The role of avoidance of emotional material in the anxiety disorders
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Applied and Preventive Psychology 11 (2004) 95–114
The role of avoidance of emotional material in the anxiety disorders
Kristalyn Salters-Pedneault∗ , Matthew T. Tull, Lizabeth Roemer
Psychology Department, University of Massachusetts at Boston, 100 Morrissey Boulevard, Boston, MA 02125, USA
Abstract
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.
© 2004 Elsevier Ltd. All rights reserved.
Keywords: Anxiety; Anxiety disorders; Emotion; Avoidance; Learning theory
Theorists have long speculated that avoidance is implicated iety disorders. In this paper, we attempt to integrate these
in the development and maintenance of the anxiety disor- literatures and examine the implications of avoidance of emo-
ders. Breuer and Freud (1966) first suggested that avoidance tional material for the etiology and maintenance of anxiety
of internal experiences interferes with an individual’s abil- psychopathology.
ity to process and recover from a threatening or emotional
event, and theorists from other traditions have conceptualized
chronic anxiety in similar ways (e.g., experiential, Greenburg 1. Behavioral theories of emotional avoidance and
& Safran, 1987; and cognitive behavioral, Foa & Kozak, anxiety
1986; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).
Behavioral models of anxiety have made explicit the role Recognition of the role of avoidance in behavioral models
of active behavioral avoidance of anxiety-producing stimuli of anxiety came with Mowrer’s (1960) two-factor theory of
(Mowrer, 1960), as well as avoidance of internal anxiety cues, fear acquisition and maintenance. Until this point, behavior-
including thoughts and emotions (Foa & Kozak, 1986; Hayes ists had focused on the role of classical conditioning in fear
et al., 1996), in prolonging the anxiety response through im- associative learning (Wolpe, 1958), but had failed to explain
peded extinction learning. Recent research, however, sug- the resilience of clinical levels of fear and anxiety despite the
gests that avoidance of emotional material may have added easy extinction of even the strongest levels of fear in labora-
consequences relevant to the development and maintenance tory settings (Annau & Kamin, 1961). Mowrer (1960) pro-
of anxious responding. posed that once fear is acquired via classical conditioning,
A number of theoretical and research literatures are related the organism organically produces an escape or avoidance
to this discussion, including theories of affect and affect reg- response when presented with a feared stimulus, resulting in
ulation, research on the suppression of emotional thoughts diminished experience of fear (a condition that is intrinsically
and responses, and findings regarding the sequelae of anx- rewarding and thereby negatively reinforced). The difficulty
that arises, and the central factor in maintaining the fear re-
sponse, is that because the conditioned stimulus is not ap-
∗ Corresponding author. Tel.: +1 617 287 6426; fax: +1 617 287 6336. proached, no new learning about the original fear association
E-mail address: ksalters@alum.american.edu (K. Salters-Pedneault). can be achieved, and thus extinction does not occur.
0962-1849/$ – see front matter © 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appsy.2004.09.00196 K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114
While the two-factor theory (1960) focuses on the role of Below we review some of the consequences of avoidance
behavioral avoidance of external fear-producing stimuli, Foa of emotional material suggested by basic research, with a
and Kozak’s (1986) model of the emotional processing ad- focus on the consequences of attempts to suppress or avoid
dresses the cognitive-emotional aspects of fear conditioning emotions and emotional material. Many of the phenomena
that were overlooked by Mowrer. Their theory incorporates seen in this basic research typify aspects of clinical anxi-
Lang’s (1979) bioinformational theory of emotion, which un- ety, and therefore have implications for our understanding
derstands emotions (such as fear) as “action tendencies” that of the development, maintenance, and treatment of anxiety
reside within a network of information including the stimu- disorders. The studies reviewed represent diverse literatures,
lus associated with the emotional response, the response itself often using disparate operationalization of constructs such as
(i.e., behavioral, physiological, subjective, and other response “emotional avoidance” and “suppression”. In our review of
characteristics), and any other information that may be related basic research we have included studies that address direct
to the stimulus/response association (such as the context and attempts to eliminate emotional material, including distress-
meaning elements). Foa and Kozak theorize that avoidance ing thoughts or cognitive representation/meaning elements of
of any aspect of the network may interfere with new learning. the emotional material (which is conceptualized as thought
In their model, avoidance of the subjective and physiological suppression), and elements of the emotional response, such
experience, the behavioral expression, and the cognitive ele- as the subjective experience of the emotion, the physiolog-
ments related to the response are also implicated diminished ical arousal associated with the emotional response, or the
extinction learning and maintenance of that response. expression of the emotional response (which is conceptual-
Theorists from the behavior analytic tradition have re- ized as emotion suppression or avoidance of emotion). It is
cently presented an expanded model of the role of emotional likely that these forms of avoidance are a few of the many
avoidance in psychopathology. Hayes et al. (1996) propose forms of emotion regulation employed by clients, and that
that the phenomenon of “experiential avoidance”, or an un- within the broad category of “avoidant regulation strategies”
willingness to experience internal responses such as sen- there may exist many sub-strategies employed differently by
sations, feelings, or thoughts, can account for many forms different individuals. Additionally, while theories of anxi-
of psychopathology. Using basic research highlighting the ety recognize other forms of avoidance (such as behavioral
bidirectional nature of human associative learning, Hayes, avoidance, substance use, etc.) that likely result in diminished
Strosahl, and Wilson (1999) argue that the pairing of an ex- emotional responding, we limit our discussion to direct at-
ternal stimulus (already associated with a negative emotional tempts to avoid internal emotional aspects of the fear–anxiety
response) with its cognitive representation will lead to fu- associative network, as we believe these forms of avoidance
ture negative emotional responses in the presence of only the have important implications for broadening exposure-based
cognitive representation (e.g., thoughts about the stimulus). treatments for anxiety (which often emphasize avoidance of
Further, as a result of the learned associations, the individ- external emotion-relevant stimuli).
