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Examining safety behavior subtypes across distinct social contexts in social

anxiety disorder and major depression

Madeleine Rassaby, Taylor Smith, Charles T Taylor

PII: S0005-7894(22)00159-9
DOI: https://doi.org/10.1016/j.beth.2022.12.009
Reference: BETH 1240

To appear in: Behavior Therapy

Received Date: 8 August 2022

Revised Date: 15 November 2022
Accepted Date: 21 December 2022

Please cite this article as: M. Rassaby, T. Smith, C.T. Taylor, Examining safety behavior subtypes across distinct
social contexts in social anxiety disorder and major depression, Behavior Therapy (2022), doi: https://doi.org/
10.1016/j.beth.2022.12.009

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SAFETY BEHAVIOR SUBTYPES 1

Examining safety behavior subtypes across distinct social contexts in social anxiety

disorder and major depression

Madeleine Rassaby, BA a, Taylor Smith, BS b; and Charles T Taylor, PhD a b

San Diego State University/UC San Diego Joint Doctoral Program in Clinical Psychology a

University of California San Diego b

* Corresponding author:

Charles T. Taylor, Ph.D.

Department of Psychiatry
University of California, San Diego
La Jolla, CA 92037
Phone: 858.534.9446
FAX: 858.534.9450
Email: c1taylor@health.ucsd.edu

Funding: This research was supported by grants awarded to Charles T. Taylor from the National
Institute of Mental Health (R00MH090243, R33MH113769), Brain and Behavior Foundation
(21695), and the University of California, San Diego, National Institute of Health Clinical and
Translational Science Awards Program Grant UL1TR001442.

Conflict of Interest: Charles T. Taylor declares that in the past 3 years he has been a paid
consultant for Bionomics and receives payment for editorial work for UpToDate and the journal
Depression and Anxiety. Madeleine Rassaby and Taylor Smith declare no conflicts of interest.
SAFETY BEHAVIOR SUBTYPES 2

Highlights

 We examined safety behaviors (SBs) in social contexts (affiliation v performance).

 SB subtype use varied by diagnosis (SAD > MDD > non-patient controls).

 The effect of diagnosis on impression management SBs depended on social context.

 SB subtype correlates depended on social context.

 Avoidance SBs related to poorer emotional and behavioral outcomes.

SAFETY BEHAVIOR SUBTYPES 3

Abstract

People with social anxiety disorder (SAD) use different types of safety behaviors that have been

classified as avoidance vs. impression management. The current study investigated differences in

safety behavior subtype use in 132 individuals with principal diagnoses of social anxiety disorder

(SAD, n=69), major depressive disorder (MDD, n=30), and non-patient controls (n=33) across

two social contexts: an interpersonal relationship-building task (social affiliation) and a speech

task (social performance). We examined whether diagnostic groups differed in safety behavior

subtype use and whether group differences varied by social context. We also explored

relationships between avoidance and impression management safety behaviors, respectively, and

positive and negative valence affective and behavioral outcomes within the social affiliation and

social performance contexts. Safety behavior use varied by diagnosis (SAD > MDD > non-

patient controls). The effect of diagnosis on impression management safety behavior use

depended on social context: use was comparable for the principal SAD and MDD groups in the

social performance context, whereas the SAD group used more impression management safety

behaviors than the MDD group in the social affiliation context. Greater use of avoidance safety

behaviors related to higher negative affect and anxious behaviors, and lower positive affect and

approach behaviors across contexts. Impression management safety behaviors were most

strongly associated with higher positive affect and approach behaviors within the social

performance context. These findings underscore the potential value of assessing safety behavior

subtypes across different contexts and within major depression, in addition to SAD.

Keywords: Safety Behaviors, Social Anxiety Disorder, Depression, Interpersonal, Social

Performance
SAFETY BEHAVIOR SUBTYPES 4

Introduction

Social anxiety disorder (SAD) is characterized by persistent fear of embarrassment or

negative evaluation by other people, resulting in functional impairment and distress (American

Psychiatric Association, 2013). Safety behaviors, defined as actions intended to prevent,

minimize, or escape a feared outcome, are recognized as an important maintaining factor in SAD

(Kirk et al., 2019; Piccirillo et al., 2016). Research suggests safety behaviors can be grouped into

two main subtypes: avoidance and impression management (Clark & Wells, 1995; Evans et al.,

2021; Gray et al., 2019; Plasencia et al., 2011). Avoidance safety behaviors serve to limit an

individual’s involvement in a social situation or hide oneself (e.g., avoiding eye contact,

minimizing talking, low self-disclosure), whereas impression management safety behaviors are

intended to control the impression one makes on others in an effort to present a positive image

(e.g., excessive rehearsal of conversation, self-monitoring). No research to date has examined the

differential use of avoidance and impression management safety behaviors across more than one

context (e.g., social affiliation versus social performance) in the same sample. Further, research

has yet to explore safety behavior subtype use in disorders other than SAD (e.g., major

depression). Finally, initial evidence suggests avoidance and impression management safety

behaviors may be linked to different affective, behavioral, and social outcomes (Evans et al.,

2021; Gray et al., 2019; Hirsch et al., 2004; Plasencia et al., 2011). Research is needed to

replicate these findings and determine whether they extend across different social contexts.

Identifying the presence and correlates of safety behavior subtypes across different contexts and

disorders may inform a more precise understanding of which safety behaviors, in what contexts,

and for whom, should be targeted in treatment.

