Further characterization of relief dynamics in the conditioning and generalization of avoidance: Effects of distress tolerance and intolerance of uncertainty

The CogLearn Toolkit for Unity: Validating a virtual reality paradigm for human avoidance learning

Avoidance learning encompasses the acquisition of behaviours that enable individuals to evade or withdraw from potentially harmful stimuli, prior to their occurrence. Maladaptive avoidance is a crucial feature of anxiety and trauma-related disorders. In biological and clinical settings, avoidance behaviours usually involve uninstructed, idiosyncratic and complex motor actions. However, there is a lack of laboratory paradigms that allow investigating how such actions are acquired. To fill this gap, we developed a wireless virtual reality platform to investigate avoidance learning in naturalistic settings, with an uncomfortable sound as unconditioned stimulus (US), a physically plausible avoidance action, and allowing for unconstrained movements. This platform, the CogLearn Toolkit for Unity, is publicly available and allows conducting various types of learning experiments with simple text files as input. We validated this platform in an exploration-confirmation approach with five independent experiments. Overall, participants showed successful acquisition of avoidance behaviour in all experiments. In three exploration experiments, we refined the paradigm and identified mean distance from US location during conditioned stimulus (CS) presentation (before US occurs) as a sensitive measure of avoidance. Two confirmation experiments revealed stronger avoidance for CS+ than CS- during avoidance learning, whether or not this phase was preceded by Pavlovian acquisition. Furthermore, we demonstrated reduced avoidance during extinction with instruction to approach CS, but persistent residual avoidance during this phase. We found evidence of reinstatement in one of two confirmation experiments. Overall, our study provides robust evidence supporting the efficacy of our paradigm in studying avoidance learning in conditions of high ecological relevance.

Pretreatment anhedonia as a predictor of exposure-based anxiety treatment outcomes

Reward processes can reinforce extinction learning and aide cognitive processes involved with inhibitory learning. Anhedonia, characterized by deficits in reward incentivization, hedonic response, and learning, may therefore predict worse treatment outcomes. The current study examined associations between pretreatment self-reported anhedonia and several measures of anxiety symptom severity and treatment outcomes in a naturalistic exposure-based treatment setting. We used multilevel models to examine the relationship between pretreatment anhedonia with change in general treatment response and disorder-specific symptoms for obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder (PD). Consistent with hypotheses, pretreatment anhedonia severity was associated with higher pretreatment anxiety symptom severity across all measures. However, inconsistent with hypotheses, higher anhedonia scores were associated with greater symptom improvement across treatment for OCD, GAD, and PD, and had no significant relationships with diagnosis-general outcome measures, PTSD symptoms, or SAD symptoms. In sensitivity analyses including number of sessions, higher anhedonia was associated with more sessions across treatment and anhedonia no longer significantly predicted OCD or GAD treatment outcomes when controlling for treatment dose. Together, findings suggest that individuals with higher pretreatment anhedonia still respond to exposure therapy for anxiety disorders, but may require more sessions. More broadly, results highlight challenges in translating laboratory research to naturalistic clinical settings and the need for intensive longitudinal studies that can assess the role of reward processes in exposure therapy.

Improvement in Distress Tolerance as a Mechanism of Symptom Reduction During Intensive Exposure and Response Prevention-Based Treatment for OCD

Exposure and Response Prevention (ERP) is an effective treatment for obsessive-compulsive disorder (OCD), yet the specific underlying mechanisms by which ERP improves symptoms remain unclear. Initial theories suggested that habituation to triggering events and stimuli was the key therapeutic factor in ERP, while other theories highlight the role of developing the ability to tolerate distress, rather than reduction of distress. The current study examined improvements in distress tolerance as a mechanism of OCD, anxiety, and depressive symptom reductions during an ERP-based intensive program. Participants (N = 180) completed weekly measures of distress intolerance, and symptom severity of OCD, anxiety, and depression. Using Multi-Level Structural Equation Modeling, we found that participants experienced significant weekly decreases in OCD, anxiety, and depressive symptom severity across the course of their ERP-based treatment. Weekly reductions in OCD symptom severity were partially accounted for by weekly improvements in participants' ability to tolerate distress, particularly for obsession symptoms. This effect was also significant for anxiety and depressive symptom severity, above and beyond the effects of weekly reductions in OCD symptom severity. The current study suggests improving the ability to tolerate distress represents a transdiagnostic mechanism of symptom severity reduction in OCD, anxiety, and depressive psychopathology via intensive ERP-based psychotherapy programming. Limitations and future directions for improving treatments for OCD, anxiety, and depressive symptoms are discussed.

Stress-induced overeating behaviors explained from a (transitory) relief-learning perspective

People use various behaviors to cope with stressful events. These behaviors are mostly adaptive, as they allow a successful release of stress without impacting other aspects of life: How nice is it to have a break with a few spoons of that favorite ice cream during a hectic working day? However, when excessive consumption of high-sugar/salt ultra-processed food becomes the gateway to find relief from stress, eating loses this adaptive function and may escalate to binge eating, lead to obesity, and other medical conditions linked to overweight. Several etiological models attempt to explain stress-induced eating and excessive overeating behaviors characterizing these clinical conditions. The popular Emotional Eating Theory proposes that stress-related (over-)eating, a major predictor of obesity and diagnosed binge eating disorders, develops based on negative reinforcement learning since food consumption regulates the negative affective state associated with stressful circumstances. Differently, the prominent Incentive Sensitization Theory explains overeating, binge eating disorders (including bulimia), and obesity in terms of excessive amplification of reward 'wanting', which is thought to emerge from overexposure to obesogenic (food)cues. The several studies oriented by these theories have paved the way to better understand stress-related (over-)eating and its clinical excesses. However, a deep mechanistic understanding of how and why stress-induced (over-)eating can escalate till clinical forms of overeating remain elusive. A well-funded connection of the mechanisms proposed by the Emotional Eating Theory and the Incentive Sensitization Theory might address this etiological open question. To avoid erroneous arguments, it is however essential to first address the internal theoretical and methodological shortcomings of each theory and connected studies. These shortcomings stem from conceptual fallacies and poorly implemented designs, which might partially explain the 'high variability and low replicability' problem of empirical findings. Next, the formulation of a new integrative model could provide fresh insight into the deep learning and biological mechanisms of this escalation. A successful formalization of this model could then create the much-needed impact in clinical and preventive research since excessive overeating is a behavior hard to change once established. In this opinion paper, I propose to apply recent insights we gathered on the role of relief from the field of safety learning to stress (over-)eating. I will present a new relief-based model that, as a starting point, has the potential to connect the Emotional Eating Theory with the Incentive Sensitization Theory, setting the base for more integrative science.

