Elevated costly avoidance in anxiety disorders: Patients show little downregulation of acquired avoidance in face of competing rewards for approach

Abstract

Background Pathological avoidance is a transdiagnostic characteristic of anxiety disorders. Avoidance conditioning re‐emerged as a translational model to examine mechanisms and treatment of avoidance. However, its validity for anxiety disorders remains unclear. Methods This study tested for altered avoidance in patients with anxiety disorders compared to matched controls (n = 40/group) using instrumental conditioning assessing low‐cost avoidance (avoiding a single aversive outcome) and costly avoidance (avoidance conflicted with gaining rewards). Autonomic arousal and threat expectancy were assessed as indicators of conditioned fear. Associations with dimensional symptom severity were examined. Results Patients and controls showed frequent low‐cost avoidance without group differences. Controls subsequently inhibited avoidance to gain rewards, which was amplified when aversive outcomes discontinued. In contrast, patients failed to reduce avoidance when aversive and positive outcomes competed (elevated costly avoidance) and showed limited reduction when aversive outcomes discontinued (persistent costly avoidance). Interestingly, elevated costly avoidance was not linked to higher conditioned fear in patients. Moreover, individual data revealed a bimodal distribution of costly avoidance: Some patients showed persistent avoidance, others showed little to no avoidance. Persistent versus low avoiders did not differ in other task‐related variables, response to gains and losses in absence of threat, sociodemographic data, or clinical characteristics. Conclusions Findings suggest that anxious psychopathology is associated with a deficit to inhibit avoidance in presence of competing positive outcomes. This offers novel perspectives for research on mechanisms and treatment of anxiety disorders.

Costly avoidance of Pavlovian fear stimuli and the temporal dynamics of its decision process

“…However, it has been argued that their validity for costly avoidance in clinical settings is limited 6 , 9 . In support, we recently demonstrated that patients with anxiety disorders compared to matched healthy controls show similar levels of low-cost avoidance, but fail to reduce avoidance in presence of competing rewards for approach 10 . Thus, more and more studies apply approach-avoidance conflict tasks where approach is concurrently linked to varying aversive but also appetitive outcomes (e.g., monetary incentives).…”

“…However, little is known about the underlying decision process leading up to this behavior. In previous work, we found elevated avoidance in patients with anxiety disorders during approach-avoidance decision conflicts (i.e., when US-avoidance conflicted with gaining rewards) 10 . Interestingly, reward and threat contingencies were easily acquired and patients did not differ from matched controls during US-avoidance in absence of conflicting rewards.…”

“…Interestingly, reward and threat contingencies were easily acquired and patients did not differ from matched controls during US-avoidance in absence of conflicting rewards. This suggests that elevated costly avoidance in patients is at least to some degree linked to deficits in the decision process during approach-avoidance conflicts rather than merely to deficits in learning 10 . Disentangling decision-making from learning is best done by providing subjects with all relevant information on the available options before they take a decision (i.e., learning is not required).…”

Striatal reactivity during emotion and reward relates to approach–avoidance conflict behaviour and is altered in adults with anxiety or depression

“…Behavioural AAC studies that compare healthy and clinical populations are rare and results have been mixed, suggesting either greater avoidance in adults with anxiety disorders 29 or similar avoidance with greater response inconsistency in an adult transdiagnostic anxiety or depression sample. 30 Differences between AAC task paradigms might partially explain these mixed behavioural findings.…”

Reducing the return of avoidance and fear by directly targeting avoidance: Comparing incentive-based and instructed extinction of avoidance to passive fear extinction

“…First, novel findings provide clinical utility as both strategies can be seen as proxies for therapeutic interventions. Instructions to “test whether a feared outcome does occur” can be seen as a laboratory proxy of the prediction-error based exposure rationale (Craske et al, 2022; Pittig et al, 2022; Pittig, Heinig, et al, 2021). Incentive-based extinction translates to therapeutic strategies emphasizing positive outcomes for approaching a feared situation.…”