Abstract
Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.
Highlights
Learning to flexibly respond to dynamic environmental challenges constitutes a highly adaptive mechanism aimed at self-protection, when faced with impending physical harm [1]
Based on the influential fear avoidance model (FAM) [3, 4], which has Avoidance in Psychosomatic Medicine initially provided a theoretical framework for the pathology of fear, avoidance behavior involves a cascade of fear-related responses shaped by associative learning, classical and operant conditioning
Avoidance is embedded within a conceptual framework of associative learning governed by principles of classical and operant conditioning
Summary
Learning to flexibly respond to dynamic environmental challenges constitutes a highly adaptive mechanism aimed at self-protection, when faced with impending physical harm [1]. Evidence from experimental research in these fields supports the assumptions of the FAM, showing that painrelated fear and avoidance are associated with dysfunctional cognitive, behavioral, and affective responses, including negative appraisal, catastrophizing, and hypervigilance [16–20] These factors promote the maintenance and exacerbation of symptoms and contribute to comorbid psychiatric disorders, increased distress, functional disability, social withdrawal, and reduced quality of life [21–24]. During exposure, patients are often encouraged to refrain from engaging in avoidance and safety behaviors, providing an opportunity to experience fear-correcting situations [36–38] Despite this outstanding relevance in the transition from acute threat to chronic disease, persistence of symptoms, and therapeutic interventions, for a long time avoidance has not received the attention owed in experimental research [39], in the context of psychosomatic medicine. We discuss chances and methodological and conceptual challenges in establishing clinically-relevant experimental models to elucidate avoidance behaviors, underlying mechanisms, and their role in long-term effects of CBT for anxiety and psychosomatic disorders
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