Pathways towards the proliferation of avoidance in anxiety and implications for treatment

Risk estimation in relation to anxiety and depression for low probability negative events

Foundational cognitive models propose that people with anxiety and depression show risk estimation bias, but most literature does not compute true risk estimation bias by comparing people's subjective risk estimates to their individualized reality (i.e., person-level objective risk). In a diverse community sample (N = 319), we calculated risk estimation bias by comparing people's subjective risk estimates for contracting COVID-19 to their individualized objective risk. Person-level objective risk was consistently low and did not differ across symptom levels, suggesting that for low probability negative events, people with greater symptoms show risk estimation bias that is driven by subjective risk estimates. Greater levels of anxiety, depression, and COVID-specific perseverative cognition separately predicted higher subjective risk estimates. In a model including COVID-specific perseverative cognition alongside anxiety and depression scores, the only significant predictor of subjective risk estimates was COVID-specific perseverative cognition, indicating that symptoms more closely tied to feared outcomes may more strongly influence risk estimation. Finally, subjective risk estimates predicted information-seeking behavior and eating when anxious, but did not significantly predict alcohol or marijuana use, drinking to cope, or information avoidance. Implications for clinical practitioners and future research are discussed.

Temporal dynamics of costly avoidance in naturalistic fears: Evidence for sequential-sampling of fear and reward information

Excessive avoidance is characteristic for anxiety disorders, even when approach would lead to positive outcomes. The process of how such approach-avoidance conflicts are resolved is not sufficiently understood. We examined the temporal dynamics of approach-avoidance in intense fear of spiders. Highly fearful and non-fearful participants chose repeatedly between a fixed no spider/low reward and a spider/high reward option with varying fear (probability of spider presentation) and reward information (reward magnitude). By sequentially presenting fear and reward information, we distinguished whether decisions are dynamically driven by both information (sequential-sampling) or whether the impact of fear information is inhibited (cognitive control). Mouse movements were recorded to assess temporal decision dynamics (i.e., how strongly which information impacts decision preference at which timepoint). Highly fearful participants showed stronger avoidance despite lower gains (i.e., costly avoidance). Time-continuous multiple regression of their mouse movements yielded a stronger impact of fear compared to reward information. Importantly, presenting either information first (fear or reward) enhanced its impact during the early decision process. These findings support sequential sampling of fear and reward information, but not inhibitory control. Hence, pathological avoidance may be characterized by biased evidence accumulation rather than altered cognitive control.

Development and Validation of a Broad and Fear-Adaptable Measure of Fear Approach and Application to Common Eating Disorder Fears

Fear approach is a theorized mechanism of exposure treatment for anxiety-based disorders. However, there are no empirically established self-report instruments measuring the tendency to approach feared stimuli. Because clinical fears are heterogeneous, it is important to create a measure that is adaptable to person- or disorder-specific fears. The current study (N = 455) tests the development, factor structure, and psychometric properties of a self-report instrument of fear approach broadly and the adaptability of this measure to specific eating disorder fears (i.e., food, weight gain). Factor analyses identified a unidimensional, nine-item factor structure as the best fitting model. This measure had good convergent, divergent, and incremental validity and good internal consistency. The eating disorder adaptations retained good fit and strong psychometric properties. These results suggest that this measure is a valid, reliable, and adaptable measure of fear approach, which can be used in research and exposure therapy treatment for anxiety-based disorders.

Tackling Costly Fearful Avoidance Using Pavlovian Counterconditioning

Avoidance behavior constitutes a major transdiagnostic symptom that exacerbates anxiety. It hampers fear extinction and predicts poor therapy-outcome. Pavlovian counterconditioning with a reward could alleviate avoidance better than traditional extinction by reducing negative valence of the feared situation. However, previous studies are scarce and did not consider that pathological avoidance is often costly and typically evolves from an approach-avoidance conflict. Therefore, we used an approach-avoidance conflict paradigm to model effects of counterconditioning on costly avoidance (i.e., avoidance that leads to missing out on rewards). Results from our preregistered Bayesian Mixed Model analyses in 51 healthy participants (43 females) indicated that counterconditioning was more effective in reducing negative valuation and decreasing costly avoidance than traditional extinction. This study supports application of a simple counterconditioning technique, shows that its efficacy transfers to more complex avoidance situations, and suggests treatment may benefit from increasing reward drive in combination with extinction to overcome avoidance. Application in a clinical sample is a necessary next step to assess clinical utility of counterconditioning.

Anxiety may alter the role of fronto-striatal circuitry in adolescent risky decision-making

BACKGROUND

Anxiety disorders often emerge in adolescence and are associated with risk aversion. Risk aversion conflicts with the typical adolescent approach-motivated phenotype and can interfere with learning and contribute to symptom maintenance.

METHODS

We investigated the neural and behavioral correlates of risk avoidance in a diverse sample of adolescents (N = 137; MAge = 11.3; 34.3 % white, 22.1 % Latino, 20 % Asian, 14.3 % Black, 9.3 % Mixed Race) as they completed a task involving risky decision-making and response inhibition during fMRI. Voluntary cautious choice was compared to successful response inhibition to isolate the neural systems underlying the decision to avoid a risk and identify their relation to risk-taking and anxiety in adolescents.

RESULTS

Anxious adolescents self-reported more avoidance but demonstrated normative risk-taking on the laboratory task. Interestingly, they responded quickly during response inhibition but took longer to decide in the face of risk. All youth showed widespread recruitment of decision-making and salience network regions when deciding to avoid risk. The neural mechanisms driving avoidance differed based on anxiety such that left inferior frontal gyrus (IFG) activation was linked to risk avoidance in adolescents with low anxiety and risk-taking in anxious adolescents, while striatal connectivity was linked to risk avoidance in anxious adolescents and risk-taking in those with low anxiety.

LIMITATIONS

This work is cross-sectional and therefore cannot speak to causality or directionality of effects.

CONCLUSIONS

These results suggest that the neural mechanisms contributing to adolescent risk-taking may function to promote avoidance in anxious youth, increasing vulnerability to maladaptive avoidance and further anxiety development.

A history of avoidance does not impact extinction learning in male rats

Pervasive avoidance is one of the central symptoms of all anxiety-related disorders. In treatment, avoidance behaviors are typically discouraged because they are assumed to maintain anxiety. Yet, it is not clear if engaging in avoidance is always detrimental. In this study, we used a platform-mediated avoidance task to investigate the influence of avoidance history on extinction learning in male rats. Our results show that having the opportunity to avoid during fear acquisition training does not significantly influence the extinction of auditory-cued fear in rats subjected to this platform-mediated avoidance procedure, which constitutes a realistic approach/avoidance conflict. This holds true irrespective of whether or not avoidance was possible during the extinction phase. This suggests that imposing a realistic cost on avoidance behavior prevents the adverse effects that avoidance has been claimed to have on extinction. However, avoidance does not appear to have clear positive effects on extinction learning nor on retention either.