ual will experience those thoughts in the presence of both
the emotional response and the stimulus in the future. Thus, 2.1. Cognitive outcomes
internal responses such as distressing thoughts and feelings
may come to elicit behavioral, emotional, and physiologi- Basic research suggests that attempts to avoid emotional
cal reactions, and can become cues that prompt efforts to material/responses may lead to a number of consequences
avoid. Hayes et al. (1996) suggest that many problematic be- for cognitive processes and content. For example, the thought
haviors (e.g., substance abuse, anxious avoidance) may be suppression literature has revealed one potential consequence
maintained because of the short-term reduction in unwanted of avoidance of emotional material: attempts to avoid un-
internal events with which they have become associated. wanted internal experiences, such as distressing thoughts,
may actually lead to increased intrusion and/or accessibil-
ity of that material. Some of the earliest work in this area was
2. The consequences of emotional avoidance: basic conducted by Wegner, Schneider, Carter, and White (1987) in
research their seminal “white bear” experiment, in which participants
who had suppressed target thoughts about a white bear had
These behavioral models explain how emotional avoid- more subsequent white bear thoughts during an expression
ance may interfere with extinction of learned emotional asso- phase than those who had expressed first—suggesting that
ciations (thereby maintaining anxiety levels), and may elicit initial suppression of a thought has the paradoxical “rebound
behaviors that interfere with or limit the range of behavioral effect” (Wegner, 1994) of increasing thought frequency af-
responses (leading to diminished behavioral flexibility and di- terwards. Wegner (1994) theorized that thought suppression
minished quality of life, as is seen in many anxiety disordered requires two mechanisms: an intentional operating process
clients). However, a body of research suggests that emotional that searches for thoughts that are not the target “to be sup-
avoidance may have additional negative consequences that pressed” thought, and an automatic monitoring process that
may further explain the intensity and persistence of clinical searches for instances of the target thought. Wegner (1994)
anxiety. proposed that, particularly during cognitive load, psychologi-K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114 97
cal distress, or any other condition when attentional resources tional avoidance may lead to increased physiological
are depleted, the intentional operating process is compro- arousal.
mised, leaving the automatic monitoring process unchecked, Gross and colleagues (Gross, 1998; Gross & Levenson,
and resulting in increased accessibility of the target. 1993, 1997; Richards & Gross, 1999) have examined the
Subsequent investigations have supported Wegner’s the- physiological effects of suppression of the behavioral (ex-
ory that thought suppression may lead to immediate (Lavy & pressive) component of the emotional response in a series of
van den Hout, 1990) or delayed (Clark, Ball, & Pape, 1991; studies. In two studies of concealment of emotional expres-
Clark, Winton, & Thynn, 1993) increases in the reported fre- sion (compared to a just-watch control condition), conceal-
quency of the target thought (although other studies have ment was associated with markers of increased physiological
failed to find this effect, see Purdon, 1999; Rassin, Merckel- arousal (Gross & Levenson, 1993, 1997). In one study, par-
bach, & Muris, 2000, for reviews), and increased accessibility ticipants in a concealment condition exhibited increased skin
of suppressed material (measured by latencies to color-name conductance, more pronounced shortening of finger pulse
target-relevant words in the modified Stroop task; Lavy & transmission times, and greater decreases in finger pulse am-
van den Hout, 1994; Wegner & Erber, 1992; Wegner, Erber, plitude (all indicators of increased sympathetic nervous sys-
& Zanakos, 1993). To date, more than 44 experimental studies tem activation) than those in a control condition during and
of the suppression of neutral or emotional thoughts have been following a disgust-eliciting film clips (although concealment
published, with a recent meta-analysis revealing a small to was associated with decreased heart rate; Gross & Levenson,
moderate rebound effect of thought suppression (which var- 1993). In a second study, concealment instructions led to
ied depending on methodological characteristics of studies; greater sympathetic activation of the cardiovascular system
Abramowitz, Tolin, & Street, 2000). It has been suggested (but decreased heart rate) during an amusement film, and
that these effects are particularly relevant in the case of dis- greater skin conductance, sympathetic activation of the car-
tressing or emotional thoughts, as these types of thoughts are diovascular system, and respiratory activity during a sadness
more likely to be targeted for suppression organically (see film, than just watch instructions (Gross & Levenson, 1997).
Roemer & Borkovec, 1994). In a third examination of the effects of different types of emo-
There is also evidence that attempts to suppress aspects of tional control (including instructions to conceal emotions,
the emotional experience may effect the content of the cog- to reappraise in order to diminish emotional response, or to
nitive system by generating more negative beliefs both about just watch a disgusting film clip; Gross, 1998), individuals
the target of suppression (or the emotional material to be sup- in the conceal condition showed greater concurrent sympa-
pressed), and about one’s own ability to regulate emotions. thetic activation (indexed by finger pulse amplitude, finger
Campbell-Sills, Barlow, Brown, and Hofmann (2004) found temperature, and skin conductance) than the reappraisal and
that lower perceived acceptability of emotions was associated no-instruction control group both while watching the film and
with greater emotional suppression during an emotion induc- during a post-film period.
tion, and that suppression was, in turn, associated with de- Equivocal findings have been demonstrated in investiga-
creased self-efficacy for coping with future emotional events. tions using other emotion types, experimental paradigms,
Together, the findings from this literature, while mixed (likely and physiological outcome measures. For example, in an
due to wide differences in methodologies; see Abramowitz investigation of the regulation of embarrassment, conceal-
et al., 2000), provide some evidence that avoidance of dis- ment instructions (versus no concealment instructions) were
tressing thoughts may be implicated in anxiety, given that associated with increased blood pressure but not heart rate
many of the anxiety disorders are characterized by intru- during an embarrassment task and recovery (Harris, 2001).
sive, distressing thoughts and hyperaccessibility of threat- Also, a study of concealment (defined as suppressing dis-
related material, and by beliefs that this material is uncontrol- cussion of an emotional topic) versus expression (Mendes,
lable. Indeed, many theorists have incorporated the effects of Reis, Seery, & Blascovich, 2003) found that concealing a
thought suppression on intrusion/accessibility into their the- personally-relevant emotional topic (which may have elicited
ories of anxiety psychopathology (e.g., Roemer & Orsillo, a variety of negative emotional reactions) was associated with
2002; Salkovskis, 1996). increased physiological threat reactivity across contexts (for
a complete discussion of threat versus challenge reactivity,
2.2. Physiological outcomes see Mendes et al., 2003). There is also evidence of increased
physiological arousal in studies investigating the effects of
There is also evidence that avoidance of emotional avoidance of the subjective component of the emotional re-
thoughts and responses may have implications for physiol- sponse. Two studies have found that instructions to accept
ogy. Not only do studies from the thought suppression lit- versus suppress subjective emotional responses to distress-
erature indicate that suppression of thoughts may lead to ing stimuli led to greater heart rate increases for suppression
increased target related autonomic arousal (Merckelbach, participants (Campbell-Sills et al., 2004; Tull, Jakupcak, &
Muris, van den Hout, & de Jong, 1991; Wegner, Shortt, Blake, Roemer, 2003).