Out with the bad, in with the good: A review on augmented extinction learning in humans

Several leading therapies for anxiety-related disorders rely on the principles of extinction learning. However, despite decades of development and research, many of these treatments remain only moderately effective. Developing techniques to improve extinction learning is an important step towards developing improved and mechanistically-informed exposure-based therapies. In this review, we highlight human research on strategies that might augment extinction learning through reward neurocircuitry and dopaminergic pathways, with an emphasis on counterconditioning and other behaviorally-augmented forms of extinction learning (e.g., novelty-facilitated extinction, positive affect training). We also highlight emerging pharmacological and non-pharmacological methods of augmenting extinction, including L-DOPA and aerobic exercise. Finally, we discuss future directions for augmented extinction learning and memory research, including the need for more work examining the influence of individual differences and psychopathology.

Do appearance related safety behaviors contribute to distress intolerance? A Multi-method examination

Individuals elevated in distress intolerance (DI) may engage in dysfunctional behavioral strategies to cope with their distress. One behavioral strategy that may be related to DI is appearance related safety behavior (ARSB; i.e., maladaptive behavior that seeks to mitigate the feared consequences of the negative evaluation of appearance). We examined the relationship between DI and ARSBs in two separate samples of women. In Study 1 (N = 91), we found in an unselected sample that ARSBs were robustly associated with DI cross-sectionally while accounting for symptoms of depression and body dysmorphia. Further, greater ARSBs predicted increases in DI longitudinally. In Study 2, among a clinical sample of women with elevated appearance concerns (N = 94), we examined the experimental effect of reducing ARSBs compared to a self-monitoring control. Relative to control, instructions to reduce ARSBs led to lower DI, but this effect was only found for individuals low in baseline DI. Overall, we found preliminary evidence that ARSBs may be a salient factor in contributing to and maintaining DI; and SB fading may be a helpful strategy for reducing DI. We discuss these findings in the context of existing literature and provide directions for future research.

Persistent defensive reactivity during extensive avoidance training as a potential mechanism for the perpetuation of safety behaviors

Safety behaviors are core features of anxiety-related disorders, specifically involving behaviors that do not completely terminate aversive situations, but rather prevent the risk of the occurrence of the expected aversive outcome (US). This study aimed to examine the dynamics of defensive reactivity associated with safety behaviors, both before and after their execution, and to investigate changes in these reactions following extensive training. Twenty-four healthy participants underwent a US-avoidance task as an experimental analog to model safety behavior, requiring a button press to avoid the US without terminating the associated warning cue (CS). Two CS+ were used, with one being devalued during a devaluation procedure to assess the formation of avoidance habits. Defensive reactivity was assessed using fear-potentiated startle (FPS) and skin conductance responses (SCR). Participants showed pronounced defensive reactivity to both CS + vs. CS- before the avoidance action, which decreased upon the opportunity to avoid the US. Contrarily, after the avoidance action, a re-emergence of defensive responses was observed as indicated by FPS and increased SCR. Only one participant showed signs of avoidance habit formation. The findings reveal a re-emergence of defensive reactivity following safety behaviors challenging the prevailing belief that relief is the primary sustaining factor of safety behavior.

Safety signals reinforce instrumental avoidance in humans

Safety signals reinforce instrumental avoidance behavior in nonhuman animals. However, there are no conclusive demonstrations of this phenomenon in humans. Using human participants in an avoidance task, Experiments 1-3 and 5 were conducted online to assess the reinforcing properties of safety signals, and Experiment 4 was conducted in the laboratory. Participants were trained with CSs+ and CSs-, and they could avoid an aversive outcome during presentations of the CSs+ by pressing their space bar at a specific time. If successful, the aversive outcome was not presented but instead a safety signal was. Participants were then tested-whilst on extinction-with two new ambiguous test CSs. If participants made an avoidance response, one of the test CSs produced the trained safety signal and the other was a control. In Experiments 1 and 4, the control was followed by no signal. In Experiment 2, the control was followed by a signal that differed in one dimension (color) with the trained safety signal, and in Experiment 3, the control differed in two dimensions (shape and color) from the trained safety signal. Experiment 5 tested the reinforcing properties of the safety signal using a choice procedure and a new response during test. We observed that participants made more avoidance responses to the ambiguous test CSs when followed by the trained signal in Experiments 1, 3, 4, and 5 (but not in Experiment 2). Overall, these results suggest that trained safety signals can reinforce avoidance behavior in humans.

