The role of avoidance of emotional material in the anxiety disorders

Many psychotherapeutic traditions have conceptualized clinical levels of anxiety as resulting from the avoidance of threatening or emotional material. In this paper, we examine behavioral models of avoidance of emotions and emotional material, integrating findings that support established behavioral theories of emotional avoidance and anxiety, and that extend these theories to further explain the intense, intrusive, and interfering nature of clinical anxiety. Research on the suppression and avoidance of emotional material suggests that emotional avoidance and thought suppression may not only hinder the learning process and maintain anxious responding, but may also (a) paradoxically heighten anxious responding to threatening cues and (b) interfere with emotion functionality, thereby further impeding adaptive responding. Findings are discussed in terms of future research and implications for clinical treatment of anxiety disorders.     

Rumination, worry, cognitive avoidance, and behavioral avoidance: examination of temporal effects

Recently, cross-sectional research has demonstrated that depressive rumination is significantly associated with the tendency to engage in cognitive and behavioral avoidance. This evidence suggests that rumination may be the result of attempts to avoid personally threatening thoughts, in a manner suggested by multiple contemporary theories of worry. This investigation examined the temporal relationship among daily levels of cognitive avoidance, behavioral avoidance, rumination, worry, and negative affect. Seventy-eight adolescents completed baseline questionnaires and then electronically completed daily measures of rumination, worry, behavioral avoidance, and cognitive avoidance, as well as sad and anxious affect for 7 days. Lagged-effect multilevel models indicated that increases in daily sadness were predicted by greater daily rumination and cognitive avoidance. Increases in daily anxiety were predicted by greater daily rumination, worry, and both cognitive and behavioral avoidance. Further, both daily rumination and worry were positively predicted by daily cognitive, but not behavioral, avoidance. Mediation analyses suggested that rumination mediated the effect of cognitive avoidance on both sadness and anxiety. Also, worry mediated the effect of cognitive avoidance on anxiety. Implications for models of avoidance, rumination, and worry are discussed.     

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

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

Using Motion Tracking to Measure Avoidance in Children and Adults: Psychometric Properties,Associations With Clinical Characteristics,and Treatment-Related Change

Avoidance is implicated in many areas of psychopathology, particularly anxiety and its disorders. Accurate, reliable, valid, and objective measurement of avoidance behavior poses methodological challenges. Two key technological advances, increased computing power and the advent of motion-tracking technology, offer novel solutions to these challenges. We describe a series of three studies using a novel motion-tracking system to measure avoidance in children and adults. The first study examined behavioral avoidance of spider stimuli in large samples of children and adults (N = 200 each; the adults were the mothers of the children). Behavioral avoidance was associated with self-rated fear of spiders and increased state anxiety from before to after the task. The second study examined avoidance of threat faces in children and adults (N = 35 each; the adults were the mothers of the children) and test-retest reliability in the adults. Avoidance of threat faces was associated with broadband anxiety symptom severity. Test-retest correlations in behavioral avoidance measured 6 weeks apart was high and significant. The third study examined behavioral avoidance of spiders in clinically anxious children (N = 25) before and after cognitive-behavioral therapy for childhood anxiety disorders. Behavioral avoidance was significantly reduced following cognitive-behavioral therapy and reduction in behavioral avoidance correlated significantly with improvement in child-rated anxiety symptoms. Taken together, these studies provide strong support for the promise of motion-tracking technology to enable a new phase of behavioral avoidance research with sensitive, valid, reliable, and cost- and time-effective measurement of behavioral avoidance across the lifespan.     

