The effects of cortisol administration on approach–avoidance behavior: An event-related potential study

Do stress hormones influence choice? A systematic review of pharmacological interventions on the HPA axis and/or SAM system

The hypothalamus-pituitary-adrenal axis (HPA axis) and the sympathetic-adrenal-medullary system (SAM system), two neuroendocrine systems associated with the stress response, have often been implicated to modulate decision-making in various domains. This systematic review summarizes the scientific evidence on the effects of pharmacological HPA axis and SAM system modulation on decision-making. We found 6375 references, of which 17 studies fulfilled our inclusion criteria. We quantified the risk of bias in our results with respect to missing outcome data, measurements, and selection of the reported results. The included studies administered hydrocortisone, fludrocortisone (HPA axis stimulants), yohimbine, reboxetine (SAM system stimulants), and/or propranolol (SAM system inhibitor). Integrating the evidence, we found that SAM system stimulation had no impact on risk aversion, loss aversion or intertemporal choice, while SAM system inhibition showed a tentative reduction in sensitivity to losses. HPA axis stimulation had no effect on loss aversion or reward anticipation but likely a time-dependent effect on decision under risk. Lastly, combined stimulation of both systems exhibited inconsistent results that could be explained by dose differences (loss aversion) and sex differences (risk aversion). Future research should address time-, dose-, and sex-dependencies of pharmacological effects on decision-making.

Hydrocortisone reduces altruistic punishment in healthy men

Psychosocial stress modulates social cognition and behavior in humans. One potentially mediating factor is cortisol as part of the human endocrine stress response. With a double-blind, placebo-controlled between-subject study design, we tested possible dose-dependent effects of hydrocortisone (0 mg, 5 mg and 20 mg) in 85 healthy males. During a socio-economic decision-making task we measured trust, trustworthiness, sharing, punishment, and non-social risk behavior. Social value orientation (SVO) was also assessed. We observed significantly lower levels of punishment after hydrocortisone, especially in the 20 mg group. Drug-induced salivary cortisol correlated negatively with punishment behavior. None of the other facets of social behavior or the SVO were affected by hydrocortisone. Our results suggest that hydrocortisone reduces the propensity to punish unfair behavior. Future studies are needed to further disentangle the role played by various psychobiological mechanisms within the stress response as well as their complex interplay on social behavior and cognition.

How pre-processing decisions affect the reliability and validity of the approach-avoidance task: Evidence from simulations and multiverse analyses with six datasets

Reaction time (RT) data are often pre-processed before analysis by rejecting outliers and errors and aggregating the data. In stimulus-response compatibility paradigms such as the approach-avoidance task (AAT), researchers often decide how to pre-process the data without an empirical basis, leading to the use of methods that may harm data quality. To provide this empirical basis, we investigated how different pre-processing methods affect the reliability and validity of the AAT. Our literature review revealed 108 unique pre-processing pipelines among 163 examined studies. Using empirical datasets, we found that validity and reliability were negatively affected by retaining error trials, by replacing error RTs with the mean RT plus a penalty, and by retaining outliers. In the relevant-feature AAT, bias scores were more reliable and valid if computed with D-scores; medians were less reliable and more unpredictable, while means were also less valid. Simulations revealed bias scores were likely to be less accurate if computed by contrasting a single aggregate of all compatible conditions with that of all incompatible conditions, rather than by contrasting separate averages per condition. We also found that multilevel model random effects were less reliable, valid, and stable, arguing against their use as bias scores. We call upon the field to drop these suboptimal practices to improve the psychometric properties of the AAT. We also call for similar investigations in related RT-based bias measures such as the implicit association task, as their commonly accepted pre-processing practices involve many of the aforementioned discouraged methods. HIGHLIGHTS: • Rejecting RTs deviating more than 2 or 3 SD from the mean gives more reliable and valid results than other outlier rejection methods in empirical data • Removing error trials gives more reliable and valid results than retaining them or replacing them with the block mean and an added penalty • Double-difference scores are more reliable than compatibility scores under most circumstances • More reliable and valid results are obtained both in simulated and real data by using double-difference D-scores, which are obtained by dividing a participant's double mean difference score by the SD of their RTs.

Developmental shift in testosterone influence on prefrontal emotion control

A paradox of testosterone effects is seen in adolescents versus adults in social emotional approach-avoidance behavior. During adolescence, high testosterone levels are associated with increased anterior prefrontal (aPFC) involvement in emotion control, whereas during adulthood this neuro-endocrine relation is reversed. Rodent work shows that, during puberty, testosterone transitions from a neuro-developmental to a social-sexual activating hormone. In this study, we explored whether this functional transition is also present in human adolescents and young adults. Using a prospective longitudinal design, we investigated the role of testosterone on neural control of social emotional behavior during the transitions from middle to late adolescence and into young adulthood. Seventy-one individuals (tested at ages 14, 17, and 20 years) performed an fMRI-adapted approach-avoidance (AA) task involving automatic and controlled actions in response to social emotional stimuli. In line with predictions from animal models, the effect of testosterone on aPFC engagement decreased between middle and late adolescence, and shifted into an activational role by young adulthood-impeding neural control of emotions. This change in testosterone function was accompanied by increased testosterone-modulated amygdala reactivity. These findings qualify the testosterone-dependent maturation of the prefrontal-amygdala circuit supporting emotion control during the transition from middle adolescence into young adulthood.

The moderating role of adrenocortical reactivity in the associations between interparental conflict, emotional reactivity, and school adjustment

This study tested whether the associations between interparental conflict, children's emotional reactivity, and school adjustment were moderated by children's cortisol reactivity in a sample of young children (N = 243; mean age = 4.6 years at Wave 1; 56% female, 44% male) and their parents. Using a longitudinal, autoregressive design, observational assessments of children's emotional reactivity at Wave 2 mediated the relationship between an observational measure of Wave 1 conflict between parents and teacher's report of children's school adjustment at Wave 3. However, children's cortisol reactivity to parent conflict at Wave 1 moderated the first link, such that emotional reactivity operated as a mediator for children with heightened cortisol reactivity but not children with low cortisol reactivity. Moderation was expressed in a "for better" or "for worse" form hypothesized by biological sensitivity to context theory. Thus, children with high cortisol reactivity experienced greater emotional reactivity than their peers when faced with more destructive conflict but also lower emotional reactivity when exposed to more constructive interparental conflict. Results are discussed as to how they advance emotional security and biological sensitivity to context theories.