Safety Behavior Subtypes and Social Context

SAFETY BEHAVIOR SUBTYPES 5

Safety behaviors are strategic in that they are used in response to the demands and fears

associated with a situation (Moscovitch et al., 2013). Notably, the demands and concerns evoked

by one situation (e.g., a social interaction) may differ from those of another situation (e.g., a

speech or other performance task). Different skills may be required to successfully engage in

each context, and fears, distress levels, and coping strategies may vary. For example, social

interactions require dynamic flow and reciprocal exchanges between two partners (e.g., attending

and being responsive to one’s partner while thinking of things to say), while social performances

increase focal attention on the performing individual, which can magnify the salience of being

observed and potential conspicuousness of anxiety. Examining variability in safety behavior

subtypes across different social contexts within the same sample has, to our knowledge, not been

done. The present study sought to address this issue.

Safety Behaviors and Depression

Although research consistently implicates safety behaviors in the maintenance of SAD

(Blakey & Abramowitz, 2016), less is known about their relevance to other conditions, such as

major depressive disorder (MDD). This may be important given the high comorbidity rates

between MDD and SAD (Kessler et al., 1999) and the fact that social impairment is common

across both conditions (Robyn et al., 2020). Consistent with work in SAD (Plasencia et al., 2016;

Taylor & Alden, 2011), if safety behaviors are used by those diagnosed with MDD, they may

limit prosocial behaviors that facilitate social connection or diminish rewarding experiences from

social engagements – factors related to the development and maintenance of depression

(Kupferberg et al., 2016). In clinical practice, providers typically treat the principal, or most

interfering diagnosis (Barlow et al., 2017). First-line treatments for MDD do not routinely assess

for or target safety behaviors. If individuals with principal MDD engage in safety behaviors in
SAFETY BEHAVIOR SUBTYPES 6

social contexts, this information may be relevant to treatment planning. Initial evidence within

SAD samples suggests higher depressive symptoms were related to increased safety behavior use

(Plasencia et al., 2011; Rowa et al., 2015). To our knowledge, research has yet to examine

whether individuals with principal major depression engage in safety behaviors (and which

types) in the context of social situations. We aimed to address this gap by including individuals

with principal MDD in this study.

Affective and Behavioral Correlates of Safety Behavior Subtypes

Insights into the unique correlates and consequences of avoidance and impression

management safety behaviors have been demonstrated using a social interaction task in which an

individual becomes acquainted with a stranger. In one such study, Plasencia and colleagues

(2011) found avoidance strategies were positively related to state anxiety and to negative

reactions from participants’ interaction partners. Impression management safety behaviors were

not associated with state anxiety or partner liking, but were shown to impede corrections in

negative predictions about future interactions. Gray et al. (2019) found healthy individuals who

engaged in either avoidance or impression management safety behaviors experienced heightened

anxiety in a social interaction task. Notably, avoidance safety behaviors had broader negative

effects on the other individual in the conversation, such as liking their partner less and enjoying

the conversation less, which were absent for the impression management safety behavior

subtype. Taken together, these studies suggest avoidance and impression management safety

behavior subtypes may have differential consequences in social interactions.

We are not aware of any studies that investigated safety behavior subtypes in social

performance contexts, such as speech tasks. Studies exploring safety behaviors more broadly in

speech tasks found safety behavior use is related to poorer performance and greater post-event
SAFETY BEHAVIOR SUBTYPES 7

processing (i.e., detailed review of a prior social situation; Mitchell & Schmidt, 2014; Rowa et

al., 2015). Research is needed to explore whether avoidance and impression management safety

behaviors have different correlates in performance-based contexts, like that observed in

interpersonal contexts. Moreover, it is unknown whether avoidance and impression management

safety behaviors elicit different emotional, behavioral, or social outcomes based on social

context. For example, a behavior that may be helpful or benign in a performance situation may

be more costly in a social interaction (e.g., brief mental rehearsal of what an individual is going

to say during a speech may minimally interrupt performance whereas it may prevent the person

from responding appropriately to an interaction partner because they missed part of what the

other person said). Some research indicates judicious use of safety behaviors during the early

stages of exposure therapy may not be detrimental to social performance, disconfirmatory

learning, or affective state (Tutino et al., 2020; but see Rowa et al., 2015). Determining whether

the correlates or outcomes of different safety behaviors vary across social contexts could inform

where and when they should be targeted in treatment. The second aim of this study was to

explore the relationships between avoidance and impression management safety behaviors,

respectively, and positive and negative valence affective and behavioral outcomes across each

social context.

Current Study

The goal of the present study was to investigate differences in safety behavior subtype

use in individuals with principal diagnoses of SAD, MDD, and non-patient controls across two

social contexts: an interpersonal relationship-building task (social affiliation) and a speech task

(social performance). We aimed to examine whether diagnostic groups differed in safety

behavior subtype use (avoidance and impression management; Aim 1) and whether group
SAFETY BEHAVIOR SUBTYPES 8

differences varied by social affiliation versus social performance contexts (moderator; Aim 2).

We also sought to explore the affective and behavioral correlates of avoidance and impression

management safety behaviors within each context (Aim 3). Data were obtained from baseline

assessments conducted within clinical trials for SAD (NCT02136212) and MDD

(NCT02330744). The research questions examined herein were not part of the parent trial aims.

