Safety behaviours or safety precautions? The role of subtle avoidance in anxiety disorders in the context of chronic physical illness

Avoidance is a hallmark symptom and a primary maintaining factor in anxiety disorders. Theories of anxiety disorders have focused not only on overt avoidance, but also on more subtle avoidance known as 'safety behaviours'. Safety behaviours involve behaviours which aim to reduce anxiety or prevent a feared outcome from occurring. In the long-term, however, these behaviours prevent the disconfirmation of threat because safety is incorrectly attributed to the safety behaviour, thus perpetuating anxiety. As a result, reducing or eliminating safety behaviours is an important target for many cognitive behaviourally oriented treatments. Notably, despite the relevance of anxiety to people with chronic health problems, the role of safety behaviours is rarely discussed in these contexts. Further, safety behaviours among those with chronic health problems pose a particularly complex problem. Distinguishing adaptive safety precautions from maladaptive safety behaviours can be a difficult task. In this paper, we discuss the role of safety behaviours in maintaining and treating anxiety problems in healthy adults, and whether these same principles apply to those with chronic illness. We propose a functional and contextual model of differentiating between safety behaviours and safety precautions amongst those with chronic physical illness. Lastly, we propose methods for adapting the treatment of anxiety disorders in the context of chronic physical illness.