The bright side of words: Norms for 9000 Spanish words in seven discrete positive emotions

In recent years, assumptions about the existence of a single construct of happiness that accounts for all positive emotions have been questioned. Instead, several discrete positive emotions with their own neurobiological and psychological mechanisms have been proposed. Of note, the effects of positive emotions on language processing are not yet properly understood. Here we provide a database for a large set of 9000 Spanish words scored by 3437 participants in the positive emotions of awe, contentment, amusement, excitement, serenity, relief, and pleasure. We also report significant correlations between discrete positive emotions and several affective (e.g., valence, arousal, happiness, negative discrete emotions) and lexico-semantic (e.g., frequency of use, familiarity, concreteness, age of acquisition) characteristics of words. Finally, we analyze differences between words conveying a single emotion ("pure" emotion words) and those denoting more than one emotion ("mixed" emotion words). This study will provide researchers a rich source of information to do research that contributes to expanding the current knowledge on the role of positive emotions in language. The norms are available at https://doi.org/10.6084/m9.figshare.21533571.v2.

Reward processes in extinction learning and applications to exposure therapy

Anxiety disorders are common and highly distressing mental health conditions. Exposure therapy is a gold-standard treatment for anxiety disorders. Mechanisms of Pavlovian fear learning, and particularly fear extinction, are central to exposure therapy. A growing body of evidence suggests an important role of reward processes during Pavlovian fear extinction. Nonetheless, predominant models of exposure therapy do not currently incorporate reward processes. Herein, we present a theoretical model of reward processes in relation to Pavlovian mechanisms of exposure therapy, including a focus on dopaminergic prediction error signaling, coinciding positive emotional experiences (i.e., relief), and unexpected positive outcomes. We then highlight avenues for further research and discuss potential strategies to leverage reward processes to maximize exposure therapy response, such as pre-exposure interventions to increase reward sensitivity or post-exposure rehearsal (e.g., savoring, imaginal recounting strategies) to enhance retrieval and retention of learned associations.

The generalization of threat beliefs to novel safety stimuli induced by safety behaviors

Safety behaviors are responses that can reduce or even prevent an expected threat. Moreover, empirical studies have shown that using safety behaviors to a learnt safety stimulus can induce threat beliefs to it. No research so far has examined whether threat beliefs induced this way generalize to other novel stimuli related to the safety stimulus. Using a fear and avoidance conditioning model, the current study (n=116) examined whether threat beliefs induced by safety behaviors generalize to other novel generalization stimuli (GSs). Participants first acquired safety behaviors to a threat predicting conditioned stimulus (CSthreat). Safety behaviors could then be performed in response to one safe stimulus (CSsafeShift) but not to another (CSsafe). In a following generalization test, participants showed a significant but small increase in threat expectancies to GSs related to CSsafeShift compared to GSs related to CSsafe. Interestingly, the degree of safety behaviors used to the CSsafeShift predicted the subsequent increase in generalized threat expectancies, and this link was elevated in trait anxious individuals. The findings suggest that threat beliefs induced by unnecessary safety behaviors generalize to other related stimuli. This study provides a potential explanation for the root of threat belief acquisition to a wide range of stimuli or situations.

The effect of typicality training on costly safety behavior generalization

BACKGROUND AND OBJECTIVES

Typicality asymmetry in generalization refers to enhanced fear generalization when trained with typical compared to atypical exemplars. Typical exemplars are highly representative of their category, whereas atypical exemplars are less representative. Individual risk factors, such as trait anxiety, attenuate this effect, due to the high level of threat ambiguity of atypical exemplars. Although recent research provided evidence for generalization of safety behavior, it is unclear whether this generalization also follows typicality asymmetry. This study examined (1) whether participants exhibited typicality asymmetry in the generalization of safety behavior and (2) whether this effect would be attenuated by individual risk factors, such as intolerance of uncertainty and trait anxiety.

METHODS

Participants were trained with either typical (Typical group, n = 53) or atypical (Atypical group, n = 55) exemplars in a fear and avoidance conditioning procedure. Participants acquired differential conditioned fear and costly safety behavior to the threat- and safety-related exemplars. In a following Generalization Test, the degree of safety behavior to novel exemplars of the same categories was tested.

RESULTS

The Atypical group showed greater differential safety behavior responses compared to the Typical group. Higher trait anxiety was associated with lower differential safety behavior generalization, driven by an increase in generalized responding to novel safety-related exemplars.

LIMITATIONS

This study used hypothetical cost instead of real cost.

CONCLUSIONS

Training with atypical exemplars led to greater safety behavior generalization. Moreover, individuals with high trait anxiety show impaired safety behavior generalization.

Measuring Intolerance of Uncertainty After Acquired Brain Injury: Factor Structure, Reliability, and Validity of the Intolerance of Uncertainty Scale-12

Intolerance of uncertainty (IU) is a risk factor for poor mental health. Acquired brain injury (ABI; for example, stroke, traumatic brain injury) often brings considerable uncertainty and increased mood disorder vulnerability. The Intolerance of Uncertainty Scale-Short Form (IUS-12) is a brief, well-validated IU measure in non-ABI samples, comprising two subscales, namely, Prospective Anxiety and Inhibitory Anxiety. Here, for the first time, we investigated its reliability and validity (N = 118), and factor structure (N = 176), in ABI. Both subscales had high test-retest reliability (intraclass correlation coefficients [ICCs] of .75 and .86) and were significantly associated with mood disorder symptoms. The two-factor model was superior to a one-factor IU model fit. Some fit statistics were less than optimal (standardized root mean square residual [SRMR] = 0.06, root mean square error of approximation [RMSEA] = 0.09); hence, exploration of other factor structures in other ABI samples may be warranted. Nonetheless, the IUS-12 appears suitable in ABI.