We hypothesized that individuals with SAD would engage in the most safety behaviors

(both avoidance and impression management) irrespective of social context (Aim 1), followed by

individuals with MDD and then non-patient controls (i.e., main effect of diagnostic group). In the

absence of past research, we did not make specific predictions about whether social context

would moderate the hypothesized diagnostic group differences in use of safety behavior

subtypes. For the exploratory correlation analyses, we predicted that avoidance safety behaviors

would be associated with greater negative valence outcomes (state anxiety, negative affect, and

anxious behaviors) and lower positive valence outcomes (positive affect, approach behaviors).

We did not make predictions about the correlates of impression management safety behaviors

due to mixed findings in previous studies. Finally, we did not make predictions about whether or

how these relationships varied across contexts due to lack of prior research.

Method

Participants

The sample included 132 participants ages 18 to 39 years (M =24.05, SD = 4.67): 69

individuals (42 women, 26 men, one who identified as other) with a principal DSM-5 diagnosis

of social anxiety disorder as determined by the Mini International Neuropsychiatric Interview

(MINI) 7.0.01 or the Structured Clinical Interview for DSM-5 (SCID-5), 30 individuals (18

1 Because enrollment began prior to the release of MINI Version 7.0.0 for DSM-5, 10 participants were
administered MINI Version 5.0.0 for DSM-IV.
SAFETY BEHAVIOR SUBTYPES 9

women, 12 men) with a principal DSM-5 diagnosis of major depressive disorder (MDD)

according to the MINI, and 33 non-patient controls (23 women, 10 men) without a history of

psychiatric diagnosis as determined by the MINI. Demographic and clinical characteristics are

displayed in Table 1. Participants were recruited from the community through IRB-approved

advertisements posted throughout community settings, online media, social media, and primary

care clinics. This study represents a secondary analysis of baseline data obtained within the

context of overarching treatment studies for SAD and MDD. ClinicalTrials.gov Identifiers:

NCT02136212; NCT02330744.

Measures

Social anxiety symptoms

The Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987) was used to assess social

anxiety symptoms. It assesses fear and avoidance of social interaction and performance

situations. Respondents are asked to rate their fear and avoidance for each of 24 situations on a

4-point scale ranging from “none/never” to “severe/usually.” The total score is calculated by

summing the scores on each item. The LSAS demonstrates strong psychometric properties

(Heimberg et al., 1999). Current sample’s Cronbach’s α = .98.

Depressive symptoms

The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) was used to

assess symptoms of depression during the past two weeks. The BDI-II consists of 21 self-report

items that are multiple choice and scored on a scale from zero to three. Total scores are

calculated by summing the items and range from 0 to 63. The BDI-II is considered a reliable,

well-validated measure (Beck et al., 1996; Dozois, Dobson, & Ahnberg, 1998). Current sample’s

Cronbach’s α = .98.
SAFETY BEHAVIOR SUBTYPES 10

Safety behaviors

A modified version of the Safety Behaviour Questionnaire (SBQ; Clark et al., 1995) as

implemented in prior research (Plasencia et al., 2011) was utilized to assess avoidance and

impression management safety behaviors (items and scoring from Plasencia et al., 2011). The

SBQ measures specific strategies used by individuals in an effort to prevent feared social

outcomes. Participants rated how frequently they utilized each strategy in the social affiliation

and performance tasks on a 9-point scale (0 = never, 8 = always). To clarify that items reflected

safety behaviors rather than general behaviors, items were answered in reference to behaviors

that were used to “make yourself feel safer or to try to prevent your feared outcome(s) from

happening.” Examples for avoidance safety behavior items include “avoided talking about

yourself” and “said little or nothing (talking as little as possible).” Examples of impression

management safety behavior items include “tried to conceal your anxiety” and “acted very

agreeable.” The impression management subscale consisted of 9 items, and the avoidance

subscale included 6 items (see Supplemental Materials for all items on each scale). Mean total

scores were calculated for each subscale to facilitate interpretation of findings (possible range 0

to 8). Current sample’s Cronbach’s α = .85 for avoidance (6 items) and .87 for impression

management (9 items) safety behaviors.

State anxiety

The state anxiety subscale of the State-Trait Anxiety Inventory (STAI; Spielberger et al.,

1983) was employed to gauge participants’ present state of anxiety directly following the social

affiliation and speech tasks. The STAI consists of 20 items describing transitory feelings (e.g., “I

am tense”) that are rated on a four-point intensity scale from 1 (not at all) to 4 (very much so).

Scores may range from 20 to 80, with higher scores indicating greater anxiety. This measure
SAFETY BEHAVIOR SUBTYPES 11

demonstrates high internal consistency (α = .92; Barnes et al., 2002). Current sample’s

Cronbach’s α = .94.

Positive and Negative Affect

The Positive and Negative Affect Schedule (PANAS; Watson et al., 1988) was utilized to

assess positive and negative affect following the social affiliation and speech tasks. The PANAS

consists of 20 self-report items that are rated on a five-point scale indicating the extent to which

an individual felt the specified emotions during the task (e.g., “excited,” “ashamed”). The

positive and negative affect subscales demonstrate high internal consistency, respectively (α =

.89, α = .85; Crawford & Henry, 2002). Current sample’s Cronbach’s α = .93 for the positive

affect subscale and .89 for the negative affect subscale.