The Impact of the Perception of Primary Facial Emotions on Corticospinal Excitability

The link between emotional experience and motor body responses has long been acknowledged. A well-established approach to exploring the effect of the perception of emotional stimuli on the motor system is measuring variations in the excitability of the corticospinal tract (CSE) through motor-evoked potentials (MEP) elicited via transcranial magnetic stimulation (TMS). Previous evidence has indicated a selective increase in MEP amplitude while participants view emotional stimuli, such as emotional facial expressions, compared to neutral cues. However, it is still not clear whether this effect depends on the specific emotional meaning conveyed by the stimulus. In the present study, we explored whether viewing faces expressing the primary emotions compared to faces with a neutral expression affects individuals' CSE, measured using TMS-elicited MEPs. Specifically, we elicited MEPs from the left motor cortex (M1) while participants passively viewed the same faces expressing either anger, fear, disgust, happiness, sadness, surprise, and no emotion (in different blocks). We found that the observation of fearful, angry, disgusted, and happy facial expressions was associated with a significant increase in the MEPs' amplitude compared to neutral facial expressions, with a comparable enhancement in the CSE occurring across these emotions. In turn, viewing sad and surprised faces did not modulate the CSE. Overall, our findings suggest that only facial expressions that signal (real or potential) danger or a rewarding stimulus, but not emotional facial expressions per se, are capable of activating action-related mechanisms.

Neural evidence of face processing in social anxiety disorder: A systematic review with meta-analysis

Numerous previous studies have used event-related potentials (ERPs) to examine facial processing deficits in individuals with social anxiety disorder (SAD). However, researchers still need to determine whether the deficits are general or specific and what the dominant factors are behind different cognitive stages. Meta-analysis was performed to quantitatively identify face processing deficits in individuals with SAD. Ninety-seven results in 27 publications involving 1032 subjects were calculated using Hedges' g. The results suggest that the face itself elicits enlarged P1 amplitudes, threat-related facial expressions induce larger P2 amplitudes, and negative facial expressions lead to enhanced P3/LPP amplitudes in SAD individuals compared with controls. That is, there is face perception attentional bias in the early phase (P1), threat attentional bias in the mid-term phase (P2), and negative emotion attentional bias in the late phase (P3/LPP), which can be summarized into a three-phase SAD face processing deficit model. These findings provide an essential theoretical basis for cognitive behavioral therapy and have significant application value for the initial screening, intervention, and treatment of social anxiety.

The effects of hydrocortisone and yohimbine on human behavior in approach-avoidance conflicts

RATIONALE

Balancing approach of positive and avoidance of negative stimuli is essential when faced with approach-avoidance conflicts, e.g., situations with both positive and negative outcomes. This balance is disturbed in several mental disorders, e.g., excessive avoidance in anxiety disorders, and heightened approach in substance use disorders. Since stress is assumed to impact these disorders' etiology and maintenance, it seems crucial to understand how stress influences behavior in approach-avoidance conflicts. Indeed, some studies suggested altered approach-avoidance behavior under acute stress, but the mechanism underlying these effects is unknown.

OBJECTIVES

Investigate how the pharmacological manipulation of major stress mediators (cortisol and noradrenaline) influences task-based approach-avoidance conflict behavior in healthy individuals.

METHODS

Ninety-six participants (48 women, 48 men) received either 20mg hydrocortisone, 20mg yohimbine, both, or placebo before performing a task targeting foraging under predation in a fully crossed double-blind between-subject design. Moreover, we investigated effects of gender and endogenous testosterone and estradiol levels on approach-avoidance behavior.

RESULTS

While biological stress markers (cortisol concentration, alpha amylase activity) indicated successful pharmacological manipulation, behavior in approach-avoidance conflicts was not affected as expected. Although yohimbine administration affected risky foraging latency under predation, we found no main effect of hydrocortisone or their interaction on behavior. In contrast, we found gender differences for almost all behavioral outcome measures, which might be explained by differences in endogenous testosterone levels.

CONCLUSIONS

The investigated major stress mediators were not sufficient to imitate previously shown stress effects on approach-avoidance conflict behavior. We discuss potential reasons for our findings and implications for future research.

Conflict in a word-based approach-avoidance task is stronger with positive words

BACKGROUND

Valence and motivational direction are linked. We approach good things and avoid bad things, and experience overriding these links as conflicting. Positive valence is more consistently linked with approach than negative valence is linked with avoidance. Therefore, avoiding positive stimuli should produce greater behavioral and neural signs of conflict than approaching negative stimuli.

METHODS

In the present event-related potential study, we tested this assumption by contrasting positive and negative conflict. We used the manikin task, in which we read positive and negative words that they needed to approach and avoid.

RESULTS

Consistent with our prediction, positive conflict prolonged reaction times more than negative conflict did. A late (500-1000 ms following word onset) event-related potential that we identified as the Conflict slow potential, was only sensitive to positive conflict.

CONCLUSION

The results of this study support the notion that avoiding positive stimuli is more conflicting than approaching negative stimuli. The fact that the conflict slow potential is typically sensitive to response conflict rather than stimulus conflict suggests that the manikin task primarily requires people to override prepotent responses rather than to identify conflicting stimuli. Thus, the present findings also shed light on the psychological processes subserving conflict resolution in the manikin task.

Behavioural approach-avoidance tendencies among individuals with elevated blood pressure

Emotional dampening (blunted responses to affective stimuli or experiences) has been reported in individuals with clinical and subclinical levels of elevated blood pressure (BP). Our aim in the present study was to explore how the basic motivational systems of approach and avoidance to positively- and negatively-valenced stimuli are affected in elevated BP. High BP (n = 27) and Low BP (n = 29) participants completed an approach-avoidance task. In this task, participants pulled the joystick towards them when viewing a happy face (approach) and pushing it away when viewing an angry face (avoid) in the congruent condition, and reversed these action-to-emotion pairings in the incongruent condition. A mixed-design ANOVA revealed a significant main effect of condition, such that overall participants were faster across trials in the congruent than trials of the incongruent condition. There was also an emotion x BP interaction. Among the Low BP group, there were no RT differences to happy and angry expressions (across congruent and incongruent conditions) but those with High BP were quicker to respond to actions paired with angry than happy facial expressions (across conditions). Findings suggest that valence-specific motivational reactions are not dampened with an increase in BP, and are rather sensitized for the negative emotion of anger.