Itsy bitsy spider: Fear and avoidance (generalization) in a free-exploratory virtual reality paradigm

Most experimental avoidance paradigms lack either control over the experimental situation or simplify real-life avoidance behavior to a great extent, making it difficult to generalize the results to the complex approach-avoidance situations that anxious individuals face in daily life. The current study aimed to examine the usability of our recently developed free-exploratory avoidance paradigm in Virtual Reality (VR) that allows for the assessment of subjective as well as behavioral avoidance in participants with varying levels of spider fear. In a VR escape room, participants searched for cues to decipher a code-locked door. Opening a wooden box marked with a post-it note (conditioned stimulus, CS) resulted in exposure to a virtual crawling spider (unconditioned stimulus, US). Avoidance of the original CS and other objects marked with the CS (generalization stimuli, GSs; EXPgen condition) or non-marked (CONT condition) objects was measured via questionnaires and relative manipulation times in a novel room. We expected a positive linear relationship between US aversiveness (levels of spider fear) and (generalization of) fear and avoidance behaviors. Avoidance learning and generalization was demonstrated on both a subjective and behavioral level. Higher levels of spider fear were, overall, related to more negative emotions in response to the encounter with the spider, higher US expectancies for the GSs, and more self-reported and behavioral avoidance of the original CS and the GSs. Finally, we explored relationships between trait anxiety and intolerance of uncertainty and fear and avoidance (generalization), but no robust associations were observed. In conclusion, we confirmed the expected positive linear relationship between spider fear and (generalization of) fear and avoidance behaviors. Our results suggest that our free-exploratory VR avoidance paradigm is well-suited to investigate avoidance behaviors and the generalization of avoidance.

A network perspective on real-life threat, anxiety, and avoidance

BACKGROUND

Anxiety, approach, and avoidance motivation crucially influence mental and physical health, especially when environments are stressful. The interplay between anxiety and behavioral motivation is modulated by multiple individual factors. This proof-of-concept study applies graph-theoretical network analysis to explore complex associations between self-reported trait anxiety, approach and avoidance motivation, situational anxiety, stress symptoms, perceived threat, perceived positive consequences of approach, and self-reported avoidance behavior in real-life threat situations.

METHODS

A total of 436 participants who were matched on age and gender (218 psychotherapy patients, 218 online-recruited nonpatients) completed an online survey assessing these factors in response to the COVID-19 pandemic.

RESULTS AND DISCUSSION

The resulting cross-sectional psychological network revealed a complex pattern with multiple positive (e.g., between trait anxiety, avoidance motivation, and avoidance behavior) and negative associations (e.g., between approach and avoidance motivation). The patient and online subsample networks did not differ significantly, however, descriptive differences may inform future research.

Exposure traced in daily life: improvements in ecologically assessed social and physical activity following exposure-based psychotherapy for anxiety disorders

BACKGROUND

Although exposure-based cognitive-behavioral therapy for anxiety disorders has frequently been proven effective, only few studies examined whether it improves everyday behavioral outcomes such as social and physical activity.

METHODS

126 participants (85 patients with panic disorder, agoraphobia, social anxiety disorder, or specific phobias, and 41 controls without mental disorders) completed smartphone-based ambulatory ratings (activities, social interactions, mood, physical symptoms) and motion sensor-based indices of physical activity (steps, time spent moving, metabolic activity) at baseline, during, and after exposure-based treatment.

RESULTS

Prior to treatment, patients showed reduced mood and physical activity relative to healthy controls. Over the course of therapy, mood ratings, interactions with strangers and indices of physical activity improved, while reported physical symptoms decreased. Overall results did not differ between patients with primary panic disorder/agoraphobia and social anxiety disorder. Higher depression scores at baseline were associated with larger changes in reported symptoms and mood ratings, but smaller changes in physical activity CONCLUSIONS: Exposure-based treatment initiates increased physical activity, more frequent interaction with strangers, and improvements in everyday mood. The current approach provides objective and fine-graded process and outcome measures that may help to further improve treatments and possibly reduce relapse.

Exploring the Symptom Profiles of Intolerance of Uncertainty in Autistic Children

Intolerance of uncertainty (IU) is a multidimensional construct involving maladaptive responses to uncertainty. IU is strongly associated with autism and anxiety, yet no studies have examined its symptom profile in autistic children. This study compares IU symptom profiles in autistic and NT children and in autistic children with and without anxiety using the Intolerance of Uncertainty Scale for Children. Compared to NT peers, autistic children exhibited heightened IU symptoms in all domains, affective, behavioral, and cognitive; affective symptoms had the highest association with autism. Autistic children with anxiety also exhibited elevated IU symptoms in all domains compared to those without anxiety; behavioral IU symptoms had the highest association with anxiety. IU symptom profiles should be considered in assessment and treatment.

Traumatic Stress-Induced Increases in Anxiety-like Behavior and Alcohol Self-Administration Are Mediated by Central Amygdala CRF1 Neurons That Project to the Lateral Hypothalamus

Avoidance stress coping, defined as persistent internal and/or external avoidance of stress-related stimuli, is a key feature of anxiety- and stress-related disorders, and contributes to increases in alcohol misuse after stress exposure. Previous work using a rat model of predator odor stress avoidance identified corticotropin-releasing factor (CRF) signaling via CRF Type 1 receptors (CRF1) in the CeA, as well as CeA projections to the lateral hypothalamus (LH) as key mediators of conditioned avoidance of stress-paired contexts and/or increased alcohol drinking after stress. Here, we report that CRF1-expressing CeA cells that project to the LH are preferentially activated in male and female rats that show persistent avoidance of predator odor stress-paired contexts (termed Avoider rats), and that chemogenetic inhibition of these cells rescues stress-induced increases in anxiety-like behavior and alcohol self-administration in male and female Avoider rats. Using slice electrophysiology, we found that prior predator odor stress exposure blunts inhibitory synaptic transmission and increases synaptic drive in CRF1 CeA-LH cells. In addition, we found that CRF bath application reduces synaptic drive in CRF1 CeA-LH cells in Non-Avoiders only. Collectively, these data show that CRF1 CeA-LH cells contribute to stress-induced increases in anxiety-like behavior and alcohol self-administration in male and female Avoider rats.SIGNIFICANCE STATEMENT Stress may lead to a variety of behavioral and physiological negative consequences, and better understanding of the neurobiological mechanisms that contribute to negative stress effects may lead to improved prevention and treatment strategies. This study, performed in laboratory rats, shows that animals that exhibit avoidance stress coping go on to develop heightened anxiety-like behavior and alcohol self-administration, and that these behaviors can be rescued by inhibiting the activity of a specific population of neurons in the central amygdala. This study also describes stress-induced physiological changes in these neurons that may contribute to their role in promoting increased anxiety and alcohol self-administration.

