Greater decision uncertainty characterizes a transdiagnostic patient sample during approach-avoidance conflict: a computational modelling approach

Greater decision uncertainty characterizes a transdiagnostic patient sample during approach-avoidance conflict: a computational modelling approach

J Psychiatry Neurosci 2021;46(1):E74-E87 | PDF | Appendix 1 | Appendix 2 | Appendix 3

Ryan Smith, PhD; Namik Kirlic, PhD; Jennifer L. Stewart, PhD; James Touthang, BS; Rayus Kuplicki, PhD; Sahib S. Khalsa, MD, PhD; Justin Feinstein, PhD; Martin P. Paulus, MD; Robin L. Aupperle, PhD

Background: Imbalances in approach-avoidance conflict (AAC) decision-making (e.g., sacrificing rewards to avoid negative outcomes) are considered central to multiple psychiatric disorders. We used computational modelling to examine 2 factors that are often not distinguished in descriptive analyses of AAC: decision uncertainty and sensitivity to negative outcomes versus rewards (emotional conflict).

Methods: A previously validated AAC task was completed by 478 participants, including healthy controls (n = 59), people with substance use disorders (n = 159) and people with depression and/or anxiety disorders who did not have substance use disorders (n = 260). Using an active inference model, we estimated individual-level values for a model parameter that reflected decision uncertainty and another that reflected emotional conflict. We also repeated analyses in a subsample (59 healthy controls, 161 people with depression and/or anxiety disorders, 56 people with substance use disorders) that was propensity-matched for age and general intelligence.

Results: The model showed high accuracy (72%). As further validation, parameters correlated with reaction times and self-reported task motivations in expected directions. The emotional conflict parameter further correlated with self-reported anxiety during the task (r = 0.32, p < 0.001), and the decision uncertainty parameter correlated with self-reported difficulty making decisions (r = 0.45, p < 0.001). Compared to healthy controls, people with depression and/or anxiety disorders and people with substance use disorders showed higher decision uncertainty in the propensity-matched sample (t = 2.16, p = 0.03, and t = 2.88, p = 0.005, respectively), with analogous results in the full sample; people with substance use disorders also showed lower emotional conflict in the full sample (t = 3.17, p = 0.002).

Limitations: This study was limited by heterogeneity of the clinical sample and an inability to examine learning.

Conclusion: These results suggest that reduced confidence in how to act, rather than increased emotional conflict, may explain maladaptive approach-avoidance behaviours in people with psychiatric disorders.


Submitted Feb. 13, 2020; Revised May 15, 2020; Accepted Jun. 22, 2020; Early-released Oct. 29, 2020

Affiliations: From the Laureate Institute for Brain Research, Tulsa, OK, USA (Smith, Kirlic, Stewart, Touthang, Kuplicki, Khalsa, Feinstein, Paulus, Aupperle); and the Oxley College of Health Sciences, University of Tulsa, Tulsa, OK, USA (Stewart, Khalsa, Paulus, Aupperle).

Competing interests: None declared.

Funding: This work was funded by the NIGMS (P20 GM121312; PI:MPP), the NIMH (K23-MH108707; PI: RLA), and the William K. Warren Foundation.

Contributors: R. Smith, R. Kuplicki, J. Feinstein, M. Paulus and R. Aupperle designed the study. J. Touthang, R. Kuplicki and M. Paulus acquired the data, which R. Smith, N. Kirlic, J. Stewart, J. Touthang, R. Kuplicki, S. Khalsa, M. Paulus and R. Aupperle analyzed. R. Smith, N. Kirlic, J. Stewart, M. Paulus and R. Aupperle wrote the article, which all authors reviewed. All authors approved the final version to be published and can certify that no other individuals not listed as authors have made substantial contributions to the paper.

Content licence: This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is non-commercial (i.e. research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

DOI: 10.1503/jpn.200032

Correspondence to: R. Smith, Laureate Institute for Brain Research, 6655 S. Yale Ave., Tulsa, OK 74136, USA; rsmith@laureateinstitute.org