Supplementary information

The online version contains supplementary material available at 10.1007/s12144-023-04337-2.

A Systematic Review of the Role of Oxytocin, Cortisol, and Testosterone in Facial Emotional Processing

A topic of interest is the way decoding and interpreting facial emotional expressions can lead to mutual understanding. Facial emotional expression is a basic source of information that guarantees the functioning of other higher cognitive processes (e.g., empathy, cooperativity, prosociality, or decision-making, among others). In this regard, hormones such as oxytocin, cortisol, and/or testosterone have been found to be important in modifying facial emotion processing. In fact, brain structures that participate in facial emotion processing have been shown to be rich in receptors for these hormones. Nonetheless, much of this research has been based on correlational designs. In recent years, a growing number of researchers have tried to carry out controlled laboratory manipulation of these hormones by administering synthetic forms of these hormones. The main objective of this study was to carry out a systematic review of studies that assess whether manipulation of these three hormones effectively promotes significant alterations in facial emotional processing. To carry out this review, PRISMA quality criteria for reviews were followed, using the following digital databases: PsycINFO, PubMed, Dialnet, Psicodoc, Web of Knowledge, and the Cochrane Library, and focusing on manuscripts with a robust research design (e.g., randomized, single- or double-blind, and/or placebo-controlled) to increase the value of this systematic review. An initial identification of 6340 abstracts and retrieval of 910 full texts led to the final inclusion of 101 papers that met all the inclusion criteria. Only about 18% of the manuscripts included reported a direct effect of hormone manipulation. In fact, emotional accuracy seemed to be enhanced after oxytocin increases, but it diminished when cortisol and/or testosterone increased. Nonetheless, when emotional valence and participants' gender were included, hormonal manipulation reached significance (in around 53% of the articles). In fact, these studies offered a heterogeneous pattern in the way these hormones altered speed processing, attention, and memory. This study reinforces the idea that these hormones are important, but not the main modulators of facial emotion processing. As our comprehension of hormonal effects on emotional processing improves, the potential to design good treatments to improve this ability will be greater.

Neural correlates of negative expectancy and impaired social feedback processing in social anxiety

Social anxiety has been associated with abnormalities in cognitive processing in the literature, manifesting as various cognitive biases. To what extent these biases interrupt social interactions remains largely unclear. This study used the Social Judgment Paradigm that could separate the expectation and experience stages of social feedback processing. Event-related potentials (ERPs) in these two stages were recorded to detect the effect of social anxiety that might not be reflected by behavioral data. Participants were divided into two groups according to their social anxiety level. Participants in the high social anxiety (HSA) group were more likely to predict that they would be socially rejected by peers than did their low social anxiety (LSA) counterparts (i.e. the control group). Compared to the ERP data of the LSA group, the HSA group showed: (a) a larger P1 component to social cues (peer faces) prior to social feedback presentation, possibly indicating an attention bias; (b) a difference in feedback-related negativity amplitude between unexpected social acceptance and unexpected social rejection, possibly indicating an expectancy bias; and (c) a diminished sensitivity of the P3 amplitude to social feedback valence (be accepted/be rejected), possibly indicating an experience bias. These results could help understand the cognitive mechanisms that comprise and maintain social anxiety.

The effects of acute stress and stress hormones on social cognition and behavior: Current state of research and future directions

Stress encompasses profound psychological and physiological changes that are observable on all levels, from cellular mechanisms, humoral changes, and brain activation to subjective experience and behavior. While the impact of stress on health has already been studied for decades, a more recent field of research has revealed effects of stress on human social cognition and behavior. Initial studies have attempted to elucidate the underlying biological mechanisms of these stress-induced effects by measuring physiological responses or by using pharmacological approaches. We provide an overview of the current state of research on the effects of acute stress induction or pharmacological manipulations of stress-related neuro circuitry on social cognition and behavior. Additionally, we discuss the methodological challenges that need to be addressed in order to gain further insight into this important research topic and facilitate replicability of results. Future directions may help to disentangle the complex interplay of psychological and biological stress variables and their effects on social cognition and behavior on health and in disorders with social deficits.

A Cross-sectional Study of Attention Bias for Facial Expression Stimulation in Patients with Stroke at the Convalescence Stage

BACKGROUND

Post-stroke depression increases the likelihood of adverse physical symptoms. Attentional bias (AB) for negative stimuli is important in depression onset, maintenance, and remission. Stroke is more likely in older adults, who can have reduced cognitive function. Individuals with mild cognitive impairment (MCI) can have delayed reaction times (RTs). We hypothesized that RT to select neutral facial expression is affected by depressive symptoms and cognitive function in patients with stroke.

METHODS

This study analyzed 61 patients with stroke. Beck Depression Inventory-Second Edition (BDI-II) and Profile of Mood States (short version) scores were determined. Task stimuli comprised eight pairs of facial expressions containing affective (angry) and neutral faces. AB was measured as the RT to select the neutral face in two simultaneously presented images using attention bias modification (ABM) software. Patients were grouped according to depressive symptoms using BDI-II scores. Between-subject factors of depressive symptoms and cognitive function were determined by ANCOVA.

RESULTS

No significant interaction was found between depressive symptoms and cognitive function on RT. There was a main effect of cognitive function, but not depressive symptoms. In patients with hemiparesis and depressive symptoms, RT was significantly shorter in patients without MCI compared with patients with MCI.

CONCLUSIONS

People with stroke and elevated depression symptoms with hemiparesis but without MCI quickly selected neutral facial expressions from neutral and aversive expressions, and thus do not need ABM to escape aversive stimuli. ABM in response to aversive stimuli may be useful in evaluating negative emotions in individuals with post-stroke depression without MCI.

Molecular and neurocircuitry mechanisms of social avoidance

Humans and animals live in social relationships shaped by actions of approach and avoidance. Both are crucial for normal physical and mental development, survival, and well-being. Active withdrawal from social interaction is often induced by the perception of threat or unpleasant social experience and relies on adaptive mechanisms within neuronal networks associated with social behavior. In case of confrontation with overly strong or persistent stressors and/or dispositions of the affected individual, maladaptive processes in the neuronal circuitries and its associated transmitters and modulators lead to pathological social avoidance. This review focuses on active, fear-driven social avoidance, affected circuits within the mesocorticolimbic system and associated regions and a selection of molecular modulators that promise translational potential. A comprehensive review of human research in this field is followed by a reflection on animal studies that offer a broader and often more detailed range of analytical methodologies. Finally, we take a critical look at challenges that could be addressed in future translational research on fear-driven social avoidance.