Social avoidance and testosterone enhanced exposure efficacy in women with social anxiety disorder: A pilot investigation

Social avoidance has been associated with more persistent social anxiety disorder (SAD) symptoms and low testosterone levels in individuals with SAD. We tested whether pre-treatment avoidance tendencies moderate the efficacy of testosterone-augmented exposure therapy. Fifty-five females with SAD received two exposure sessions during which fear levels were assessed. Session 1 was augmented with testosterone (0.50 mg) or placebo. Avoidance tendencies and symptom severity were assessed pre- and post-exposure. Participants showed stronger avoidance for social versus non-social stimuli and this tendency remained stable over time. Stronger pretreatment avoidance tendencies were associated with larger fear reduction in the testosterone but not the placebo condition. This effect did not transfer to the second non-enhanced session or symptom severity. The findings support the hypothesis that individuals suffering from SAD with relatively stronger pretreatment avoidance tendencies benefit more from testosterone-augmentation, pointing to a potential behavioral marker for testosterone enhancement of exposure therapy.

Persistence of extensively trained avoidance is not elevated in anxiety disorders in an outcome devaluation paradigm

BACKGROUND

A habitual avoidance component may enforce the persistence of maladaptive avoidance behavior in anxiety disorders. Whether habitual avoidance is acquired more strongly in anxiety disorders is unclear.

METHODS

Individuals with current social anxiety disorder, panic disorder and/or agoraphobia (n = 62) and healthy individuals (n = 62) completed a devaluation paradigm with extensive avoidance training, followed by the devaluation of the aversive outcome. In the subsequent test phase, habitual response tendencies were inferred from compatibility effects. Neutral control trials were added to assess general approach learning in the absence of previous extensive avoidance training.

RESULTS

The compatibility effects indicating habitual control did not differ between patients with anxiety disorders and healthy controls. Patients showed lower overall approach accuracy, but this effect was unrelated to the compatibility effects.

CONCLUSIONS

In this study, anxiety disorders were characterized by reduced approach but not stronger habitual avoidance. These results do not indicate a direct association between anxiety disorders and the acquisition of pervasive habitual avoidance in this devaluation paradigm.

Understanding anxiety symptoms as aberrant defensive responding along the threat imminence continuum

Threat-anticipatory defensive responses have evolved to promote survival in a dynamic world. While inherently adaptive, aberrant expression of defensive responses to potential threat could manifest as pathological anxiety, which is prevalent, impairing, and associated with adverse outcomes. Extensive translational neuroscience research indicates that normative defensive responses are organized by threat imminence, such that distinct response patterns are observed in each phase of threat encounter and orchestrated by partially conserved neural circuitry. Anxiety symptoms, such as excessive and pervasive worry, physiological arousal, and avoidance behavior, may reflect aberrant expression of otherwise normative defensive responses, and therefore follow the same imminence-based organization. Here, empirical evidence linking aberrant expression of specific, imminence-dependent defensive responding to distinct anxiety symptoms is reviewed, and plausible contributing neural circuitry is highlighted. Drawing from translational and clinical research, the proposed framework informs our understanding of pathological anxiety by grounding anxiety symptoms in conserved psychobiological mechanisms. Potential implications for research and treatment are discussed.

Behavioural and physiological indicators of anxiety reflect shared and distinct profiles across individuals with neurogenetic syndromes

Anxiety is heightened in individuals with intellectual disability, particularly in those with specific neurogenetic syndromes. Assessment of anxiety for these individuals is hampered by a lack of appropriate measures that cater for communication impairment, differences in presentation, and overlapping features with co-occurring conditions. Here, we adopt a multi-method approach to identify fine-grained behavioural and physiological (via salivary cortisol) responses to anxiety presses in people with fragile X (FXS; n = 27; Mage = 20.11 years; range 6.32 - 47.04 years) and Cornelia de Lange syndromes (CdLS; n = 27; Mage = 18.42 years; range 4.28 - 41.08 years), two neurogenetic groups at high risk for anxiety, compared to neurotypical children (NT; n = 21; Mage = 5.97 years; range 4.34 - 7.30 years). Results indicate that physical avoidance of feared stimuli and proximity seeking to a familiar adult are prominent behavioural indicators of anxiety/stress in FXS and CdLS. Heightened pervasive physiological arousal was identified in these groups via salivary cortisol. An association between autistic characteristics and anxiety was evident in the FXS group but not in the CdLS group pointing to syndrome-specific nuances in the association between anxiety and autism. This study furthers understanding of the behavioural and physiological presentation of anxiety in individuals with intellectual disability and progresses theoretical developments regarding the development and maintenance of anxiety at the intersection of autism.

The nature and neurobiology of fear and anxiety: State of the science and opportunities for accelerating discovery

Fear and anxiety play a central role in mammalian life, and there is considerable interest in clarifying their nature, identifying their biological underpinnings, and determining their consequences for health and disease. Here we provide a roundtable discussion on the nature and biological bases of fear- and anxiety-related states, traits, and disorders. The discussants include scientists familiar with a wide variety of populations and a broad spectrum of techniques. The goal of the roundtable was to take stock of the state of the science and provide a roadmap to the next generation of fear and anxiety research. Much of the discussion centered on the key challenges facing the field, the most fruitful avenues for future research, and emerging opportunities for accelerating discovery, with implications for scientists, funders, and other stakeholders. Understanding fear and anxiety is a matter of practical importance. Anxiety disorders are a leading burden on public health and existing treatments are far from curative, underscoring the urgency of developing a deeper understanding of the factors governing threat-related emotions.

Anxiety as a disorder of uncertainty: implications for understanding maladaptive anxiety, anxious avoidance, and exposure therapy

In cognitive-behavioral conceptualizations of anxiety, exaggerated threat expectancies underlie maladaptive anxiety. This view has led to successful treatments, notably exposure therapy, but is not consistent with the empirical literature on learning and choice alterations in anxiety. Empirically, anxiety is better described as a disorder of uncertainty learning. How disruptions in uncertainty lead to impairing avoidance and are treated with exposure-based methods, however, is unclear. Here, we integrate concepts from neurocomputational learning models with clinical literature on exposure therapy to propose a new framework for understanding maladaptive uncertainty functioning in anxiety. Specifically, we propose that anxiety disorders are fundamentally disorders of uncertainty learning and that successful treatments, particularly exposure therapy, work by remediating maladaptive avoidance from dysfunctional explore/exploit decisions in uncertain, potentially aversive situations. This framework reconciles several inconsistencies in the literature and provides a path forward to better understand and treat anxiety.