Risk estimation in relation to anxiety and depression for low probability negative events

Foundational cognitive models propose that people with anxiety and depression show risk estimation bias, but most literature does not compute true risk estimation bias by comparing people's subjective risk estimates to their individualized reality (i.e., person-level objective risk). In a diverse community sample (N = 319), we calculated risk estimation bias by comparing people's subjective risk estimates for contracting COVID-19 to their individualized objective risk. Person-level objective risk was consistently low and did not differ across symptom levels, suggesting that for low probability negative events, people with greater symptoms show risk estimation bias that is driven by subjective risk estimates. Greater levels of anxiety, depression, and COVID-specific perseverative cognition separately predicted higher subjective risk estimates. In a model including COVID-specific perseverative cognition alongside anxiety and depression scores, the only significant predictor of subjective risk estimates was COVID-specific perseverative cognition, indicating that symptoms more closely tied to feared outcomes may more strongly influence risk estimation. Finally, subjective risk estimates predicted information-seeking behavior and eating when anxious, but did not significantly predict alcohol or marijuana use, drinking to cope, or information avoidance. Implications for clinical practitioners and future research are discussed.

The cycle of solitude and avoidance: a daily life evaluation of the relationship between internet addiction and symptoms of social anxiety

A consistent association has been observed between internet addiction and symptoms of social anxiety. However, there is a lack of empirical research that delves into potential explanations for this relationship and its directionality, making it difficult to translate findings into development of interventions for social anxiety that account for technology-related behaviors. The present study aimed to evaluate the longitudinal dynamics between internet addiction, symptoms of social anxiety, avoidance of social interactions, and using the internet to cope with loneliness. By means of an ecological momentary assessment study, we evaluated a sample of 122 young adults from Chile using intensive self-report measurements five times a day, for a period of 10 days. Using mixed-effects models, we examined the directionality between internet addiction and symptoms of social anxiety, together with an explanation of their relationship. Results indicate that internet addiction antecedes symptoms of social anxiety; however, the reverse relationship was not observed. Furthermore, instances where individuals avoided social interactions or used the internet to cope with loneliness were predictive of later increases in levels of internet addiction, suggesting a vicious cycle. Significant heterogeneity was observed in these effects, highlighting the need for a more personalized approach when including technology-related behaviors in social anxiety interventions. Theoretical and clinical implications are discussed.

Itsy bitsy spider: Fear and avoidance (generalization) in a free-exploratory virtual reality paradigm

Most experimental avoidance paradigms lack either control over the experimental situation or simplify real-life avoidance behavior to a great extent, making it difficult to generalize the results to the complex approach-avoidance situations that anxious individuals face in daily life. The current study aimed to examine the usability of our recently developed free-exploratory avoidance paradigm in Virtual Reality (VR) that allows for the assessment of subjective as well as behavioral avoidance in participants with varying levels of spider fear. In a VR escape room, participants searched for cues to decipher a code-locked door. Opening a wooden box marked with a post-it note (conditioned stimulus, CS) resulted in exposure to a virtual crawling spider (unconditioned stimulus, US). Avoidance of the original CS and other objects marked with the CS (generalization stimuli, GSs; EXPgen condition) or non-marked (CONT condition) objects was measured via questionnaires and relative manipulation times in a novel room. We expected a positive linear relationship between US aversiveness (levels of spider fear) and (generalization of) fear and avoidance behaviors. Avoidance learning and generalization was demonstrated on both a subjective and behavioral level. Higher levels of spider fear were, overall, related to more negative emotions in response to the encounter with the spider, higher US expectancies for the GSs, and more self-reported and behavioral avoidance of the original CS and the GSs. Finally, we explored relationships between trait anxiety and intolerance of uncertainty and fear and avoidance (generalization), but no robust associations were observed. In conclusion, we confirmed the expected positive linear relationship between spider fear and (generalization of) fear and avoidance behaviors. Our results suggest that our free-exploratory VR avoidance paradigm is well-suited to investigate avoidance behaviors and the generalization of avoidance.

Multiclassification of the symptom severity of social anxiety disorder using digital phenotypes and feature representation learning

Objective

Social anxiety disorder (SAD) is characterized by heightened sensitivity to social interactions or settings, which disrupts daily activities and social relationships. This study aimed to explore the feasibility of utilizing digital phenotypes for predicting the severity of these symptoms and to elucidate how the main predictive digital phenotypes differed depending on the symptom severity.

Method

We collected 511 behavioral and physiological data over 7 to 13 weeks from 27 SAD and 31 healthy individuals using smartphones and smartbands, from which we extracted 76 digital phenotype features. To reduce data dimensionality, we employed an autoencoder, an unsupervised machine learning model that transformed these features into low-dimensional latent representations. Symptom severity was assessed with three social anxiety-specific and nine additional psychological scales. For each symptom, we developed individual classifiers to predict the severity and applied integrated gradients to identify critical predictive features.

Results

Classifiers targeting social anxiety symptoms outperformed baseline accuracy, achieving mean accuracy and F1 scores of 87% (with both metrics in the range 84-90%). For secondary psychological symptoms, classifiers demonstrated mean accuracy and F1 scores of 85%. Application of integrated gradients revealed key digital phenotypes with substantial influence on the predictive models, differentiated by symptom types and levels of severity.

Conclusions

Leveraging digital phenotypes through feature representation learning could effectively classify symptom severities in SAD. It identifies distinct digital phenotypes associated with the cognitive, emotional, and behavioral dimensions of SAD, thereby advancing the understanding of SAD. These findings underscore the potential utility of digital phenotypes in informing clinical management.

Relation among, trait anxiety, intolerance to uncertainty and early maltreatment experiences on fear discrimination learning and avoidance generalization online task

BACKGROUND AND OBJECTIVES

Early aversive experiences, which have been associated with elevated anxiety and intolerance of uncertainty (IUS), may contribute negatively to fear conditioning learning. The aim of the present study was to analyze the relation among individual differences in childhood maltreatment experiences, trait anxiety, and IUS in adulthood; and to determine how these variables could affect fear learning discrimination and avoidance generalization.

