Background: Insomnia has become a major public health concern. Aims: The study examined the efficacy of a web-based unguided self-help programme with automated feedback. The programme was based on cognitive behaviour therapy for insomnia (CBT-I). The investigation particularly focused on factors that contribute to the maintenance of insomnia and tested whether treatment effects were stable over a period of 12 months. Method: Fifty-six participants were randomly assigned either to web-based CBT-I or to the waiting-list control group. Included measures assessed insomnia severity, sleep-related cognitions, safety behaviours, depression, anxiety and somatization. In the intervention group, a sleep diary was used to assess sleep continuity parameters, sleep quality and daytime performance. Results: Large between- and within-group effect sizes (d = 1.79, d = 1.59) for insomnia severity were found. The treatment group effect remained stable over the period of 12 months. Further, sleep-related cognitions, safety behaviours, depression and somatization significantly decreased in the treatment group compared with the control group. On all sleep diary parameters, medium to large effects were revealed within the treatment group. Anxiety did not decrease significantly from pre- to post-assessment. For all measures except somatization and anxiety significant within-group effects were found at 12-month follow-up assessment indicating long-lasting effects. Conclusions: This study adds evidence to the literature on unguided online interventions for insomnia, and indicates that online CBT-I can have substantial long-term effects on relevant sleep-related outcome parameters. Moreover, the results indicate that sleep-related cognitions and safety behaviour can be successfully altered with an unguided CBT-I intervention.

Background: Environmental factors have been associated with psychosis but there is little qualitative research looking at how the ongoing interaction between individual and environment maintains psychotic symptoms. Aims: The current study investigates how people with persecutory delusions interpret events in a virtual neutral social environment using qualitative methodology. Method: 20 participants with persecutory delusions and 20 controls entered a virtual underground train containing neutral characters. Under these circumstances, people with persecutory delusions reported similar levels of paranoia as non-clinical participants. The transcripts of a post-virtual reality interview of the first 10 participants in each group were analysed. Results: Thematic analyses of interviews focusing on the decision making process associated with attributing intentions of computer-generated characters revealed 11 themes grouped in 3 main categories (evidence in favour of paranoid appraisals, evidence against paranoid appraisals, other behaviour). Conclusions: People with current persecutory delusions are able to use a range of similar strategies to healthy volunteers when making judgements about potential threat in a neutral environment that does not elicit anxiety, but they are less likely than controls to engage in active hypothesis-testing and instead favour experiencing “affect” as evidence of persecutory intention.

Background and Aims: Several studies have shown that cognitive therapy is an effective treatment for social anxiety disorder (SAD). However, it remains unclear which of the complex interventions are associated with an anxiety reduction during the course of treatment. The aim of this study was to examine the impact of the intervention referred to as the “self-focused attention and safety behaviours experiment” on treatment outcome. Method: This study was part of a randomized controlled trial including 16 sessions of either individual cognitive therapy (CT) or interpersonal therapy (IPT) for SAD. Of particular importance, a concomitant time-series analysis was used to investigate the impact of the self-focused attention and safety behaviours experiment on subsequent social anxiety (1, 2, 3, and 4 weeks after the intervention) in 32 patients with SAD, who are receiving cognitive treatment. Results: The results revealed a significant reduction of social anxiety after the self-focused attention and safety behaviours experiment during the subsequent month of treatment. Conclusion: The findings of the current study confirm current cognitive theories of SAD and demonstrate the importance of interventions that target self-focused attention and safety behaviour in cognitive therapy for SAD.

Background: Randomized controlled trials have established that individual cognitive therapy based on the Clark and Wells (1995) model is an effective treatment for social anxiety disorder that is superior to a range of alternative psychological and pharmacological interventions. Normally the treatment involves up to 14 weekly face-to-face therapy sessions. Aim: To develop an internet based version of the treatment that requires less therapist time. Method: An internet-delivered version of cognitive therapy (iCT) for social anxiety disorder is described. The internet-version implements all key features of the face-to-face treatment; including video feedback, attention training, behavioural experiments, and memory focused techniques. Therapist support is via a built-in secure messaging system and by brief telephone calls. A cohort of 11 patients meeting DSM-IV criteria for social anxiety disorder worked through the programme and were assessed at pretreatment and posttreatment. Results: No patients dropped out. Improvements in social anxiety and related process variables were within the range of those observed in randomized controlled trials of face-to-face CT. Nine patients (82%) were classified as treatment responders and seven (64%) achieved remission status. Therapist time per patient was only 20% of that in face-to-face CT. Conclusions: iCT shows promise as a way of reducing therapist time without compromising efficacy. Further evaluation of iCT is ongoing.

Background: Eating disturbances and poor body image are maintained by body-related safety behaviours and their associated cognitions. These include body checking, avoidance, comparison and display, which can be seen as safety behaviours, maintaining eating pathology and poor body image. It is not clear from the existing literature whether these behavioural and cognitive patterns are independently related to eating psychopathology. Method: This study of a non-clinical group of women and men (N = 250) explored the association of eating attitudes and behaviours with these four elements of body-related behaviours and cognitions. Results: It was found that each of the four elements had independent associations with eating attitudes and behaviours. Those associations were not explained by anxiety or depression levels. Discussion: Whilst these findings require study within a clinical group, they suggest that all four elements of body-related behaviours and cognitions need to be considered as potential maintaining factors when formulating eating psychopathology and body image disturbance.