Impaired action-safety learning and excessive relief during avoidance in patients with anxiety disorders

Anxiety-related disorders are characterized by high levels of avoidance, but experimental research into avoidance learning in patients is scarce. To fill this gap, we compared healthy controls (HC, n = 47) with patients with obsessive-compulsive disorder (OCD, n = 33), panic disorder with agoraphobia (PDA, n = 40), and post-traumatic stress disorder (PTSD, n = 66) in a computer-based avoidance learning task, in order to examine (1) differences in rates of avoidance responses, (2) differences in action-safety learning during avoidance, and (3) differences in subjective relief following successful avoidance. The task comprised aversive negative pictures (unconditional stimulus, US) that followed pictures of two colored lamps (conditional stimuli, CS+), but not a third colored lamp (safety stimulus, CS-), and could be avoided by pressing a button during one CS+ (CS+ avoidable) but not the other (CS+ unavoidable). Participants rated their US-expectancy and level of relief on a trial-by-trial basis. Compared to the HC group, patient groups displayed higher levels of avoidance to the safety stimulus, and higher levels of US-expectancy and relief following the safety and avoidable danger stimulus. We propose that patients with anxiety disorders have low confidence in the safety consequences of avoidance actions, which induces increased relief during US omissions that reinforce the avoidance action.

Understanding clinical fear and anxiety through the lens of human fear conditioning

Fear is an adaptive emotion that mobilizes defensive resources upon confrontation with danger. However, fear becomes maladaptive and can give rise to the development of clinical anxiety when it exceeds the degree of threat, generalizes broadly across stimuli and contexts, persists after the danger is gone or promotes excessive avoidance behaviour. Pavlovian fear conditioning has been the prime research instrument that has led to substantial progress in understanding the multi-faceted psychological and neurobiological mechanisms of fear in past decades. In this Perspective, we suggest that fruitful use of Pavlovian fear conditioning as a laboratory model of clinical anxiety requires moving beyond the study of fear acquisition to associated fear conditioning phenomena: fear extinction, generalization of conditioned fear and fearful avoidance. Understanding individual differences in each of these phenomena, not only in isolation but also in how they interact, will further strengthen the external validity of the fear conditioning model as a tool with which to study maladaptive fear as it manifests in clinical anxiety.

Managing fear and anxiety in development: A framework for understanding the neurodevelopment of emotion regulation capacity and tendency

How we manage emotional responses to environmental threats is central to mental health, as difficulties regulating threat-related distress can blossom into symptoms of anxiety disorders. Given that anxiety disorders emerge early in the lifespan, it is crucial we understand the multi-level processes that support effective regulation of distress. Scholars have given increased attention to behavioral and neural development of emotion regulation abilities, particularly cognitive reappraisal capacity (i.e., how strongly one can down-regulate negative affect by reinterpreting a situation to change one's emotions). However, this work has not been well integrated with research on regulatory tendency (i.e., how often one spontaneously regulates emotion in daily life). Here, we review research on the development of both emotion regulation capacity and tendency. We then propose a framework for testing hypotheses and eventually constructing a neurodevelopmental model of both dimensions of emotion regulation. Clarifying how the brain supports both effective and frequent regulation of threat-related distress across development is crucial to identifying multi-level signs of dysregulation and developing interventions that support youth mental health.

The effects of stress on avoidance in rodents: An unresolved matter

In the face of a possible threat, a range of physiological (e.g., increased heart rate) and behavioral (e.g., avoidance or escape) responses are recruited. Here, we will focus on avoidance, in its persistent form one of the core symptoms of anxiety disorders and obsessive-compulsive disorder. The initial goal of fear and avoidance responses is to increase survival, but if they become persistent or overgeneralize, they can disrupt normal daily functioning, and ultimately even result in anxiety-related disorders. Relatedly, acute stress responses promote adaptation and survival, while chronic stress has been found to aggravate pathophysiology. Thus, stress might trigger the transition from adaptive to maladaptive responses, e.g., from goal-directed to persistent avoidance. Animal models are prime tools to unravel if and how stress influences avoidance. This is typically done by performing stress inductions prior to the assessment of (passive or active) avoidance behavior. Despite its clinical relevance, the current literature on this topic is fragmented, and an overall conclusion is lacking. In this Review, we first recapitulate the state of the art regarding stress and active as well as passive avoidance procedures. We then summarize the behavioral effects of acute and chronic stress on active and passive avoidance, and discuss the main neurobiological findings of the field. Finally, we highlight possible reasons for the largely contradictory findings in the literature and we propose strategies to further unravel the effect of stress on avoidance behavior. A deeper understanding of this currently unresolved matter may provide further insights in the etiology and treatment of anxiety-related disorders.

Common and separable behavioral and neural mechanisms underlie the generalization of fear and disgust

Generalization represents the transfer of a conditioned responses to stimuli that resemble the conditioned stimulus (CS). Previous studies on generalization of defensive avoidance responses have primarily focused on fear and have neglected disgust generalization, which represents a key pathological mechanism in some anxiety disorders. In the present study we examined common and distinct mechanisms of fear and disgust generalization by means of a fear or disgust multi-CS conditioning and generalization paradigm with concomitant event-related potential (ERPs) acquisition in n = 62 subjects. We demonstrate that compared to fear, disgust-relevant generalized stimuli (GS) elicited larger expectancy ratings and longer reaction times (RTs) reflecting stronger ratings of 'risk'. On the electrophysiological level, increased P2 amplitudes were found in response to conditioned CS+ versus CS- across both domains, possibly reflecting higher motivational and attentional salience of aversive conditioned stimuli per se. Contingent negative variation (CNV) amplitude was significantly larger for disgust-CS+ than disgust-CS-, reflecting a stronger preparation of the disgust US. Additionally, we found that the contingent negative variation (CNV) fear generalization gradient, and CNV amplitude were increased with similarity to CS+. In contrast the CNV to disgust-GS did not differ and did not reflect disgust generalization. Together this may indicate that the CNV represents a highly fear-specific index for generalization learning. This study provides the first neurobiological evidence for common and distinct generalization learning in fear versus disgust suggesting that dysregulations in separable defensive avoidance mechanisms may underly different anxiety disorder subtypes.

Fear one, fear them all: A systematic review and meta-analysis of fear generalization in pathological anxiety

It is a defining feature of anxiety disorders that fear is elicited by a circumscribed class of stimuli rather than by only one specific exemplar of that class. Therefore, fear generalization, a mechanism by which associative fear extends from one conditioned stimulus to similar cues, has been central to theories on anxiety. Yet, experimental evidence for the link between generalization and pathological anxiety, as well as its moderators, has not been formally integrated. This systematic review and meta-analysis of empirical findings clarifies the relationship between fear generalization and pathological anxiety. In conclusion, enhanced fear generalization is associated with several anxiety disorders and stress-related disorders, which is supported statistically by a small, but robust effect size of g = 0.44 for risk ratings as an index of fear generalization. However, empirical results are inconsistent across disorders and they rarely allow for conclusions on their causality in the disorders' etiology. Therefore, based on theoretical considerations, we recommend directions for intensified research, especially on the causal relationship between overgeneralization and pathological fear.

