Response rates for CBT for anxiety disorders: Need for standardized criteria

State-of-the-art and future directions for extinction as a translational model for fear and anxiety

Through advances in both basic and clinical scientific research, Pavlovian fear conditioning and extinction have become an exemplary translational model for understanding and treating anxiety disorders. Discoveries in associative and neurobiological mechanisms underlying extinction have informed techniques for optimizing exposure therapy that enhance the formation of inhibitory associations and their consolidation and retrieval over time and context. Strategies that enhance formation include maximizing prediction-error correction by violating expectancies, deepened extinction, occasional reinforced extinction, attentional control and removal of safety signals/behaviours. Strategies that enhance consolidation include pharmacological agonists of NMDA (i.e. d-cycloserine) and mental rehearsal. Strategies that enhance retrieval include multiple contexts, retrieval cues, and pharmacological blockade of contextual encoding. Stimulus variability and positive affect are posited to influence the formation and the retrieval of inhibitory associations. Inhibitory regulation through affect labelling is considered a complement to extinction. The translational value of extinction will be increased by more investigation of elements central to extinction itself, such as extinction generalization, and interactions with other learning processes, such as instrumental avoidance reward learning, and with other clinically relevant cognitive-emotional processes, such as self-efficacy, threat appraisal and emotion regulation, will add translational value. Moreover, framing fear extinction and related processes within a developmental context will increase their clinical relevance.This article is part of a discussion meeting issue 'Of mice and mental health: facilitating dialogue between basic and clinical neuroscientists'.

Multiple memory systems, multiple time points: how science can inform treatment to control the expression of unwanted emotional memories

Memories that have strong emotions associated with them are particularly resilient to forgetting. This is not necessarily problematic, however some aspects of memory can be. In particular, the involuntary expression of those memories, e.g. intrusive memories after trauma, are core to certain psychological disorders. Since the beginning of this century, research using animal models shows that it is possible to change the underlying memory, for example by interfering with its consolidation or reconsolidation. While the idea of targeting maladaptive memories is promising for the treatment of stress and anxiety disorders, a direct application of the procedures used in non-human animals to humans in clinical settings is not straightforward. In translational research, more attention needs to be paid to specifying what aspect of memory (i) can be modified and (ii) should be modified. This requires a clear conceptualization of what aspect of memory is being targeted, and how different memory expressions may map onto clinical symptoms. Furthermore, memory processes are dynamic, so procedural details concerning timing are crucial when implementing a treatment and when assessing its effectiveness. To target emotional memory in its full complexity, including its malleability, science cannot rely on a single method, species or paradigm. Rather, a constructive dialogue is needed between multiple levels of research, all the way 'from mice to mental health'.This article is part of a discussion meeting issue 'Of mice and mental health: facilitating dialogue between basic and clinical neuroscientists'.

Towards an unconscious neural reinforcement intervention for common fears

Conventional therapies for the treatment of anxiety disorders are aversive, and as a result, many patients terminate treatment prematurely. We have developed an unconscious method to bypass the unpleasantness in conscious exposure using functional magnetic resonance imaging neural reinforcement. Using this method, participants learn to generate brain patterns similar to the multivariate brain pattern of a feared animal. We demonstrate in a double-blind placebo-controlled experiment that neural reinforcement can lead to reliable reductions in physiological fear responses. Crucially, this intervention can be achieved completely unconsciously and without any aversive reaction. Extending our approach to other forms of psychopathologies, such as posttraumatic stress disorders, might eventually provide another means of intervention for patients currently receiving insufficient exposure treatments.

Can “hardwired” physiological fear responses (e.g., for spiders and snakes) be reprogramed unconsciously in the human brain? Currently, exposure therapy is among the most effective treatments for anxiety disorders, but this intervention is subjectively aversive to patients, causing many to drop out of treatment prematurely. Here we introduce a method to bypass the subjective unpleasantness in conscious exposure, by directly pairing monetary reward with unconscious occurrences of decoded representations of naturally feared animals in the brain. To decode physiological fear representations without triggering excessively aversive reactions, we capitalize on recent advancements in functional magnetic resonance imaging decoding techniques, and use a method called hyperalignment to infer the relevant representations of feared animals for a designated participant based on data from other “surrogate” participants. In this way, the procedure completely bypasses the need for a conscious encounter with feared animals. We demonstrate that our method can lead to reliable reductions in physiological fear responses, as measured by skin conductance as well as amygdala hemodynamic activity. Not only do these results raise the intriguing possibility that naturally occurring fear responses can be “reprogrammed” outside of conscious awareness, importantly, they also create the rare opportunity to rigorously test a psychological intervention of this nature in a double-blind, placebo-controlled fashion. This may pave the way for a new approach combining the appealing rationale and proven efficacy of conventional psychotherapy with the rigor and leverage of clinical neuroscience.

