تصمیم گیری اجتنابی در اختلال اضطراب اجتماعی: وظیفه آزمایشگاهی مربوط به اضطراب داخل بدن و نتیجه درمان

Abstract Recent studies on reward-based decision-making in the presence of anxiety-related stimuli demonstrated that approach-avoidance conflicts can be assessed under controlled laboratory conditions. However, the clinical relevance of these decision conflicts has not been demonstrated. To this end, the present study investigated avoidant decisions in treatment-seeking individuals with social anxiety disorder (SAD). In a gambling task, advantageous choices to maximize gains were associated with task-irrelevant angry faces and disadvantageous choices with happy faces. The clinical relevance of avoidant decisions for in vivo anxiety in a social stress situation (public speaking) were examined (n = 44). In a subsample (n = 20), the predictive value for a reduction of avoidance following behavioral therapy was also evaluated. Results indicated a close link between more frequent avoidant decisions and elevated in vivo anxiety. Moreover, individuals who showed a deficit in the goal-directed adjustment of their decisions also showed higher and sustained distress during the social stressor and reported less decrease of avoidance following treatment. The findings highlight the importance of an avoidant decision-making style for the experience of acute distress and the maintenance of avoidance in SAD. Assessing avoidant decision-making may help to predict the response to behavioral treatments.

1. Introduction Avoidance of social performance and social interaction are hallmark features of social anxiety disorder (SAD) (American Psychiatric Association, 2013). Such behavioral avoidance is triggered by the confrontation with anxiety-related stimuli. In this regard, anxiety is thought to drive avoidance (Klein, 1980 and Mowrer, 1960). In support, individuals who report higher anxiety also report higher levels of avoidance (e.g., Heimberg et al., 1999) and exhibit elevated behavioral and physiological indicators of avoidance (Heuer et al., 2007, Mogg et al., 2004, Rinck and Becker, 2007, Schulz et al., 2008 and Tolin et al., 1999). Other studies have, however, pointed to more de-synchrony between anxiety and avoidance in individuals with anxiety disorders (Craske and Barlow, 1988 and Rachman and Hodgson, 1974). This de-synchrony may indicate that avoidance is not a simple function of behavioral responding to anxiety-related stimuli, but dependent on additional factors such as incentives for approach (Craske & Barlow, 1988). Individuals with SAD, for example, do not always avoid social situations, but sometimes endure them with high levels of distress (Hofmann, Alpers, & Pauli, 2009). This motivation to enter and endure social situations may result from competing desires such as making new friends or performing well in a job interview (Kashdan, Elhai, & Breen, 2008). Resolutions of the resulting approach-avoidance conflicts may be seen as a repeated decision-making process that characterizes the daily life of individuals with anxiety disorders (Pittig et al., 2014 and Stein and Paulus, 2009). These decision conflicts may play an important role in the development and maintenance anxiety disorders, because a shift towards avoidant decisions results in severe impairments. Following this assumption, recent experimental studies investigated decision conflicts between the approach of goal-directed rewards and avoidance by linking advantageous decisions to anxiety-related stimuli. Exemplary results showed that spider fearful individuals avoid advantageous decisions, when these decisions were also paired with a presentation of a spider picture (Pittig, Brand, Pawlikowski, & Alpers, 2014). These avoidant decisions resulted in significant cost (i.e., lower overall gains). More importantly, there is first evidence that socially threating stimuli may trigger similar avoidant decisions in healthy (Averbeck and Duchaine, 2009 and Furl et al., 2012) and socially anxious individuals (Pittig, Pawlikowski, Craske, & Alpers, 2014). In these studies, participants had to maximize overall gains (i.e., hypothetical money) by repeatedly choosing pictures of either a happy or an angry face. In line with previous research, angry facial expressions were used as stimuli for social threat and rejection (e.g., Gilboa-Schechtman et al., 1999, Mogg et al., 2004 and Wieser et al., 2009). Although these facial expressions were irrelevant for goal-directed behavior, decisions of healthy individuals were initially biased towards selecting the happy face, even if prior reward feedback favored the angry face (Averbeck and Duchaine, 2009 and Furl et al., 2012). We recently demonstrated that such initial avoidance may be even more pronounced in individuals with elevated levels of social anxiety (Pittig et al., 2014 and Pittig et al., 2014). These pronounced avoidant decisions may reflect a habitual avoidance tendency and may thus be linked to individual levels of in vivo anxiety, which is thought to drive avoidance. However, no studies to date examined whether an avoidant decision-making style is associated with situational social anxiety in individuals with clinically severe SAD. Of particular clinical interest is the predictive value of avoidant decision making for the outcomes following an intervention. Current behavioral treatments for anxiety disorders, such as cognitive-behavioral therapy (CBT) or acceptance-commitment therapy (ACT), include exposure-based interventions, which involve approach toward anxiety-related stimuli in order to enable corrective learning (Arch and Craske, 2009 and Craske et al., 2014). Exposure therapy requires the individual's courage to confront anxiety-related stimuli, otherwise common treatment failures of drop-out and refusal will arise (Alpers, 2010 and Arch and Craske, 2009). Likewise, approach needs to be maintained and protected against habitual avoidance tendencies. The mechanisms of the initial confrontation with an anxiety-related stimuli and the maintenance of (goal-directed) approach may be captured in the laboratory decision task by initial avoidant decisions and their change due to the integration of ensuing reward feedback. Thus, performance in experimental decision-making paradigms may be predictive of successful reduction of avoidance following behavioral treatment. In sum, the present study investigated avoidant decisions in individuals with SAD when they were confronted with angry facial expressions. In a gambling task, net gains were associated with pictures of angry facial expressions and net losses with pictures of happy facial expressions. Individuals with SAD had to learn to choose the advantageous angry facial expressions to maximize net gains. The first aim of the study was to evaluate the relationship between avoidant decisions in the laboratory task and in vivo social anxiety in a realistic social stress situation. Specifically, the link between avoidant decisions and anxiety during public speaking was investigated, which is one of the most commonly feared situations for individuals suffering from SAD (Mannuzza et al., 1995 and Pollard and Henderson, 1988). The second aim was to evaluate the predictive value of avoidant decision making for treatment outcome after behavioral therapy. The second aim was investigated for a subgroup of the current sample who completed a 12-week behavioral treatment for SAD as part of a larger randomized controlled trial (see Craske, Niles, et al., 2014).

5. Conclusion The present study linked data from a laboratory task to a larger treatment study. Results provide first evidence that avoidant decisions are clinically relevant for in vivo social anxiety in individuals with SAD. In terms of treatment outcome, individuals who learned to make less and less avoidant decisions in favor of goal-directed choices before treatment also reported a larger decrease in avoidance following behavioral therapy. Thus, the present results highlight the importance of an avoidant decision-making style for the maintenance of in vivo distress and response to behavioral treatments in SAD.