoccurrence of feared outcomes to their engaging in a safety behavior (e.g., “no one tried to attack me because they could see I was sitting near the exit and could easily run out and call for help”; Salkovskis, 1991). At the same time, some authors have argued that safety behaviors do not always interfere with anxiety treatment (Rachman, Radomsky, & Shafran, 2008).
Despite growing interest in the nuanced role of safety behaviors, little research on this topic has been conducted in relation to posttraumatic stress (McLean & Foa, 2011). In their investigation of the link between posttraumatic stress symptoms and a broad range of “maladaptive control strategies” (e.g., avoiding unfamiliar places/situations, carrying a weapon), Dunmore, Clark, and Ehlers (2001) assessed a sample of 57 adults with assault-related PTSD within 4 months of their assault and again at follow-up. These authors found that avoidance and safety-seeking strategies-but not ruminative attempts to mentally erase or alter the trauma memory-significantly predicted PTSD severity at 6 and 9 months after a participant’s assault (see also Ehring, Ehlers, & Glucksman, 2008; Freeman et al., 2013). Goodson and Haeffel (2018) later examined the relationship between PTSD symptoms and anxiety-related safety behaviors (i.e., things people do “to make themselves feel more comfortable,” such as scoping places out before entering or overplanning for everyday events) in a sample of veterans with PTSD at pre- and posttreatment. These authors detected small-to-moderate associations between safety behaviors and PTSD symptom severity across assessments, with the strongest correlation (r = .39) observed between pretreatment scores on both measures.
Results from these studies highlight the importance of safety behaviors in the maintenance of posttraumatic stress symptoms, but they are also limited by certain methodological issues. First, although some survey items used in Dunmore et al.’s (2001) study linked behaviors to the assault (e.g., “try to push thoughts of the assault to the back of your mind”), other items were not explicitly connected to the trauma (e.g., “avoid unfamiliar places or situations”). Similarly, the measure used by Goodson and Haeffel (2018) was designed to be “a broad measure of safety behaviors found in those suffering from social anxiety, PTSD, generalized anxiety, panic, obsessive-compulsive disorder, and health-related anxiety” (Goodson, Haeffel, Raush, & Hershenberg, 2016, p. 1101). As a result, these surveys might have captured maladaptive strategies that either predated trauma exposure or were not specifically performed to neutralize trauma-related distress (i.e., they could have looked like safety behaviors but not function as safety behaviors; Thwaites & Freeston, 2005). Second, posttraumatic stress symptoms were measured with a self-report measure only; additional research incorporating interview assessment could bolster findings on the link between maladaptive coping efforts and posttraumatic stress symptoms. Thus, a renewed examination of the association between posttraumatic stress symptoms and safety behaviors applying a more comprehensive and precise assessment approach is needed.
The purpose of the current study was twofold. First, we sought to conduct a descriptive analysis of trauma-related coping strategies performed by individuals reporting symptoms of posttraumatic stress that might function as problematic safety behaviors. Second, we aimed to build on existing work by supplementing self-report data with interview assessment to examine the association between trauma-related coping efforts and posttraumatic stress symptoms according to current diagnostic criteria and conceptual operationalizations of safety behaviors (American Psychiatric Association, 2013; Helbig-Lang & Petermann, 2010; Telch & Lancaster, 2012). To characterize safety behavior use among individuals with a diverse trauma history, we recruited two samples in the current investigation: 89 trauma-exposed adults living in the Western United States and 47 adults with a diagnosis of current PTSD living in the Southeastern United States. Based on a review of the relevant literature, we hypothesized that greater use of posttraumatic safety behaviors would be positively associated with more severe posttraumatic stress symptoms and trauma-related cognitions.