Measuring maladaptive avoidance: from animal models to clinical anxiety

Avoiding stimuli that predict danger is required for survival. However, avoidance can become maladaptive in individuals who overestimate threat and thus avoid safe situations as well as dangerous ones. Excessive avoidance is a core feature of anxiety disorders, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). This avoidance prevents patients from confronting maladaptive threat beliefs, thereby maintaining disordered anxiety. Avoidance is associated with high levels of psychosocial impairment yet is poorly understood at a mechanistic level. Many objective laboratory assessments of avoidance measure adaptive avoidance, in which an individual learns to successfully avoid a truly noxious stimulus. However, anxiety disorders are characterized by maladaptive avoidance, for which there are fewer objective laboratory measures. We posit that maladaptive avoidance behavior depends on a combination of three altered neurobehavioral processes: (1) threat appraisal, (2) habitual avoidance, and (3) trait avoidance tendency. This heterogeneity in underlying processes presents challenges to the objective measurement of maladaptive avoidance behavior. Here we first review existing paradigms for measuring avoidance behavior and its underlying neural mechanisms in both human and animal models, and identify how existing paradigms relate to these neurobehavioral processes. We then propose a new framework to improve the translational understanding of maladaptive avoidance behavior by adapting paradigms to better differentiate underlying processes and mechanisms and applying these paradigms in clinical populations across diagnoses with the goal of developing novel interventions to engage specific identified neurobehavioral targets.

Anxiety predicts impulsive-compulsive behaviours in Parkinson's disease: Clinical relevance and theoretical implications

Patients with Parkinson's disease (PD) often present symptoms of anxiety, depression and apathy. These negative affect manifestations have been recently associated with the presence of impulsive compulsive behaviours (ICBs). However, their relation with the use of dopamine replacement therapy (DRT), a renewed risk factor for ICBs, is still not fully understood. Elucidating the role of these different ICBs predictors in PD could inform both prevention/intervention recommendations as well as theoretical models. In the present study, we have analysed data collected in 417 PD patients, 50 patients with Parkinsonian symptoms but with scan without evidence of dopaminergic deficit (SWEDD), and 185 healthy controls (HC). We examined each patient's clinical profile over a two-year time window, investigating the role of both negative affect and DRT on ICBs. Results confirmed the presence of higher levels of anxiety in both the clinical groups, and of higher level of ICBs in SWEDD patients, respect to both PD and HC. Mixed model analyses revealed a statistically significant association between anxiety and ICBs in the SWEDD patients who did not take any DRT. Findings suggest the independence between anxiety and DRT in ICBs development, and provide new evidence for the motivational opponency theoretical framework.

Empathy, compassion, and theory of mind in obsessive-compulsive disorder

OBJECTIVES

Individuals with obsessive-compulsive disorder (OCD) often suffer from impairments in social functioning. This study investigates differences in empathy, compassion, and Theory of Mind (ToM) in individuals with OCD as a possible cause for social functioning deficits.

DESIGN

Sixty-four individuals diagnosed with OCD and 62 healthy individuals completed a naturalistic behavioural task (EmpaToM) and a self-report measure (Interpersonal Reactivity Index, IRI).

METHODS

Three preregistered repeated measures analyses of variance (ANOVAs).

RESULTS

People with OCD exhibited higher empathy levels - namely increased sharing of others' suffering - in the EmpaToM task and reported more distress (IRI) compared with healthy individuals. Furthermore, no differences in compassion (EmpaToM) between both groups emerged, although people with OCD reported more concern for others (IRI) compared with healthy individuals. Concerning the ToM, no group differences were detected, neither in the behavioural task, nor self-report.

CONCLUSION

By investigating OCD with diverse scientific practices we shed light on the higher levels of empathy exhibited by individuals with OCD, which are relevant for clinical practice and our understanding of OCD symptomatology.

PRACTITIONER POINTS

●People with obsessive-compulsive disorder show higher levels of empathy, that is the increased sharing of others' suffering, compared with healthy individuals in both a traditional self-report and a naturalistic task. ●Regarding compassion, that is caring for others, their self-reported compassion was higher in people with OCD. ●In Theory of Mind, that is cognitively understanding the situation of another person, no differences have been found neither at self-report nor in a naturalistic task compared with healthy individuals. ●Independent of traditional interventions, it could prove useful to improve emotion regulation skills so people with OCD learn to cope with empathic distress. Furthermore, it might strengthen the treatment gains and lower dropout rates if the social mind and consequently social relationships become a topic in the treatment and prevention of OCD.

The prefrontal cortex, pathological anxiety, and anxiety disorders

Anxiety is experienced in response to threats that are distal or uncertain, involving changes in one's subjective state, autonomic responses, and behavior. Defensive and physiologic responses to threats that involve the amygdala and brainstem are conserved across species. While anxiety responses typically serve an adaptive purpose, when excessive, unregulated, and generalized, they can become maladaptive, leading to distress and avoidance of potentially threatening situations. In primates, anxiety can be regulated by the prefrontal cortex (PFC), which has expanded in evolution. This prefrontal expansion is thought to underlie primates' increased capacity to engage high-level regulatory strategies aimed at coping with and modifying the experience of anxiety. The specialized primate lateral, medial, and orbital PFC sectors are connected with association and limbic cortices, the latter of which are connected with the amygdala and brainstem autonomic structures that underlie emotional and physiological arousal. PFC pathways that interface with distinct inhibitory systems within the cortex, the amygdala, or the thalamus can regulate responses by modulating neuronal output. Within the PFC, pathways connecting cortical regions are poised to reduce noise and enhance signals for cognitive operations that regulate anxiety processing and autonomic drive. Specialized PFC pathways to the inhibitory thalamic reticular nucleus suggest a mechanism to allow passage of relevant signals from thalamus to cortex, and in the amygdala to modulate the output to autonomic structures. Disruption of specific nodes within the PFC that interface with inhibitory systems can affect the negative bias, failure to regulate autonomic arousal, and avoidance that characterize anxiety disorders.

What's Playing in Your Waiting Room? Patient and Provider Stress and the Impact of Waiting Room Media

Patients enter the healthcare space shouldering a lot of personal stress. Concurrently, health care providers and staff are managing their own personalstressors as well as workplace stressors. As stress can negatively affect the patient-provider experience and cognitive function of both individuals, it is imperative to try to uplift the health care environment for all. Part of the healthcare environmental psychology strategy to reduce stress often includes televisions in waiting rooms, cafeterias, and elsewhere, with the intent to distract the viewer and make waiting easier. Although well-intentioned, many select programming which can induce stress (eg, news). In contrast, as positive media can induce desirable changes in mood, it is possible to use it to decrease stress and uplift viewers, including staff. Positive media includes both nature media, which can relax and calm viewers and kindness media, which uplifts viewers, induces calm, and promotes interpersonal connection and generosity. Careful consideration of waiting room media can affect the patient-provider experience.