METHODS

We adapted an avoidance procedure in an online fear learning task. Two pictures of different lamp colors (CS+) were first associated with two aversive images (US), while a third color was not (CS-). Next, clicking a button during one CS + could effectively avoid the US (CS + av), but not during the other (CS + unav). Finally, avoidance generalization was tested to lamp colors that were between CS- and CS + av (safety dimension) and CS + av and CS + unav (avoidability dimension). With a sample of 67 participants, we measured ratings of relief, expectancy, and anxiety, as well as button presses and individual differences (STAI, IUS and MAES).

RESULTS

Aversive early experiences were positively related to trait anxiety and intolerance of uncertainty. The results of the task further suggested that maltreatment experience contributes to be more attentive to aversive signals, which could be implicated in leading to difficulties in discrimination learning.

LIMITATIONS

Online experiments implies some loss of control over subjects and environment that can threaten internal validity. Likewise, the commitment of participants may be low.

CONCLUSIONS

Results suggest that early aversive experience and anxiety could contribute to the development of IUS, which likely contributes to the development of avoidance behavior.

An Integrative Model of Youth Anxiety: Cognitive-Affective Processes and Parenting in Developmental Context

Multiple theoretical frameworks have been proposed to provide a more comprehensive picture of the risk factors that influence anxiety-related developmental trajectories. Nonetheless, there remains a need for an integrative model that outlines: (1) which risk factors may be most pertinent at different points in development, and (2) how parenting may maintain, exacerbate, or attenuate an affective style that is characterized by high negative emotional reactivity to unfamiliar, uncertain, and threatening situations. A developmentally informed, integrative model has the potential to guide treatment development and delivery, which is critical to reducing the public health burden associated with these disorders. This paper outlines a model integrating research on many well-established risk mechanisms for anxiety disorders, focusing on (1) the developmental progression from emotional reactivity constructs early in life to those involving higher-level cognitive processes later in youth, and (2) potential pathways by which parenting may impact the stability of youth's cognitive-affective responses to threat-relevant information across development.

Working hard to avoid: Fixed-ratio response effort and maladaptive avoidance in humans

Maladaptive avoidance of safe stimuli is a defining feature of anxiety and related disorders. Avoidance may involve physical effort or the completion of a fixed series of responses to prevent occurrence of, or cues associated with, the aversive event. Understanding the role of response effort in the acquisition and extinction of avoidance may facilitate the development of new clinical treatments for maladaptive avoidance. Despite this, little is known about the impact of response effort on extinction-resistant avoidance in humans. Here, we describe findings from two laboratory-based treatment studies designed to investigate the impact of high and low response effort on the extinction (Experiment 1) and return (Experiment 2) of avoidance. Response effort was operationalised as completion of fixed-ratio (FR) reinforcement schedules for both danger and safety cues in a multi-cue avoidance paradigm with behavioural, self-report, and physiology measures. Completion of the FR response requirements cancelled upcoming shock presentations following danger cues and had no impact on the consequences that followed safety cues. Both experiments found persistence of high response-effort avoidance across danger and safety cues and sustained (Experiment 1) and reinstated (Experiment 2) levels of fear and threat expectancy. Skin conductance responses evoked by all cues were similar across experiments. The present findings and paradigm have implications for translational research on maladaptive anxious coping and treatment development.

The effect of experimentally induced positive affect on the generalization of pain-related avoidance and relief

Avoiding pain-associated activities can prevent tissue damage. However, when avoidance spreads excessively (or overgeneralizes) to safe activities, it may culminate into chronic pain disability. Gaining insight into ways to reduce overgeneralization is therefore crucial. An important factor to consider in this is relief, as it reinforces avoidance behavior and therefore may be pivotal in making avoidance persist. The current study investigated whether experimentally induced positive affect can reduce generalization of pain-related avoidance and relief. We used a conditioning task in which participants (N = 50) learned that certain stimuli were followed by pain, while another was not. Subsequently, they learned an avoidance response that effectively omitted pain with one stimulus, but was ineffective with another. Next, one group of participants performed an exercise to induce positive affect, while another group performed a control exercise. During the critical generalization test, novel stimuli that were perceptually similar to the original stimuli were presented. Results showed that both avoidance and relief generalized to novel stimuli, thus replicating previous work. However, increasing positive affect did not reduce generalization of avoidance, nor relief.

Impaired action-safety learning and excessive relief during avoidance in patients with anxiety disorders

Anxiety-related disorders are characterized by high levels of avoidance, but experimental research into avoidance learning in patients is scarce. To fill this gap, we compared healthy controls (HC, n = 47) with patients with obsessive-compulsive disorder (OCD, n = 33), panic disorder with agoraphobia (PDA, n = 40), and post-traumatic stress disorder (PTSD, n = 66) in a computer-based avoidance learning task, in order to examine (1) differences in rates of avoidance responses, (2) differences in action-safety learning during avoidance, and (3) differences in subjective relief following successful avoidance. The task comprised aversive negative pictures (unconditional stimulus, US) that followed pictures of two colored lamps (conditional stimuli, CS+), but not a third colored lamp (safety stimulus, CS-), and could be avoided by pressing a button during one CS+ (CS+ avoidable) but not the other (CS+ unavoidable). Participants rated their US-expectancy and level of relief on a trial-by-trial basis. Compared to the HC group, patient groups displayed higher levels of avoidance to the safety stimulus, and higher levels of US-expectancy and relief following the safety and avoidable danger stimulus. We propose that patients with anxiety disorders have low confidence in the safety consequences of avoidance actions, which induces increased relief during US omissions that reinforce the avoidance action.