Honoring the Past, Envisioning the Future: ABCT's 50th Anniversary Presidential Address

The theme of the Association for Behavioral and Cognitive Therapies (ABCT) 50th Anniversary was to honor the past and envision the future. From the wisdom, foresight, and determination of the pioneers of our organization, and the continuous upholding of the scientific method over the last 50 years, cognitive behavioral therapy (CBT) has become the most empirically supported psychological treatment for a wide array of mental health problems. Yet, we still have a long way to go. This address outlines a vision for the future of CBT, which involves greater collaborative science, with all minds working together on the same problem, and greater attention to the risk factors and critical processes that underlie psychopathology and explain treatment change. Such knowledge generation can inform the development of new, more efficient and more effective therapies that are tailored with more precision to the needs of each person. Latest technologies provide tools for a precision focus while at the same time increasing the reach of our treatments to the many for whom traditional therapies are unavailable. Our impact will be greatly enhanced by large samples with common methods and measures that inform a precision approach. We have come a long way since ABCT was founded in 1966, and we are poised to make even larger strides in our mission to enhance health and well-being by harnessing science, our major guiding principle.

Implementation of a Guided, Digital Cognitive Behavioral Program for Anxiety in Primary Care: Preliminary Findings of Engagement and Effectiveness

BACKGROUND

Implementation of digital behavioral health programs in primary care (PC) can improve access to care for patients in need.

INTRODUCTION

This study provides preliminary data on user engagement and anxiety symptom change among patients referred by their PC provider to a guided, mobile cognitive behavioral program, Lantern.

MATERIALS AND METHODS

Adults aged 20-65 years with at least mild anxiety (GAD-7 ≥ 5) during routine clinical screening in two PC practices were offered Lantern. The primary outcome was self-reported anxiety collected at baseline and 2 months. Linear mixed effects modeling was used to examine anxiety symptom reduction from baseline to 2 months. Post hoc analyses evaluated how number of units completed, number of techniques practiced, and days of usage impacted symptom change.

RESULTS

Sixty-three participants signed up for Lantern and had both baseline and 2- month GAD-7. A mixed effects model adjusted for age, gender, medical complexity score, and physical health found a significant effect of time on GAD-7 (β = -2.08, standard error = 0.77, t(62) = -2.71, p = 0.009). Post hoc analyses indicated that mean number of units, techniques, and usage days did not significantly impact GAD-7 change over 2 months. However, there was significantly greater improvement in anxiety in participants who completed at least three techniques.

DISCUSSION

Results benchmark to previous studies that have found statistically significant symptom change among participants after 4-9 weeks of face-to-face or Internet-based cognitive behavioral therapy (CBT).

CONCLUSIONS

This study suggests that use of Lantern is associated with anxiety reduction and provides proof-of-concept for the dissemination and implementation of guided, CBT-based mobile behavioral health interventions in PC settings.

Effects of differential rates of alternative reinforcement on resurgence of human behavior

Despite the success of exposure-based psychotherapies in anxiety treatment, relapse remains problematic. Resurgence, the return of previously eliminated behavior following the elimination of an alternative source of reinforcement, is a promising model of operant relapse. Nonhuman resurgence research has shown that higher rates of alternative reinforcement result in faster, more comprehensive suppression of target behavior, but also in greater resurgence when alternative reinforcement is eliminated. This study investigated rich and lean rates of alternative reinforcement on response suppression and resurgence in typically developing humans. In Phase 1, three groups (Rich, n = 18; Lean, n = 18; Control, n = 10) acquired the target response. In Phase 2, target responding was extinguished and alternative reinforcement delivered on RI 1 s, RI 3 s, and extinction schedules, respectively. Resurgence was assessed during Phase 3 under extinction conditions for all groups. Target responding was suppressed most thoroughly in Rich and partially in Lean. Target responding resurged in the Rich and Lean groups, but not in the Control group. Between groups, resurgence was more pronounced in the Rich group than the Lean and Control groups. Clinical implications of these findings, including care on the part of clinicians when identifying alternative sources of reinforcement, are discussed.