家庭功能与学前儿童行为问题的关系:依恋回避和社交焦虑的多重中介作用

采用纵向的研究设计,对上海市两所公办幼儿园192名学前儿童进行为期一年半的追踪调查,探讨了家庭功能与学前儿童行为问题之间的关系以及依恋回避和社交焦虑的中介作用。结果发现：（1）家庭功能、依恋回避、社交焦虑和儿童行为问题之间存在两两相关;（2）家庭功能能够显著负向预测儿童行为问题;（3）依恋回避和社交焦虑分别在家庭功能和行为问题之间起独立中介作用;（4）依恋回避和社交焦虑在家庭功能和行为问题之间起序列中介作用。研究结果进一步揭示了家庭功能对学前儿童行为问题影响的内在机制。     

家庭功能与学前儿童行为问题的关系:依恋回避和社交焦虑的多重中介作用

采用纵向的研究设计,对上海市两所公办幼儿园192名学前儿童进行为期一年半的追踪调查,探讨了家庭功能与学前儿童行为问题之间的关系以及依恋回避和社交焦虑的中介作用。结果发现：（1）家庭功能、依恋回避、社交焦虑和儿童行为问题之间存在两两相关;（2）家庭功能能够显著负向预测儿童行为问题;（3）依恋回避和社交焦虑分别在家庭功能和行为问题之间起独立中介作用;（4）依恋回避和社交焦虑在家庭功能和行为问题之间起序列中介作用。研究结果进一步揭示了家庭功能对学前儿童行为问题影响的内在机制。     

How anxious and avoidant attachment affect romantic relationship quality differently: A meta‐analytic review

Adult attachment has been studied as an important predictor of romantic relationship quality in many empirical studies. This meta‐analysis quantitatively summarized the associations between the two insecure adult attachment dimensions, anxiety and avoidance, and cognitive, emotional, and behavioral indicators of romantic relationship quality based on 73 previous studies with 118 independent samples of 21 602 individuals. More importantly, we examined the different effects of anxiety and avoidance on relationship quality. We also tested the potential moderating effects of gender on the strength of these associations. Meta‐analytic results confirmed that both anxiety and avoidance were detrimental to the cognitive, emotional, and behavioral aspects of relationship quality. Compared with anxiety, avoidance was more negatively associated with general satisfaction, connectedness, and general support in relationships. In contrast, anxiety was more positively associated with general conflict in relationships. The moderating effect of gender was weak. However, supplementary analyses found that the type of couple interaction measures (self‐report versus observation) significantly moderated the relations between insecure attachments and the behavioral indicators of relationship quality. Our results integrate and extend previous findings about the dynamics of adult attachment and romantic relationship quality. Copyright © 2012 John Wiley & Sons, Ltd.     

Working models of attachment and person perception processes

This study investigated the effects of attachment working models on social perception processes. Participants estimated the number of behavioral instances they would require to confirm and disconfirm hypothetical others’ possession of various traits. The attachment dimension of avoidance was associated with a defensively conservative style of social perception. High scorers on avoidance required more evidence to make a positive judgment and also more evidence to reject a negative judgment. In contrast, the attachment dimension of anxiety was associated with a relatively impulsive and labile perceptional style. High scorers on anxiety tended to require less evidence to make both positive and negative judgments of others. Results are discussed in terms of their concordance with previous findings and their implications for research on attachment and social perception.     

The Role of Emotional Distress Tolerance on Fear Responding in a Heights-Fearful Sample: Perceived Versus Actual Behavior

Emotional distress tolerance (EDT)—or the ability to withstand negative emotional states—is considered a transdiagnostic risk factor for psychopathology. Although EDT is theorized to play a role in anxiety development and maintenance, research aiming to delineate the relationship between anxiety and EDT is lacking. The current study tested whether self-reported EDT predicted self-reported and actual avoidance in the presence of feared stimuli using a heights-fearful sample. Moreover, the study tested whether EDT predicted other in-the-moment fear responses, such as peak anxiety, anxious cognitions, and bodily sensations. Participants (N = 128) completed questionnaires assessing fear of heights, negative affect, anxious cognitions, and bodily sensations, as well as two heights behavioral avoidance tasks (BATs). Results demonstrated that EDT did not predict actual avoidance or other in-the-moment fear responses, except for peak anxiety in one BAT. However, EDT predicted self-reported avoidance of heights beyond fear of heights and negative affect. Taken together, results suggest that perception of ability to tolerate emotional distress predicts perception of avoidance of heights, but not actual avoidance of heights or reactions to heights (with the exception of peak anxiety in one BAT). Given these findings, self-reported EDT may not adequately predict how individuals react in anxiety-provoking situations.     

