Assessing excessive reassurance seeking in the anxiety disorders

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Abstract

Reassurance seeking has long been hypothesized to be a key factor in the maintenance of anxiety within contemporary cognitive-behavioral approaches to the conceptualization and treatment of anxiety disorders. However, empirical studies have lagged due to the absence of a reliable and valid measure of reassurance seeking. The present study sought to develop and examine the psychometric properties of a theoretically derived measure of reassurance seeking in treatment-seeking participants with DSM-IV-TR (American Psychiatric Association, 2000) social phobia (n = 116), generalized anxiety disorder (n = 75), panic disorder with or without agoraphobia (n = 50), and obsessive compulsive disorder (n = 42). Participants (N = 283) completed the Reassurance Seeking Scale (RSS), Depression Anxiety Stress Scale, Beck Anxiety Inventory, and Beck Depression Inventory-II. An exploratory factor analysis resulted in a coherent three factor solution reflecting the need to seek excessive reassurance regarding: (1) uncertainty about decisions, (2) attachment and the security of relationships, and (3) perceived general threat and anxiety. The RSS was found to possess good internal consistency and was moderately correlated with measures of anxiety, stress, and depression. The psychometric properties of the RSS appear promising for the promotion of programmatic research on reassurance seeking and its treatment in the anxiety disorders.

Highlights

► The Reassurance Seeking Scale assesses reassurance seeking across the anxiety disorders. ► The RSS has good internal consistency. ► The RSS is correlated with measures of anxiety, stress, and depression.

Introduction

Excessive reassurance seeking (ERS) has long been described as an important mechanism in managing psychological distress. Reassurance seeking has been shown to immediately reduce anxiety, but this temporary reduction in anxiety is typically followed by a paradoxical increase in anxiety and an urge to seek additional reassurance, leading to increased frequency of reassurance seeking over time (Abramowitz et al., 2002, Salkovskis and Warwick, 1986). Excessive reassurance seeking also appears to interfere with habituation to anxiety and contributes to the maintenance of threat and an underestimation of the person's ability to cope on their own with anxiety (Lohr et al., 2007, Parrish and Radomsky, 2010). Several definitions of ERS have been proposed, ranging from generic behavioral definitions such as “direct verbal requests for the repetitive provision of old information” (Salkovskis, 1985), to definitions that include the motivational factors thought to underlie ERS in specific psychological disorders.

Salkovskis (1985) described ERS in the context of obsessive compulsive disorder (OCD) as an attempt to “put things right” and avert the possibility of being blamed by self or others for something that one may be responsible for by diffusing responsibility for adverse events. Rachman (2002) notes that despite appearing as requests for information, requests for reassurance are most typically attempts to find safety from harm. Thus, requests for reassurance might temporarily reduce psychological distress by reducing the perceived threat and/or increasing perceived coping resources by diffusing responsibility for adverse events so that one does not have to cope with the threat alone.

Reassurance sought by individuals with OCD has been conceptualized as a compulsive checking behavior (Parrish and Radomsky, 2010, Rachman, 2002) and a form of neutralization behavior (Salkovskis, 1985). Reassurance seeking, neutralization, and compulsive checking share common features, and all can be conceptualized as attempts to reduce the probability of an adverse event, the effects of the event, or one's responsibility for the event (Rachman, 2002, Salkovskis, 1996). For example, individuals with OCD might ask for reassurance that they will not become contaminated or spread contaminants to others after coming into contact with bodily fluids or dirty substances. They might also ask others to ensure that doors are locked and appliances are turned off in order to prevent harm to self or others, or as a way of diffusing responsibility in the event that a catastrophic event occurs.

In the first empirical study to examine the content, triggers, and functions of ERS, individuals with OCD were compared to those with depression and healthy controls using a semi-structured interview (Parrish & Radomsky, 2010). Individuals with OCD reported that they most frequently sought reassurance regarding potential general threats (e.g., “Are you sure the stove is off”?), social threats (e.g., “Are you sure you’re not mad at me?”), and perceived performance/competence (e.g., “Would you tell me if I made the wrong choice?”). At the onset of ERS episodes, individuals with OCD reported elevated levels of anxiety and perceived threat. The most commonly endorsed triggers for ERS episodes were anxiety and doubts regarding potential threats, and to a lesser extent, perceived social threats. The primary functions of ERS were to reduce anxiety and to prevent harm. Consistent with observations made by Rachman (2002), it was concluded that ERS is functionally equivalent to checking behavior in the context of OCD.

