Reliance on distraction is associated with increased avoidance behavior under approach-avoidance conflict

The use of less effective emotional regulation strategies, such as distraction, may relate to greater reliance on avoidance behavior under conflict. Tulsa 1000 participants (n = 478) were recruited trans diagnostically and completed an approach avoidance conflict (AAC) task. Following the task, participants reported their use of distraction as an emotional regulation strategy. Quantile regression showed negative main effects of distraction and age on approach behavior under conflict. This suggests that individuals who use distraction as a regulation strategy are more likely to engage in avoidance behavior under conflict, which has treatment implications.


Introduction
Emotion regulation refers to the processes by which individuals consciously or non-consciously influence their experience of an emotion provoking incident to increase/ decrease components of an emotional response. Avoidance is generally considered a maladaptive outcome (Gross, 1999), unlike more positive approaches such as cognitive reappraisal (Gross, 2002). Avoidance has been shown to be related to suppressive tendencies (Gross, 1998) and is associated with psychopathology (Blackledge & Hayes, 2001). Depression-sensitive participants who used thought suppression strategies had higher levels of depression and obsessive symptoms than those who did not (Wegner & Zanakos, 1994). Maladaptive suppressive strategies such as repressive coping and distraction may manifest at different emotional processing stages following an initial stimulus. Attentional deployment, an example of a less effective regulation strategy, is used to modify early information processes, such as distracting oneself from an attention-grabbing emotional condition (Sheppes & Gross, 2012;Sheppes et al., 2011;Van Dillen & Koole, 2007). This distraction strategy is typically used when emotional intensity is higher, cognitive generation is complex, and short-term relief is desired (Sheppes et al., 2011).
Approach-avoidance conflict (AAC) is described as a situation in which both a reward and punishment are presented, and these two conflicting drives must be reconciled in order to make a decision to approach or avoid. Under situations of potential reward, individuals with anxiety disorder symptoms prefer avoidance compared to potential receipts of a negative outcome (Book Sapolsky, 2004). An imbalance of approach and avoidance drive has been shown to result in less favorable decision-making and is associated with the development of psychopathology (Aupperle & Paulus, 2010). Increased avoidance behavior is a coping mechanism often used in stressful situations (Holahan et al., 2005). This strategy has been associated with higher levels of depressive symptoms (Krohne, 1996) and blunted reward-related decision-making (Vrieze et al., 2013). Based on distraction and avoidance both being associated with worse decision-making and clinical outcomes, in the present study, under situations of AAC, we hypothesize that greater use of distraction will result in increased avoidance behavior under conflict.

Subjects
The first 500 of the Tulsa 1000 participants (Victor et al., 2018) were recruited transdiagnostically. Clinical participants were screened for inclusion on the basis of the following scores: (1) Patient Health Questionnaire (PHQ-9), ≥ 10 and/or (2) Overall Anxiety Symptom and Impairment Scale (OASIS) (Skinner, 1982) ≥ 8 and/or (3) Drug Abuse Screening Test (DAST-10) (Norman et al., 2006) ≥ 3. Sample demographics are reported in Table 1. Participants completed multilevel assessments including an AAC task. Twenty-two participants were excluded as they did not have complete AAC data. The final sample included 169 participants with depression and anxiety (D + A), 19 with anxiety, 73 with depression, 159 with substance use disorder (SUD), and 58 healthy controls (HC).

Procedures
The AAC task (Aupperle et al., 2011) (Fig. 1a) quantifies decision-making behavior during situations that involve conflicting outcomes using a combination of reward points and negative affective stimuli (image/sounds). For each trial, participants were presented with pictures of two potential outcomes, which included positive and negative affective stimuli. The positive affective stimulus was indicated by a sun, and a negative affective stimulus was indicated by a cloud. The level of reward points was represented by a red rectangle. Using a joystick, participants moved an avatar on a runway towards each potential outcome. The likelihood of each outcome increased the closer the avatar moves to one side (up to 90%). The AAC behavioral data included the total average approach/avoidance decisions for all of the conflict trials (54 trials). After the task, participants rated on a 1-7 Likert scale how much they tried to think about something unrelated to the negative stimuli to distract themselves.