Avoidance and depression: the construction of the cognitive-behavioral avoidance scale

Previous research has demonstrated a relationship between avoidance and depression, although the nature of this relationship has been confused by inconsistent definitions of avoidance. Following a review of the construct of avoidance and an examination of past research, a new multidimensional measure of avoidance was developed and validated using an undergraduate student sample (245 females and 146 males). Four reliable factors reflecting combinations of cognitive/behavioral and social/nonsocial dimensions of avoidance were obtained from the factor analysis of the new scale, entitled the "Cognitive-Behavioral Avoidance Scale" (CBAS). The scale showed the predicted relationships with convergent and divergent measures used for construct validation. As predicted, subscales of the CBAS, as well as the overall scale score, were significantly related to the depression and anxiety criterion measures. The findings from this study suggest that avoidance may be an important construct in the psychosocial conceptualization of depression. In addition, this integrated measure of avoidance has potential utility for depression researchers. Suggestions for further scale development and research are provided.     

Coping and anxiety in women recalled for additional diagnostic procedures following an abnormal screening mammogram.

This study characterized women's concurrent and subsequent levels of emotional distress associated with a questionable mammogram screening and relationships between women's coping and psychosocial adjustment. State anxiety was assessed in 98 women 1 day after receiving a mammogram screening (Time 1), after notification of a questionable screening result that necessitated additional testing (Time 2), and after being informed of their breast-cancer-free status (Time 3). Key findings include (a) women reported a significant increase in anxiety following notification of the need to return for follow-up testing; (b) significant and positive associations were found between anxiety and behavioral approach, behavioral avoidance, cognitive approach, and cognitive avoidance coping in cross-sectional analyses; and (c) cognitive avoidance coping was a strong predictor of final levels of state anxiety in women. Findings suggest that cognitive avoidance coping plays an important role in reducing anxiety in women recalled to clarify an initially ambiguous screening procedure.     

Individual differences in disgust sensitivity and health-related avoidance: Examination of specific associations

This present study examined the specificity of disgust sensitivity in predicting health-related anxiety and behavioral avoidance. Participants (n = 60) completed self-report measures of disgust sensitivity, health anxiety, anxiety, and depression. They then completed three randomly presented health-related behavioral avoidance tasks (BATs) that consisted of potential exposure to the common cold, the flu, and mononucleosis. Results indicated that disgust sensitivity was significantly associated with anxious and avoidant responding to the health-related BATs. This association also remained largely intact after controlling for gender, anxiety, depression, and health anxiety. These findings indicate that disgust sensitivity has a specific and robust association with health-related anxiety and avoidance commonly observed among those with excessive health anxiety and obsessive compulsive disorder. The unique role of disgust sensitivity in relation to health anxiety is discussed in the context of a disease-avoidance model.     

The relationship between rumination, avoidance and depression in a non-clinical sample

Recent commentaries have proposed conceptualizations of rumination in terms of both cognitive and behavioral avoidance. This study examined the relationship between rumination, avoidance and depression using a newly developed self-report measure of avoidance in depression, the Cognitive-Behavioral Avoidance Scale (CBAS) [Ottenbreit, N.D., & Dobson, K.S. (2004). Avoidance and depression: The construction of the cognitive-behavioral avoidance scale. Behaviour Research and Therapy, 42, 293-313]. A non-clinical sample (N=104) of undergraduate students completed self-report measures of depression, anxiety, rumination and avoidance. Rumination, avoidance and depression were all significantly correlated. Rumination and behavioral avoidance remained intercorrelated when anxiety was controlled, confirming an association that is independent of anxiety. By contrast, the relationship between cognitive avoidance and rumination disappeared when anxiety was partialled out. Notably, avoidance predicted unique variance in depression scores, over and above anxiety and rumination. Consistent with the proposal of Ottenbreit and Dobson [Avoidance and depression: The construction of the cognitive-behavioral avoidance scale. Behaviour Research and Therapy, 42, 293-313], our findings support the value of clinicians and psychopathologists giving consideration to avoidance in their conceptualization of depression.     

