Avoidance in Fear Conditioning and Anxiety Disorders

This dissertation is a three-paper investigation of ways to improve treatment outcomes for anxiety disorders. Study 1 investigates whether training implicit approach or avoidance to feared stimuli augments or impedes fear extinction. We also investigate whether baseline explicit avoidance predicts extinction performance or future avoidance behavior. Extinction performance is used as a proxy for exposure therapy. Results revealed no effect of training implicit approach or avoidance on extinction performance nor future behavioral avoidance. Baseline explicit avoidance did not predict extinction performance, whereas it did predict future behavioral avoidance. Findings suggest that explicit avoidance may not affect fear extinction in an unambiguous fear-conditioning paradigm, but that it may affect future tendency to approach feared stimuli.Study 2 investigates behavioral avoidance as a moderator of treatment outcome for two behavioral therapies for social anxiety disorder. Individuals who were highly behaviorally avoidant on a public speaking task had better long-term treatment outcomes following cognitive behavioral therapy (CBT) than acceptance and commitment therapy. From a deficit correction model, individuals who are more behaviorally avoidant may benefit from a treatment that more systematically targets that avoidance. A version of this work has been published in the Journal of Behavior Therapy and Experimental Psychiatry (2017).Study 3 investigates interoceptive and in vivo avoidance as moderators of treatment outcome for two different CBTs for panic disorder. Individuals who displayed more in vivo avoidance at baseline had better outcome following CBT with interoceptive exposures than CBT with interoceptive and in vivo exposures. This suggests that avoidant individuals benefit more from a therapy that targets their primary interoceptive concerns as opposed to one that expands to in vivo avoidance.Taken together, these studies aim to improve treatment outcomes in behavioral therapies for anxiety disorders. Study 1 suggests that retraining implicit approach avoidance behavior does not augment fear extinction in an unambiguous fear conditioning design. Studies 2 and 3 suggest that individuals with anxiety disorders who are highly avoidant at baseline may benefit from treatments that explicitly target their primary avoidance. This line of research can provide evidence-based methods for treatment selection to better match individuals to specific therapies. Additionally, all three studies contribute to our understanding of implicit and explicit avoidance in fear and anxiety

Avoidance in Fear Conditioning and Anxiety Disorders

This dissertation is a three-paper investigation of ways to improve treatment outcomes for anxiety disorders. Study 1 investigates whether training implicit approach or avoidance to feared stimuli augments or impedes fear extinction. We also investigate whether baseline explicit avoidance predicts extinction performance or future avoidance behavior. Extinction performance is used as a proxy for exposure therapy. Results revealed no effect of training implicit approach or avoidance on extinction performance nor future behavioral avoidance. Baseline explicit avoidance did not predict extinction performance, whereas it did predict future behavioral avoidance. Findings suggest that explicit avoidance may not affect fear extinction in an unambiguous fear-conditioning paradigm, but that it may affect future tendency to approach feared stimuli.Study 2 investigates behavioral avoidance as a moderator of treatment outcome for two behavioral therapies for social anxiety disorder. Individuals who were highly behaviorally avoidant on a public speaking task had better long-term treatment outcomes following cognitive behavioral therapy (CBT) than acceptance and commitment therapy. From a deficit correction model, individuals who are more behaviorally avoidant may benefit from a treatment that more systematically targets that avoidance. A version of this work has been published in the Journal of Behavior Therapy and Experimental Psychiatry (2017).Study 3 investigates interoceptive and in vivo avoidance as moderators of treatment outcome for two different CBTs for panic disorder. Individuals who displayed more in vivo avoidance at baseline had better outcome following CBT with interoceptive exposures than CBT with interoceptive and in vivo exposures. This suggests that avoidant individuals benefit more from a therapy that targets their primary interoceptive concerns as opposed to one that expands to in vivo avoidance.Taken together, these studies aim to improve treatment outcomes in behavioral therapies for anxiety disorders. Study 1 suggests that retraining implicit approach avoidance behavior does not augment fear extinction in an unambiguous fear conditioning design. Studies 2 and 3 suggest that individuals with anxiety disorders who are highly avoidant at baseline may benefit from treatments that explicitly target their primary avoidance. This line of research can provide evidence-based methods for treatment selection to better match individuals to specific therapies. Additionally, all three studies contribute to our understanding of implicit and explicit avoidance in fear and anxiety

Attentional bias and emotional reactivity as predictors and moderators of behavioral treatment for social phobia.