Method
Participants and Procedure
Western U.S. sample
Data were collected from university students who provided written informed consent to participate in a larger institutional review board-approved study on the assessment of functional outcomes in trauma survivors. To be considered eligible, participants must have (a) been at least 18 years old, (b) endorsed exposure to at least one potentially traumatic event, and (c) reported at least some continued distress associated with that event during an initial screening survey. Individuals who met these eligibility screening criteria were invited to attend an in-person study appointment. After providing written informed consent, participants completed a clinical interview with the study staff, followed by an online self-report battery containing the measures described in the ‘Measures’ section, below.
Southeastern U.S. sample
Data were collected from adults participating in a larger institutional review board-approved study of the effect of PTSD treatment on cardiovascularrisk factors. Participants were recruited from a university-surrounding area through several methods, including online advertisements (e.g., Craigslist) and flyers posted in the community. To be considered eligible, participants must have been between the ages of 40 and 65 years and have had a DSM-5 diagnosis of current PTSD. Participants taking psychiatric medications were eligible if they were medication stable for at least 3 months prior to enrollment. Participants were ineligible if they had received trauma-focused psychotherapy for PTSD in the past 6 months, had current cognitive impairment as determined by a cutoff score of 20 on the Montreal Cognitive Assessment (Nasreddine et al., 2005; Waldron-Perrine & Axelrod, 2012), had a lifetime diagnosis of schizophrenia or bipolar disorder, reported alcohol and/or substance use that caused problems in day-to-day life, reported regular cocaine or methamphetamine use (due to these substances’ implications for cardiovascular functioning), were pregnant (due to pregnancy’s effects on the metabolic system), or reported heart disease, abnormal heart rhythm, uncontrolled HIV infection, cancer, epilepsy, rheumatoid arthritis, inflammatory bowel disease, lupus, or any other inflammatory disease. Interested individuals contacted the study staff to complete a phone screen to determine initial eligibility before attending an in-person assessment with the study staff. After providing written informed consent, participants completed a clinical interview and self-report battery containing the study measures described below.
Measures
Clinician-Administered Posttraumatic Stress Disorder Scale for Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition
The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013) is a structured interview that assesses PTSD diagnosis and symptom severity according to DSM-5 criteria (American Psychiatric Association, 2013). Respondents first identify an index Criterion A trauma, which serves as the focus of past month posttraumatic stress symptom inquiry. Participants reporting exposure to multiple Criterion A traumas were asked to select the incident (or closely related incidents; e.g., combat experiences) that resulted in the greatest level of ongoing distress and functional impairment. The CAPS-5 yields a total score (total scores range from 0 to 80, with higher scores indicating greater symptom severity), symptom cluster scores (subscale score ranges vary by cluster), and PTSD diagnosis (yes/no). CAPS-5 administrators at both research sites underwent rigorous training, which included didactic instruction, experiential role-plays, review of scored training tapes, supervised administration of at least one CAPS-5 interview, and ongoing supervision.1
The CAPS-5 has shown good-to-excellent internal consistency, test-retest reliability, convergent validity, and discriminative validity in previous research (Bovin et al., 2016; Weathers et al., 2018). Analysis of the 20 PTSD symptom criteria items showed that the CAPS-5 demonstrated good internal consistency in the current samples (αWestern United States = .90; αSoutheastern United States = .79).
Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition
The PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) is a 20-item self-report measure of current PTSD symptoms according to DSM-5 criteria (American Psychiatric Association, 2013). After identifying a single index trauma, participants rate the degree to which they experienced each symptom over a specific period using a scale of 0 (not at all) to 4 (extremely). Total scores range from 0 to 80, with higher scores indicating greater posttraumatic stress symptom severity. The PCL-5 was used to assess past month symptom severity in the Western U.S. sample. Within the Southeastern U.S. sample, the PCL-5 was used to assess past month symptoms for approximately half of the participants and past week symptoms for the remaining participants.2
The PCL-5 has demonstrated strong psychometric properties in previous work (Blevins, Weathers, Davis, Witte, & Domino, 2015). Internal consistency for the PCL-5 was excellent in the Western U.S. sample (α = .92) and the Southeastern U.S. sample (αmonth = .91; αweek = .94).
