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

Author: Franziska Labrenz1, Marcella L Woud2, Sigrid Elsenbruch1,3, Adriane Icenhour1
Affiliation: <sup>1</sup> Department of Medical Psychology and Medical Sociology, Ruhr University Bochum, Bochum, Germany. <sup>2</sup> Mental Health Research and Treatment Center, Department of Psychology, Ruhr-University Bochum, Bochum, Germany. <sup>3</sup> Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany.
Conference/Journal: Front Psychiatry
Date published: 2022 Feb 18
Other: Volume ID: 13 , Pages: 841734 , Special Notes: doi: 10.3389/fpsyt.2022.841734. , Word Count: 265

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.

Keywords: anxiety; associative learning; avoidance; conditioning; gut-brain axis; pain; psychosomatic medicine.

PMID: 35250678 PMCID: PMC8894646 DOI: 10.3389/fpsyt.2022.841734