No joy - why bother? Higher anhedonia relates to reduced pleasure from and motivation for threat avoidance

Anhedonia impairs various components of the pleasure cycle, including wanting, liking, and the learning of pleasure-related associations. While successfully controlling threats might be inherently pleasurable, it remains unclear whether anhedonia affects this form of pleasure as well. With aversive pictures as threats, we conducted an online study ( N = 200) to investigate the role of anhedonia during active avoidance learning process. Participants first learned cue-threat associations for different cues (threat vs. safety cues). In a subsequent avoidance learning phase, these cues signaled either avoidable, unavoidable, or no threat; participants could perform avoidance responses to prevent the upcoming threats during those cue presentations. Subjective relief pleasantness was measured after each threat omission. We found that higher trait anticipatory and consummatory anhedonia were both associated with lower relief pleasantness. Higher trait anticipatory anhedonia was also associated with fewer avoidance attempts. Since reduced threat-controlling behavior is reminiscent of a learned-helplessness state, the current results contribute to a better understanding of the connections between anhedonia and learned helplessness that have mostly been studied separately in the context of mood disturbance.

The neurobiology of Pavlovian safety learning: Towards an acquisition-expression framework

Safety learning creates associations between conditional stimuli and the absence of threat. Studies of human fear conditioning have accumulated evidence for the neural signatures of safety over various paradigms, aligning on several common brain systems. While these systems are often interpreted as underlying safety learning in a generic sense, they may instead reflect the expression of learned safety, pertaining to processes of fear inhibition, positive affect, and memory. Animal models strongly suggest these can be separable from neural circuits implicated in the conditioning process itself (or safety acquisition). While acquisition-expression distinctions are ubiquitous in behavioural science, this lens has not been applied to safety learning, which remains a novel area in the field. In this mini-review, we overview findings from prevalent safety paradigms in humans, and synthesise these with insights from animal models to propose that the neurobiology of safety learning be conceptualised along an acquisition-expression model, with the aim of stimulating richer brain-based characterisations of this important process.

Increased positive affect is associated with less generalization of pain-related avoidance

Fear-avoidance models of chronic pain consider excessive spreading (or overgeneralization) of pain-related avoidance toward safe activities to play a crucial role in chronic pain disability. This study (N = 96) investigated whether avoidance generalization is mitigated by positive affect induction. Pain-free, healthy participants performed an arm-reaching task during which certain movements were followed by pain, while another was not. One group then performed an exercise to induce positive affect (positive affect group), while another group performed a neutral exercise (neutral group). A third group also performed the neutral exercise, but did not learn to avoid pain during the arm-reaching task (yoked neutral group). To test generalization, we introduced novel but similar movements that were never followed by pain in all groups. Results showed no differences in generalization between the positive affect and neutral groups; however, across groups, higher increases in positive affect were associated with less generalization of avoidance, and less generalization of pain-expectancy and pain-related fear. Compared to the yoked neutral group, the neutral group showed avoidance generalization, as well as pain-expectancy and pain-related fear generalization. These results point toward the potential of positive affect interventions in attenuating maladaptive spreading of pain-related avoidance behavior to safe activities.

More engagement in inefficient avoidance through partial reinforcement

BACKGROUND AND OBJECTIVES

In anxiety-related disorders, excessive avoidance often coexists with an impaired sense of control over external threats. In contrast, lab studies have shown that avoidance responding increase with higher objective controllability over threat, accompanied with more confidence in the effectiveness of the avoidance response. One reason for this divergence could be that those lab studies are overly simplistic with a single, avoidable threat.

METHODS

We conducted an experiment that additionally included a completely uncontrollable threat, and we manipulated the reinforcement rate of the avoidance response to the (semi-)controllable threat (75% versus 100%).

RESULTS

The 100% group showed increased avoidance to the controllable threat and decreased avoidance to the unavoidable threat over learning. Interestingly, compared to the 100% group, the 75% group displayed less confidence in their avoidance to the controllable threat and they avoided the uncontrollable threat more often.

LIMITATIONS

Only two reinforcement rates of effective avoidance were included, which may limit the generalizability of the current findings. Perceived control was not directly measured.

CONCLUSIONS

Lower reinforcement rates create ambiguity between effective and ineffective situations of avoidance, which engenders generalization of unpredictability from effective to ineffective situation, thereby driving up ineffective avoidance rates. Partially reinforced effective avoidance responses and elevated ineffective avoidance responses together lead to more exposure to uncontrollable threat, weakening the sense of control over the threat, which could further increase avoidance behaviors. Controllability is often overlooked in avoidance research but can be key to understanding the development of maladaptive avoidance behaviors.

Overnight fasting affects avoidance learning and relief

OBJECTIVES

prolonged fasting influences threat and reward processing, two fundamental systems underpinning adaptive behaviors. In animals, overnight fasting sensitizes the mesolimbic-dopaminergic activity governing avoidance, reward, and fearextinction learning. Despite evidence that overnight fasting may also affect reward and fear learning in humans, effects on human avoidance learning have not been studied yet. Here, we examined the effects of 16 h-overnight fasting on instrumental avoidance and relief from threat omission.

METHODS

to this end, 50 healthy women were randomly assigned to a Fasting (N = 25) or a Re-feeding group (N = 25) and performed an Avoidance-Relief Task.

RESULTS

we found that fasting decreases unnecessary avoidance during signaled safety; this effect was mediated via a reduction in relief pleasantness during signaled absence of threat. A fasting-induced reduction in relief was also found during fear extinction learning.

DISCUSSION

we conclude that fasting optimizes avoidance and safety learning. Future studies should test whether these effects also hold for anxious individuals.