Event-related and readiness potentials when preparing to approach and avoid alcohol cues following cue avoidance training in heavy drinkers

RATIONALE

Cue avoidance training (CAT) reduces alcohol consumption in the laboratory. However, the neural mechanisms that underlie the effects of this intervention are poorly understood.

OBJECTIVES

The present study investigated the effects of a single session of CAT on event-related and readiness potentials during preparation of approach and avoidance movements to alcohol cues.

METHODS

Heavy drinking young adults (N = 60) were randomly assigned to complete either CAT or control training. After training, we recorded participants' event-related and motor readiness potentials as they were preparing to respond.

RESULTS

In the CAT group, N200 amplitude was higher when preparing to approach rather than avoid alcohol pictures. In the control group, N200 amplitudes did not differ for approach and avoidance to alcohol pictures. Regarding the late positive potential (LPP), in the CAT group, the negativity of this was blunted when preparing to avoid alcohol pictures relative to when preparing to avoid control pictures. In the control group, the negativity of the LPP was blunted when preparing to approach alcohol pictures relative to when preparing to approach control pictures. There were no effects on motor readiness potentials. Behavioural effects indicated short-lived effects of training on reaction times during the training block that did not persist when participants were given time to prepare their motor response before executing it during the EEG testing block.

CONCLUSIONS

After a single session of CAT, the enhanced N200 when approaching alcohol cues may indicate the engagement of executive control to overcome the associations learned during training. These findings clarify the neural mechanisms that may underlie the effects of CAT on drinking behaviour.

How interindividual differences shape approach-avoidance behavior: Relating self-report and diagnostic measures of interindividual differences to behavioral measurements of approach and avoidance

Responding to stimuli in ambiguous environments is partially governed by approach-avoidance tendencies. Imbalances in these approach-avoidance behaviors are implicated in many mental disorders including anxiety disorders, phobias and substance use disorders. While factors biasing human behavior in approach-avoidance conflicts have been researched in numerous experiments, a much-needed comprehensive overview integrating those findings is missing. Here, we systematically searched the existing literature on individual differences in task-based approach-avoidance behavior and aggregated the current evidence for the effect of self-reported approach/avoidance traits, anxiety and anxiety disorders, specific phobias, depression, aggression, anger and psychopathy, substance use and related disorders, eating disorders and habits, trauma, acute stress and, finally, hormone levels (mainly testosterone, oxytocin). We highlight consistent findings, underrepresented research areas and unexpected results, and detail the amount of controversy between studies. We discuss potential reasons for ambiguous results in some research areas, offer practical advice for future studies and highlight potential variables such as task-related researcher decisions that may influence how interindividual differences and disorders drive automatic approach-avoidance biases in behavioral experiments.

Human Lateral Frontal Pole Contributes to Control over Emotional Approach-Avoidance Actions

Regulation of emotional behavior is essential for human social interactions. Recent work has exposed its cognitive complexity, as well as its unexpected reliance on portions of the anterior PFC (aPFC) also involved in exploration, relational reasoning, and counterfactual choice, rather than on dorsolateral and medial prefrontal areas involved in several forms of cognitive control. This study anatomically qualifies the contribution of aPFC territories to the regulation of prepotent approach-avoidance action tendencies elicited by emotional faces, and explores a possible structural pathway through which this emotional action regulation might be implemented. We provide converging evidence from task-based fMRI, diffusion-weighted imaging, and functional connectivity fingerprints for a novel neural element in emotional regulation. Task-based fMRI in human male participants (N = 40) performing an emotional approach-avoidance task identified aPFC territories involved in the regulation of action tendencies elicited by emotional faces. Connectivity fingerprints, based on diffusion-weighted imaging and resting-state connectivity, localized those task-defined frontal regions to the lateral frontal pole (FPl), an anatomically defined portion of the aPFC that lacks a homologous counterpart in macaque brains. Probabilistic tractography indicated that 10%-20% of interindividual variation in emotional regulation abilities is accounted for by the strength of structural connectivity between FPl and amygdala. Evidence from an independent replication sample (N = 50; 10 females) further substantiated this result. These findings provide novel neuroanatomical evidence for incorporating FPl in models of control over human action tendencies elicited by emotional faces.SIGNIFICANCE STATEMENT Successful regulation of emotional behaviors is a prerequisite for successful participation in human society, as is evidenced by the social isolation and loss of occupational opportunities often encountered by people suffering from emotion regulation disorders, such as social-anxiety disorder and psychopathy. Knowledge about the precise cortical regions and connections supporting this control is crucial for understanding both the nature of computations needed to successfully traverse the space of possible actions in social situations, and the potential interventions that might result in efficient treatment of social-emotional disorders. This study provides evidence for a precise cortical region (lateral frontal pole) and a structural pathway (the ventral amygdalofugal bundle) through which a cognitively complex form of emotional action regulation might be implemented in the human brain.

Coping With Stigma in the Workplace: Understanding the Role of Threat Regulation, Supportive Factors, and Potential Hidden Costs

Despite changes in their representation and visibility, there are still serious concerns about the inclusion and day-to-day workplace challenges various groups face (e.g., women, ethnic and cultural minorities, LGBTQ+, people as they age, and those dealing with physical or mental disabilities). Men are also underrepresented in specific work fields, in particular those in Health care, Elementary Education, and the Domestic sphere (HEED). Previous literature has shown that group stereotypes play an important role in maintaining these inequalities. We outline how insights from research into stigma, social identity, and self-regulation together increase our understanding of how targets are affected by and regulate negative stereotypes in the workplace. This approach starts from the basis that members of negatively stereotyped groups are not just passive recipients of negative attitudes, stereotypes, and behaviors but are active individuals pursuing multiple goals, such as goals for belonging and achievement. We argue that it is only by understanding stigma from the target's perspective (e.g., how targets are affected and respond) that we can successfully address workplace inequality. Key in this understanding is that stereotypes, prejudice, and discrimination have taken on much more subtle forms, with consequences for the way members of stigmatized groups cope. These insights lead us to propose an approach to understanding barriers to workplace equality that highlights four key aspects: (1) the different (often subtle) potential triggers of identity threat in the workplace for members of stigmatized groups; (2) the ways in which members of stigmatized groups cope with these threats; (3) the role of supportive factors that mitigate potential threats and affect self-regulation; and (4) potential hidden costs for the self or others of what appears at first to be effective self-regulation. The focus on threats, coping, support, and potential hidden costs helps us understand why current diversity efforts are not always successful in increasing and maintaining members of stigmatized groups in organizations and provides insight into how we can aid efforts to effectively lower barriers to workplace equality.

