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8 DISCUSSION 195 SAFETY BEHAVIOR AND THE EXACERBATION AND RETURN OF THREAT BELIEFS In chapter 4 , we investigated the causal influence of safety behavior on anxiety by examining whether checking safety behavior exacerbates OCD-related threat beliefs. Healthy participants spent a week between a pre- and post-test either performing clinically representative checking behavior on a daily basis, monitoring their normal checking behavior, or received no instructions on checking behavior. Checking safety behavior exacerbated cognitions about the severity of threat (van Uijen & Toffolo, 2015). Checking behavior may thus directly contribute to the severity of fears in OCD. Along with previous studies showing that contamination-related safety behavior increases contamination fear (Deacon & Maack, 2008), health-related safety behavior increases health anxiety (Olatunji, Etzel, Tomarken, Ciesielski, & Deacon, 2011), and safety behavior displayed in response to a safety cue increases threat expectations to this cue (Engelhard, van Uijen, van Seters, & Velu, 2015), this suggests that safety behavior contributes to the exacerbation of pathological anxiety symptoms. This is in line with findings presented in chapter 5 , in which we investigated the effect of safety behavior on the return of fear after extinction in a fear conditioning experiment (van Uijen, Leer, & Engelhard, 2017). The results showed that safety behavior was resistant to fear extinction, and promoted a partial return of fear (van Uijen, Leer, et al., 2017). This, together with the findings of Vervliet and Indekeu (2015) suggests that safety behavior may be involved in relapse after exposure therapy. Together, the findings presented in chapter 4 and 5 suggest that safety behavior itself can provide information about the danger of a situation. Safety behavior increased the perceived severity (van Uijen & Toffolo, 2015) and likelihood of threat (i.e., threat expectancy; Engelhard et al., 2015; van Uijen, Leer, et al., 2017). The extent to which a stimulus (CS) evokes fear (CR) depends on the strength of the CS – US association (i.e., the perceived likelihood of threat), and the evaluation of the US (i.e.,