& Page, 1990), but studies of the suppression of ele- There have also inconsistent findings; one study found
ments of the emotional response itself suggest that emo- that attempts to suppress subjective negative emotions in re-98 K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114
sponse to emotionally evocative images resulted in decreased covery. Instructions to suppress (versus accept) emotions af-
eyeblink startle magnitude and corrugator activity (two phys- ter a second emotional induction were also associated with
iological measures of affective reactions) compared to indi- slower mood recovery (Campbell-Sills et al., 2004). Tull et
viduals asked to enhance their emotion or given no instruction al. (2003) similarly found that while acceptance of subjective
(Jackson, Malmstadt, Larson, & Davidson, 2000), suggest- emotions was associated with a decrease in emotional distress
ing that for at least some physiological markers of emotion- from an emotionally evocative context to a mildly distress-
ality, suppression of emotional experiences may actually re- ing interpersonal context, suppression was associated with no
sult in decreased emotional reactivity. Another recent study decrease from one context to the next. Further, suppression
found that individuals with a tendency to attempt to avoid or was associated with greater distress than acceptance in a fol-
control their internal experiences demonstrated less physio- low up phase (Tull et al., 2003). Gross and colleagues, how-
logical arousal (heart rate) to two distress-eliciting (fear and ever, have found effects of emotional concealment on physi-
disgust) films (although these participants reported greater ological arousal, but not on subjective emotional experience
subjective distress; Sloan, 2004). In a third study, individu- (Gross, 1998; Gross & Levenson, 1993, 1997), suggesting
als with high anxiety sensitivity (or fear of fear) were given that this effect may only be seen when particular aspects of
instructions to suppress or accept their internal experiences the emotional response are suppressed.
(versus a no instruction control) during a CO2 challenge; in-
dividuals asked to suppress had equivalent arousal to those in 2.4. Learning outcomes
other conditions (Eifert & Heffner, 2003). Thus, while there
is a growing literature supporting paradoxical physiological Concealing or avoiding emotional material may have
effects of emotional avoidance, more work is needed to under- other negative effects, including drawing from the individ-
stand the complexity of these effects. For example, the spe- ual’s existing cognitive resources (Baumeister, Bratslavsky,
cific channels of physiological responding affected by emo- Muraven, & Tice, 1998; Richards & Gross, 1999) or inter-
tional avoidance are not fully understood. The current state fering with approach and engagement behaviors (Eifert &
of the literature suggests clearer paradoxical effects of emo- Heffner, 2003; Levitt, Brown, Orsillo, & Barlow, in press;
tional suppression on activation of the sympathetic nervous Muraven, Tice, & Baumeister, 1998; Tull et al., 2003). In-
system but not on heart rate or somatic activity (Campbell- structions to conceal or suppress emotions have been associ-
Sills et al., 2004; Tull et al., 2003 are exceptions, although ated with diminished memory for information presented dur-
these compared suppression to acceptance and the findings ing concealment (Richards & Gross, 1999), and diminished
may be due to the effects of acceptance of emotions). Also, performance on cognitive tasks during suppression of behav-
the research suggests a desynchrony between physiological ioral and subjective emotional responses (Baumeister et al.,
and subjective reports of paradoxical effects that must be 1998). This consequence of emotional concealment may in-
clarified. Further investigation of the physiological effects of terfere with the individual’s ability to engage adaptively with
emotional avoidance is warranted, given the potential physi- their environment, may impede learning of non-threatening
cal health consequences of chronic emotional inhibition (see associations, and thus may further increase distress. Also, re-
Traue & Pennebaker, 1993, for a book length review), and search has suggested that emotional suppression is associated
the relevancy of these findings for anxiety pathology, which with quicker disengagement from frustrating or distressing
is often marked by hyperarousal (as in PTSD), tension (as tasks (Muraven et al., 1998). And, instructions to suppress
in GAD), and other forms of sympathetic activation (APA, or accept emotions may affect participants’ willingness to
1994). approach emotional situations in the future, with those in
acceptance conditions more likely to report that they would
2.3. Emotional outcomes be willing to participate in other emotionally evocative tasks
(Eifert & Heffner, 2003; Levitt et al., in press; Tull et al.,
Further, avoidance of emotion may lead to paradoxical in- 2003). Unwillingness to continue to engage in or to approach
creases in emotional experiencing. Basic research has found emotional situations may also interfere with individuals’ op-
instructions to suppress emotionally laden thoughts leads to portunities for new associative learning to occur, and may
increased target-related anxiety (Roemer & Borkovec, 1994) further maintain emotional responses.
and discomfort (Purdon & Clark, 2001). A similar effect
was found for individual differences in emotional suppres- 2.5. Emotional functionality outcomes
sion: Sloan (2004) found that high experiential avoiders re-
ported greater emotional reactivity to emotionally evocative The integration of findings from basic theories of and re-
(fear-, disgust-, or happiness-inducing) films. In another re- search on the utility of emotions reveals another consequence
cent study, Campbell-Sills et al. (2004) found that individu- of emotional avoidance that is not frequently addressed by
als with clinical mood disorders were more likely to report traditional behavioral conceptualizations of anxiety. Evo-
spontaneous use of emotional suppression while watching lutionary explanations suggest that emotions have a wide
an emotional film clip, and that suppression was associated range of functions; the behavioral, subjective, and biologi-
with negative outcomes, such as poorer subjective mood re- cal/physiological components of the emotional response con-K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114 99
tribute to a coordinated system of behavioral activation and/or of and engagement with emotional stimuli. These conse-
inhibition that promotes decision-making, social inclusion, quences, in turn, may lead to diminished adaptiveness of the
problem-solving, communication, and survival (among oth- emotional system, and greater distress and interference. Al-
ers; for a more complete discussion, see Cosmides & Tooby, ternatively, acceptance of emotional material may facilitate
2000). extinction learning and produce the paradoxical effects of
Emotional avoidance may interfere with the function of diminished physiological responding or subjective distress,
the emotional experience in several ways. If the avoidance is suggesting a potential treatment strategy and mechanism of
successful in the short term, the individual is not privy to a action.
