Deciding Which Fears to Face: Behavioral and Neural Mechanisms of Costly Avoidance in Clinical Anxiety

Abstract

Clinical anxiety is often characterized by a behavioral pattern of relinquishing rewards in order to avoid potential threats, a decision-making bias that confers substantial functional impairment. However, the mechanisms of such costly avoidance have received scant attention in the literature. The present work addresses this gap, applying fear-conditioning methodology and functional magnetic resonance imaging (fMRI) to probe the neural and psychological processes contributing to costly avoidance. A sample of 153 adults with and without clinical anxiety underwent fMRI while completing a fear-conditioning and generalization paradigm in which participants decide between risky approach and costly avoidance. Anxious individuals were more likely than others to make costly, unnecessary avoidance decisions in the context of generalized Pavlovian fear, as has been seen previously. Subsequent analyses provide novel insights into this finding. When assessing risk and reward appraisals, anxious individuals demonstrated a greater likelihood of avoidance in the context of moderate expected risk or low expected reward. Brain-wide correlations and multivariate pattern analyses revealed that neural activity during choice deliberation in regions associated with cognitive control, sensory processing, and perception-motor integration scaled with risk and reward appraisals and was predictive of choice. Among anxious individuals, however, these neural processes were less correlated with expected risk and were less predictive of choice, suggesting that the observed avoidance bias may stem from a relatively weak formation of a prepotent approach response, and for a tendency to second-guess or ignore the results of deliberative valuation. Taken together, the present findings represent a significant advance in the conceptualization of costly avoidance in clinical anxiety.