Although preliminary empirical studies examining ERS have focused on OCD, ERS has been hypothesized to play an important role in the maintenance of anxiety across the anxiety disorders, including social phobia (Heerey & Kring, 2007), generalized anxiety disorder (Woody & Rachman, 1994), panic disorder (Onur, Alkin, & Tural, 2007), and health anxiety (Abramowitz and Moore, 2007, Taylor and Asmundson, 2004). In this broader context, ERS has been defined as “the repeated solicitation of safety-related information from others about a threatening object, situation or interpersonal characteristic despite having already received this information” (Parrish & Radomsky, 2010, p. 211) with the purpose of “seeking to restore a sense of confidence or to reduce anxiety or apprehension” (Simpson & Weiner, 1989). In the anxiety literature, ERS has been included among a variety of “safety signals” (Lohr et al., 2007), “safety behaviors” (Abramowitz & Moore, 2007), and “anxiety neutralizing behaviors” (Parrish & Radomsky, 2006) used by anxious individuals to promote a sense of security. Safety behaviors have been defined as “behaviors which are performed in order to prevent or minimize a feared catastrophe” (Salkovskis, 1991), whereas safety signals are cues that signal either the offset of an aversive event or the absence of onset of an aversive event, and thus, assure safety from threat and allow for reduced vigilance (Lohr et al., 2007). Safety signals may be inanimate objects (e.g., hospital), but they are frequently other people (Carter, Hollon, Carson, & Shelton, 1995).

Due to their fear of evaluation, individuals with social phobia often seek reassurance from others to ensure their anxiety symptoms were not apparent to others, they appeared competent during a presentation, or they came across okay at a social gathering. A recent psychometric study of safety behaviors in social phobia found that the item “Ask others about your performance” was one of the highest loading (.61) items on a factor reflecting ‘active’ safety behaviors, defined as actions performed by an individual in an attempt to present well in social situations (Cuming et al., 2009). A study examining social interactions in dyads consisting of two non-socially anxious individuals or one socially anxious and one non-socially anxious individual found that the social interactions with socially anxious individuals were characterized by more frequent reassurance seeking and giving (Heerey & Kring, 2007). Further, the reassurance seeking of socially anxious individuals was negatively correlated with their partners’ ratings of positive affect and perceptions of interaction quality, highlighting the interpersonal consequences of ERS.

Individuals with GAD make frequent contact with, and repeatedly seek reassurance from, family, friends, professionals, and authorities (Woody & Rachman, 1994). The diagnostic criteria proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) includes “repeatedly seeking reassurance due to worries” as a behavior associated with GAD (www.dsm5.org). Individuals with GAD might call romantic partners or friends to ensure their relationships are secure, family members to ensure they are safe, and doctors to ensure they are in good health. Individuals with GAD might also consult with several people before making decisions due to their intolerance of uncertainty (Dugas, Gagnon, Ladouceur, & Freeston, 1998).

Individuals with panic disorder and agoraphobia experience anxiety when in places or situations in which escape might be difficult or help might not be available in the event of a panic attack. Bowlby (1973) suggested that agoraphobia can be understood as a condition of “anxious attachment” related to fear and apprehension over the availability and responsiveness of key attachment figures. Notably, anxiety is reduced substantially when the individual is accompanied by a “safe” reassuring person (Carter et al., 1995). Individuals with panic disorder who experience predominant respiratory symptoms (i.e., shortness of breath, choking/smothering sensations, fear of dying, chest pain/discomfort, and tingling/numbness) have been found to engage in significantly more reassurance seeking behavior compared to those without prominent respiratory symptoms (Onur et al., 2007). Those with predominant respiratory symptoms might rely on comfort provided by the safe person as a way of coping with a distressing sense of insecurity and disability (Onur et al., 2007).

Taken together, empirical studies of reassurance seeking in OCD (Parrish and Radomsky, 2006, Parrish and Radomsky, 2010) and cognitive-behavioral modeling of the anxiety disorders, suggest that ERS is a common problem that is motivated by a variety of concerns, including perceived threats to the safety of self/others, doubts about personal competence/abilities such as decision making, and social threats to interpersonal relationships. Beyond the conceptual development of ERS in the anxiety disorders, empirical research conducted with dysphoric and depressed participants has contributed to our understanding of the motivational factors underlying ERS as it pertains to different clinical disorders.