The role of relief, perceived control, and prospective intolerance of uncertainty in excessive avoidance in uncertain-threat environments

Excessive avoidance is a key feature of pathological anxiety. However, the precise mechanisms underlying the development of excessive avoidance are still unknown. In the present study, we tested the hypothesis that excessive avoidance, especially in individuals with high Intolerance of Uncertainty (IU) is aimed at distress reduction via the enhancement of subjective perceived control in uncertain-threat environments. In our experiment, participants learned to avoid an uncertain aversive sound through a discriminated free operant procedure. In a later test phase in extinction, we manipulated the amount of avoidance responses available per trial by creating a limited and an unrestricted response condition. Nonetheless, the aversive sound could be effectively avoided in both conditions. We measured response frequency, avoidance confidence ratings and anxiety-predisposing traits such as intolerance of uncertainty, trait anxiety and distress tolerance. The degree of distress suffered during trials was inferred from post-trial relief ratings that were requested after trials in which the aversive sound had been omitted. In the avoidance acquisition phase, we found a positive association between prospective intolerance of uncertainty (P-IU) and the decline rate of distress. This relationship was not significant, however, when inhibitory intolerance of uncertainty (I-IU) was controlled for. At test, we found that the increase in avoidance responses led to distress reduction through the enhancement of avoidance confidence. Finally, we found a significant modulating role of P-IU in the effect of response limit on distress reduction that lends further support to our hypothesis. Specifically, P-IU was positively associated with the effect of response limit on distress. However, such modulating role was not significant when controlling for trait anxiety or I-IU.

Using what we know about threat reactivity models to understand mental health during the COVID-19 pandemic

The COVID-19 pandemic has been accompanied by unprecedented levels of stress and threats in a variety of domains (e.g., health, livelihood). Individual differences in threat reactivity may explain why some individuals are at elevated risk for the development or maintenance of psychopathology during the COVID-19 pandemic. This article describes several prominent models, mechanisms, and components of threat reactivity (e.g., appraisals, intolerance of uncertainty, avoidance) and discusses how they might help improve understanding of changes in psychopathology during and following the COVID-19 pandemic.

The Good, the Bad, and the Ugly-Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.

Avoiding a feared stimulus: Modelling costly avoidance of learnt fear in a sensory preconditioning paradigm

Avoidance of learnt fear prevents the onset of a feared stimulus and the threat that follows. In anxiety-related disorders, it turns pathological given its cost and persistence in the absence of realistic threat. The current study examined the acquisition of costly avoidance of learnt fear in healthy individuals (n = 45), via a sensory preconditioning paradigm. Two neutral preconditioning stimuli (PSs) were paired with two neutral conditioned stimuli (CSs). One CS then came to predict an aversive outcome whereas the other CS came to predict safety. In test, participants engaged in stronger avoidance to the PS associated with the fear-related CS than the PS associated with the safety-related CS. Of note, executing behavioral avoidance led to missing out a competing reward, thus rendering avoidance costly. The results also provide preliminary evidence that threat anticipation and a negative change in valence play a role in driving costly avoidance of learnt fear. Future studies should examine how avoidance of learnt fear maintains pathological anxiety.

Fear learning, avoidance, and generalization are more context-dependent for adults than adolescents

This study examined developmental differences in contextual and perceptual generalization of fear and avoidance learning. Adults (N = 39) and adolescents (N = 44) completed differential fear acquisition wherein each conditional stimulus (CS) appeared in a background context. In the dangerous context, one stimulus (CS+) predicted an aversive sound, and the other stimulus (CS-) did not. In the safe context, the aversive sound was never administered with either CS. During fear generalization, participants were presented with three generalization stimuli (GSs), ranging on a perceptual continuum from threat to safety stimuli, in both contexts. Participants then completed avoidance conditioning and avoidance generalization phases, allowing them to actively avoid the upcoming aversive sound by pressing an avoidance button. Developmental differences emerged in threat perception, physiological arousal, avoidance behavior, and eye movements during contextual fear learning and generalization. Adolescents showed less discrimination between stimuli and contexts than adults, resulting primarily from their elevated fear responses to safety and generalized stimuli. Developmental differences in fear learning should be further explored in future research, as they could explain why adolescence is a sensitive developmental period for anxiety.

How Patients with an Uncertain Diagnosis Experience Intolerance of Uncertainty: A Grounded Theory Study

PURPOSE

To develop a conceptual framework to explain how patients with uncertain diagnoses experience intolerance of uncertainty (IU) in order to achieve an in-depth understanding of the process of facing uncertainty in this population.

PATIENTS AND METHODS

A grounded theory study using semi-structured interviews was conducted with 21 patients with uncertain diagnoses in China from December 2018 to March 2019. The coding process followed the procedures of Strauss and Corbin: open coding, axial coding, and selective coding.

RESULTS

We developed a conceptual framework called 'Facing an Uncertain Diagnosis'. This framework considers not only the external and internal context of IU generation but also the ongoing process of how IU impacts patients' psychological status, cognitive response, behavior, and decision making.

CONCLUSION

We suggest that healthcare professionals should be aware of the high level of IU and its psychological, cognitive, and behavioral manifestations in patients with uncertain diagnoses. Healthcare professionals should also be more cautious in shared decision making with patients with uncertain diagnoses.