Posttraumatic Cognitions Inventory
The Posttraumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) is a 33-item self-report measure of negative trauma-related cognitions (i.e., negative beliefs about the self, negative beliefs about the world, and self-blame). Participants rate their agreement with each item on a scale of 1 (totally disagree) to 7 (totally agree). Total scores range from 33 to 231, with higher scores indicating stronger negative posttraumatic cognitions. The PTCI has demonstrated good internal consistency, good discriminative validity, and moderate-to-high correlations with PTSD severity in past work (Beck et al., 2004; Foa et al., 1999). The PTCI was administered to the Western U.S. sample only and demonstrated excellent internal consistency (α = .96).
Shame and Guilt After Trauma Scale
The Shame and Guilt After Trauma Scale (SGATS; Aakvaag et al., 2016) is a brief self-report measure of trauma-related guilt (five items) and shame (four items). Respondents rate the degree to which they agree with each item using a score of 0 (no), 1 (yes, a little), or 2 (yes, a lot). Mean scores on this measure range from 0 to 2, with higher scores indicating greater trauma-related shame and guilt. The SGATS has demonstrated acceptable psychometric properties, including internal consistency and convergent validity, in preliminary research (Aakvaag et al., 2016). The SGATS was administered to a subset of the Southeastern U.S. sample (n = 30) and demonstrated good internal consistency (α = .89).
Posttraumatic Safety Behavior Questionnaire
The Posttraumatic Safety Behavior Questionnaire (PSBQ) is a novel self-report inventory developed to assess the frequency of posttraumatic safety behaviors (see the Appendix). Items assessing potentially relevant behaviors were derived from the existing literature on PTSD and safety behaviors (Clapp et al., 2011; Dunmore et al., 2001; Ehlers & Clark, 2000; Foa et al., 2007; Kamphuis & Telch, 1998; Telch & Lancaster, 2012). To ensure that the assessed trauma-related coping strategies were functionally consistent with current definitions of safety behaviors (Telch & Lancaster, 2012; Thwaites & Freeston, 2005), respondents were instructed to only consider behaviors they performed in to prevent a feared outcome and/or reduce distress associated with their index trauma when completing the questionnaire. Participants rated the degree to which they engaged in each of 23 assessed safety behaviors using a 0 (never) to 4 (always) scale. After rating use of (a) recreational or nonprescribed drugs (Item 13), (b) sleeping aids (Item 15), (c) nonlethal weapons (Item 22), and (d) potentially lethal weapons (Item 23) as safety behaviors, participants identified specific substance(s) and/or weapon(s) used. The PSBQ showed acceptable-to-good internal consistency in the current samples (αWestern United States = .77; αSoutheastern United States = .82).
Data Analytic Strategy
All analyses were performed using SPSS Version 24. We first ran descriptive statistics to characterize the demographic and clinical characteristics of each sample. We then conducted item-level analyses of the (a) frequency with which participants endorsed engaging in an array of potential safety behaviors and (b) associations between specific PSBQ items and outcome measures. Finally, we computed zero-order correlations to test our hypothesis that more frequent overall use of trauma-related safety behaviors would be positively associated with posttraumatic stress symptom severity and trauma-related cognitions. All analyses were conducted separately within each sample using a two-tailed critical α level of .05.
Results
Sample Characteristics
Sample demographic and clinical data are presented in Table 1.
Whereas current DSM-5 PTSD diagnosis was required for study participation in the Southeastern U.S. sample, 13.5% of the Western U.S. sample of trauma survivors met full diagnostic criteria for current PTSD. Regarding hallmark trauma-related cognitions, the Western U.S. sample’s median PTCI score (Mdn = 66.00) fell between the median PTCI scores of trauma-exposed individuals without PTSD (Mdn = 49.00) and with PTSD (Mdn = 133.00), as reported by Foa et al. (1999). The Southeastern U.S. sample’s mean SGATS scores reflected moderate levels of trauma-related shame and guilt.