Emotionally Aversive Cues Suppress Neural Systems Underlying Optimal Learning in Socially Anxious Individuals

Learning and decision-making are modulated by socio-emotional processing and such modulation is implicated in clinically relevant personality traits of social anxiety. The present study elucidates the computational and neural mechanisms by which emotionally aversive cues disrupt learning in socially anxious human individuals. Healthy volunteers with low or high trait social anxiety performed a reversal learning task requiring learning actions in response to angry or happy face cues. Choice data were best captured by a computational model in which learning rate was adjusted according to the history of surprises. High trait socially anxious individuals used a less-dynamic strategy for adjusting their learning rate in trials started with angry face cues and unlike the low social anxiety group, their dorsal anterior cingulate cortex (dACC) activity did not covary with the learning rate. Our results demonstrate that trait social anxiety is accompanied by disruption of optimal learning and dACC activity in threatening situations.SIGNIFICANCE STATEMENT Social anxiety is known to influence a broad range of cognitive functions. This study tests whether and how social anxiety affects human value-based learning as a function of uncertainty in the learning environment. The findings indicate that, in a threatening context evoked by an angry face, socially anxious individuals fail to benefit from a stable learning environment with highly predictable stimulus-response-outcome associations. Under those circumstances, socially anxious individuals failed to use their dorsal anterior cingulate cortex, a region known to adjust learning rate to environmental uncertainty. These findings open the way to modify neurobiological mechanisms of maladaptive learning in anxiety and depressive disorders.

Recognising and reacting to angry and happy facial expressions: a diffusion model analysis

Researchers have reported two biases in how people recognise and respond to angry and happy facial expressions: (1) a gender-expression bias (Becker et al. in J Pers Soc Psychol, 92(2):179–190, 10.1037/0022-3514.92.2.179, 2007)—faster identification of male faces as angry and female faces as happy and (2) an approach–avoidance bias—faster avoidance of people who appear angry and faster approach responses people who appear happy (Heuer et al. in Behav Res The, 45(12):2990–3001, 10.1016/j.brat.2007.08.010 2007; Marsh et al. in Emotion, 5(1), 119–124, 10.1037/1528-3542.5.1.119, 2005; Rotteveel and Phaf in Emotion 4(2):156–172, 10.1037/1528-3542.4.2.156, 2004). The aim of the current research is to gain insight into the nature of such biases by applying the drift diffusion model to the results of an approach–avoidance task. Sixty-five participants (33 female) identified faces as either happy or angry by pushing and pulling a joystick. In agreement with the original study of this effect (Solarz 1960) there were clear participant gender differences—both the approach avoidance and gender-expression biases were larger in magnitude for female compared to male participants. The diffusion model results extend recent research (Krypotos et al. in Cogn Emot 29(8):1424–1444, 10.1080/02699931.2014.985635, 2015) by indicating that the gender-expression and approach–avoidance biases are mediated by separate cognitive processes.

Dehydroepiandrosterone and Dehydroepiandrosterone-Sulfate and Emotional Processing

Steroid hormones are important regulators of brain development, physiological function, and behavior. Among them, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) also do modulate emotional processing and may have mood enhancement effects. This chapter reviews the studies that bear relation to DHEA and DHEAS [DHEA(S)] and brain emotional processing and behavior. A brief introduction to the mechanisms of action and variations of DHEA(S) levels throughout life has also been forward in this chapter. Higher DHEA(S) levels may reduce activity in brain regions involved in the generation of negative emotions and modulate activity in regions involved in regulatory processes. At the electrophysiological level, higher DHEA-to-cortisol and DHEAS-to-DHEA ratios were related to shorter P300 latencies and shorter P300 amplitudes during the processing of negative stimuli, suggesting less interference of negative stimuli with the task and less processing of the negative information, which in turn may suggest a protective mechanism against negative information overload. Present knowledge indicates that DHEA(S) may play a role in cortical development and plasticity, protecting against negative affect and depression, and at the same time enhancing attention and overall working memory, possibly at the cost of a reduction in emotional processing, emotional memory, and social understanding.

Anxiety symptoms and children's eye gaze during fear learning

BACKGROUND

The eye region of the face is particularly relevant for decoding threat-related signals, such as fear. However, it is unclear if gaze patterns to the eyes can be influenced by fear learning. Previous studies examining gaze patterns in adults find an association between anxiety and eye gaze avoidance, although no studies to date examine how associations between anxiety symptoms and eye-viewing patterns manifest in children. The current study examined the effects of learning and trait anxiety on eye gaze using a face-based fear conditioning task developed for use in children.

METHODS

Participants were 82 youth from a general population sample of twins (aged 9-13 years), exhibiting a range of anxiety symptoms. Participants underwent a fear conditioning paradigm where the conditioned stimuli (CS+) were two neutral faces, one of which was randomly selected to be paired with an aversive scream. Eye tracking, physiological, and subjective data were acquired. Children and parents reported their child's anxiety using the Screen for Child Anxiety Related Emotional Disorders.

RESULTS

Conditioning influenced eye gaze patterns in that children looked longer and more frequently to the eye region of the CS+ than CS- face; this effect was present only during fear acquisition, not at baseline or extinction. Furthermore, consistent with past work in adults, anxiety symptoms were associated with eye gaze avoidance. Finally, gaze duration to the eye region mediated the effect of anxious traits on self-reported fear during acquisition.

CONCLUSIONS

Anxiety symptoms in children relate to face-viewing strategies deployed in the context of a fear learning experiment. This relationship may inform attempts to understand the relationship between pediatric anxiety symptoms and learning.

