Rethinking avoidance: Toward a balanced approach to avoidance in treating anxiety disorders

Abstract

Avoidance is typically considered a maladaptive behavioral response to excessive fear and anxiety, leading to the maintenance of anxiety disorders. Exposure is a core element of cognitive-behavioral therapy for anxiety disorders. One important aspect of this treatment is repeated and prolonged exposure to a threat while discouraging patients from using avoidance strategies, such as escape or safety behaviors. We will first revisit the role of avoidance learning in the development and maintenance of anxiety disorders, including important insights from the neuroscience literature. Next, we will consider both the negative and positive aspects of avoidance for therapeutic interventions. Finally, we will explore the application of adaptive avoidance in exposure therapy for anxiety disorders. We will argue that there are occasions when avoidance behaviors can serve as effective coping strategies to enhance the person's perception of control over the environment and the potential threat. We conclude that avoidance behaviors can be a valuable therapeutic element, depending on the function of these behaviors.

Renewal of instrumental avoidance in humans

“…First, a clear demonstration of renewal in human instrumental avoidance suggests that the principles governing extinction of human instrumental avoidance obey similar principles as those of human fear extinction, and of course extinction (Pavlovian and instrumental) in other animals (Todd, Vurbic & Bouton, 2014). This means that much of what we know about extinction of fear can also be applied to avoidance behaviour, and this is relevant given recent suggestions that considering avoidance as part of the treatment (or as an adjunct to exposure therapy) can be Avoidance renewal 15 beneficial (Hofmann & Hay, 2018;Treanor & Barry, 2017). Second, a design that provides a clear demonstration of renewal in human instrumental avoidance will enable studies investigating the effectiveness of ERP upon changes in contextual background.…”

The Association Between Posttraumatic Negative Self‐Conscious Cognitions and Emotions and Maladaptive Behaviors: Does Time Since Trauma Exposure Matter?

“…These behaviors appear to be deleterious as they may contribute to relational disconnectedness, revictimization, and posttraumatic disorders (e.g., Dorahy, ; Littleton, Horsley, John, & Nelson, ; Najdowski & Ullman, ). To date, the vast majority of research examining factors that may be associated with maladaptive behaviors has focused on fear and anxiety (e.g., Hofmann & Hay, ), although negative self‐conscious cognitions and emotions have been strongly implicated (e.g., Ehlers & Clark, ; Lee et al., ). The current results extend the existing empirical literature (e.g., Street et al., ; Kleim et al., ) by showing a significant combined contribution of negative self‐conscious cognitions and emotions to the variance in dissociation, alcohol use, and avoidant problem‐solving, with medium‐to‐large effect sizes.…”

Renewal of fear and avoidance in humans to escalating threat: Implications for translational research on anxiety disorders

“…Avoidance may also paradoxically increase self-reported fear, while excessive avoidance is likely to facilitate relapse of anxiety symptoms and coping strategies after therapy (Craske, Hermans, & Vervliet, 2018;Craske et al, 2008;Hermans et al, 2006). Indeed, while it is known that avoidance may promote return of fear and interfere with recovery from anxiety disorders (Craske et al, 2018;Treanor & Barry, 2017), evidence suggests that expanding the therapeutic focus from fear alone to include avoidance may lead to a better understanding of why exposure treatments sometimes fail and lead to relapse (Carpenter, Pinaire, & Hofmann, 2019;Hofmann & Hay, 2018;Nakajima, 2014;Vervliet & Indekeu, 2015). As Craske et al (2018) highlighted, "albeit often underappreciated, return of fear is problematic only when accompanied by escape or avoidance behaviors.…”