Observer-rated social behaviors

Anxious behaviors consisted of six items reflective of observable displays of anxiety

(show signs of anxiety, tremble or shake, speak fluently/clearly, create uncomfortable pauses,

appear tense or rigid, fidget; Taylor & Alden, 2011). Social approach behaviors included five

items reflective of prosocial behaviors (talk openly about yourself, appear actively engaged,

convey interest in your partner/audience, appear friendly, talkative; Taylor & Alden, 2011). The

items were rated on a 7-point scale with the anchors of “not at all” and “very much.” Past

research demonstrated adequate internal consistency (Cronbach’s α range from .75-.90 and .90-

.91, respectively; Taylor & Alden, 2011). The intraclass correlation coefficient (ICC; two-way

mixed model) was used to assess interrater reliability. On the social affiliation task, the average

measure ICC was .704 for approach behaviors (95% CI [.558, .807]) and .728 for anxious

behaviors (95% CI [.595, .823]). For the speech task, the average measure ICC was .816 for
SAFETY BEHAVIOR SUBTYPES 12

approach behaviors (95% CI [.692, .885]) and .822 for anxious behaviors (95% CI [.737, .880]),

indicating acceptable inter-rater agreement.

Design and Procedure

Study procedures were approved by the institutional review board and all participants

provided informed written consent prior to engaging in study procedures. The current study

involved completing questionnaires assessing social anxiety and depression levels and the

completion of two behavioral approach tests, each of which was followed by a questionnaire on

the utilization of safety behaviors during the test. The social affiliation task was completed first,

followed by a filler task (to prevent carryover effects), then the social performance task.

Participants were informed that the behavioral approach tasks would be video recorded. Upon

completion, participants were debriefed.

Social affiliation task

Participants completed a social affiliation task with a trained confederate (for full task

description and psychometric properties, see Hoffman et al., 2021). Participants and confederates

alternated responding to a series of six questions with each question gradually increasing in

intimacy level and self-disclosure elicited (see Supplemental Materials for the list of questions).

Confederates were trained to engage in friendly, warm behavior.2 With the confederate present,

the experimenter explained to the participant that the purpose of the task was to get to know each

other by answering questions about themselves. Before leaving the room, the experimenter

started a video recording of the dyad. The interaction lasted approximately 25 minutes. Hoffman

2 Observer raters used a five-item scale assessing confederate warm / affiliative behavior displays (friendly,
talkative, disinterested, distant, self-disclosive). Items were rated from 0 (not at all) to 7 (very much) and averaged
to create a score. The mean warm / affiliative behavior display score was 5.87, with a standard deviation of .41.
SAFETY BEHAVIOR SUBTYPES 13

and colleagues (2021) provided psychometric support for this paradigm as a reliable method of

inducing and measuring social affiliation.

Filler task

Participants watched a five-minute neutral video of fish swimming to the sound of

calming music.

Social performance task

Participants were asked to complete a five-minute impromptu speech (performance-based

task), which is a common and well-established behavioral approach test used to assess anxiety

and avoidance responses (Hofmann et al., 1995). The experimenter informed participants they

would be video recorded for later quality assurance. Participants chose a controversial speech

topic from a list of 5 options: abortion, nuclear power, corporal punishment, seatbelt laws, and

the American health system. They were given two-minutes to prepare their speech, then given

instructions to stand in a designated area in front of a video camera to deliver the speech.

Participants were encouraged to speak for the full five minutes, but were told they could end the

speech at any time by informing the experimenter.

Data Analytic Plan

Statistical analyses were conducted in SPSS version 25.0. Group differences on

demographic and clinical characteristics were examined using chi-square tests for categorical

variables and one-way analyses of variance (ANOVAs) for continuous variables. A 3 (Group:

SAD, MDD, non-patient controls) x 2 (Context: social affiliation vs. social performance)

repeated measures multivariate analysis of variance (MANOVA) was performed to examine

whether the amount of impression management and avoidance safety behaviors varied based on

diagnosis (between-subjects; Aim 1) and whether social context (within-subjects) moderated

SAFETY BEHAVIOR SUBTYPES 14

diagnostic group differences (Aim 2). Dependent variables were scores on the avoidance and

impression management subscales of the SBQ – entered together within a MANOVA to protect

against type I error inflation. We confirmed whether the data violated assumptions of

MANOVA. Pillai’s trace was used when Box’s Test for Equivalence of Covariance Matrices was

violated (Nimon, 2012). Univariate outcomes for each safety behavior subtype were examined

following a significant (p < .05) multivariate effect. Pending significant main and/or interaction

effects, Tukey’s HSD post-hoc analyses were conducted to compare groups on the relevant

outcomes, and paired-samples t-tests were run to examine the differential use of safety behaviors

across social contexts within each diagnosis separately. For the exploratory correlation analysis

(Aim 3), bivariate correlations were computed in the combined SAD and MDD groups to

investigate associations between safety behavior subtypes and outcome measures, including

observer-rated anxiety and approach behaviors, positive and negative affect, and state anxiety

following the social affiliation and social performance tasks, respectively. The clinical samples

were combined for the correlational analyses in order to increase power.