Costly habitual avoidance is reduced by concurrent goal-directed approach in a modified devaluation paradigm

Avoidance habits potentially contribute to maintaining maladaptive, costly avoidance behaviors that persist in the absence of threat. However, experimental evidence about costly habitual avoidance is scarce. In two experiments, we tested whether extensively trained avoidance impairs the subsequent goal-directed approach of rewards. Healthy participants were extensively trained to avoid an aversive outcome by performing simple responses to distinct full-screen color stimuli. After the subsequent devaluation of the aversive outcome, participants received monetary rewards for correct responses to neutral object pictures, which were presented on top of the same full-screen colors. These approach responses were either compatible or incompatible with habitual avoidance responses. Notably, the full-screen colors were not relevant to inform approach responses. In Experiment 1, participants were not instructed about post-devaluation stimulus-response-reward contingencies. Accuracy was lower in habit-incompatible than in habit-compatible trials, indicating costly avoidance, whereas reaction times did not differ. In Experiment 2, contingencies were explicitly instructed. Accuracy differences disappeared, but reaction times were slower in habit-incompatible than in habit-compatible trials, indicating low-cost habitual avoidance tendencies. These findings suggest a small but consistent impact of habitual avoidance tendencies on subsequent goal-directed approach. Costly habitual responding could, however, be inhibited when competing goal-directed approach was easily realizable.

The enhancing effects of testosterone in exposure treatment for social anxiety disorder: a randomized proof-of-concept trial

Individuals with a social anxiety disorder (SAD) show hypofunctioning of the hypothalamus-pituitary-gonadal (HPG) axis, which is linked to social fear and avoidance behavior. As testosterone administration has been shown to facilitate social-approach behavior in this population, it may enhance the effectiveness of exposure treatment. In this proof-of-concept study, we performed a randomized clinical assay in which 55 women diagnosed with SAD received two exposure therapy sessions. Session 1 was supplemented with either testosterone (0.50 mg) or placebo. Next, transfer effects of testosterone augmentation on within-session subjective fear responses and SAD symptom severity were assessed during a second, unenhanced exposure session (session 2) and at a 1-month follow-up, respectively. The participants having received testosterone showed a more reactive fear pattern, with higher peaks and steeper reductions in fear levels in session 2. Post-hoc exploration of moderating effects of endogenous testosterone levels, revealed that this pattern was specific for women with high basal testosterone, both in the augmented and in the transfer session. In contrast, the participants with low endogenous testosterone showed reduced peak fear levels throughout session 1, again with transfer to the unenhanced session. Testosterone did not significantly affect self-reported anxiety. The effects of testosterone supplementation on fear levels show transfer to non-enhanced exposure, with effects being modulated by endogenous testosterone. These first preliminary results indicate that testosterone may act on important fear mechanisms during exposure, providing the empirical groundwork for further exploration of multi-session testosterone-enhanced exposure treatment for SAD.

Bidirectional Influence of Limbic GIRK Channel Activation on Innate Avoidance Behavior

Systemic administration of ML297, a selective activator of G-protein-gated inwardly rectifying K+ (GIRK) channels, decreases innate avoidance behavior in male C57BL/6J mice. The cellular mechanisms mediating the ML297-induced suppression of avoidance behavior are unknown. Here, we show that systemic ML297 administration suppresses elevated plus maze (EPM)-induced neuronal activation in the ventral hippocampus (vHPC) and basolateral amygdala (BLA) and that ML297 activates GIRK1-containing GIRK channels in these limbic structures. While intracranial infusion of ML297 into the vHPC suppressed avoidance behavior in the EPM test, mirroring the effect of systemic ML297, intra-BLA administration of ML297 provoked the opposite effect. Using neuron-specific viral genetic and chemogenetic approaches, we found that the combined inhibition of excitatory neurons in CA3 and dentate gyrus (DG) subregions of the vHPC was sufficient to decrease innate avoidance behavior in the EPM, open-field, and light-dark tests in male C57BL/6J mice, while performance in the marble-burying test was not impacted. Furthermore, genetic ablation of GIRK channels in CA3/DG excitatory neurons precluded the suppression of avoidance behavior evoked by systemic ML297 in the EPM test. Thus, acute inhibition of excitatory neurons in the ventral CA3 and DG subregions of the vHPC is necessary for the apparent anxiolytic efficacy of systemic ML297 and is sufficient to decrease innate avoidance behavior in male C57BL/6J mice.SIGNIFICANCE STATEMENT We interrogated the cellular mechanisms underlying the apparent anxiolytic efficacy of ML297, a selective activator of G-protein-gated inwardly rectifying K+ (GIRK) channels and promising lead compound. Intracranial infusion of ML297 into the ventral hippocampus (vHPC) and basolateral amygdala (BLA) complex exerted opposing influence on innate avoidance behavior in male C57BL/6J mice, the former recapitulating the suppression of avoidance behavior evoked by systemic ML297. Using viral genetic and chemogenetic approaches, we showed that combined inhibition of excitatory neurons in CA3 and dentate gyrus (DG) subregions of the vHPC is sufficient to decrease innate avoidance behavior in male mice and mediates the decrease in avoidance behavior evoked by systemic ML297. These findings establish a foundation for future investigations into the therapeutic potential of GIRK channel modulation in anxiety disorders.

Increased anxiety of public situations during the COVID-19 pandemic: Evidence from a community and a patient sample

Background

Increases in emotional distress in response to the global outbreak of the SARS-CoV-2 (COVID-19) pandemic have been reported. So far, little is known about how anxiety responses in specific everyday public life situations have been affected.

Method

Self-reported anxiety in selected public situations, which are relevant in the COVID-19 pandemic, was investigated in non-representative samples from the community (n = 352) and patients undergoing psychotherapy (n = 228). Situational anxiety in each situation was rated on a 5-point Likert scale (0 = no anxiety at all to 4 = very strong anxiety). Situational anxiety during the pandemic was compared with retrospectively reported situational anxiety before the pandemic (direct change) and with anxiety levels in a matched sample assessed before the pandemic (n = 100; indirect change).

Results

In the community and patient sample, indirect and direct change analyses demonstrated an increase in anxiety in relevant public situations but not in control situations. Average anxiety levels during the pandemic were moderate, but 5-28% of participants reported high to very high levels of anxiety in specific situations. Interestingly, the direct increase in anxiety levels was higher in the community sample: patients reported higher anxiety levels than the community sample before, but not during the pandemic. Finally, a higher increase in situational anxiety was associated with a higher perceived danger of COVID-19, a higher perceived likelihood of contracting COVID-19, and stronger symptoms of general anxiety and stress.

Conclusions

Preliminary findings demonstrate an increase in anxiety in public situations during the COVID-19 pandemic in a community and a patient sample. Moderate anxiety may facilitate compliance with public safety measures. However, high anxiety levels may result in persistent impairments and should be monitored during the pandemic.