range of information conveyed by the emotional response; the
behavioral tendency associated with the emotion is disrupted,
the interpersonal value of the emotion is lost, and the input 3. Emotional avoidance and the anxiety disorders
of the emotion into decision-making is disregarded. In short,
the successful avoidance of the emotion renders the individ- Individual differences in the suppression/avoidance of
ual less adaptive in their interaction with the environment, emotions are related to a range of poor mental health out-
and likely prone to make less effective actions (and thereby comes. The tendency to avoid emotional expression has been
likely to experience more emotional distress) in the future. associated with self-reports of less positive and more nega-
Further, given the potential consequences of emotional avoid- tive affect, poorer interpersonal functioning (including expe-
ance discussed above (e.g., paradoxically intensifying one or riencing more emotional distance and receiving less social
more components of the emotional response), the emotion support from others; Gross & John, 2003), and higher lev-
that is eventually experienced by the individual may actually els of arousal when exposed to threat (Notarius & Levenson,
provide inaccurate or distorted information. For example, the 1979). Further, the tendency to be non-accepting of emo-
intensification of the anxiety response may communicate to tional experiences is correlated with self-reported difficul-
the individual that the mildly anxiety-producing stimulus is ties in emotion regulation and impulsive behaviors (including
actually extremely threatening. Or, avoidance of the emotion self-harm; Gratz & Roemer, 2004), and emotional inhibition
may hide the source of the emotional response, and may lead (defined as both thought suppression and ambivalence about
to ineffectual guidance of behavioral action. For example, if emotional expression) has been found to mediate the rela-
an individual has suppressed the experience of anger in an tionship between intensity of negative affect and symptoms
interaction with a coworker, the individual may be unaware of depression (Lynch, Robins, Morse, & Krause, 2001).
of their reaction, and may instead experience an undifferen- The consequences of emotional avoidance reviewed above
tiated emotion without a clear or direct source, leading to the often correspond with the symptoms of anxiety, and empirical
incorrect behavioral response (e.g., expressing anger towards evidence of the relationship between avoidance of emotional
their spouse). material across the anxiety disorders is mounting. Below we
Thus, avoidance of emotional material may disrupt the review correlational and experimental research highlighting
adaptiveness of the emotional response, ultimately leading connections between various forms of emotional avoidance
to less effective behavior and thereby more emotional dis- and the anxiety disorders. These findings suggest that indi-
tress. And, this process likely leads emotional responses to vidual differences in negative reactivity to emotions and emo-
be increasingly intense, aversive, and confusing. The research tional material (a likely precursor to emotional avoidance),
literature in emotion regulation augments this argument. Dis- and in the tendency to avoid emotions and emotional material,
ruptions in emotional processing and regulation and have are related to many forms of psychopathology. Additionally,
been associated with a range of psychopathologies (see Kring a burgeoning experimental literature conducted in analogue
& Bachorowski, 1999, for a review) including many disorders and clinical populations suggests that emotional avoidance
of anxiety. may play a causal role in the development of anxiety symp-
While basic research is limited in volume and scope, with toms.
clear directions for future work indicated, it thus far suggests
that avoiding emotional thoughts or the subjective or expres- 3.1. Obsessive-compulsive disorder
sive components of the emotional response may have sev-
eral negative consequences beyond direct interference with The primary features of obsessive-compulsive disorder
extinction learning. Suppression of emotional thoughts may (OCD) are recurrent and excessive obsessive or intrusive
lead to increased intrusion and/or hyperaccessibility of the thoughts and engagement in repetitive behaviors or mental
emotional material, may increase target-related or general activities (i.e., compulsions; APA, 1994). Rachman and De
distress and arousal, and may alter beliefs regarding the ma- Silva (1978) found that obsessive thoughts are quite common
terial (e.g., the threat posed by or controllability of the ma- in the general population, however, obsessions reported by
terial). Further, suppression of one or more channels of the OCD patients, in comparison to a non-clinical control group,
emotional response may lead to paradoxical increases in that are more frequent, intense, of longer duration, and result in
response, including heightened physiological arousal, greater greater discomfort. Theories of OCD development and main-
subjective distress, and may interfere with future approach tenance suggest that the compulsive behaviors and/or mental100 K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114
activities in OCD serve an avoidant function (they are associ- control of thoughts as a result of expressing them (Newth &
ated with the reduction, at least in the short-term, of tension Rachman, 2001).
and anxiety) and ultimately contribute to the maintenance of A comprehensive review of the correlational and experi-
anxiety and obsessive thoughts (APA, 1994; see also Purdon, mental literature investigating the role of thought suppression
1999; Smári, 2001). in OCD and obsessive-compulsive symptoms is beyond the
Individuals with OCD may engage in additional inter- scope of this paper (for reviews, see Purdon, 1999; Purdon
nal avoidance strategies that exacerbate or maintain the OC & Clark, 2000; Smári, 2001); instead, the few experimen-
symptoms. For example, cognitive-behavioral conceptualiza- tal studies that have examined thought suppression among
tions of OCD (e.g., Rachman, 1998; Salkovskis, 1996) sug- clinical samples of individuals diagnosed with OCD will be
gest that the ways in which individuals with OCD respond to briefly reviewed. Studies by Janeck and Calamari (1999) and
their obsessional thoughts may contribute to the maintenance Purdon, Rowa, and Antony (in press) failed to find evidence of
of obsessions. In particular, negative appraisals of obsessional either an immediate enhancement or rebound effect among
thoughts lead to an increased motivation to attempt to con- individuals with OCD when asked to suppress their most
trol or suppress these thoughts. However, these attempts ul- obsessional thought, although Janeck and Calamari (1999)
timately fail, as previously discussed, so that attempts (and did report a tendency for a greater number of individuals
subsequent failures) at suppression may eventually contribute with OCD to demonstrate a rebound effect as compared to a
to an increase in the intensity and frequency of obsessions. non-anxious control group. According to Tolin, Abramowitz,
These intrusions are then perceived as evidence of the impor- Przeworksi, and Foa (2002), these limited findings may be
tance and self-relevance of the thought, as well as an inability due to the use of personally relevant, negative thoughts as
to cope with it, resulting in greater motivation to suppress and targets for suppression. According to cognitive-behavioral
continuation of a vicious cycle (e.g., Salkovskis, 1996). Con- conceptualizations of OCD, individuals with OCD are regu-
sistent with this, thought suppression has been found to be larly suppressing these thoughts, and thus, experimental in-
more strongly associated with obsessive, as compared to com- structions asking participants to suppress or not to suppress
pulsive, symptoms (Rafnsson & Smári, 2001). In addition, these thoughts may have little influence. Therefore, Tolin,
negative appraisals of intrusive thoughts predict thought un- Abramowitz, Przworski, et al. (2002) examined thought sup-
controllability and frequency (Purdon & Clark, 1994), and a pression of neutral thoughts (i.e., a white bear) among par-
tendency to over-evaluate the significance and consequences ticipants with either OCD, generalized social phobia (anx-
of intrusive thoughts (referred to as thought–action fusion ious controls), or no diagnosed anxiety disorder (non-anxious
or TAF; Shafran, Thordarson, & Rachman, 1996) has been controls). When asked to suppress thoughts of a white bear,
found to lead to thought suppression attempts which results OCD participants exhibited an immediate enhancement ef-
in greater report of obsessive-compulsive symptoms (Rassin, fect while anxious and non-anxious controls did not (no re-
Muris, Schmidt, & Merckelbach, 2000). Furthermore, there bound effect was observed in any group). Participants did not
is evidence that thought suppression may initially reduce differ in regard to self-reported suppression effort, suggested
distress associated with TAF-associated intrusions (Rassin, that this finding is not due to differences in effort.