Results

Preliminary Analyses

Table 2 summarizes group differences on social anxiety and depression symptom

measures. One-way ANOVAs revealed a significant effect of diagnostic group on LSAS scores

(SAD > MDD > non-patient controls; F(2, 129) = 192.68, p < .001, η2 = .53) and BDI-II scores

(MDD > SAD > non-patient controls; F(2, 127) = 63.61, p < .001, η2 = .86) for the three

conditions. There were no significant diagnostic group differences in gender, race, or ethnicity

(all p > .05). A one-way ANOVA indicated a significant diagnostic group difference in age (F(2,

129) = 3.72, p = .027, η2 = .05). Specifically, a post hoc Tukey test showed that the principal
SAFETY BEHAVIOR SUBTYPES 15

MDD group (M = 25.57, SD = 5.24) was significantly older on average than the principal SAD

group (M = 23.04, SD = 4.42; d = .52); there were no differences between the non-patient control

group and the other groups in age.3

Primary Analyses

Does Safety Behavior Subtype Use Differ Across SAD, MDD, and Control Groups?

A 3 x 2 repeated measures MANOVA revealed safety behavior use differed significantly

across the three diagnostic groups (Pillai’s Trace = 0.53, F(4,258) = 23.48, p < .001, η2 = 0.27),

but did not differ across contexts (Pillai’s Trace = 0.01, F(2,128) = .61, p = .543, η2 = 0.01).

Univariate tests revealed group differences for both impression management (F(2, 129) = 35.05,

p < .001, η2 = .35) and avoidance safety behaviors (F(2,129) = 52.02, p < .001, η2 = .45).

Tukey’s post-hoc comparisons indicated that the SAD group (M = 4.49, SD = 1.27) and MDD

group (M = 4.09, SD = 1.49) did not differ on mean impression management safety behavior use

(p = .333; d = .29), but they both engaged in more impression management safety behaviors than

the non-patient controls group (M = 2.26, SD = 1.48) at p < .001 (SAD versus HC: d = 1.62;

MDD versus HC: d = 1.24). Tukey’s post-hoc comparisons showed that the SAD group (M =

3.27, SD = 1.58) used significantly more avoidance safety behaviors on average than the MDD

group (M = 2.17, SD = 1.48; d = .72), and both groups used significantly more avoidance safety

behaviors than the non-patient controls group (M = 0.57, SD = 0.77) at p < .001 (SAD versus

HC: d = 2.18; MDD versus HC: d = 1.36).

Does Social Context Influence Safety Behavior Subtype Use Across Diagnoses?

The main multivariate effect of diagnostic group was qualified by a significant group by

social context interaction (Pillai’s Trace = .17, F(4,258) = 5.92, p < .001, η2 = 0.08). This

3No significant associations emerged between age and impression management or avoidance safety behaviors in
either social context.
SAFETY BEHAVIOR SUBTYPES 16

multivariate effect was driven by impression management safety behaviors (F(2,129) = 12.06, p

< .001, η2 = 0.16), but not avoidance safety behaviors (F(2,129) = 1.65, p = .196, η2 = .03; see

Table 3 and previously reported post hoc tests for the main univariate effect of diagnosis on

avoidance safety behaviors).

Impression Management Safety Behaviors by Social Context

Following the significant group by context interaction, results of a paired sample t-test

indicated that the SAD group engaged in significantly more impression management safety

behaviors on the social affiliation task (M = 4.71, SD = 1.19) compared to the social performance

task (M = 4.27, SD = 1.34; p < .001; t(68) = 3.24, p = .002, d = .39). The MDD group, however,

did not differ in impression management safety behavior use on the social affiliation task (M =

4.03, SD = 1.55) compared to the social performance task (M = 4.16, SD = 1.42; p = .426; t(29) =

-0.81, p = .426, d = -.15). The non-patient controls group engaged in significantly more

impression management safety behaviors on the social performance task (M = 2.57, SD = 1.66)

compared to the social affiliation task (M = 1.95, SD =1.30; p < .001; t(32) = -3.65, p < .001, d =

0.64).

A one-way ANOVA revealed a significant effect of diagnostic group on impression

management safety behavior use in the social affiliation context (SAD > MDD > non-patient

controls; F(2, 129) = 50.18, p < .001, η2 = .44) and the social performance context (SAD =

MDD > non-patient controls; F(2, 129) = 16.60, p < .001, η2 = .21). For the social affiliation

task, the SAD group (M = 4.71, SD = 1.19) used significantly more impression management

safety behaviors than the MDD group (M = 4.03, SD = 1.55; d = .49) and non-patient controls

group (M = 1.95, SD =1.30; d = 2.21); the MDD group engaged in significantly more impression

management safety behaviors than the non-patient controls group (d = 1.45). For the social
SAFETY BEHAVIOR SUBTYPES 17

performance task, the SAD group (M = 4.27, SD = 1.34) did not differ significantly in

impression management safety behavior use than the MDD group (M = 4.16, SD = 1.42; d =

.08); but both groups used more than the non-patient controls (M = 2.57, SD = 1.66; SAD versus

HC: d = 1.13; MDD versus HC: d = 1.03). Table 3 and Figure 1 summarize group differences in

impression management safety behavior use in each context.