Approach and avoidance tendencies in depression and anxiety disorders

Anxiety is linked to increased avoidance and inhibition, whereas depression is linked to decreased approach and diminished behavioral activation. Although these notions are widely recognized, systematic investigation of approach-avoidance tendencies is lacking across these diagnostic groups. Participants (mean age = 45.6; 65.8% female) were subdivided in healthy controls (405), remitted patients (877) and currently anxious (217), depressed (154) or comorbid (154) patients. Automatic approach-avoidance tendencies in reaction to facial expression were assessed using the Approach-Avoidance-Task (AAT). Self-reported trait approach and avoidance tendencies were assessed using the BIS/BAS scale. Severity of psychopathology was assessed to examine dose-response relationships. We did not find any consistent associations of automatic approach-avoidance tendencies with psychiatric variables. In contrast, medium to large differences in BIS scores showed increased trait avoidance tendencies in all patient groups relative to healthy controls. Overall, it seems that increased trait avoidance, rather than decreased approach, is a characteristic of affective disorders. This holds for both depressed and anxious patients and more strongly so in severe and chronic patients. It underlines the importance to address trait avoidance tendencies in the treatment of affective disorders.

Oxytocin reduces amygdala responses during threat approach

Oxytocin reduces amygdala responses to threatening social stimuli in males and has been suggested to facilitate approach-related processing by either decreasing anxiety or intensifying salience. The current administration study tested whether oxytocin either reduces or enhances amygdala responses during threat approach in a placebo-controlled randomized, double-blind, between-subjects design with 52 healthy males undergoing fMRI during a social approach-avoidance task. Oxytocin decreased amygdala activation during threat approach and not during threat avoidance. This neural effect supports oxytocin's social anxiolytic effects and provides a neuroendocrine mechanism promoting social approach. The findings may yield clinical implications for individuals suffering from dysregulations of social approach such as patients with anxiety disorders.

On the Control of Social Approach-Avoidance Behavior: Neural and Endocrine Mechanisms

The ability to control our automatic action tendencies is crucial for adequate social interactions. Emotional events trigger automatic approach and avoidance tendencies. Although these actions may be generally adaptive, the capacity to override these emotional reactions may be key to flexible behavior during social interaction. The present chapter provides a review of the neuroendocrine mechanisms underlying this ability and their relation to social psychopathologies. Aberrant social behavior, such as observed in social anxiety or psychopathy, is marked by abnormalities in approach-avoidance tendencies and the ability to control them. Key neural regions involved in the regulation of approach-avoidance behavior are the amygdala, widely implicated in automatic emotional processing, and the anterior prefrontal cortex, which exerts control over the amygdala. Hormones, especially testosterone and cortisol, have been shown to affect approach-avoidance behavior and the associated neural mechanisms. The present chapter also discusses ways to directly influence social approach and avoidance behavior and will end with a research agenda to further advance this important research field. Control over approach-avoidance tendencies may serve as an exemplar of emotional action regulation and might have a great value in understanding the underlying mechanisms of the development of affective disorders.

Endocrine and emotional response to exclusion among women and men; cortisol, salivary alpha amylase, and mood

BACKGROUND AND OBJECTIVES

Social exclusion is ubiquitous and painful. Evolutionary models indicate sex differences in coping with social stress. Recent empirical data suggest different sex patterns in hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) reactivity. The present study sought to test this hypothesis.

DESIGN

We examined differences in endocrine and emotional response to exclusion by using a virtual ball tossing paradigm (Cyberball). Saliva samples and mood ratings were collected to reflect levels before, and repeatedly following, exclusion.

METHODS

The sample included 21 women and 23 men. Cortisol and salivary alpha amylase (sAA), biomarkers of the HPA and SAM systems, respectively, were used as indices of two arms of stress response.

RESULTS

Following exclusion, all participants experienced mood worsening followed by mood improvement, with men reporting less distress than women. Women evinced decline in cortisol following the Cyberball task, whereas men's cortisol levels showed a non-significant rise, and then decline, following exclusion.

CONCLUSIONS

Our results concur with previous findings showing SAM reactivity to be gender-neutral and HPA reactivity to be gender-divergent. Additional studies are needed to examine sex-specific response to social exclusion. Implications for individual differences in recovery from stress are discussed.

Effects of basal and acute cortisol on cognitive flexibility in an emotional task switching paradigm in men

The stress hormone cortisol is assumed to influence cognitive functions. While cortisol-induced alterations of declarative memory in particular are well-investigated, considerably less is known about its influence on executive functions. Moreover, most research has been focused on slow effects, and rapid non-genomic effects have not been studied. The present study sought to investigate the impact of acute cortisol administration as well as basal cortisol levels on cognitive flexibility, a core executive function, within the non-genomic time frame. Thirty-eight healthy male participants were randomly assigned to intravenously receive either cortisol or a placebo before performing a task switching paradigm with happy and angry faces as stimuli. Cortisol levels were measured at six points during the experiment. Additionally, before the experiment, basal cortisol measures for the cortisol awakening response were collected on three consecutive weekdays immediately following awakening and 30, 45, and 60min after. First and foremost, results showed a pronounced impact of acute and basal cortisol on reaction time switch costs, particularly for angry faces. In the placebo group, low basal cortisol was associated with minimal switch costs, whereas high basal cortisol was related to maximal switch costs. In contrast, after cortisol injection, basal cortisol levels showed no impact. These results show that cognitive flexibility-enhancing effects of acute cortisol administration are only seen in men with high basal cortisol levels. This result supports the context dependency of cortisol administration and shows the relevance of taking basal cortisol levels into account.

Reduced Affective Biasing of Instrumental Action With tDCS Over the Prefrontal Cortex

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We assessed whether tDCS over the anterior prefrontal cortex can reduce affective biasing of instrumental action.

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Cathodal prefrontal tDCS reduced affective biasing of instrumental action.

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Anodal prefrontal tDCS did not reduce affective biasing of instrumental action.

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We demonstrate the potential utility of prefrontal tDCS as a tool for reducing affective biasing of instrumental behavior.

Background

Instrumental action is well known to be vulnerable to affective value. Excessive transfer of affective value to instrumental action is thought to contribute to psychiatric disorders. The brain region most commonly implicated in overriding such affective biasing of instrumental action is the prefrontal cortex.

Objective

The aim of the present study was to reduce affective biasing of instrumental action using transcranial direct current stimulation (tDCS) in young healthy human volunteers.

Methods

In a double-blind, randomized between-group design, 120 participants received anodal, cathodal and sham tDCS while at the same time (online) performing a task that assessed affective biasing of instrumental action. We placed tDCS electrodes over the anterior part of the prefrontal cortex based on evidence from brain stimulation work demonstrating the role of this brain region in controlling affective biasing of instrumental action.