2001). Experimental research has also provided support for the
There is evidence that OCD patients are more likely to en- occurrence of self-referent negative appraisals of thought
dorse using worry and self-punishment to control unwanted suppression failure among individuals with OCD. Tolin,
unpleasant thoughts as compared to individuals with other Abramowitz, Hamlin, Foa, and Synodi (2002) found that
anxiety disorders or controls. Use of punishment (followed participants with OCD who experienced the occurrence of
by worry) as a thought control strategy has been found at least one intrusive thought while attempting to suppress
to discriminate individuals with OCD from those without thoughts of a white bear were more likely to believe that
(Abramowitz, Whiteside, Kalsy, & Tolin, 2003; Amir, Cash- their suppression failure could be attributed to internal, nega-
man, & Foa, 1997). Likewise, Rassin and Diepstraten (2003) tive qualities (e.g., I am mentally weak). Similarly, Purdon et
found a relationship between tendencies to engage in thought al. (in press) also found an association between attributions
suppression and self-punishment among individuals with of thought suppression failures and distress over thought oc-
OCD. Newth and Rachman (2001) also suggest that individ- currences among individuals with OCD.
uals with OCD may not only attempt to suppress obsessive Even less research has been conducted on the avoidance or
thoughts, but may also conceal these thoughts from others. suppression of emotional experience (as compared to the sup-
They found that OCD patients often report being troubled, pression of emotional material or emotional thoughts) among
shamed, and frightened by their obsessive thoughts, and as individuals with OCD. However, findings from one study sug-
a result, conceal those thoughts for fear of negative evalua- gest that it may be a worthwhile area to investigate. Oltmanns
tion from others. However, as with thought suppression, this and Gibbs (1995) had non-clinical OC and non-OC control
concealment may have a paradoxical effect as the conceal- participants watch three emotion film clips that elicited a
ment of obsessive thoughts may reinforce the notion that the range of positive and negative emotions (e.g., fear, disgust,
thoughts are potentially a source of shame and embarrass- happiness, etc.). They found evidence that OC participants
ment. Some patients with OCD also reported fear of losing may have attempted to suppress the expression of negativeK. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114 101
emotion through the display of positive emotion. Specifically, light the role of behavioral avoidance of trauma-related cues
OC participants displayed more smiles and laughs during a as well as the active avoidance of internal experiences, such
frightening film clip than non-OC participants, and this find- as thoughts and feelings related to the trauma, in the develop-
ing was more pronounced among the OC males as compared ment and maintenance of these disorders (e.g., Foa, Steketee,
to OC females. However, OC males, as compared to controls, & Rothbaum, 1989), and recent evidence suggests that avoid-
also had a tendency to display more negative emotional facial ance of distressing emotional material may be integral to the
expression. Together, these findings led the authors to suggest symptoms observed in PTSD and ASD.
that the male OC participants may have experienced a height- Foa et al. (1989) argue that while Mowrer’s two-factor the-
ened emotional response to the frightening film clip (given ory of fear acquisition (through classical conditioning) and
a tendency towards the greater display of negative emotion) maintenance (through behavioral avoidance) may begin to
and attempted to control these reactions through the display explain some of the symptoms seen post-trauma (e.g., fear
of an opposite emotional state. reactions when exposed to traumatic stimuli and avoidance
As a result of these findings, Oltmanns and Gibbs (1995) of trauma-related stimuli), this theory does not account for
propose a negative emotional sensitivity model of OCD, such many other symptoms associated with PTSD, such as exten-
that individuals with OCD may have a tendency to experience sive generalization of trauma cues. The emotional processing
intense emotions that are perceived as unpleasant and aver- model proposed by Foa and Kozak (1986) and the relational
sive, resulting in attempts to avoid or control these intense frame theory account of human learning (for a review, see
emotional experiences. This attempted avoidance, however, Hayes et al., 1999) better explain some of the symptoms re-
may only result in increased arousal and greater distress. It is lated to PTSD; these theories account for the extensive gen-
interesting as well to note that the above findings were only eralization of trauma cues to include thoughts of the trauma,
obtained for men, suggesting that there may be gender dif- memories of the trauma, and even emotional responses as-
ferences in the avoidance strategies used among individuals sociated with the trauma. However, other consequences of
with OCD. Due to male gender socialization, men with OCD avoidance of emotional material reviewed above may further
may be more likely than women to evaluate certain emotional account for symptoms seen uniquely post-trauma, including
experiences as unacceptable and thus engage in attempts to symptoms of emotional numbing, generalized hyperarousal,
suppress or mask those emotions. Furthermore, it is possi- intrusive, distressing thoughts and feelings (APA, 1994), and
ble that due to a fear of negative evaluation and increased increased accessibility of traumatic material (e.g., Cassiday,
social anxiety (see Newth & Rachman, 2001), individuals McNally & Zeitlin, 1992; McNally, English, & Lipke, 1993).