Posttraumatic Safety Behavior Questionnaire Descriptive Statistics
Posttraumatic safety behavior data are presented in Figure 1.
Figure 1. Posttraumatic safety behavior use in two samples. Parenthetical values indicate the percentage of the Western and Southeastern U.S. samples, respectively, endorsing any use of that safety behavior. Bars represent mean frequency of safety behavior use in each sample.
In each sample, the most commonly endorsed behaviors were carrying a cell phone to call for help in case of an emergency, checking car side/rear mirrors while driving, and distracting attention away from trauma-related triggers. Specific substances used3
and weapons carried specifically to prevent a feared trauma-related outcome and/or reduce associated distress are shown in Table 2.
Of all self-reported drug use, participants most commonly endorsed using medication/supplements to minimize trauma-related sleep disturbance. The following weapon-related safety behaviors were common in both samples: carrying mace/pepper spray, placing keys in one’s fist/fingers, and keeping access to pocket knives.
Table 3
presents PSBQ item-level correlations with measures of posttraumatic stress symptoms and trauma-related cognitions. Four items did not correlate with any symptom or cognitions measure in either sample: driving at least 5 mph below the speed limit (Item 5), keeping one’s hand near the car horn while driving (Item 6), performing religious rituals when experiencing trauma-related distress (Item 7), and carrying a cell phone to call for help in case of an emergency (Item 20). Because these items appeared to reflect normative rather than pathology-related behaviors, they were excluded from the computed PSBQ sum score that was used in later analyses.4
Thus, possible total scores on the reduced (19-item) PSBQ ranged from 0 to 76, with higher scores indicating more frequent safety behavior use.
Associations Between Posttraumatic Safety Behaviors and Symptom Severity
Zero-order correlations between study variables are presented in Table 4.
As predicted, PSBQ scores were significantly and positively correlated with all study variables in both the Western and Southeastern U.S. samples (ps < .05). Across samples, the magnitude of correlations between PSBQ scores and other study variables ranged from medium to large (rs = .32-.72), with the strongest association in both groups being between the PSBQ and PCL-5.
Discussion
Despite substantial research on maladaptive safety behaviors germane to anxiety disorders and OCD, few studies have investigated these strategies among individuals reporting symptoms of posttraumatic stress (Meulders, Van Daele, Volders, & Vlaeyen, 2016). Although gold-standard PTSD measures assess avoidance of trauma-related memories and cues (Weathers, Blake, et al., 2013; Weathers, Litz, et al., 2013), more subtle strategies can go undetected in routine clinical practice. Posttraumatic safety behaviors might be especially difficult to recognize if they are covert (e.g., drinking specifically to alleviate posttraumatic stress symptoms) or socially normative at the topographic level (e.g., carrying mace, exercising). In light of growing debate surrounding the effects of safety behaviors during CBT for clinical anxiety, elucidating common trauma-related safety behaviors could inform future PTSD research, assessment, and treatment.
The current study recruited two samples of trauma-exposed adults to identify specific posttraumatic safety behaviors and examine their relation to trauma-related symptoms and cognitions. Although samples varied in PTSD symptom severity, both groups endorsed frequently engaging in posttraumatic safety behaviors. Moreover, patterns of most commonly endorsed safety behaviors were similar across samples, with participants in each group reporting engaging in checking, distraction, and arousal-reduction strategies to mitigate trauma-related threat and/or distress. Item-level analyses showed that certain behaviors were strongly related to posttraumatic symptomatology (e.g., sitting/standing near exits, self-medicating posttraumatic symptoms or distress), whereas other behaviors were not (e.g., engaging in religious rituals, driving more than 5 mph below the speed limit).