Results

We showed that prefrontal tDCS reduced affective biasing of instrumental action. Specifically, prefrontal tDCS reduced the degree to which aversive (versus appetitive) cues potentiated instrumental avoidance and suppressed instrumental approach. Contrary to our hypothesis, this effect was seen for cathodal tDCS rather than anodal tDCS.

Conclusion

The results demonstrate the potential utility of prefrontal tDCS as a tool for reducing affective biasing of instrumental behavior, thus opening avenues for interventional research on psychiatric disorders that implicate excessive transfer of affective value.

Dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) and emotional processing - A behavioral and electrophysiological approach

Dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) may have mood enhancement effects: higher DHEAS concentrations and DHEA/cortisol ratio have been related to lower depression scores and controlled trials of DHEA administration have reported significant antidepressant effects. The balance between DHEAS and DHEA has been suggested to influence brain functioning. We explored DHEAS, DHEA, cortisol, DHEA/cortisol and DHEAS/DHEA ratios relations to the processing of negative emotional stimuli at behavioral and brain levels by recording the electroencephalogram of 21 young women while performing a visual task with implicit neutral or negative emotional content in an audio-visual oddball paradigm. For each condition, salivary DHEA, DHEAS and cortisol were measured before performing the task and at 30 and 60min intervals. DHEA increased after task performance, independent of the implicit emotional content. With implicit negative emotion, higher DHEAS/DHEA and DHEA/cortisol ratios before task performance were related to shorter visual P300 latencies suggesting faster brain processing under a negative emotional context. In addition, higher DHEAS/DHEA ratios were related to reduced visual P300 amplitudes, indicating less processing of the negative emotional stimuli. With this study, we could show that at the electrophysiological level, higher DHEAS/DHEA and DHEA/cortisol ratios were related to shorter stimulus evaluation times suggesting less interference of the implicit negative content of the stimuli with the task. Furthermore, higher DHEAS/DHEA ratios were related to reduced processing of negative emotional stimuli which may eventually constitute a protective mechanism against negative information overload.

Testosterone biases the amygdala toward social threat approach

Testosterone enhances amygdala reactions to social threat, but it remains unclear whether this neuroendocrine mechanism is relevant for understanding its dominance-enhancing properties; namely, whether testosterone biases the human amygdala toward threat approach. This pharmacological functional magnetic-resonance imaging study shows that testosterone administration increases amygdala responses in healthy women during threat approach and decreases it during threat avoidance. These findings support and extend motivational salience models by offering a neuroendocrine mechanism of motivation-specific amygdala tuning.

Why do fearful facial expressions elicit behavioral approach? Evidence from a combined approach-avoidance implicit association test

Despite communicating a "negative" emotion, fearful facial expressions predominantly elicit behavioral approach from perceivers. It has been hypothesized that this seemingly paradoxical effect may occur due to fearful expressions' resemblance to vulnerable, infantile faces. However, this hypothesis has not yet been tested. We used a combined approach-avoidance/implicit association test (IAT) to test this hypothesis. Participants completed an approach-avoidance lever task during which they responded to fearful and angry facial expressions as well as neutral infant and adult faces presented in an IAT format. Results demonstrated an implicit association between fearful facial expressions and infant faces and showed that both fearful expressions and infant faces primarily elicit behavioral approach. The dominance of approach responses to both fearful expressions and infant faces decreased as a function of psychopathic personality traits. Results suggest that the prosocial responses to fearful expressions observed in most individuals may stem from their associations with infantile faces. (PsycINFO Database Record

Emotion regulation: exploring the impact of stress and sex

Emotion regulation is a major prerequisite for adaptive behavior. The capacity to regulate emotions is particularly important during and after the encounter of a stressor. However, the impact of acute stress and its associated neuroendocrine alterations on emotion regulation have received little attention so far. This study aimed to explore how stress-induced cortisol increases affect three different emotion regulation strategies. Seventy two healthy men and women were either exposed to a stressor or a control condition. Subsequently participants viewed positive and negative images and were asked to up- or down-regulate their emotional responses or simultaneously required to solve an arithmetic task (distraction). The factors stress, sex, and strategy were operationalized as between group factors (n = 6 per cell). Stress caused an increase in blood pressure and higher subjective stress ratings. An increase in cortisol was observed in male participants only. In contrast to controls, stressed participants were less effective in distracting themselves from the emotional pictures. The results further suggest that in women stress enhances the ability to decrease negative emotions. These findings characterize the impact of stress and sex on emotion regulation and provide initial evidence that these factors may interact.

Individual differences in bodily freezing predict emotional biases in decision making

Instrumental decision making has long been argued to be vulnerable to emotional responses. Literature on multiple decision making systems suggests that this emotional biasing might reflect effects of a system that regulates innately specified, evolutionarily preprogrammed responses. To test this hypothesis directly, we investigated whether effects of emotional faces on instrumental action can be predicted by effects of emotional faces on bodily freezing, an innately specified response to aversive relative to appetitive cues. We tested 43 women using a novel emotional decision making task combined with posturography, which involves a force platform to detect small oscillations of the body to accurately quantify postural control in upright stance. On the platform, participants learned whole body approach-avoidance actions based on monetary feedback, while being primed by emotional faces (angry/happy). Our data evidence an emotional biasing of instrumental action. Thus, angry relative to happy faces slowed instrumental approach relative to avoidance responses. Critically, individual differences in this emotional biasing effect were predicted by individual differences in bodily freezing. This result suggests that emotional biasing of instrumental action involves interaction with a system that controls innately specified responses. Furthermore, our findings help bridge (animal and human) decision making and emotion research to advance our mechanistic understanding of decision making anomalies in daily encounters as well as in a wide range of psychopathology.

Approach, avoidance, and affect: a meta-analysis of approach-avoidance tendencies in manual reaction time tasks

Approach action tendencies toward positive stimuli and avoidance tendencies from negative stimuli are widely seen to foster survival. Many studies have shown that approach and avoidance arm movements are facilitated by positive and negative affect, respectively. There is considerable debate whether positively and negatively valenced stimuli prime approach and avoidance movements directly (i.e., immediate, unintentional, implicit, automatic, and stimulus-based), or indirectly (i.e., after conscious or non-conscious interpretation of the situation). The direction and size of these effects were often found to depend on the instructions referring to the stimulus object or the self, and on explicit vs. implicit stimulus evaluation. We present a meta-analysis of 29 studies included for their use of strongly positive and negative stimuli, with 81 effect sizes derived solely from the means and standard deviations (combined N = 1538), to examine the automaticity of the link between affective information processing and approach and avoidance, and to test whether it depends on instruction, type of approach-avoidance task, and stimulus type. Results show a significant small to medium-sized effect after correction for publication bias. The strongest arguments for an indirect link between affect and approach-avoidance were the absence of evidence for an effect with implicit evaluation, and the opposite directions of the effect with self and object-related interpretations. The link appears to be influenced by conscious or non-conscious intentions to deal with affective stimuli.