Estradiol decreases anxiety behavior and enhances inhibitory avoidance and gestational stress produces opposite effects

Although there is evidence that estradiol has effects in women and in animal models to reduce anxiety and depressive behavior and enhance performance in some cognitive tasks, this is not seen among all individuals. Given the interaction between estradiol and hypothalamic-pituitary-adrenal function, we hypothesized that an individual's prior exposure to stress may mitigate some of the subsequent effects of estradiol. To address this, rats were exposed to gestational stress, or not, to determine if stress exposure during development alters behavioral responses to estradiol in adulthood. If estradiol's effects on anxiety and cognitive behavior are modulated by prior stress experience, then gestationally-stressed rats administered estradiol should have decreased anti-anxiety (open field, elevated plus maze) behavior and cognitive performance in the inhibitory avoidance task. Offspring of dams that were exposed to restraint stress daily on gestational days 14-20, or no such manipulation, were used as adults either intact in behavioral estrus (high estradiol) or diestrus (low estradiol), or ovariectomized (OVX) with empty or estradiol-containing silastic implants. Rats were used for blood collection to determine plasma corticosterone and estradiol concentrations, or were used for behavioral testing. Compared with rats in diestrus or OVX and vehicle-replaced, rats in behavioral estrus and OVX rats with estradiol implants had higher estradiol concentrations, entered more central squares in an open field, spent more time on the open arms of the plus maze, and had a longer latency to crossover to the dark, shock-associated side of the inhibitory avoidance chamber. Gestational stress increased plasma corticosterone but not estradiol levels, decreased plus maze open arm time in cycling rats, and decreased inhibitory avoidance performance. Thus, estradiol and gestational stress can have opposite effects on anxiety and inhibitory avoidance performance.     

Enhancing the Efficacy of Cognitive Bias Modification for Social Anxiety

Cognitive bias modification for interpretation (CBM-I) is a promising treatment modality for social anxiety disorder, but effect sizes are relatively small across investigations (Hallion & Ruscio, 2011). Additionally, the extent to which CBM-I impacts other cognitive, emotional, and behavioral outcomes is unclear. This study investigated whether two empirically supported treatment components for anxiety disorders, imaginal exposure (IE) and relaxation, augment the effects of CBM-I and increase the extent to which the effects of CBM-I generalize to behavioral and affective outcomes. We randomly assigned 111 undergraduate students with social anxiety to undergo IE, relaxation, or neutral thinking prior to CBM-I, then measured their interpretation biases, as well as their speaking time, anxiety, and subjective evaluations of performance during a speech task. Results indicated that individuals who received IE prior to CBM-I evidenced more adaptive interpretation biases and less behavioral avoidance during the speech task than did individuals who engaged in relaxation or neutral thinking. However, they did not report differential anxiety, habituation, or evaluations of their performance on the speech task. These findings suggest that the combination of CBM-I with adjunct components that target behavioral, rather than cognitive, mechanisms can facilitate transfer of the effects of CBM-I to reducing behavioral avoidance.     

Cognitive Behavior Therapy for Women With Generalized Anxiety Disorder in the Perinatal Period: Impact on Problematic Behaviors

Generalized anxiety disorder (GAD) is the most frequently diagnosed anxiety disorder among women in the perinatal period (pregnancy to one year postpartum). Recent studies have examined the relationship between problematic behaviors and GAD symptoms. Studies in nonperinatal samples indicate that adults with GAD engage in avoidance and safety behaviors and these behaviors are associated with greater symptom severity. Little research has examined the use of problematic behaviors among pregnant or postpartum women. However, preliminary research suggests that these behaviors may have a negative impact on both anxious women and their children. Our aim was to examine the extent to which women with GAD in pregnancy or the postpartum engage in problematic behaviors and whether cognitive behavioral therapy is effective in reducing these behaviors. Fifty-eight women with GAD in pregnancy or postpartum were recruited from a larger clinical trial (Clinicaltrials.gov ID NCT02850523) evaluating the effectiveness of group-based cognitive behavioral therapy (CBGT) for perinatal anxiety disorders. The results indicated that women with perinatal GAD reported high levels of avoidance and safety behaviors and greater engagement in these behaviors was associated with higher levels of worry and related symptoms. CBGT was effective in reducing GAD symptoms and problematic behaviors and a bidirectional relationship was found between changes in worry and problematic behaviors during treatment. Limitations and future directions are discussed.     