Primary analyses supported our hypothesis, as greater reliance on safety behaviors overall was significantly and positively associated with self-reported and interviewer-rated posttraumatic stress symptom severity and trauma-related cognitions in both samples, despite sample-specific idiosyncrasies regarding the specific type of safety behavior(s) used. Our findings are consistent with current conceptualizations of safety behaviors (Telch & Lancaster, 2012; Thwaites & Freeston, 2005) as well as previous research on the link between PTSD and maladaptive coping (Dunmore et al., 2001; Ehring et al., 2008; Freeman et al., 2013; Goodson & Haeffel, 2018). Thus, findings from the current study point to specific trauma-related behaviors that would be important to consider in a clinical context.
Our study’s participants endorsed diverse sets of posttraumatic safety behaviors and only one individual safety behavior-sitting/standing near exits-was unilaterally associated with all study measures in both samples. This might be partially because of demographic heterogeneity between the Western U.S. and Southeastern U.S. samples. It is also possible that participants became “specialists” in certain safety behaviors but not others because of unique differential reinforcement histories of strategies that were (in)effective at reducing trauma-related distress. Between-person variability in posttraumatic safety behavior patterns is congruent with clinical observation and would be important to account for in future research on the nature and treatment of PTSD. Candidate factors that likely influence the form and frequency of safety behavior use include an individual’s gender and index trauma type.
Safety behaviors have been implicated in the development and maintenance of clinical anxiety because of their potential to bias attention toward threat (Sloan & Telch, 2002), cause misattributions of safety (Salkovskis, 1991), and paradoxically increase the frequency of unwanted internal experiences (Abramowitz, Tolin, & Street, 2001). Safety behaviors could also interfere with CBT for PTSD, as continued engagement in posttraumatic safety behaviors not only signals poorer treatment adherence but also precludes patients from learning that feared situations/stimuli are not harmful or dangerous (Foa et al., 2007). Because many common posttraumatic safety behaviors are socially normative (e.g., traveling with a companion), the current findings suggest clinicians treating people with PTSD should conduct a functional analysis of suspected safety behaviors (Abramowitz, Deacon, & Whiteside, 2011). For example, clinicians could ask about an individual’s motivation for engaging in the behavior (e.g., socializing with a friend vs. ensuring access to safety or reassurance) and how the individual would feel if the behavior were prevented (e.g., bored vs. anxious). Psychoeducation could similarly emphasize the “why” instead of the “what” by helping patients understand how seemingly benign or “normal” behaviors can nevertheless maintain symptoms of posttraumatic stress in the long term.
Strengths of this study included use of DSM-5 diagnostic screening measures, integrated interview and self-report assessment, two samples that differed along demographic and clinical variables, and a nomothetic approach to understanding idiosyncratic coping strategies. Another strength was that the scope of the PSBQ was explicitly restricted to behaviors performed to reduce perceived threat and/or distress associated with one’s trauma history. Accordingly, the current study built on previous work to provide a more specific examination of posttraumatic coping strategies that could function as safety behaviors, regardless of how “normal” they appear at surface level (Telch & Lancaster, 2012; Thwaites & Freeston, 2005).
At the same time, findings from this study should be interpreted in light of several limitations. For example, this study relied on a cross-sectional design, which prevents drawing conclusions about the direction of the relationship between posttraumatic stress symptoms, cognitions, and behaviors. Because we did not include a control group of individuals denying trauma exposure, we cannot rule out the possibility that our findings were an artifact of comorbid anxiety disorders (which often co-occur with PTSD and are also associated with safety behavior use). Our relatively moderate sample sizes may be considered another limitation. Longitudinal studies recruiting larger and more diverse samples would shed additional light on the link between posttraumatic stress symptoms and safety behaviors.