with OCD, in general, may be more likely to mask intense The thought suppression literature has made particular
emotional experiences for fear that they will be shamed or contributions in understanding the cognitive symptoms that
embarrassed. are seen post-trauma. PTSD is associated with trauma event-
Research on the presence of avoidance strategies in OCD related thoughts that are intrusive (APA, 1994), and extremely
has primarily focused on thought suppression. Yet, this re- distressing and anxiety producing. PTSD is also associated
search is still in its early stages, as experimental investiga- with hyperaccessibility of trauma related material (as mea-
tions of thought suppression among individuals diagnosed sured by latency to color-name trauma-related words in the
with OCD are limited (Smári, 2001), and research pertain- modified emotional Stroop paradigm; Cassiday et al., 1992;
ing to the role of emotional avoidance in OCD is even more McNally et al., 1993). These phenomena correspond with the
limited. However, it is a worthwhile area of study, especially effects of the thought suppression reviewed above, including
given suggestions of negative emotional sensitivity in OCD increases in intrusion of suppressed material (e.g., Wegner
(Oltmanns & Gibbs, 1995) and the potential tendency towards et al., 1987), hyperaccessibility of suppressed material (Lavy
the experience of shame among individuals with OCD as a & van den Hout, 1994; Wegner & Erber, 1992; Wegner et
result of obsessional thoughts and subsequent failures to con- al., 1993), and increased target-related anxiety (Roemer &
trol them (e.g., Newth & Rachman, 2001; Tolin, Abramowitz, Borkovec, 1994) and discomfort (Purdon & Clark, 2001).
Hamlin, et al., 2002). Continued examination of the specific Basic research in thought suppression and emotional
strategies individuals with OCD may use to avoid or control avoidance may also explain the generalized hyperarousal as-
unwanted thoughts and emotions may provide a better un- sociated with PTSD that is not well accounted for by cogni-
derstanding of the development and maintenance of OCD, as tive behavioral models (e.g., Foa et al., 1989). Thought sup-
well as inform its treatment. pression is associated with target-related autonomic arousal
(Merckelbach et al., 1991; Wegner et al., 1990), and increased
3.2. Post-traumatic stress disorder and acute stress autonomic arousal during thought suppression of analogue
disorder traumatic material (Roemer & Salters, 2004). Further, the
basic research reviewed above suggests paradoxical physio-
Avoidance of emotional material is thought to be a cen- logical effects of emotional concealment and suppression. If
tral factor in negative post-traumatic outcomes such as post- emotional material such as thoughts and emotional responses
traumatic stress disorder (PTSD) and acute stress disorder related to a potentially traumatic event are suppressed or
(ASD). Major cognitive behavioral theories of PTSD high- avoided (and the motivation to avoid this very evocative ma-102 K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114
terial is likely high), paradoxical physiological effects may ing material, and with PTSD diagnosis (Ehlers, Mayou, &
account both for heightened arousal associated with trauma Bryant, 1998), symptom severity (Steil & Ehlers, 2000), and
cues and for hyperarousal that generalizes beyond trauma symptom persistence (Mayou, Ehlers, & Bryant, 2002). In-
cues. dividuals with PTSD may also be likely to view their cog-
Emotional numbing symptoms (including symptoms of nitions as unallowable events; individuals with PTSD were
disinterest, detachment, and restricted range of affect; APA, more likely to rate their cognitions as unacceptable than those
1994) are post-traumatic outcomes that also may be related to with depression (Reynolds & Brewin, 1998), and negative in-
emotional avoidance, although this is a widely debated topic. terpretation of intrusive memories has been found to be a fac-
Some theorists have suggested that emotional numbing is an tor associated with PTSD symptom maintenance (Mayou et
automatic process that occurs due to biological mechanisms al., 2002). Experimental studies in clinical and analogue ASD
associated with exposure to traumatic, uncontrollable events and PTSD populations have also demonstrated a connection
(e.g., Foa, Zinbarg, & Rothbaum, 1992; Glover, 1992; van between suppression and intrusion of distressing or traumatic
der Kolk, Greenberg, Boyd, & Krystal, 1985), while oth- material (Harvey & Bryant, 1998a, 1998b; Shipherd & Beck,
ers have suggested that emotional numbing is the result of 1999) although some studies have failed to find this effect
chronic hyperarousal and reactivity that deplete emotional ca- (for a complete review, see Purdon, 1999).
pacities in the presence of trauma-related stimuli (Litz, 1992; A very large self-report literature also supports the con-
Litz & Gray, 2002). While these automatic, passive processes nection between avoidance of distressing emotions and the
may indeed be related to the emotional numbing cluster of development of post-traumatic symptomatology. Generally
symptoms, the possibility that active attempts to avoid emo- emotionally avoidant coping styles have been associated with
tional experiences are also related to numbing has also been poorer post-traumatic outcomes (Bryant & Harvey, 1995;
proposed (Litz et al., 1997; Roemer, Litz, Orsillo, & Wag- Clohessy & Ehlers, 1999; Marx & Sloan, 2002; Nightingale
ner, 2001; Tull & Roemer, 2003). These theorists highlight & Williams, 2000; Tull, Gratz, Salters, & Roemer, in press).
the possibility that emotional numbing is a consequence of And, post-traumatic symptoms are associated with a number
chronic attempts to control or avoid emotional responses. of emotional disturbances related to emotional avoidance,
There is some mixed support for this proposal. Roemer et including alexithymia (or an inability to describe emotional
al. (2001) found that combat veterans with PTSD reported experiences; Cloitre, Scarvalone, & Difede, 1997) and con-
significantly more frequent and intense withholding of emo- stricted emotionality (Lisak, Hopper, & Song, 1996).
tions compared to well-adjusted combat veterans, and that There is also evidence that the tendency to react to one’s
this withholding was uniquely associated with PTSD symp- emotional responses as threatening (which likely motivates
tomatology (above and beyond variance contributed by gen- attempts to emotionally avoid) may be related to poorer post-
eral depressive and anxious symptoms). Another recent study traumatic adjustment. Individuals with PTSD report greater
demonstrated incongruence between emotional expression anxiety sensitivity (or fear of their fear reactions) than those
and reports of emotional experience in women with PTSD any other anxiety diagnostic category (Taylor, Koch, & Mc-
such that women with PTSD demonstrated the same level of Nally, 1992), and fear of fear is a stronger predictor of PTSD
emotional expression as controls in response to emotionally symptoms than even trauma-related beliefs (Federoff, Tay-
evocative images, but reported greater subjective experience lor, Asmundson, & Koch, 2000). Further, fear of a
of emotion (suggesting that the PTSD group may have been range of emotional responses (e.g., fear of anxiety,
suppressing the expression of their subjectively more intense sadness, anger, and positive emotions) may be related
emotional reaction; Wagner, Roemer, Orsillo, & Litz, 2003). to analogue PTSD symptomatology (Salters & Roemer,
Additionally, Litz, Orsillo, Kaloupek, and Weathers (2000) 2004). Salters and Roemer (2004) found that a tendency to
demonstrated reduced facial muscle activity in response to view emotional reactions as frightening was correlated with
positively-valenced images following a trauma-related prime greater distress and negative affect during and following ex-
in male combat-exposed veterans with PTSD compared to posure to a trauma-related film, and with greater accessibility
well-adjusted combat-exposed veterans. However, some re- of film-related thoughts.