Brain circuitry underlying the ABC model of anxiety

Anxiety Disorders are prevalent and often chronic, recurrent conditions that reduce quality of life. The first-line treatments, such as serotonin reuptake inhibitors and cognitive behavioral therapy, leave a significant proportion of patients symptomatic. As psychiatry moves toward targeted circuit-based treatments, there is a need for a theory that unites the phenomenology of anxiety with its underlying neural circuits. The Alarm, Belief, Coping (ABC) theory of anxiety describes how the neural circuits associated with anxiety interact with each other and domains of the anxiety symptoms, both temporally and spatially. The latest advancements in neuroimaging techniques offer the ability to assess these circuits in vivo. Using Neurosynth, a large open-access meta-analytic imaging database, the association between terms related to specific neural circuits was explored within the ABC theory framework. Alarm-related terms were associated with the amygdala, anterior cingulum, insula, and bed nucleus of stria terminalis. Belief-related terms were associated with medial prefrontal cortex, precuneus, bilateral temporal poles, and hippocampus. Coping-related terms were associated with the ventrolateral and dorsolateral prefrontal cortices, basal ganglia, and anterior cingulate. Neural connections underlying the functional neuroanatomy of the ABC model were observed. Additionally, there was considerable interaction and overlap between circuits associated with the symptom domains. Further neuroimaging research is needed to explore the dynamic interaction between the functional domains of the ABC theory. This will pave the way for probing the neuroanatomical underpinnings of anxiety disorders and provide an evidence-based foundation for the development of targeted treatments, such as neuromodulation.

Avoidance in Anorexia Nervosa: Towards a research agenda

Anorexia Nervosa is a severe and disabling mental disorder and a huge challenge to treat. Intense fears of e.g., food, eating, weight gain and social evaluation are core features of anorexia nervosa and obstacles during treatment. The perceived threats trigger avoidance and safety behaviors like highly restrictive eating, strict eating rules, vomiting and body checking, to minimize feared outcomes. The role of avoidance in anorexia nervosa is however hardly studied experimentally. In the present article, the focus is on a new transdiagnostic research agenda featuring both basic and clinical experimental research into avoidance as a most important mechanism maintaining the eating disorder. Avoidance learning and the generalization of learned avoidance behaviors are discussed, as well as safety behaviors and the need for inhibitory learning as a treatment target during exposure therapy.

Latent cause inference during extinction learning in trauma-exposed individuals with and without PTSD

BACKGROUND

Problems in learning that sights, sounds, or situations that were once associated with danger have become safe (extinction learning) may explain why some individuals suffer prolonged psychological distress following traumatic experiences. Although simple learning models have been unable to provide a convincing account of why this learning fails, it has recently been proposed that this may be explained by individual differences in beliefs about the causal structure of the environment.

METHODS

Here, we tested two competing hypotheses as to how differences in causal inference might be related to trauma-related psychopathology, using extinction learning data collected from clinically well-characterised individuals with varying degrees of post-traumatic stress (N = 56). Model parameters describing individual differences in causal inference were related to multiple post-traumatic stress disorder (PTSD) and depression symptom dimensions via network analysis.

RESULTS

Individuals with more severe PTSD were more likely to assign observations from conditioning and extinction stages to a single underlying cause. Specifically, greater re-experiencing symptom severity was associated with a lower likelihood of inferring that multiple causes were active in the environment.

CONCLUSIONS

We interpret these results as providing evidence of a primary deficit in discriminative learning in participants with more severe PTSD. Specifically, a tendency to attribute a greater diversity of stimulus configurations to the same underlying cause resulted in greater uncertainty about stimulus-outcome associations, impeding learning both that certain stimuli were safe, and that certain stimuli were no longer dangerous. In the future, better understanding of the role of causal inference in trauma-related psychopathology may help refine cognitive therapies for these disorders.

Avoidance learning as predictor of posttraumatic stress in firefighters

BACKGROUND

Avoidance is a well-established maintenance factor in anxiety-related psychopathology. Individuals prone to anxiety show more maladaptive avoidance responses in conditioning paradigms aimed at avoidance learning, which indicates impairments in safety learning. To what extent avoidance learning is associated with posttraumatic stress disorder (PTSD) is still unclear, despite the logical relevance to the symptomatology. In this prospective study, we investigate avoidance learning responses in first responders, a population at high risk for traumatic exposure and thus PTSD development, and studied whether avoidance learning was associated with concurrent and future PTSD symptoms.

METHOD

Firefighters (N = 502) performed an avoidance learning task at baseline assessment in which they first learned that two conditioned stimuli (CS+) were followed by an aversive stimulus (US) and one conditioned stimulus (CS-) was not. After that, they could learn to which CS avoidance of the US was effective, ineffective or unnecessary. Self-reported PTSD symptoms were assessed at baseline, and at 6, 12, 18 and 24 months.

RESULTS

Participants exhibited comparable avoidance patterns to low anxiety individuals from previous studies. Avoidance learning responses were not associated with PTSD symptoms at baseline nor at follow-up.

DISCUSSION

Our study found no evidence that avoidance learning was related to PTSD symptom severity in a high-risk, yet low symptomatic population, nor did it predict the development of PTSD symptoms at a later point in time. Future research should focus on studying avoidance learning in a clinical or high symptomatic sample to further clarify the role of avoidance learning in PTSD development.

The Role of Disgust in Eating Disorders

PURPOSE OF REVIEW

In current review, we evaluate the current literature examining the role of disgust in eating disorders (EDs), and provide a theoretical model designed to inform the study and treatment of disgust-based symptoms in EDs.

RECENT FINDINGS

Findings from this review suggest that aberrant disgust-conditioning processes represent promising but understudied mechanisms that may contribute to the risk and maintenance of core eating disorder (ED) psychopathology. In addition, preliminary evidence supports the use of interventions designed to target aversive disgust cues and disrupt maladaptive disgust-based conditioning that may maintain eating pathology. However, experimental studies designed to elucidate the role of disgust and aversive learning processes remain limited. Disgust is a promising risk and maintenance factor in EDs. Future systematic investigation is needed to examine disgust-based processes at a mechanistic level in order to better understand the links between disgust, avoidance behaviors, and EDs. Further investigation of the mechanistic role of disgust in EDs is warranted.

A Taxometric Analysis of Experiential Avoidance

Experiential avoidance, a trait-like construct referring to the tendency to rigidly avoid or change unpleasant internal experiences stemming from an unwillingness to experience them, is believed to contribute to the development and maintenance of various forms of psychopathology. Despite significant research on this construct, it remains unclear whether experiential avoidance is dimensional or categorical at the latent level. The current study examined the latent structure of experiential avoidance using three taxometric analytic approaches (MAXimum Eigenvalue, Mean Above Minus Below A Curve, Latent-Mode Factor Analysis) applied to data from two independent samples and using three widely used measures of experiential avoidance. The first sample (n = 922) completed the Multidimensional Experiential Avoidance Questionnaire (Gámez, Chmielewski, Kotov, Ruggero, & Watson, 2011), while the second sample (n = 615) completed the Brief Experiential Avoidance Questionnaire (Gámez et al., 2014) and Acceptance and Action Questionnaire-II (Bond et al., 2011). Across both samples and all three measures, experiential avoidance exhibited a dimensional structure. The clinical and research implications of this finding for experiential avoidance are discussed.