NIRS as a tool for assaying emotional function in the prefrontal cortex

Despite having relatively poor spatial and temporal resolution, near-infrared spectroscopy (NIRS) has several methodological advantages compared with other non-invasive measurements of neural activation. For instance, the unique characteristics of NIRS give it potential as a tool for investigating the role of the prefrontal cortex (PFC) in emotion processing. However, there are several obstacles in the application of NIRS to emotion research. In this mini-review, we discuss the findings of studies that used NIRS to assess the effects of PFC activation on emotion. Specifically, we address the methodological challenges of NIRS measurement with respect to the field of emotion research, and consider potential strategies for mitigating these problems. In addition, we show that two fields of research, investigating (i) biological predisposition influencing PFC responses to emotional stimuli and (ii) neural mechanisms underlying the bi-directional interaction between emotion and action, have much to gain from the use of NIRS. With the present article, we aim to lay the foundation for the application of NIRS to the above-mentioned fields of emotion research.

Aversive disinhibition of behavior and striatal signaling in social avoidance

Social avoidance is a major factor contributing to the development and maintenance of anxiety and depressive symptoms. Converging evidence suggests that social avoidance is associated with abnormal aversive processing and hyperactive amygdala signaling. However, what are the consequences of such abnormal aversive processing for action and for the neural mechanisms implementing action is unclear. Existing literature is conflicting, pointing at either enhanced or reduced action inhibition. We investigated the interaction between aversion and action in social avoidance by comparing the effects of aversive vs appetitive faces on a go/no-go task and associated striatal signals in 42 high and low socially avoidant individuals. We combined fMRI with a novel probabilistic learning task, in which emotional valence (angry and happy faces) and optimal response (go- and no-go-responses) were manipulated independently. High compared with low socially avoidant individuals showed reduced behavioral inhibition (proportion no-go-responses) for angry relative to happy faces. This behavioral disinhibition correlated with greater striatal signal during no-go-responses for angry relative to happy faces. The results suggest that social avoidant coping style is accompanied by disinhibition of action and striatal signal in the context of social threat. The findings concur with recent theorizing about aversive disinhibition and affective disorders.

N1 and N2 ERPs reflect the regulation of automatic approach tendencies to positive stimuli

The Approach-Avoidance Task (AAT) measures automatic approach-avoidance tendencies and their regulation: compatible reactions (approach positive, avoid negative) are faster than incompatible ones (approach negative, avoid positive). The present study assessed event-related potentials (ERPs) in 15 healthy persons for depicting neuropsychological sub-processes of such stimulus-response compatibility (SRC) effects. Early attention allocation preparing efficient stimulus classification (N1 ERP) and response inhibition on the level of response representations (N2 ERP) were found to underlie the solution of the AAT-conflict. For positive stimuli, these processes were enhanced during the incompatible condition avoid positive compared to the compatible condition approach positive. Source localization analysis revealed activity in right occipital areas (N1 ERP), and in left DLPFC and insula (N2 ERP) to be neuronal generators of these electrophysiological SRC effects. This neuronal regulation resulted in no influence of incompatibility at the behavioural level. For negative pictures, we found the reversed pattern: there were no electrophysiological SRC effects, but clear behavioural SRC effects in both RTs and error frequency, i.e. participants were faster and made fewer errors during avoiding than approaching negative pictures. These valence-specific differences are in line with previous studies indicating negative stimuli - probably due to higher importance for survival - to more strongly influence behaviour.

Pharmacological secondary prevention of PTSD in youth: challenges and opportunities for advancement

Child and adolescent posttraumatic stress disorder (PTSD) is associated with an increased risk for a number of deleterious mental and physical health outcomes that if untreated may persist throughout the life course. Efficacious interventions applied soon after trauma exposure have the potential to reduce or prevent the development of PTSD symptoms and their associated impact on behavior and physical health. We review extant research related to treatment-modifiable peritraumatic predictors of pediatric PTSD, which have informed an emerging field of pharmacologic secondary prevention (i.e., occurring shortly following trauma exposure) of PTSD. Challenges and opportunities for early posttrauma PTSD prevention are described. Finally, we offer new models for biologically informed integration of pharmacologic and psychosocial secondary prevention intervention strategies for children and adolescents.

Automatic avoidance tendencies in patients with psychogenic non-epileptic seizures

INTRODUCTION

Psychogenic Non Epileptic Seizures (PNES) have been theorized to reflect a learned pattern of avoidant behavior to deal with stressors. Although such observation may be relevant for our understanding of the etiology of PNES, evidence for this theory is largely build on self-report investigations and no studies have systematically tested actual avoidance behavior in patients with PNES. In this study, we tested automatic threat avoidance tendencies in relation to stress and cortisol levels in patients with PNES and healthy controls (HCs).

METHODS

The approach and avoidance (AA) task was administered to 12 patients with PNES and 20 matched HCs at baseline and following stress-induction using the Cold Pressor Test (CPT). The AA task requires participants to evaluate the emotional valence of pictures of angry and happy faces by making arm movements (arm flexion or extension) that are either affect-congruent (avoid-angry; approach-happy) or affect-incongruent (approach-angry; avoid-happy) with their intuitive action tendencies. Saliva cortisol was measured throughout the experiment.

RESULTS

Patients, but not HCs, showed increased approach-avoidance congruency-effects for angry faces on the AA task at baseline, with relatively slower approach of angry faces, which was overall associated with basal pre-task cortisol. This congruency-effect disappeared after the CPT.

DISCUSSION

The present findings provide an objective confirmation of previous suggestions from self-report studies indicating that PNES patients show relatively increased avoidance tendencies to social threat cues. The registering of threat avoidance behavior may prove to be a clinically valuable contribution to evaluate psychological treatment effectiveness and perhaps even PNES prognosis.