Avoidance and its bi-directional relationship with conditioned fear:Mechanisms, moderators, and clinical implications

Fear motivates different types of defensive behaviors. These behaviors are, however, not mere byproducts of fear. In this review, we highlight a bi-directional relationship between conditioned fear and instrumental defensive behavior in humans. We discuss mechanisms involved in the link from fear to goal-directed avoidance (e.g., relief, generalization), that may become habitual. These defensive behaviors may in turn reduce, preserve, or amplify fear responding (e.g., protection-from-extinction, behavior-as-information). Multiple factors moderate the bi-directional relationship. Evidence for amplifying and dampening effects of inter-individual differences (e.g., trait anxiety, distress tolerance), intra-individual states (e.g., stress), and external factors (e.g., incentives for competing behavior) on goal-directed and/or habitual defensive behavior is reviewed. However, the exact mechanisms by which these factors moderate the bi-directional relationship are still largely unknown (e.g., modulating avoidance directly vs. indirectly via conditioned fear). Finally, we discuss major implications: First, understanding factors moderating the bi-directional relationship provides insights into risk and resilience factors for anxious psychopathology. Second, specific experimental models and clinical interventions can be mapped onto distinct defensive behaviors (e.g., goal-directed vs. habitual avoidance). More precise matching will help to develop nuanced models and interventions to reduce pathological behaviors and individualize treatments.</p

Generalization of extinction with a generalization stimulus is determined by learnt threat beliefs

Expectancy violation refers to the mismatch between an expected and the actual outcome. Maximizing expectancy violation is crucial for exposure-based treatment. Since the original stimulus of fear acquisition (CS+) is rarely available, stimuli that resemble the CS+ (generalization stimuli; GSs) are presented during treatment. A given GS may evoke either strong or weak generalized fear depending on an individual's threat beliefs. Presenting this GS in extinction would then evoke different levels of expectancy violation, which determines the strength of the subsequent generalization of extinction to other stimuli, including the CS+. After differential fear conditioning, participants exhibited discrete generalization gradients depending on their inferred relational rules (Linear vs Similarity). Crucially, the Linear group showed strong generalized fear to the GS used in extinction. This strong expectancy violation led to enhanced extinction learning and subsequently to strong generalization of extinction as characterized by a flat generalization gradient, and reduced conditioned fear to the CS+. In contrast, the Similarity group showed weak generalized fear to the same GS in extinction, and limited generalization of extinction. These results corroborate the importance of expectancy violation in exposure-based treatment, and suggest that exposure sessions designed to evoke strong threat beliefs may lead to better treatment outcome.</p

Generalization of extinction with a generalization stimulus is determined by learnt threat beliefs

Expectancy violation refers to the mismatch between an expected and the actual outcome. Maximizing expectancy violation is crucial for exposure-based treatment. Since the original stimulus of fear acquisition (CS+) is rarely available, stimuli that resemble the CS+ (generalization stimuli; GSs) are presented during treatment. A given GS may evoke either strong or weak generalized fear depending on an individual's threat beliefs. Presenting this GS in extinction would then evoke different levels of expectancy violation, which determines the strength of the subsequent generalization of extinction to other stimuli, including the CS+. After differential fear conditioning, participants exhibited discrete generalization gradients depending on their inferred relational rules (Linear vs Similarity). Crucially, the Linear group showed strong generalized fear to the GS used in extinction. This strong expectancy violation led to enhanced extinction learning and subsequently to strong generalization of extinction as characterized by a flat generalization gradient, and reduced conditioned fear to the CS+. In contrast, the Similarity group showed weak generalized fear to the same GS in extinction, and limited generalization of extinction. These results corroborate the importance of expectancy violation in exposure-based treatment, and suggest that exposure sessions designed to evoke strong threat beliefs may lead to better treatment outcome.</p

Increased Anxiety of Public Situations During the COVID-19 Pandemic: Evidence From a Community and a Patient Sample

[Background] Increases in emotional distress in response to the global outbreak of the SARS-CoV-2 (COVID-19) pandemic have been reported. So far, little is known about how anxiety responses in specific everyday public life situations have been affected. [Method] Self-reported anxiety in selected public situations, which are relevant in the COVID-19 pandemic, was investigated in non-representative samples from the community (n = 352) and patients undergoing psychotherapy (n = 228). Situational anxiety in each situation was rated on a 5-point Likert scale (0 = no anxiety at all to 4 = very strong anxiety). Situational anxiety during the pandemic was compared with retrospectively reported situational anxiety before the pandemic (direct change) and with anxiety levels in a matched sample assessed before the pandemic (n = 100; indirect change). [Results] In the community and patient sample, indirect and direct change analyses demonstrated an increase in anxiety in relevant public situations but not in control situations. Average anxiety levels during the pandemic were moderate, but 5-28% of participants reported high to very high levels of anxiety in specific situations. Interestingly, the direct increase in anxiety levels was higher in the community sample: patients reported higher anxiety levels than the community sample before, but not during the pandemic. Finally, a higher increase in situational anxiety was associated with a higher perceived danger of COVID-19, a higher perceived likelihood of contracting COVID-19, and stronger symptoms of general anxiety and stress. [Conclusions] Preliminary findings demonstrate an increase in anxiety in public situations during the COVID-19 pandemic in a community and a patient sample. Moderate anxiety may facilitate compliance with public safety measures. However, high anxiety levels may result in persistent impairments and should be monitored during the pandemic

A network perspective on real-life threat, anxiety, and avoidance

Background: Anxiety, approach, and avoidance motivation crucially influence mental and physical health, especially when environments are stressful. The interplay between anxiety and behavioral motivation is modulated by multiple individual factors. This proof-of-concept study applies graph-theoretical network analysis to explore complex associations between self-reported trait anxiety, approach and avoidance motivation, situational anxiety, stress symptoms, perceived threat, perceived positive consequences of approach, and self-reported avoidance behavior in real-life threat situations. 'Methods: A total of 436 participants who were matched on age and gender (218 psychotherapy patients, 218 online-recruited nonpatients) completed an online survey assessing these factors in response to the COVID-19 pandemic. Results and Discussion: The resulting cross-sectional psychological network revealed a complex pattern with multiple positive (e.g., between trait anxiety, avoidance motivation, and avoidance behavior) and negative associations (e.g., between approach and avoidance motivation). The patient and online subsample networks did not differ significantly, however, descriptive differences may inform future research.</p