Elevated decision uncertainty and reduced avoidance drives in depression, anxiety and substance use disorders during approach-avoidance conflict: a replication study

Abstract

Background: Decision-making under approach-avoidance conflict (AAC; e.g., sacrificing quality of life to avoid feared outcomes) may be affected in multiple psychiatric disorders. Recently, we used a computational (active inference) model to characterize information processing differences during AAC in individuals with depression, anxiety and/or substance use disorders. Individuals with psychiatric disorders exhibited increased decision uncertainty (DU) and reduced sensitivity to unpleasant stimuli. This preregistered study aimed to determine the replicability of this processing dysfunction.

Methods: A new sample of participants completed the AAC task. Individual-level computational parameter estimates, reflecting decision uncertainty and sensitivity to unpleasant stimuli ("emotion conflict"; EC), were obtained and compared between groups. Subsequent analyses combining the prior and current samples allowed assessment of narrower disorder categories.

Results: The sample in the present study included 480 participants: 97 healthy controls, 175 individuals with substance use disorders and 208 individuals with depression and/or anxiety disorders. Individuals with substance use disorders showed higher DU and lower EC values than healthy controls. The EC values were lower in females, but not males, with depression and/or anxiety disorders than in healthy controls. However, the previously observed difference in DU between participants with depression and/or anxiety disorders and healthy controls did not replicate. Analyses of specific disorders in the combined samples indicated that effects were common across different substance use disorders and affective disorders.

Limitations: There were differences, although with small effect size, in age and baseline intellectual functioning between the previous and current sample, which may have affected replication of DU differences in participants with depression and/or anxiety disorders.

Conclusion: The now robust evidence base for these clinical group differences motivates specific questions that should be addressed in future research: can DU and EC become behavioural treatment targets, and can we identify neural substrates of DU and EC that could be used to measure severity of dysfunction or as neuromodulatory treatment targets?

Figure 1

Lifetime DSM-IV/DSM-5 psychiatric diagnosis composition within exploratory (above diagonal) and confirmatory (below diagonal) samples. Four individuals with depression/anxiety disorders in the exploratory sample and 4 in the confirmatory sample were included only in the total counts because they had unspecified depressive disorders (3 exploratory, 2 confirmatory) and/or showed bipolar (2 confirmatory) or psychotic symptoms (1 exploratory). Alc. = alcohol use disorders; Can. = cannabis use disorders; DU = decision uncertainty; EC = emotion conflict; GAD = generalized anxiety disorder; Hal. = hallucinogen use disorders; MDD = major depressive disorder; Op. = opioid use disorders; PTSD = posttraumatic stress disorder; SAD = social anxiety disorder; Sed. = sedative use disorders; Stim. = stimulant use disorders; SUD = substance use disorder.

Figure 2

Diagram representing the approach–avoidance (AAC) task. On each trial, participants choose to move an avatar to 1 of 9 positions on a runway. Pictures are shown on each side of the runway, indicating the types of stimuli that could be presented at the end of the trial. A sun or cloud represented potential positive or negative affective stimuli, respectively (each being an image–sound combination), while the height of the red fill in a rectangle signified the number of points that would be received in conjunction. Participants were told the ending position of the avatar determined the probability of each of these outcomes occurring (in increments of 10%, from 90% to 10% with each step away from the associated stimulus indicator images). (Left) Example trial, in which the negative stimulus and 2 points were presented based on the probabilities associated with the chosen runway position. (Right) The 5 trial types and associated probabilities of each outcome at each runway position. The task consisted of a total of 60 trials, with 12 of each of the 5 trial types. After task completion, a screen appeared displaying total points received and an award ribbon. Adapted from our previous paper.

Figure 3

Scatterplots showing associations between model parameters and (left panels) self-reported task experience (Q2 and Q3 in Table 3) and (right panels) response times (RTs) in seconds in relevant task conditions. The substance use disorder group showed significantly different values than the other groups with respect to both model parameters and both RT measures. The depression/anxiety group also differed from healthy controls on emotion conflict (EC). Note that EC and decision uncertainty (DU) are shown in log-space.

Figure 4

Raincloud plots (including densities, boxplots, means and standard errors [SEs], and individual data points) and bar plots (means and SEs) showing differences between healthy controls (HC) and clinical groups in 2 measures of avoidance (top row) and 2 measures of uncertainty (bottom row) in which values were significantly different in the substance use disorder (SUD) group compared with the other groups: The emotional conflict (EC) model parameter, reflecting expected aversiveness of negative stimuli relative to reward; a self-reported emotion regulation strategy (Q6 in Table 3; lower values indicate individuals closed their eyes more often to avoid the negative stimuli); the decision uncertainty (DU) model parameter, reflecting indeterminacy in choice; and response times (RTs) in seconds in the avoid condition. The depression/anxiety disorder group (D/A) also differed from healthy controls on EC. Note that EC and DU are shown in log-space.

Figure 5

Comparison of results (means with standard errors) for the emotion conflict (EC) parameter in our previous study and the current sample when separated by clinical group and sex. This illustrates the consistency of prior results with the interaction between group and sex found in the present study, indicating reduced avoidance (EC) in both clinical groups in females compared with healthy controls (HC). D/A = depression/anxiety disorder group; SUD = substance use disorder group.

Figure 6

Comparison of healthy controls (HC) and subsets of individuals with specific affective disorders in the depression/anxiety disorder (D/A) group (top row) and with specific substance use disorders (SUD; middle row), some of whom also had affective disorders, within the combined exploratory and confirmatory data sets (sample size per group is indicated within each bar, based on groupings shown in Figure 1). Red asterisks indicate that, in logistic regressions, model parameters could predict whether individuals were healthy controls or had a specific disorder (i.e., removing individuals from analyses without the disorder in question), either including comorbidities (top 2 rows) or in individuals without comorbidities (bottom row; *p < 0.05, **p < 0.01, ***p < 0.001). Individuals with depression and comorbid anxiety (Anx. MDD) have also been included in the bottom plots to compare with those with depression (MDD only) or generalized anxiety disorder (GAD only) alone. Blue asterisks indicate that model parameters could further predict whether an individual had one disorder relative to other disorders (i.e., removing healthy controls from analyses). Statistical results are reported in Appendix 1, Tables S10–S13, available at www.jpn.ca/lookup/doi/10.1503/jpn.220226/tab-related-content. Alc. = alcohol use disorders; Can. = cannabis use disorders; DU = decision uncertainty; EC = emotion conflict; Hal. = hallucinogen use disorders; Op. = opioid use disorders; PTSD = posttraumatic stress disorder; SAD = social anxiety disorder; Sed. = sedative use disorders; Stim. only = stimulant use disorders without comorbidities.