Attachment and resource sharing

In three studies we examined the associations between resource sharing (RS) and attachment, and the enhancement of RS using attachment security primes. In Study 1, we showed that attachment avoidance was negatively associated with RS. We also identified differences and similarities between RS and pro‐sociality. In Studies 2 and 3, we showed that research participants were more likely to share their monetary resources after they were primed with attachment security. Study 3 further revealed that security priming affected mainly people low on state attachment anxiety. Our findings extend previous work on pro‐sociality into the specific realm of RS, provide behavioral evidence, and tie attachment and close relationships in with game theory and research on economic decision making.     

Unique contributions of anxiety sensitivity to avoidance: a prospective study in adolescents

Examination of the prospective relation between anxiety sensitivity (AS) and behavioral avoidance is largely absent from the literature. In a longitudinal study of a community sample of 2246 adolescents, participants completed the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally (1986). Behaviour Research & Therapy, 24, 1-8), State-Trait Anxiety Inventory (STAI; Spielberger (1983). STAI: Manual for the Stait-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press), and the Fear Questionnaire (Marks & Matthews (1979). Behaviour Research & Therapy, 17, 263-267) on an annual basis. To stringently test AS's ability to prospectively predict behavioral avoidance, linear regression was used to test whether AS factors predicted variance in follow-up behavioral avoidance scores after controlling for gender, trait anxiety, panic attacks, and baseline avoidance. Results indicted that the mental and physical subscales of the ASI predicted change in behavioral avoidance. The findings of the study are consistent with the view that AS may serve as a precursor to avoidant behavior and that, regardless of whether or not acute panic has been experienced, those who fear autonomic arousal may be more likely to avoid situations in which those sensations may be present.     

“Digging in” or “Giving in”: Attachment-related threat moderates the association between attachment orientation and reactions to conflict

Prior research suggests that individuals higher in attachment anxiety react to conflict in a more hostile manner than those lower in attachment anxiety. Although less pronounced, there is also evidence that attachment anxiety is associated with submissive behavior in conflict. Thus, the literature presents a paradox, as attachment anxiety is associated with both domineering and submissive responses to relationship conflict. We proposed that attachment-related threat moderates the effects of attachment orientations on conflict behavior, such that under conditions of low threat attachment anxiety would be associated with dominance, whereas under conditions of high threat attachment anxiety would be associated with submission. Further, we expected that this interaction between attachment anxiety and threat condition would be stronger for individuals lower in attachment avoidance, relative to those higher in avoidance. We found support for our hypotheses, such that attachment anxiety, attachment avoidance, and threat interacted to predict responses to relationship conflict.     

Test anxiety and ego-threatening stress: Over- (and under-) estimation of emotional reactivity

Abstract

This study examined discrepancies between subjective and objective measures of state anxiety as a function of test anxiety in undergraduates. Under evaluative stress conditions, state anxiety was assessed in terms of (a) self-reported cognitive and somatic anxiety, (b) behavioral reactivity (motor and facial tension, avoidance comments and avoidance of eye contact), (c) physiological arousal (heart rate and skin resistance), and (d) cognitive and motor task performance. Participants high in test anxiety showed disproportionately greater self-reported than objective state anxiety. In contrast, those low in test anxiety showed lower self-reported than objective anxiety. The high- and the low-test-anxiety groups differed only in self-reported emotional reactivity. In line with current cognitive theories of anxiety, overestimation of reactivity in high-test anxiety, as well as underestimation in low-test anxiety, are conceptualized as a hypervigilance bias and an avoidance bias, respectively, in processing internal cues, i.e., prioritization and inhibition of attention to one's own behavioral and physiological signs of distress.