Secondary Analyses

To assess whether findings based on principal diagnoses were influenced by comorbid

diagnosis, we created a comorbid SAD and MDD group (n = 29), SAD only group (n = 50),

MDD only group (n = 19), and non-patient controls group (n = 33), and repeated the analyses

(see Supplemental Results for details). The pattern of findings for the SAD only group was

consistent with those of the primary analyses for the SAD principal diagnosis group. Findings for

non-patient controls also remained consistent. In contrast to the initial findings for the MDD

principal diagnosis group, the MDD only group engaged in more impression management safety

behaviors on the social performance task (M = 4.14, SD = 1.57) compared to the social affiliation

task (M = 3.76, SD = 1.64; t(19) = -2.23, p = .038, d = -.50). The comorbid SAD and MDD

group did not differ in impression management safety behavior use across contexts (social

affiliation: M = 4.97, SD = 1.05; social performance: M = 4.69, SD = 1.14; t(28) = 1.46, p = .156,

d = .27); this finding converges with that observed for the principal diagnosis MDD group in the

main analyses.

A one-way ANOVA revealed a significant effect of diagnostic group on the number of

impression management safety behaviors used in the social affiliation context (SAD+MDD =

SAD; SAD+MDD > MDD; SAD = MDD; all patient groups > non-patient controls; F(3, 129) =
SAFETY BEHAVIOR SUBTYPES 18

35.86, p < .001, η2 = .46) and the social performance context (SAD+MDD = SAD = MDD >

non-patient controls; F(2, 129) = 12.73, p < .001, η2 = .23).

Do Safety Behavior Subtypes Relate to Affective and Behavioral Processes within Different

Social Contexts?

Correlational Analyses – Social Affiliation Task

See Table 4 for intercorrelations among measures in the clinical sample for the social

affiliation task (N = 99).4 Avoidance safety behaviors were positively associated with observer-

rated anxious behaviors, and negatively associated with observer-rated approach behaviors.

Avoidance safety behaviors were also positively correlated with self-reported negative affect and

state anxiety, and negatively correlated with self-reported positive affect.

Impression management safety behaviors were positively correlated with self-reported

negative affect; however, there were no significant correlations between impression management

safety behaviors and observer-rated anxious or approach behaviors, or self-reported state anxiety

or positive affect.

Correlational Analyses – Speech Task

Table 5 displays the intercorrelations among measures in the clinical sample for the

speech task. Greater use of avoidance safety behaviors was associated with higher observer-rated

anxious behaviors and lower observer-rated approach behaviors. Avoidance safety behaviors

were also correlated with higher negative affect and state anxiety, and lower positive affect.

Greater use of impression management safety behaviors was associated with lower observer-

4 N = 72 for observer-reported anxious and approach behaviors on the social performance task. A sensitivity
analysis was run including only subjects who had complete data for observer-reported behavior outcomes across
both social contexts. The patterns of findings were similar to those reported in the main text. See Supplemental
Materials for full analyses.
SAFETY BEHAVIOR SUBTYPES 19

rated anxious behaviors, and higher observer-rated approach behaviors and self-reported positive

affect.

Discussion

The current study explored avoidance and impression management safety behavior

subtypes in individuals with SAD, MDD, and non-patient controls across social affiliation and

social performance contexts. Safety behavior use varied by diagnosis, an effect that depended on

social context for impression management but not avoidance safety behaviors. Further, different

patterns of correlates emerged across safety behavior subtypes depending on context. These

findings underscore the potential value of assessing safety behaviors across different contexts

and within major depression, in addition to SAD, and may have implications for developing

more targeted treatment approaches.

Social context moderated the relationship between diagnosis and impression management

safety behavior use with a large effect size. Individuals with principal SAD engaged in more

impression management safety behaviors on the social affiliation task compared to the social

performance task with a small to medium effect size. In contrast, individuals with principal

MDD did not differ in impression management safety behavior use across social contexts, and

non-patient controls demonstrated greater use on the social performance task (medium effect

size). We observed that in the social affiliation context, the principal SAD group engaged in

more impression management safety behaviors than the principal MDD group, who engaged in

more than the non-patient controls. However, in the social performance context, the SAD and

MDD groups did not differ in impression management safety behavior use, but both engaged in

more than the non-patient controls. These findings suggest individuals with principal depression
SAFETY BEHAVIOR SUBTYPES 20

may experience similar concerns to those with SAD about managing the impression they make

on others in social situations, particularly in performance contexts.

When the primary analyses were repeated with comorbid versus non-comorbid diagnostic

groups, results were mostly consistent, with the exception that the MDD group engaged in more

impression management safety behaviors on the social performance task compared to the social

affiliation task. The comorbid SAD and MDD group did not differ in impression management

safety behavior use across contexts, suggesting the presence of both high social anxiety and

depression symptoms influences impression management safety behavior use by reducing the

differentiation between social contexts. Taken together, these results underscore the heightened

use of impression management safety behaviors in both SAD and MDD, and also suggest social

interaction contexts may induce particularly heightened impression management safety behavior

use in individuals with SAD.

The SAD group used more avoidance safety behaviors than the MDD and control groups,

irrespective of social context. The MDD group also engaged in more avoidance safety behaviors

than the non-patient controls. These findings may indicate individuals with principal MDD

experience heightened avoidance in social situations, though less so than those with principal

SAD. This aligns with the findings by Plasencia and colleagues (2011) demonstrating that

greater use of avoidance safety behaviors was associated with increased depressive symptoms in

individuals with SAD.