Cognitive behavioral therapy (CBT) is a well-established treatment for anxiety disorders, and evidence is accruing for the effectiveness of acceptance and commitment therapy (ACT). Little is known about factors that relate to treatment outcome overall (predictors), or who will thrive in each treatment (moderators). The goal of the current project was to test attentional bias and negative emotional reactivity as moderators and predictors of treatment outcome in a randomized controlled trial comparing CBT and ACT for social phobia. Forty-six patients received 12 sessions of CBT or ACT and were assessed for self-reported and clinician-rated symptoms at baseline, post treatment, 6, and 12 months. Attentional bias significantly moderated the relationship between treatment group and outcome with patients slow to disengage from threatening stimuli showing greater clinician-rated symptom reduction in CBT than in ACT. Negative emotional reactivity, but not positive emotional reactivity, was a significant overall predictor with patients high in negative emotional reactivity showing the greatest self-reported symptom reduction

Attentional bias and emotional reactivity as predictors and moderators of behavioral treatment for social phobia.

Cognitive behavioral therapy (CBT) is a well-established treatment for anxiety disorders, and evidence is accruing for the effectiveness of acceptance and commitment therapy (ACT). Little is known about factors that relate to treatment outcome overall (predictors), or who will thrive in each treatment (moderators). The goal of the current project was to test attentional bias and negative emotional reactivity as moderators and predictors of treatment outcome in a randomized controlled trial comparing CBT and ACT for social phobia. Forty-six patients received 12 sessions of CBT or ACT and were assessed for self-reported and clinician-rated symptoms at baseline, post treatment, 6, and 12 months. Attentional bias significantly moderated the relationship between treatment group and outcome with patients slow to disengage from threatening stimuli showing greater clinician-rated symptom reduction in CBT than in ACT. Negative emotional reactivity, but not positive emotional reactivity, was a significant overall predictor with patients high in negative emotional reactivity showing the greatest self-reported symptom reduction

Public speaking avoidance as a treatment moderator for social anxiety disorder.

Background and objectivesCognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) have both garnered empirical support for the effective treatment of social anxiety disorder. However, not every patient benefits equally from either treatment. Identifying moderators of treatment outcome can help to better understand which treatment is best suited for a particular patient.MethodsForty-nine individuals who met criteria for social anxiety disorder were assessed as part of a randomized controlled trial comparing 12 weeks of CBT and ACT. Pre-treatment avoidance of social situations (measured via a public speaking task and clinician rating) was investigated as a moderator of post-treatment, 6-month follow-up, and 12-month follow-up social anxiety symptoms, stress reactivity, and quality of life.ResultsPublic speaking avoidance was found to be a robust moderator of outcome measures, with more avoidant individuals generally benefitting more from CBT than ACT by 12-month follow-up. In contrast, clinician-rated social avoidance was not found to be a significant moderator of any outcome measure.LimitationsResults were found only at 12-month follow-up. More comprehensive measures of avoidance would be useful for the field moving forward.ConclusionsFindings inform personalized medicine, suggesting that social avoidance measured behaviorally via a public speaking task may be a more robust factor in treatment prescription compared to clinician-rated social avoidance

Neural connectivity during affect labeling predicts treatment response to psychological therapies for social anxiety disorder

BackgroundAlthough psychological treatments for social anxiety disorder (SAD) can be highly effective, many individuals do not respond to treatment. Identifying factors associated with improved outcomes can facilitate individualized treatment choices. We investigated whether patterns of neural connectivity predicted treatment responses and whether treatment type, cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT), moderated this effect.MethodsParticipants with SAD (n = 34) underwent fMRI prior to treatment and completed implicit and explicit emotion regulation tasks. Neural connectivity measures were estimates of amygdala-prefrontal cortex connectivity. Treatment responder status was defined using the 'clinically significant change index' (Loerinc et al., 2015).ResultsRight amygdala-right ventrolateral prefrontal cortex connectivity during implicit emotion regulation was a significant predictor of treatment response (OR = 9.01, 95% CI = 1.77, 46.0, p = .008). Stronger inverse connectivity was associated with greater likelihood of treatment response. There were no significant neural moderators of treatment response to CBT versus ACT.LimitationsThe primary limitation of this work was the small sample size which restricted the power to detect significant moderation effects, and results should be interpreted as preliminary.ConclusionsAmygdala-vlPFC connectivity during affect labeling predicted treatment responder status following CBT or ACT for social anxiety disorder. This suggests that the functioning of neural circuitry supporting emotion regulation capacities may be a 'gateway' to receiving benefit from psychological treatments. Future work should aim to replicate this effect in a larger sample and consider methods for enhancing functional connectivity within this circuitry as a potential treatment adjunct