In the context of depression research, ERS has been defined as “the relatively stable tendency to excessively and persistently seek assurance from others that one is lovable and worthy, regardless of whether such assurance has already been provided” (Burns, Brown, Plant, Sachs-Ericsson, & Joiner, 2006, p. 136). Seeking of reassurance to reduce threats associated with potential loss and abandonment in depression is consistent with cognitive accounts of depression that focus on the role of loss and issues pertaining to worthiness as a motivation source for ERS (Beck, 1967, Beck, 1976). The psychometric operationalization of ERS in depression research has occurred exclusively with The Depressive Interpersonal Relationships Inventory—Reassurance Seeking subscale which consists of four items that assess an individual's tendency to excessively seek reassurance that others truly care about him or her (Joiner & Metalsky, 2001). For example, respondents are asked, “Do you frequently seek reassurance from the people you feel close to as to whether they really care about you?” and “Do the people you feel close to sometimes become irritated with you for seeking reassurance from them about whether they really care about you?” (Joiner & Metalsky, 2001, p. 372). A recent meta-analysis (Starr & Davila, 2008) reported that ERS is associated with both concurrent depression and interpersonal rejection, but concluded, “Perhaps the most striking finding of this meta-analysis is the near complete lack of methodological diversity across studies. Research has virtually always relied on a single, four item self-report measure of excessive reassurance seeking. Although this scale has shown strong psychometric properties, the exclusivity of its use makes it impossible to explore whether other methods of assessing excessive reassurance seeking yield similar results (p. 773).”

Given accumulating evidence from the anxiety literature that a wide variety of perceived threats can trigger ERS, the Reassurance Seeking subscale (Joiner & Metalsky, 2001) may have inadequate construct validity in the broader assessment of ERS due to its exclusive focus on perceived threats of social loss or rejection. Parrish and Radomsky (2010) compared participants with depression versus OCD and found that the primary type of perceived threat that triggered ERS differed between clinical groups, such that individuals with depression most frequently sought reassurance regarding perceived social threats whereas those with OCD most frequently sought reassurance regarding perceived general threats. The qualitative assessment of ERS beyond the sole use of the Reassurance Seeking subscale demonstrated the significance of ERS to anxiety disorders, moving beyond previous research that only used the Reassurance Seeking subscale and found that ERS was unrelated cross-sectionally and prospectively to the development of anxiety symptoms (Joiner and Metalsky, 2001, Joiner and Schmidt, 1998). Interestingly, Parrish and Radomsky (2010) found that although the source of threat differed between the depressed and OCD groups, the primary motivation for ERS was similar in both diagnostic groups: ERS episodes were precipitated by elevated anxiety and threat estimations, and anxiety reduction was cited most frequently as the primary function of ERS, thus highlighting the importance of the ERS construct in anxiety.

Empirical and clinical anecdotal evidence converge in suggesting that excessive reassurance is commonly sought by individuals with anxiety disorders in response to a variety of perceived threats, which in turn, contributes to the long-term maintenance of anxiety and threat. The existing measures of reassurance seeking were not designed to assess diverse triggers for seeking reassurance in the anxiety disorders, and instead, assess reassurance only with a limited set of items pertaining to perceived social threats in the context of depression (Joiner & Metalsky, 2001). There have been recent attempts to measure reassurance seeking behaviors with a single (Muse, McManus, Hackman, Williams, & Williams, 2010; “I seek reassurance about my health”) or limited set of behavioral items in response to physical health threats (Speckens, Spinhoven, vanHemert, & Bolk, 2000) and worry and uncertainty (Comer et al., 2009, Gosselin et al., 2008). However, the content and construct validity of these scales as a measure of the motivations for seeking reassurance and their clinical usefulness to assess ERS in the broader anxiety disorder spectrum may be somewhat limited. Given accumulating evidence that ERS is a common mechanism across the anxiety disorders, the aim of the current study was to develop a comprehensive measure of ERS tapping a variety of reasons for seeking reassurance that would be transdiagnostic across the anxiety disorders, and potentially a variety of clinical and non-clinical populations.

Section snippets

Participants

Participants (N = 283) were continuous referrals to a large university-based anxiety disorders assessment and treatment clinic. The sample was comprised of individuals meeting DSM-IV-TR (American Psychiatric Association, 2000) criteria for primary social phobia (n = 116), generalized anxiety disorder (n = 75), panic disorder with or without agoraphobia (n = 50), and obsessive compulsive disorder (n = 42). All diagnoses were based on the Structured Clinical Interview for Axis 1 Disorders (SCID-1/P version

Exploratory factor analysis

Using a sample of 283 participants, with all 40 items as variables, the analysis proceeded by first calculating the matrix of polychoric correlations among all possible pairs of items. We examined the polychoric correlation matrix to identify item pairs that were highly correlated and therefore possibly locally dependent. Results suggested the elimination of three items from the scale. Next the EFA was conducted with the polychoric correlations using ULS estimation. To assess number of factors

Discussion

The present study sought to develop and examine psychometric properties of a measure of reassurance seeking that assessed common triggers for patients with primary DSM-IV anxiety disorders. Items were theoretically derived and an exploratory factor analysis resulted in a three factor solution reflecting excessive reassurance seeking around indecisiveness and making decisions, social affiliation and fear of loss and rejection, and perceived general threat and the ability to cope with anxiety.

Acknowledgements

The authors would like to thank Sam Hanig and Vincent Man for their editorial assistance in the preparation of this manuscript.

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