Anxiety as a disorder of uncertainty: Implications for understanding maladaptive anxiety, anxious avoidance, and exposure therapy

Abstract

Cognitive-behavioral conceptualizations of anxiety view exaggerated threat expectancies as central to maladaptive anxiety. This view has led to successful treatments, notably exposure therapy, but is not consistent with the empirical literature on learning and choice alterations in anxiety. Empirically, anxiety is better described as a disorder of uncertainty. How disruptions in uncertainty lead to impairing avoidance and are treated with exposure-based methods, however, is unclear. Here, we integrate concepts from neurocomputational learning models with clinical literature on exposure therapy to propose a new framework for understanding maladaptive uncertainty functioning in anxiety, particularly fear-based disorders. Specifically, we propose that anxiety disorders are fundamentally disorders of uncertainty learning and that successful treatments, particularly exposure therapy, work by remediating maladaptive avoidance from dysfunctional explore/exploit decisions in uncertain, potentially aversive situations. This framework reconciles several inconsistencies in the literature and provides a path forward to better understand and treat anxiety.