Statistical analysis
As the number of approach decisions was skewed, the effect of self-reported distraction on avoidance behavior under conflict was analyzed using quantile regression in R (covariates: sex, age) with a significance threshold of p < = 0.05. The interaction of diagnosis and distraction was also included in the analysis (levels: HC, D + A, anxious, SUD).

Results
Quantile regression with reference to the median showed negative main effects of both self-reported distraction ß = -0.45, 95%CI = [-0.62, -0.28], d = 0.16 and age ß = -0.03, 95%CI = [-0.06, -0.01], d = 0.1 on approach behavior under conflict (Fig. 1b). There was no main effect of sex on approach behavior under conflict and no main effects or interactions with diagnosis. A correlational analysis showed no significant relationships between distraction and self-reported anxiety; (OASIS) or depression (PROMIS Depression scale) (all p > 0.4).

Discussion
This analysis presented results showing that individuals who use distraction as a regulation strategy are more likely to engage in avoidance behavior in conflict situations. These results align with prior research suggesting distraction is a maladaptive emotion regulation strategy (Gross, 1998;Sheppes & Gross, 2012;Van Dillen & Koole, 2007). Under AAC, participants who used distraction as a regulatory strategy were more likely to disregard the reward incentive and move towards the least aversive condition. This finding extends previous research on the implementation of distraction as a coping strategy under unfavorable conditions (Holahan et al., 2005). This suggests a relationship between emotional regulation styles and avoidance that could be targeted with treatment focusing on the development of alternative strategies. Cognitive reappraisal is an example of an emotion regulation strategy that is activated before an emotional response has entirely generated (Cutuli, 2014). Cognitive reappraisal is considered less taxing on cognitive function because it decreases negative expression without increasing physiological activation (Gross & Levenson, 1993). In a healthy control study, individuals who engaged in reappraisal showed lower depression symptoms and exhibited better coping skills (John & Gross, 2004).
Contrary to previous research (Holahan et al., 2005), our data did not show a relationship between sex and approach under AAC. Prior findings indicated that males employed higher levels of avoidance than females. This could be because of our quantile regression approach (linear regression showed sex effects) or that the effect of self-report distraction explained some of the variance that might be otherwise attributed to sex effects.
Given that this is a cross-sectional, correlational study, it cannot be determined whether the use of distraction is causally related to avoidance behavior. Additionally, assessment of emotion regulation relied on self-report of strategies used during the AAC task. Future work would benefit from incorporating more objective measures and other emotion regulation questionnaires, as well as longitudinal and experimental designs. In addition, we did not show a relationship between distraction and depression and/or anxiety ratings, or between distraction and sex. Future work could examine the relationship between emotion regulation styles and other clinical outcomes, such as suicidality (Baldessarini et al., 2017).
In sum, the results indicate that the use of distraction as an emotion regulation strategy leads to greater avoidance behavior under conflict, suggesting this is a maladaptive strategy. Further research is needed to delineate directionality of relationships; for example, by examining changes in approachavoidance behavior after emotion regulation therapy (Fresco et al., 2013). Future research is needed to explore relationships between more adaptive approaches (e.g., reappraisal) and approach/avoidance behavior under conflict. Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate Approval for the study was obtained from the Western Institutional Review Board and written informed consent was obtained from all participants.

Competing interests
Dr. Paulus is an advisor to Spring Care, Inc., a behavioral health startup, he has received royalties for an article about methamphetamine in UpToDate; Dr. Aupperle reports no financial relationships with commercial interests; Dr. Kuplicki reports no financial relationships with commercial interests; Dr. Guinjoan reports no financial relationships with commercial interests; Dr. Khalsa reports no financial relationships with commercial interests; Dr. Savitz reports no financial relationships with commercial interests; Dr. Stewart reports no financial relationships with commercial interests; Dr. Victor reports no financial relationships with commercial interests; Dr. Ironside reports no financial relationships with commercial interests; Ms. Walker reports no financial relationships with commercial interests.
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