The Good, the Bad, and the Ugly—Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

Abstract

Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.

Trauma-Informed Design of Supported Housing: A Scoping Review through the Lens of Neuroscience

“…Learning that an environment/cue is safe or learning to avoid a predicted aversive event not only reduces the physiological and behavioral reactions seen during the recall of fear memories, it also produces positive emotional states that reward the attainment and occupation of safe spaces within an environment (e.g., a nest) [ 68 , 69 ]. Consistent with this, deficits in learning about safety and, as such, to make use of sources of safety in the environment is a key symptom of PTSD [ 69 , 70 , 71 , 72 ].…”

Prefrontal dopamine circuits are required for active avoidance learning but not for fear learning

“…Primary treatments include cognitive behavioral therapy and drugs whose targets cluster in neuromodulatory systems, including in the dopamine system. But once instantiated, excessive avoidance can interfere with therapy and exacerbate features of psychiatric illness 61 . Establishing a mechanistically detailed and temporally specific understanding of the role of mPFC DA in specific types of learning promises to enable more precise interventions that combine pharmacologic, brain stimulation and/or psychotherapeutic modalities during precise windows of vulnerability or capacity for change.…”

Cellular Processes and Synaptic Interactions in Nuclei of the Amygdala

“…In this paradigm, participants are exposed to neutral stimuli (such as tones or images) paired with aversive stimuli (such as electric shocks or unpleasant images). Over time, the neutral stimuli become associated with fear responses [73][74][75]. The amygdala is critically involved in the acquisition and consolidation of fear-related memories during fear conditioning.…”