Background: It has been suggested that socially anxious individuals often engage in a wide range of safety behaviours in social situations that are intended to reduce the risk of social failure and humiliation. Method: This study explored the interpretations that people make for behaviours considered to be safety seeking. High and low socially anxious individuals completed one version of a questionnaire that assessed how the safety behaviours that they may exhibit are interpreted by others, and then completed a second version of the same questionnaire that assessed how they typically interpret safety behaviours in other people. Participants rated the extent to which each of eight interpretations was viewed as a likely interpretation of the behaviour. Results: Individuals high in social anxiety were more likely than low socially anxious participants to think that being arrogant, suffering from a psychological problem, or experiencing a normal level of anxiety, nervousness or fear are likely explanations for safety behaviours, regardless of who exhibits them. Additionally, high socially anxious participants were more likely than those low in social anxiety to think that others interpreted these behaviours as being indicative of intense anxiety or other negative emotional condition. Conclusions: The results suggested that socially anxious people are, at least, aware of the negative effects of certain behaviours characterized as safety seeking.

The concept of safety (seeking) behaviours has been very important in cognitive behavioural models of anxiety disorders. Morrison (1998) considered how a similar process may be involved in the development and maintenance of auditory hallucinations; however there has been no research that specifically explores safety behaviours in people who hear voices. The S-REF model (Wells and Matthews, 1994) proposed that compensatory beliefs mediate the choice of coping mechanism. The aim of this study was to explore whether people who hear voices have interpretations about the experience of hearing voices and if this interpretation threatens their physiological or psychological wellbeing, do they engage in safety behaviours to prevent this feared outcome. The study also considered whether the choice of behaviour was cognitively mediated. Twelve participants who had heard voices in the previous 2 weeks completed the study; 11 participants reported catastrophic interpretations and 12 reported using safety behaviours. The theoretical and clinical implications are discussed.

Numerous research studies have found evidence of psychotic-like experiences in the general population which are unrelated to psychopathology. Recent cognitive models of psychosis have considered these findings and have taken a normalizing approach to psychosis. It is suggested that hallucinations and delusions are essentially “normal” but are interpreted and responded to in an unhelpful way by individuals who come into contact with services. A web-based cross-sectional survey was conducted in which 544 students completed measures of predisposition to psychotic phenomena, appraisals of hallucinations and delusions, the use of safety behaviours and thought control strategies and a measure of general health. Positive appraisals of psychotic-like phenomena were found to be associated with the frequency of such phenomena but no more so than negative beliefs. Negative appraisals were more strongly associated with distress than positive appraisals but when the frequency of psychotic-like phenomena was controlled for negative appraisals made only a small contribution to distress. Avoidant safety behaviours and punishment-based thought control strategies were found to be associated with both distress and the frequency of psychotic-like phenomena. These findings provide some support for recent cognitive conceptualizations of psychosis, but essentially they emphasize the multi-faceted nature of vulnerability to psychosis.

Safety-seeking behaviours are seen as playing a key role in the maintenance of various anxiety disorders. This article examines their role in panic disorder and social phobia and suggests that, whilst there are clear theoretical differences between safety-seeking behaviours and adaptive coping strategies, the difficult issue in clinical practice is being able to distinguish between the two. It builds on previous work by Salkovskis and colleagues and provides a detailed discussion of the problems in distinguishing between safety-seeking behaviours (direct avoidance, escape and subtle avoidance) and adaptive coping strategies in clinical practice. The suggestion is made that topology can only be a guide to categorizing the two types of responses and they can only be fully distinguished by taking into account the intention of the individual and their perceived function to that individual in the specific context. It is suggested that further analysis of the use of safety-seeking behaviours aimed at avoiding a variety of outcomes at differing levels of catastrophe may provide useful information that would clarify our understanding of the role of such behaviours in maintaining anxiety disorders.

The present study presents the development and validation of the Social Interaction and Performance Anxiety and Avoidance Scale (SIPAAS), a self-report questionnaire to assess the level of distress and avoidance in a wide range of performance and social interaction situations, and the Social Phobia Safety Behaviours Scale (SPSBS), a self-report questionnaire designed to evaluate in-situation safety behaviours in which social phobics engage to try to prevent social catastrophe. The psychometric adequacy of both scales was evaluated in three different samples: social phobic patients, other anxiety disordered patients, and normal population. Both scales were normally distributed and were shown to possess high levels of internal consistency and temporal stability. They reliably discriminate patients with generalized social phobia from patients with non-generalized social phobia, other anxiety disordered patients, and normal population. Both subscales of the SIPAAS have shown high correlations with other measures of social anxiety (SAD, FNE), whereas the SPSBS has shown low to moderate correlations with SAD and FNE. It appears that these new self-report scales are reliable, valid and useful measures of social phobia for clinical and research purposes.