An Approach-Avoidance, Computational Framework for Predicting Behavioral Therapy Outcome in Anxiety and Depression

PROJECT SUMMARY
Depression and anxiety disorders are highly comorbid and rank in the top ten causes of years lived with
disability. Current gold-standard treatments are effective but do not work as well as we would like, with less
than 50% experiencing long-lasting improvements. Two gold-standard behavioral interventions for depression
and anxiety include behavioral activation, focused on enhancing approach behavior towards meaningful and
reinforcing activities, and exposure-based therapy, focused on decreasing avoidance and challenging negative
expectations through exposure to anxiety-provoking cues or situations. While these interventions have
divergent approach versus avoidance treatment targets, there is currently little knowledge to guide clinical
decision-making, i.e., to inform which strategies should be provided in the frequent case of comorbid anxiety
and depression symptoms. Approach-avoidance decision-making paradigms focus on assessing neural and
behavioral responses when faced with potential rewards and threats, tapping into processes though to be
important for both anxiety and depression as well as behavioral activation and exposure-based therapy.
For this study, we will recruit individuals reporting both anxiety and depression symptoms and
randomize them to one of three different psychotherapeutic interventions delivered in a group setting, including
(1) behavioral activation, (2) exposure-based therapy, and a non-specific therapy approach (3) supportive
therapy. Participants will complete clinical, self-report, behavioral, and functional magnetic resonance imaging
(fMRI) assessments before and after therapy. Clinical symptoms will also be assessed three and six months
following therapy completion. We will use a computational approach to model the different factors that may
influence one’s behavior during approach-avoidance decision-making, including drives to avoid threat versus
approach reward and confidence versus uncertainty in one’s decisions.
This project will accomplish the following aims (1) Determine how changes in brain and behavior
responses during approach-avoidance conflict relate to changes in mental health symptoms with the different
therapy approaches, (2) Determine the degree to which baseline brain and behavior responses during
approach-avoidance conflict predict response to the different therapy approaches, above and beyond the
influence of demographics and baseline symptom severity.
Results will have enhance our understanding of how different psychotherapy approaches (behavioral
activation, exposure-based therapy) may impact brain responses and decisions when faces with potential
reward versus threat and approach versus avoidance drives. In addition, results will have important
implications concerning the potential for a more personalized approach to psychotherapy, enhancing
knowledge of which types of therapy strategies may be most beneficial for which individuals.

Grant Number: 5R01MH123691-05
NIH Institute/Center: NIH
Principal Investigator: ROBIN AUPPERLE