Relapse of anxiety‐related fear and avoidance: Conceptual analysis of treatment with acceptance and commitment therapy

Abstract

Excessive fear and avoidance in relatively safe situations can lead to a narrowing of one's behavioral repertoire and less engagement with valued aspects of living. Ultimately, these processes can reach clinical levels, as seen in anxiety, trauma, and obsessive-compulsive disorders. Research on the basic behavioral processes underlying successful treatment with exposure therapy is growing, yet little is known about the mechanisms contributing to clinical relapse. Until recently, these mechanisms have largely been conceptualized in terms of Pavlovian return of fear, with relatively little research into operant processes. In the current paper, we briefly review translational research in anxiety disorders and the connections between fear and avoidance, focusing on recent work in the acquisition, extinction, and relapse of avoidance behavior and the generalization of this learning through arbitrary symbolic relations. We then introduce one possible treatment approach to mitigating clinical relapse, acceptance and commitment therapy (ACT), and provide a conceptual analysis for why ACT may be especially well-situated to address this issue. Finally, we end with potential directions for future research on treatment and relapse of anxiety disorders.

Resurgence and downshifts in alternative reinforcement rate

“…Resurgence is theoretically important because it provides a testing ground for examining core questions about the allocation and regulation of operant behavior across time and changing circumstances (see Shahan, 2017, 2020, for discussions). Further, resurgence is of applied significance because it may contribute to instances of treatment relapse following otherwise successful differential‐reinforcement‐based interventions for a range of problematic behaviors including, but not limited to, destructive behavior in intellectual and developmental disorders (e.g., Volkert et al, 2009; Wacker et al, 2011), substance abuse (e.g., Podlesnik et al, 2006; Quick et al, 2011; Silverman et al, 1999) and anxiety disorders (see Smith et al, 2020).…”

Transitions from avoidance: Reinforcing competing behaviours reduces generalised avoidance in new contexts

“…To manage avoidance, exposure therapy typically relies on Pavlovian procedures that are also effective at reducing fear like extinction learning (Treanor & Barry, 2017). However, techniques derived from operant principles might be useful adjuncts to standard treatments because avoidance is a product of operant conditioning (Dinsmoor, 2001; Smith et al, 2020). One operant-based approach to reduce avoidance might be to reinforce competing and incompatible behaviours (Petscher et al, 2009; Poling & Ryan, 1982).…”

The Infinity Formulation: how transdiagnostic behaviours and endeavours for behavioural change serve to maintain co-morbid mental health presentations

“…1, this triggers core, intermediate and/or automatic thoughts typically associated with one of the diagnosis-specific presentations (Beck, 2011), such as worry in anxiety (Wells, 1997), depressive cognitive content in depression (Beck and Perkins, 2001), over-valuation of eating, weight or shape in eating disorders (Fairburn et al, 2003) or threat beliefs in paranoia (Freeman, 2016). This in turn develops into a cycle in which rumination and/or avoidance serve to maintain the initial presentation in any one of the presentations in which one of these behaviours has been implicated [avoidance: psychosis (Tully et al, 2017), eating pathology (MacLeod et al, 2019), depression (Huang et al, 2019), anxiety disorders (Smith et al, 2020); rumination: mood disorders (Wahl et al, 2019), BPAD (Hanssen et al, 2018), eating disorders (Cowdrey and Park, 2012), psychosis (Hartley et al, 2014)]. The consequences of these behaviours (e.g.…”