The role of intolerance of uncertainty in classical threat conditioning: Recent developments and directions for future research

Intolerance of uncertainty (IU), the tendency to find uncertainty aversive, is an important transdiagnostic dimension in mental health disorders. Over the last decade, there has been a surge of research on the role of IU in classical threat conditioning procedures, which serve as analogues to the development, treatment, and relapse of anxiety, obsessive-compulsive, and trauma- and stressor-related disorders. This review provides an overview of the existing literature on IU in classical threat conditioning procedures. The review integrates findings based on the shared or discrete parameters of uncertainty embedded within classical threat conditioning procedures. Under periods of unexpected uncertainty, where threat and safety contingencies change, high IU, over other self-reported measures of anxiety, is specifically associated with poorer threat extinction learning and retention, as well as overgeneralisation. Under periods of estimation and expected uncertainty, where the parameters of uncertainty are being learned or have been learned, such as threat acquisition training and avoidance learning, the findings are mixed for IU. These findings provide evidence that individual differences in IU play a significant role in maintaining learned fear and anxiety, particularly under volatile environments. Recommendations for future research are outlined, with discussion focusing on how parameters of uncertainty can be better defined to capture how IU is involved in the maintenance of learned fear and anxiety. Such work will be crucial for understanding the role of IU in neurobiological models of uncertainty-based maintenance of fear and anxiety and inform translational work aiming to improve the diagnosis and treatment of relevant psychopathology.

Avoidance in Anorexia Nervosa: Towards a research agenda

Anorexia Nervosa is a severe and disabling mental disorder and a huge challenge to treat. Intense fears of e.g., food, eating, weight gain and social evaluation are core features of anorexia nervosa and obstacles during treatment. The perceived threats trigger avoidance and safety behaviors like highly restrictive eating, strict eating rules, vomiting and body checking, to minimize feared outcomes. The role of avoidance in anorexia nervosa is however hardly studied experimentally. In the present article, the focus is on a new transdiagnostic research agenda featuring both basic and clinical experimental research into avoidance as a most important mechanism maintaining the eating disorder. Avoidance learning and the generalization of learned avoidance behaviors are discussed, as well as safety behaviors and the need for inhibitory learning as a treatment target during exposure therapy.

The drive for thinness: Towards a mechanistic understanding of avoidance behaviors in a non-clinical population

Fear of weight gain is a cardinal feature of eating disorders, including Anorexia Nervosa (AN). This fear motivates behaviors aimed at avoiding weight gain, such as restricting food intake. Of note, avoidance in AN is not confined to food-related items but extends to intense emotional states. Despite the presence of several forms of excessive avoidance in AN, little is known about the mechanisms underpinning avoidance behavior in AN. In the present exploratory study, we investigated whether university students with an elevated desire to avoid weight gain (as measured through self-reported Drive for Thinness, DT) show deficits in generic avoidance learning. Two-hundred and seventy-five female students filled in the Eating Disorder Inventory-II (EDI-II) and performed a food-unrelated avoidance task. Generalized and linear mixed models (GLMM) revealed that students scoring higher on the DT scale of the EDI-II showed more ineffective avoidance, suggesting a tendency for excessive avoidance in at-risk individuals for AN. Similar results might extend to other eating disorders.

Avoidance learning as predictor of posttraumatic stress in firefighters

BACKGROUND

Avoidance is a well-established maintenance factor in anxiety-related psychopathology. Individuals prone to anxiety show more maladaptive avoidance responses in conditioning paradigms aimed at avoidance learning, which indicates impairments in safety learning. To what extent avoidance learning is associated with posttraumatic stress disorder (PTSD) is still unclear, despite the logical relevance to the symptomatology. In this prospective study, we investigate avoidance learning responses in first responders, a population at high risk for traumatic exposure and thus PTSD development, and studied whether avoidance learning was associated with concurrent and future PTSD symptoms.

METHOD

Firefighters (N = 502) performed an avoidance learning task at baseline assessment in which they first learned that two conditioned stimuli (CS+) were followed by an aversive stimulus (US) and one conditioned stimulus (CS-) was not. After that, they could learn to which CS avoidance of the US was effective, ineffective or unnecessary. Self-reported PTSD symptoms were assessed at baseline, and at 6, 12, 18 and 24 months.

RESULTS

Participants exhibited comparable avoidance patterns to low anxiety individuals from previous studies. Avoidance learning responses were not associated with PTSD symptoms at baseline nor at follow-up.

DISCUSSION

Our study found no evidence that avoidance learning was related to PTSD symptom severity in a high-risk, yet low symptomatic population, nor did it predict the development of PTSD symptoms at a later point in time. Future research should focus on studying avoidance learning in a clinical or high symptomatic sample to further clarify the role of avoidance learning in PTSD development.

Emotional and Behavioral Consequences of the COVID-19 Pandemic: The Role of Health Anxiety, Intolerance of Uncertainty, and Distress (In)Tolerance

The COVID-19 pandemic represents a worldwide threat to mental health. To optimize the allocation of health care resources, research on specific vulnerability factors, such as health anxiety, intolerance of uncertainty, and distress (in)tolerance, and particularly their effect on the time course of SARS-CoV-2 related anxiety appears crucial for supporting high risk groups suffering from elevated mental distress during the pandemic. N = 887 participants (78.4% female; Mage = 38.15, SD = 17.04) completed an online survey in Germany (April to mid-May 2020), comprising measures of SARS-CoV-2 related anxiety, health anxiety, safety and preventive behavior, intolerance of uncertainty, and distress intolerance. Higher levels of health anxiety pre and during COVID-19 were associated with an initially intensified increase (b = 1.10, p < 0.001), but later on a more rapid dampening (b = -0.18, p < 0.001) of SARS-CoV-2 related anxiety. SARS-CoV-2 related preventive behavior was intensified by both pre (b = 0.06, p = 0.01) and during (b = 0.15, p < 0.001) COVID-19 health anxiety, while reassurance behavior only was associated with health anxiety during COVID-19 (b = 0.14, p < 0.001). Distress intolerance and intolerance of uncertainty did not moderate the relationship between health anxiety and SARS-CoV-2 related anxiety and behavior. The results suggest detrimental effects of health anxiety on the emotional and behavioral response to virus outbreaks.