Individual differences in costly fearful avoidance and the relation to psychophysiology

Excessive avoidance behaviour is a cardinal symptom of anxiety disorders. Avoidance is not only associated with the benefits of avoiding threats, but also with the costs of missing out on rewards upon exploration. Psychological and psychophysiological mechanisms contributing to these costly avoidance decisions in prospect of mixed outcomes remain unclear. We developed a novel Fearful Avoidance Task (FAT) that resembles characteristics of real-life approach-avoidance conflicts, enabling to disentangle reward and threat effects. Using the FAT, we investigated individual differences in avoidance behaviour and anticipatory psychophysiological states (i.e. startle reflex and skin conductance) in a relatively large sample of 343 (78 females) participants. Avoidance under acute threat of shock depends on a trade-off between perceived reward and threat. Both increased startle and skin conductance in the absence of threat of shock emerged as predictors of increased avoidance (potentially indicative of fear generalization). Increased avoidance was also associated with female sex and trait anxiety, dependent on reward and threat levels. Our findings highlight distinct possible predictors of heightened avoidance and add to mechanistic understanding of how individual propensity for costly avoidance may emerge. Distinct avoidance typologies based on differential reward and threat sensitivities may have different mechanistic origins and thereby could benefit from different treatment strategies.

Converging Multi-modal Evidence for Implicit Threat-Related Bias in Pediatric Anxiety Disorders

This report examines the relationship between pediatric anxiety disorders and implicit bias evoked by threats. To do so, the report uses two tasks that assess implicit bias to negative-valence faces, the first by eye-gaze and the second by measuring body-movement parameters. The report contrasts task performance in 51 treatment-seeking, medication-free pediatric patients with anxiety disorders and 36 healthy peers. Among these youth, 53 completed an eye-gaze task, 74 completed a body-movement task, and 40 completed both tasks. On the eye-gaze task, patients displayed longer gaze duration on negative relative to non-negative valence faces than healthy peers, F(1, 174) = 8.27, p = .005. In contrast, on the body-movement task, patients displayed a greater tendency to behaviorally avoid negative-valence faces than healthy peers, F(1, 72) = 4.68, p = .033. Finally, implicit bias measures on the two tasks were correlated, r(38) = .31, p = .049. In sum, we found an association between pediatric anxiety disorders and implicit threat bias on two tasks, one measuring eye-gaze and the other measuring whole-body movements. Converging evidence for implicit threat bias encourages future research using multiple tasks in anxiety.

Threat or thrill? the neural mechanisms underlying the development of anxiety and risk taking in adolescence

Anxiety is common in adolescence and has been linked to a plethora of negative outcomes across development. While previous studies of anxiety have focused on threat sensitivity, less work has considered the concurrent development of threat- and reward-related neural circuitry and how these circuits interact and compete during puberty to influence typical adolescent behaviors such as increased risk taking and exploration. The current review integrates relevant findings from clinical and developmental neuroimaging studies to paint a multidimensional picture of adolescent-onset anxiety against the backdrop of typical adolescent development. Ultimately, this paper argues that longitudinal neuroimaging studies tracking approach and avoidance motivations across development are needed to fully understand the mechanisms underlying the development of anxiety in adolescence and to identify and provide effective interventions for at-risk youth.

Decomposing conditioned avoidance performance with computational models

Avoidance towards innocuous stimuli is a key characteristic across anxiety-related disorders and chronic pain. Insights into the relevant learning processes of avoidance are often gained via laboratory procedures, where individuals learn to avoid stimuli or movements that have been previously associated with an aversive stimulus. Typically, statistical analyses of data gathered with conditioned avoidance procedures include frequency data, for example, the number of times a participant has avoided an aversive stimulus. Here, we argue that further insights into the underlying processes of avoidance behavior could be unraveled using computational models of behavior. We then demonstrate how computational models could be used by reanalysing a previously published avoidance data set and interpreting the key findings. We conclude our article by listing some challenges in the direct application of computational modeling to avoidance data sets.

Endogenous testosterone levels are predictive of symptom reduction with exposure therapy in social anxiety disorder

The Hypothalamus-Pituitary-Gonadal (HPG)-axis, and testosterone in particular, play an important role in social motivational behavior. Socially avoidant behavior, characteristic of social anxiety disorder (SAD), has been linked to low endogenous testosterone levels, and can be alleviated by testosterone administration in SAD. Although these beneficial effects of testosterone may translate to exposure therapy, it remains unknown whether testosterone increases prior to exposure improve therapy outcomes. In this proof-of-principle study, we tested whether pre-exposure (reactive and baseline) endogenous testosterone levels were predictive of exposure outcome in SAD. Seventy-three participants (52 females) with a principal SAD diagnosis performed four speech exposures: three during one standardized exposure therapy session and one at post-assessment one week later. Subjective fear levels were assessed before and after each speech exposure and social anxiety symptoms were assessed at pre- and post-treatment. Pre-treatment testosterone levels were assessed before (baseline) and in response to a pre-exposure instruction session (reactive). Pre-treatment testosterone levels were not related to fear levels during exposure therapy, but predicted pre- to post-treatment reductions in social anxiety symptom severity. Specifically, low baseline and high reactive pre-treatment testosterone levels were associated with larger reductions in social anxiety symptom severity. These findings support the role of HPG-axis in social fear reduction. Specifically, our finding that high reactive testosterone as well as low baseline testosterone predicted exposure outcome in SAD, suggests that good reactivity of the HPG-axis is a promising marker for the symptom-reducing effects of exposure therapy.

Anxiety, avoidance, and sequential evaluation

Anxiety disorders are characterized by a range of aberrations in the processing of and response to threat, but there is little clarity what core pathogenesis might underlie these symptoms. Here we propose that a particular set of unrealistically pessimistic assumptions can distort an agent's behavior and underlie a host of seemingly disparate anxiety symptoms. We formalize this hypothesis in a decision theoretic analysis of maladaptive avoidance and a reinforcement learning model, which shows how a localized bias in beliefs can formally explain a range of phenomena related to anxiety. The core observation, implicit in standard decision theoretic accounts of sequential evaluation, is that the potential for avoidance should be protective: if danger can be avoided later, it poses less threat now. We show how a violation of this assumption - via a pessimistic, false belief that later avoidance will be unsuccessful - leads to a characteristic, excessive propagation of fear and avoidance to situations far antecedent of threat. This single deviation can explain a range of features of anxious behavior, including exaggerated threat appraisals, fear generalization, and persistent avoidance. Simulations of the model reproduce laboratory demonstrations of abnormal decision making in anxiety, including in situations of approach-avoid conflict and planning to avoid losses. The model also ties together a number of other seemingly disjoint phenomena in anxious disorders. For instance, learning under the pessimistic bias captures a hypothesis about the role of anxiety in the later development of depression. The bias itself offers a new formalization of classic insights from the psychiatric literature about the central role of maladaptive beliefs about control and self-efficacy in anxiety. This perspective also extends previous computational accounts of beliefs about control in mood disorders, which neglected the sequential aspects of choice.