Within the combined clinical samples (i.e., SAD and MDD), greater use of avoidance

safety behaviors was related to negative valence outcomes, including higher negative affect

(including anxiety), and greater observer-rated anxious behaviors across social contexts. Greater

use of avoidance safety behaviors was also associated with lower positive affect and observer-
SAFETY BEHAVIOR SUBTYPES 21

rated approach behaviors across both social contexts. All effect sizes were medium-to-large in

magnitude. These results replicate what was previously observed in interpersonal contexts

(Evans et al., 2021; Gray et al., 2019; Hirsch et al., 2004), and extend these patterns of

association into a performance context, suggesting avoidance safety behaviors may have

pervasive detrimental consequences.

On the social affiliation task, impression management safety behaviors were not related

to observer-rated anxious or approach behaviors. This finding is consistent with the literature

linking avoidance, but not impression management safety behaviors to negative perceptions by

observers on social affiliation tasks and poorer quality of interactions (Evans et al., 2021; Gray et

al., 2019; Hirsch et al., 2004). Greater use of impression management safety behaviors correlated

with higher negative affect (small effect), but not state anxiety. These findings add to but do not

further clarify the already mixed literature on the relationship between impression management

safety behaviors and state anxiety (Gray et al., 2019; but see Plasencia et al., 2011). A surprising

finding was that, on the speech task, impression management safety behaviors were negatively

correlated with observer-rated anxious behaviors (small-to-medium effect), and positively

associated with positive affect and observer-rated approach behaviors (moderate effect sizes).

This suggests impression management safety behaviors may be beneficial for one’s emotional

state and ability to actively engage in performance situations – at least when measured in a

circumscribed and controlled experimental context. It is possible impression management safety

behaviors fulfill their intended purpose in performance situations, but not in more reciprocal,

dynamic social interaction contexts. Indeed, it has been suggested that strategies like rehearsing

phrases or feigning friendliness (i.e., impression management behaviors) may increase likability

(Piccirillo et al., 2016). Determining the boundary conditions of such effects (e.g., in what
SAFETY BEHAVIOR SUBTYPES 22

contexts, at what frequency, and over how long are impression management displays helpful,

benign, or costly) remains to be established.

Several limitations should be considered when interpreting results of this study. First,

data on safety behavior utilization was collected via self-report. This may impact findings as

participants could under- or overestimate their use of safety behaviors (e.g., due to social

desirability, recall biases, or limited awareness). However, research indicates that self- and

observer-report data of some safety behaviors correlate highly (Kocovsky et al., 2016). Second,

the sample size for this study was relatively modest and was unbalanced across diagnostic

groups, which may reduce power. Third, the MDD only group endorsed relatively elevated levels

of social anxiety, which precludes forming conclusions about whether safety behavior usage in

the MDD group reflects depression-specific processes or can be explained by the presence of

subclinical levels of social anxiety. Future research may seek to disentangle the mechanisms

underlying this relationship. Fourth, study tasks were not counterbalanced, which could lead to

possible order effects (e.g., due to sensitizing or fatiguing effects from the first task). Fifth,

exploratory analyses were correlational, preventing conclusions of causation. It is therefore

possible that affective state may have impacted safety behavior use (rather than the reverse).

Further, given that the clinical samples were combined to increase power for the correlational

analyses, it was not determined whether findings differed by clinical diagnosis (SAD versus

MDD). This study involved single social events, which may not be representative of longer-term

outcomes of safety behavior use (e.g., threat disconfirmation). Finally, we did not assess other

outcomes that may be impacted by impression management safety behaviors, such as

maintaining threat predictions as was seen in Plasencia and colleagues (2011).

SAFETY BEHAVIOR SUBTYPES 23

Despite limitations of this investigation, findings contribute to the body of literature on

safety behaviors by providing insights into how social context and diagnosis may impact safety

behavior use, and how safety behavior subtypes are differentially related to affective and

behavioral outcomes across distinct contexts. Clinically, our results suggest it may be valuable to

assess safety behavior use in people seeking treatment for principal MDD, in addition to SAD.

Findings also indicate it may be valuable to consider safety behavior type and social context

before deciding whether or when to address safety behaviors in exposure therapy. For example,

clinicians may consider prioritizing addressing avoidance safety behaviors (before impression

management safety behaviors) given that these are associated with more detrimental affective

and behavioral outcomes. Considering the judicious use of some safety behaviors (e.g.,

impression management) within some contexts (e.g., social performance) could be considered

early in treatment to facilitate engagement in especially challenging situations, after which safety

behavior fading and elimination could proceed (Rachman et al., 2008; Goetz et al., 2016). It may

also be useful to evaluate which contexts elicit which safety behaviors from a given individual in

order to provide a more personalized or idiographic treatment approach. Further research on the

longer-term impacts of safety behavior subtype use across different contexts could inform

intervention targets and promote effective and efficient exposure-based therapy for individuals

experiencing social anxiety and depression.