searchers have found that hyperarousal symptoms are a better Finally, there is evidence that approach of and engage-
predictor of emotional numbing symptoms than active avoid- ment with emotional material is associated with more posi-
ance symptoms (Flack, Litz, Hsieh, Kaloupek, & Keane, tive post-traumatic outcomes. Facial expressiveness of dis-
2000; Litz et al., 1997) or a general tendency to experien- tressing (fear) responses during initial imaginal recall of
tially avoid (Tull & Roemer, 2003). Clearly, more research rape memories mediates the relationship between sever-
is needed to determine whether strategic or automatic emo- ity of psychopathology and symptom improvement follow-
tional avoidance is related to emotional numbing. ing prolonged exposure treatment in female assault victims
Research supports the proposed relationship between sup- with PTSD (Foa, Riggs, Massei, & Yarczower, 1995). And,
pression of traumatic material and PTSD. The self-reported Jaycox, Foa, and Morral (1998) found that among women
tendency to suppress thoughts has been found to be associ- undergoing prolonged exposure treatment for PTSD associ-
ated with hyperaccessibility (Rassin, Merckelbach, & Muris, ated with assault, those with high initial emotional engage-
2001), and intrusion (Davies & Clark, 1998) of distress- ment and between-session habituation were more likely toK. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114 103
benefit from treatment. While further research is indicated, (e.g., Borkovec, Alcaine, & Behar, 2004; Roemer & Orsillo,
particularly to understand the potentially causal relationships 2002; also see discussion of worry below). Turk, Heimberg,
between emotional avoidance and PTSD symptoms such as Luterek, Mennin, and Fresco (in press) examined emotion
intrusion/accessibility of emotional material, hyperarousal, regulation among GAD, SAD, and non-anxious control par-
and emotional numbing, the current literature suggests that ticipants, and found evidence of significant deficits. Indi-
attempts to avoid a range of emotional material and responses viduals with SAD reported greater inexpressivity of positive
may be related to the development of PTSD symptomatology, emotions, reduced attention towards emotions, and decreased
and that clinical interventions that encourage approach of and emotional clarity as compared to GAD and control partici-
engagement with emotions may be implicated in treatment. pants. In addition, individuals with SAD reported greater fear
of both positive and negative emotions, greater difficulty in
3.3. Social anxiety disorder the identification of their emotions, and decreased ability to
repair a negative mood state as compared to control partic-
Social phobia or social anxiety disorder (SAD) is charac- ipants (but were comparable to GAD participants). These
terized by fear of negative evaluation in social situations and findings are consistent with other research demonstrating as-
the subsequent avoidance of those situations (or intense anx- sociations between SAD and deficits in the identification and
iety and distress should the situation be unavoidable; APA, description of emotions (Cox, Swinson, Shulman, & Bour-
1994). Beyond the direct avoidance of social situations, there deau, 1995; Fukunishi, Kikuchi, Wogan, & Takubo, 1997),
is some limited evidence of avoidance of distressing thoughts as well as recent data demonstrating decreased willingness to
and emotional responses in SAD. Fehm and Margraf (2002) express emotions among individuals with SAD as compared
found that individuals with SAD exhibit a general tendency to controls (Novick-Kline, Turk, Mennin, Hoyt, & Gallagher,
to suppress undesirable negative thoughts, regardless of con- 2004). Interestingly, Novick-Kline et al. (2004) also found,
tent, and that social anxiety was the best predictor of per- counter to previously reported findings, increased emotional
centage of time devoted to unwanted negative thoughts, dif- awareness among individuals with SAD, suggesting the need
ficulty suppressing unwanted negative thoughts, and num- for further research into this particular aspect of emotion reg-
ber of subsequent intrusions. Although it is interesting that ulation in SAD.
thought suppression extended across all situations (regard- Decreased emotional clarity among individuals with SAD
less of whether they were social in nature), it would not be may diminish the extent to which they can flexibly and adap-
surprising to expect that individuals with SAD are motivated tively respond to contingencies present in the current environ-
to suppress thoughts of a social nature in particular, as it has ment, resulting in unsuccessful emotion regulation attempts
been found that individuals with SAD exhibit a negative in- (Feldman-Barrett, Gross, Conner-Christensen, & Benvenuto,
terpretation bias in evaluating ambiguous social events that is 2001). Turk et al. (in press) suggest that deliberate attempts
marked by catastrophic thinking (e.g., Stopa & Clark, 2000). to suppress the expression of emotion among individuals
However, limited research has examined thought suppression with SAD may prevent the expression of needs, as well as
as a specific form of avoidance in SAD. negatively influence the reactions of others. While this strat-
The role and presence of direct emotional avoidance has egy may reduce the likelihood that the individual with SAD
also yet to be studied extensively in SAD. However, its devel- will become the center of attention (and thus risk negative
opment is likely especially given theories that social anxiety evaluation), it also prevents the attainment of closeness and
may be intensified when individuals expect or perceive that affiliation that individuals with SAD desire (Turk et al., in
their experience of anxiety can be detected by others (Clark press), and likely interferes with interpersonal functioning
& Wells, 1995; Rapee & Heimberg, 1997). The experience (Gross & John, 2003). Also, as reviewed above, expressive
of embarrassment in SAD is associated with fears of negative suppression may increase sympathetic arousal—a sensation
evaluation, and it has been suggested that this emotion, in par- individuals with SAD may be particularly sensitive to as a
ticular, has behavioral and physiological consequences that sign of embarrassment (Gerlach, Wilhelm, & Roth, 2003)
serve to maintain social anxiety (e.g., McNeil, Ries, & Turk, or as a precursor to blushing (Gerlach, Wilhelm, Gruber, &
1995). Thus, individuals with SAD may be highly motivated Roth, 2001). In addition, Erwin et al. (2003) found that the
to avoid the experience of embarrassment associated with ac- suppression of anger among individuals with SAD, in par-
tual or imagined social situations in particular. These findings ticular, was associated with worse outcome in response to a
may extend to avoidance of expression of other emotions; cognitive-behavioral group treatment for SAD. Conversely,
Erwin, Heimberg, Schneier, and Liebowitz (2003) found that Block and Wulfert (2002) found that an acceptance-based
individuals with SAD exhibit more anger than non-anxious treatment for social anxiety was associated with decreased
controls, but had poorer anger expression skills. behavioral avoidance during a post-treatment exposure task,
Consistent with these findings, a growing body of re- as compared to cognitive behavioral group therapy and a no-
search has demonstrated emotion regulation deficits among treatment control.