Although the PSBQ assessed a wide range of strategies that could function as posttraumatic safety behaviors, the PSBQ is not a comprehensive list and not every individual who has experienced a traumatic event engages in all safety behaviors assessed by the PSBQ. As discussed elsewhere (Abramowitz et al., 2011; Telch & Lancaster, 2012), safety behaviors-as well as the threat-related beliefs that motivate anxious individuals to perform them-are idiosyncratic. Consequently, there are challenges to measuring an individual’s specific repertoire of safety behaviors using a nomothetic approach and self-report assessment. For example, whereas some individuals may report extensively relying on only a few safety behaviors, other individuals may alternate between a vast repertoire of safety behaviors without using any particular strategy very frequently. Diverse sociocultural and political attitudes across regions of the country might further influence the expression of posttraumatic coping (e.g., carrying a firearm vs. carrying mace).
Furthermore, given that safety behaviors are often long-standing and automatic, participants may not always recognize their safety behavior routine to be connected to a trauma history. Although one strength of the PSBQ is that it captures both situationally prompted (“reactive”) and habitual (“everyday”) behaviors, a consequent limitation of this measure is that it might have captured behaviors falling beyond the scope of maladaptive strategies. It is also possible participants did not accurately differentiate adaptive coping (e.g., engaging in positively reinforced exercise that improves physical and emotional health) from maladaptive safety behaviors (e.g., engaging in negatively reinforced exercise that temporarily mitigates posttraumatic stress symptoms). Thus, rather than relying on a self-report questionnaire, future research might assess posttraumatic safety behaviors with an interview administered by trained evaluators holding expertise in the conceptualization of clinical anxiety and safety behaviors (as is often done in the assessment of OCD; Goodman et al., 1989a, 1989b). Similarly, a self-report questionnaire might best be used in clinical practice as a “springboard” for additional (functional) assessment of possible posttraumatic safety behaviors, with careful differentiation between situation-specific and generalized strategies.
Conclusion
This preliminary investigation built on previous work to characterize a broad range of posttraumatic safety behaviors and provide empirical evidence for their relation to symptom severity in two samples. This study represents an important step toward identifying common-and potentially maladaptive-coping strategies that could be relevant to case conceptualization and treatment planning. Replicating this study in larger and more diverse samples would further enhance the robustness of the current findings. In addition to developing and psychometrically evaluating a posttraumatic safety behavior scale or interview, future studies could examine the bidirectional effects of safety behaviors during trauma-focused treatment. Time-series analyses examining session-by-session changes in PTSD symptoms and safety behaviors, for example, would help illuminate the sequence of change in these phenomena over time. We hope that findings from the current study inform additional research on the systematic link between posttraumatic safety behaviors, trauma-related cognitions, and PTSD.
Appendix: Posttraumatic Safety Behavior Questionnaire
Instructions: Below is a list of behaviors people sometimes perform when they are in a distressing situation that may be related to a traumatic history in some way. Please rate the extent to which you engage in the following behaviors in order to prevent a feared outcome and/or reduce distress associated with a traumatic experience(s).
Footnotes
1 At the Western U.S. site, interrater reliability for CAPS-5 PTSD diagnosis was excellent (Cohen’s κ = .87 for 27 [30.34%] randomly selected interviews) and intraclass correlations among CAPS-5 total and subscale scores ranged between .91 and .97. CAPS-5 reliability estimates for the Southeastern U.S. site were not available.
2 This change was deliberate within the larger trial to directly compare self-reported PTSD symptoms at baseline with past week PCL-5 scores collected weekly during treatment.
3 Other than alcohol, cigarettes, and marijuana, which were assessed separately in the PSBQ.
4 The pattern of findings did not change when these four items were retained in the PSBQ total score.
Acknowledgements
Corresponding Author
We thank the participants who consented to take part in this study and Dr. Joshua Kemp and Ms. Johanna Meyer for their input during measure development.Correspondence concerning this article should be addressed to Shannon M. Blakey, Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Davie Hall (Campus Box 3270), Chapel Hill, NC 27599-3270
Email: [email protected]
Publication History
Received February 4, 2019
Revision received May 4, 2019
Accepted May 7, 2019
First published online June 13, 2019
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