SAFETY BEHAVIOR SUBTYPES 24

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Table 1
Sociodemographic Characteristics of Participants

SAD MDD HC
Measure n % n % n %
Gender
Female 42 60.9% 18 60% 23 69.7%
Male 26 37.7% 12 40% 10 30.3%
Other 1 1.4% 0 0% 0 0%
Ethnicity
Hispanic 17 24.6% 9 31.0% 7 21.2%
Not Hispanic 52 75.4% 20 69.0% 26 78.8%
Race
Black 4 5.8% 3 10.3% 1 3.0%
White 27 39.1% 10 34.5% 15 45.5%
Asian-American 26 37.7% 4 13.8% 13 39.4%
Native American 1 1.4% 0 0% 0 0%
Native Hawaiian 2 2.9% 0 0% 0 0%
or Pacific Islander
Unknown or 2 2.9% 2 6.9% 0 0%
Declined to
Respond
More than 1 race 5 7.2% 5 17.2% 4 12.1%
Other 2 2.9% 5 17.2% 0 0%
SAFETY BEHAVIOR SUBTYPES 30

Table 2
Means and Standard Deviations of LSAS and BDI-II Measures

SAD MDD HC F(2, 129) η2

Measure M SD M SD M SD
LSAS 82.48a 16.39 55.77b 26.95 8.70c 6.66 192.68*** .53
BDI-II 19.36a 10.59 25.68b 8.56 2.03c 2.52 63.61*** .86
Note. ***p < .001. Means with different subscripts (a, b, and c) indicate group differences at p <
.05.
SAFETY BEHAVIOR SUBTYPES 31

Table 3
Means and Standard Deviations of Impression Management and Avoidance Safety Behaviors on
Social Affiliation and Social Performance Tasks

SAD MDD HC
SB Type Context M SD M SD M SD
IM SBs Soc Affil 4.71a 1.19 4.03b 1.55 1.95c 1.30
Speech 4.27a 1.34 4.16a 1.42 2.57b 1.66
Av SBs Soc Affil 3.32a 1.51 2.19b 1.50 0.39c 0.65
Speech 3.22a 1.65 2.14b 1.46 0.74c 0.88
Note. Means with different subscripts (a, b, and c) indicate group differences at p < .05 on each
respective task. IM SBs = impression management safety behaviors; Av SBs = avoidance safety
behaviors; Soc Affil = social affiliation task; Speech = social performance task.
SAFETY BEHAVIOR SUBTYPES 32

Figure 1

Average Impression Management Safety Behaviors Across Social Contexts by Diagnosis.

7
Impression Management Saftey Behaviors

0
SAD MDD Non-patient Controls
Diagnostic Group

Social Affiliation Social Performance

Note. Error bars indicate +/- one standard deviation.

SAFETY BEHAVIOR SUBTYPES 33

Table 4
Intercorrelations among measures in clinical sample – Social Affiliation Task
Measure n M SD 1. 2. 3. 4. 5. 6 7.
1. Imp_SBs 99 4.51 1.34 --
2. Avoid_SBs 99 2.98 1.59 .26* --
3. Anx_Behav 99 19.99 4.74 .11 .31** --
4. App_Behav 99 23.07 4.36 -.03 -.39*** -.64*** --
5. STAI-S 99 46.28 9.46 .19 .45*** .36*** -.36*** --
6. PANAS_N 99 15.15 4.76 .25* .46*** .27** -.23* .68*** --
7. PANAS_P 99 20.72 6.83 .13 -.28** -.24* .33** -.52*** -.10 --

Note. * p < .05, ** p < .01, *** p < .001. Imp_SBs = impression management safety behaviors (SBQ); Avoid_SBs = avoidance safety
behaviors (SBQ); Anx_Behav = observer-reported anxious behaviors (SJQ); App_Behav = observer-reported approach behaviors
(SJQ); STAI = state anxiety (STAI); PANAS_N = negative affect (PANAS); PANAS_P = positive affect (PANAS)
SAFETY BEHAVIOR SUBTYPES 34

Table 5
Intercorrelations among measures in clinical sample – Social Performance Task
Measure n M SD 1. 2. 3. 4. 5. 6 7.
1. Imp_SBs 99 4.23 1.36 --
2. Avoid_SBs 99 2.89 1.66 .24* --
3. Anx_Behav 72 20.89 6.70 -.29* .37** --
4. App_Behav 72 20.85 4.92 .37** -.31** -.73*** --
5. STAI-S 99 51.62 11.36 .01 .49*** .55*** -.42*** --
6. PANAS_N 99 18.82 7.32 .19 .44*** .43*** -.32*** .77*** --
7. PANAS_P 99 19.93 7.64 .34** -.29** -.45*** .52*** -.52*** -.15 --

Note. * p < .05, ** p < .01, *** p < .001. Imp_SBs = impression management safety behaviors (SBQ); Avoid_SBs = avoidance safety
behaviors (SBQ); Anx_Behav = observer-reported anxious behaviors (SJQ); App_Behav = observer-reported approach behaviors
(SJQ); STAI = state anxiety (STAI); PANAS_N = negative affect (PANAS); PANAS_P = positive affect (PANAS)

Highlights

 We examined safety behaviors (SBs) in social contexts (affiliation v performance).

 SB subtype use varied by diagnosis (SAD > MDD > non-patient controls).

 The effect of diagnosis on impression management SBs depended on social context.

 SB subtype correlates depended on social context.

 Avoidance SBs related to poorer emotional and behavioral outcomes.

SAFETY BEHAVIOR SUBTYPES 35

Declaration of interests
☐ The authors declare that they have no known competing financial interests or personal relationships
that could have appeared to influence the work reported in this paper.
☒ The authors declare the following financial interests/personal relationships which may be considered
as potential competing interests:

Charles T Taylor reports financial support was provided by National Institute of Mental Health. Charles
T Taylor reports financial support was provided by Brain and Behavior Foundation. Charles T. Taylor
declares that in the past 3 years he has been a paid consultant for Bionomics and receives payment
for editorial work for UpToDate and the journal Depression and Anxiety.