individuals with SAD. For example, individuals with social While SAD has been associated with increased recogni-
anxiety disorder exhibit elevated levels of worry, which has tion of negative or critical emotional faces and behavior (e.g.,
been suggested to serve an emotionally avoidant function Foa, Gilboa-Schechtman, Amir, & Freshman, 2000; Lundh104 K. Salters-Pedneault et al. / Applied and Preventive Psychology 11 (2004) 95–114
& Öst, 1996; Valjaca & Rapee, 1998), as well as greater phys- Antony, and Barlow (1992) found that individuals with spe-
iological reactivity to the presentation of slides of angry or cific phobia exhibit less fear (but greater fear as compared to
critical faces (Merckelbach, van Hout, van den Hout, & Mer- non-anxious controls) in response to a biological challenge
sch, 1989; Stein, Goldin, Sareen, Zorrilla, & Brown, 2002), task as compared to individuals with panic disorder. Thus, in-
SAD has also been associated with the avoidance of emo- dividuals with specific phobia may be less likely to develop
tional faces, both positive and negative. Chen, Ehlers, Clark, a tendency to fear (and subsequently take actions to avoid)
and Mansell (2002) and Mansell, Clark, Ehlers, and Chen internal sensations not associated with the fear-relevant stim-
(1999) found that high socially anxious individuals exhibit an ulus.
attentional bias away from negative and positive emotional However, there may be some differences among the vari-
faces when under conditions of social threat. This avoidance ous subtypes of specific phobia. Situational phobias, in par-
has been found to be primarily in the form of eye contact ticular, have been associated with heightened anxiety sensi-
avoidance (Horley, Williams, Gonsalvez, & Gordon, 2003). tivity as compared to other specific phobia subtypes (Craske
Mansell et al. (1999) suggest that the avoidance of both pos- & Sipsas, 1992), and Davey, Menzies, and Gallardo (1997)
itive and negative faces may be a learned response to disen- found that a fear of bodily sensations is associated with an
gage from a situation when any type of emotional reaction is avoidance of heights but not a fear and avoidance of spi-
detected, as individuals with SAD may also be more likely ders. Likewise, Valentiner and colleagues (Valentiner, Telch,
to interpret positive facial expressions as negative reactions Ilai, & Hehmsoth, 1993; Valentiner, Telch, Petruzzi, & Bolte,
(e.g., I am being laughed at). 1996) found that anxiety sensitivity interacts with expected
Facial expressions are a major source of information con- anxiety to predict avoidance behavior in claustrophobic sit-
cerning the ways in which others react to one in a social uations, and Craske and Sipsas (1992) found that situational
context. Therefore, for individuals who fear negative evalua- phobics were more fearful in response to a biological chal-
tion, attentional avoidance would serve to reduce some of the lenge as compared to individuals with a spider or snake pho-
more threatening aspects of a social situation (especially if bia. Furthermore, situational phobics were as fearful during
actual escape is not possible), and thus, this avoidance would the challenge as they were of being in contact with a fear-
be negatively reinforced. However, as with expressive sup- relevant stimulus.
pression, long-term negative consequences of this behavior Although there is little doubt that behavioral avoidance is
would likely result. For instance, avoidance of eye contact the primary form of avoidance that occurs in specific phobia,
may make individuals with SAD appear uninterested or dis- the suppression of fear-relevant thoughts in specific phobia
satisfied with an interpersonal interaction, thereby decreasing has also gained some attention, primarily among individuals
the likelihood of receiving a positive response from others. with dental or spider phobia. For example, de Jongh, Muris,
In addition, disengagement from positive social interactions Merckelbach, and Shoenmakers (1996) found that among in-
may reduce the extent to which individuals with SAD come dividuals with heightened dental anxiety, dental anxiety was
into contact with positively reinforcing aspects of the interac- associated with greater frequency of negative thoughts, and
tion, further maintaining anxiety and fear of social situations. decreased ability to suppress those thoughts, during a fear-
Research regarding the presence of emotional avoidance relevant imagery exercise. Consistent with these findings,
and emotion regulation deficits in SAD is still in its infancy. Muris, Merckelbach, Horselenberg, Sijsenaar, and Leeuw
Much of the research examining emotion regulation deficits (1997) found that individuals with a spider phobia reported
in SAD (e.g., Novick-Kline et al., 2004; Turk et al., in press) a heightened level of fear-relevant thoughts and expressed
uses self-report methodology and is cross-sectional in nature; greater effort in trying to control these thoughts as com-
therefore, future research would benefit from experimental pared to individuals without a spider phobia and regardless
investigations. Further research may lead to a better under- of whether or not they were asked to suppress fear-relevant
standing of how emotional avoidance may influence the de- thoughts. Muris, de Jongh, Merckelbach, Postema, and Vet
velopment and maintenance of SAD (and vice versa), thereby (1998) also found that, while individuals with dental phobia
more adequately informing treatment and prevention. reported greater intrusive thoughts and greater effort in sup-
pressing fear-relevant thoughts, instructions to suppress those
thoughts had no additional negative effect. Given that individ-
3.4. Specific phobia uals with spider and dental phobia exhibited greater negative
intrusive thoughts regardless of suppression instruction, it is
The primary feature of specific phobia is a marked and possible that thought suppression may a common strategy
persistent fear of specific objects or situations (APA, 1994). used among individuals with a specific phobia. However, a
Although individuals with specific phobia may respond to major limitation of the above studies is that distress in partic-
certain stimuli with intense fear reactions, there is limited ipants was not activated prior to engaging in thought suppres-
evidence that this fear reaction results in the fear of anxiety sion, and as a result, one cannot determine with certainty if
sensations in general. Taylor et al. (1992) found that specific fear-relevant distress would interfere with thought suppres-
phobia was not associated with increased anxiety sensitivity sion attempts (see Purdon, 1999). To address this question,
compared to a non-anxious control group, and Rapee, Brown, Wenzel, Barth, and Holt (2003) primed individuals with andYou can also read