Examining the short-term anxiolytic and antidepressant effect of Floatation-REST

Floatation-REST (Reduced Environmental Stimulation Therapy) reduces sensory input to the nervous system through the act of floating supine in a pool of water saturated with Epsom salt. The float experience is calibrated so that sensory signals from visual, auditory, olfactory, gustatory, thermal, tactile, vestibular, gravitational and proprioceptive channels are minimized, as is most movement and speech. This open-label study aimed to examine whether Floatation-REST would attenuate symptoms of anxiety, stress, and depression in a clinical sample. Fifty participants were recruited across a spectrum of anxiety and stress-related disorders (posttraumatic stress, generalized anxiety, panic, agoraphobia, and social anxiety), most (n = 46) with comorbid unipolar depression. Measures of self-reported affect were collected immediately before and after a 1-hour float session, with the primary outcome measure being the pre- to post-float change score on the Spielberger State Anxiety Inventory. Irrespective of diagnosis, Floatation-REST substantially reduced state anxiety (estimated Cohen’s d > 2). Moreover, participants reported significant reductions in stress, muscle tension, pain, depression and negative affect, accompanied by a significant improvement in mood characterized by increases in serenity, relaxation, happiness and overall well-being (p < .0001 for all variables). In reference to a group of 30 non-anxious participants, the effects were found to be more robust in the anxious sample and approaching non-anxious levels during the post-float period. Further analysis revealed that the most severely anxious participants reported the largest effects. Overall, the procedure was well-tolerated, with no major safety concerns stemming from this single session. The findings from this initial study need to be replicated in larger controlled trials, but suggest that Floatation-REST may be a promising technique for transiently reducing the suffering in those with anxiety and depression.

Trial registration: ClinicalTrials.gov NCT03051074

Efficacy of inhibitory learning theory-based exposure and response prevention and selective serotonin reuptake inhibitor in obsessive-compulsive disorder management: A treatment comparison

BACKGROUND

The majority of treatment research on obsessive-compulsive disorder (OCD) has focused on emotional processing theory (EPT)-based exposure-based interventions. Despite the outcomes of EPT-based exposure and response prevention (ERP), a sizeable percentage of patients do not respond whereas 50%-60% of those who respond experience at least partial relapse at follow-up assessments. Inhibitory learning theory (ILT) provides a novel foundation for understanding how exposure therapy can be maximized to overcome such deficits but has not been adequately studied and compared to other evidence-based management in OCD.

AIM

The aim of this study was to compare ILT-based ERP plus selective serotonin reuptake inhibitor (SSRI) with only SSRI treatment in OCD patients.

MATERIALS AND METHODS

The present study is pretest/posttest control group design with single masking, where participants (n = 32) diagnosed with OCD were randomly assigned into two treatment groups, namely ILT-based ERP plus SSRI and SSRI alone. Yale-Brown obsessive-compulsive scale was primary outcome measure. Intervention was done for 3 months. Thereafter, the participants were followed up for 6 months.

RESULTS

ILT-based ERP and SSRI are both effective treatments. There was no significant difference in treatment effects between combined treatments of SSRI plus ILT-based ERP and SSRI alone in immediate post assessment. However, combined treatment of SSRI plus ILT-based ERP had significantly better treatment effects on follow-ups than SSRI alone.

CONCLUSIONS

SSRI combined with ILT-based strategies to maximize ERP is significantly better than SSRI alone in the treatment of OCD.

"Gold Standards," Plurality and Monocultures: The Need for Diversity in Psychotherapy

For psychotherapy of mental disorders, presently several approaches are available, such as interpersonal, humanistic, systemic, psychodynamic or cognitive behavior therapy (CBT). Pointing to the available evidence, proponents of CBT claim that CBT is the gold standard. Some authors even argue for an integrated CBT-based form of psychotherapy as the only form of psychotherapy. CBT undoubtedly has its strengths and CBT researchers have to be credited for developing and testing treatments for many mental disorders. A critical review, however, shows that the available evidence for the theoretical foundations of CBT, assumed mechanisms of change, quality of studies, and efficacy is not as robust as some researchers claim. Most important, there is no consistent evidence that CBT is more efficacious than other evidence-based approaches. These findings do not justify regarding CBT as the gold standard psychotherapy. They even provide less justification for the idea that the future of psychotherapy lies in one integrated CBT-based form of psychotherapy as the only type of psychotherapy. For the different psychotherapeutic approaches a growing body of evidence is available. These approaches have their strengths because of differences in their respective focus on interpersonal relationships, affects, cognitions, systemic perspectives, experiential, or unconscious processes. Different approaches may be suitable to different patients and therapists. As generally assumed, progress in research results from openness to new ideas and learning from diverse perspectives. Thus, different forms of evidence-based psychotherapy are required. Plurality is the future of psychotherapy, not a uniform "one fits all" approach.

Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts

Background: Suboptimal response and high dropout rates leave room for improvement of trauma-focused treatment (TFT) effectiveness in ameliorating posttraumatic stress disorder (PTSD) symptoms. Objective: To explore the effectiveness and safety of intensive prolonged exposure (iPE) targeting chronic PTSD patients with a likely diagnosis of ICD-11 Complex PTSD following multiple interpersonal trauma and a history of multiple treatment attempts. Method: Participants (N = 73) received iPE in 12 × 90-minute sessions over four days (intensive phase) followed by four weekly 90-minute booster prolonged exposure (PE) sessions (booster phase). The primary outcomes, clinician-rated severity of PTSD symptoms, and diagnostic status (Clinician-Administered PTSD Scale; CAPS-IV) were assessed at baseline, post-treatment, and at three and six months. Treatment response trajectories were identified and predictors of these trajectories explored. Results: Mixed model repeated measures analysis of CAPS-IV scores showed a baseline-to-posttreatment decrease in PTSD symptom severity (p < .001) that persisted during the three- and six-month follow-ups with large effect sizes (Cohen's d > 1.2); 71% of the participants responded. None of the participants dropped out during the intensive phase and only 5% during the booster phase. Adverse events were extremely low and only a minority showed symptom exacerbation. Cluster analysis demonstrated four treatment response trajectories: Fast responders (13%), Slow responders (26%), Partial responders (32%), and Non-responders (29%). Living condition and between-session fear habituation were found to predict outcome. Participants living alone were more likely to belong to the Partial responders than to the Non-responders cluster, and participants showing more between-session fear habituation were more likely to belong to the Fast responders than to the Non-responders cluster. Conclusions: The results of this open study suggest that iPE can be effective in PTSD patients with multiple interpersonal trauma and after multiple previous treatment attempts. In addition, in this chronic PTSD population iPE was safe.

Does d-cycloserine facilitate the effects of homework compliance on social anxiety symptom reduction?

BACKGROUND

Prior studies examining the effect of d-cycloserine (DCS) on homework compliance and outcome in cognitive-behavior therapy (CBT) have yielded mixed results. The aim of this study was to investigate whether DCS facilitates the effects of homework compliance on symptom reduction in a large-scale study for social anxiety disorder (SAD).

METHODS

169 participants with generalized SAD received DCS or pill placebo during 12-session exposure-based group CBT. Improvements in social anxiety were assessed by independent raters at each session using the Liebowitz social anxiety scale (LSAS).

RESULTS

Controlling for LSAS at the previous session, and irrespective of treatment condition, greater homework compliance in the week prior related to lower LSAS at the next session. However, DCS did not moderate the effect of homework compliance and LSAS, LSAS on homework compliance, or the overall augmenting effect of DCS on homework compliance. Furthermore, LSAS levels were not predictive of homework compliance in the following week.

CONCLUSION

The findings support the general benefits of homework compliance on outcome, but not a DCS-augmenting effect. The comparably small number of DCS-enhanced sessions in this study could be one reason for the failure to find a facilitating effect of DCS.

Can Cognitive Behavioral Therapy for Anxiety and Depression Be Improved with Pharmacotherapy? A Meta-analysis

The present meta-analysis examined controlled trials of pharmacologic augmentation of cognitive-behavioral therapy (CBT) for patients with anxiety or depressive disorders. The additive effect of medications was small for both anxiety and depressive disorders at posttreatment, and there was no additive benefit after medications were discontinued. A small body of evidence suggested that antidepressant medications are an efficacious second-line treatment for patients failing to respond to CBT alone. In anxiety disorders, novel agents thought to potentiate the biological mechanisms of CBT showed small effects at posttreatment; after discontinuation, some of these agents were associated with an increasing effect.

A preregistered, direct replication attempt of the retrieval-extinction effect in cued fear conditioning in rats

In 2009, Monfils and colleagues proposed a behavioral procedure that was said to result in a permanent attenuation of a previously established fear memory, thereby precluding a possible return of fear after extinction (Monfils, Cowansage, Klann, & LeDoux, 2009). By presenting a single retrieval trial one hour before standard extinction training, they found an enduring reduction of fear. The retrieval-extinction procedure holds great clinical potential, particularly for anxiety patients, but the findings are not undisputed, and several conceptual replications have failed to reproduce the effect. These failures have largely been attributed to small procedural differences. This preregistered study is the first endeavor to exactly replicate three key experiments of the original report by Monfils et al. (2009), thereby gauging the robustness of their seminal findings. Despite adhering to the original procedures as closely as possible, we did not find any evidence for reduced return of fear with the retrieval-extinction procedure relative to regular extinction training, as assessed through spontaneous recovery, reinstatement and renewal. Behavior of animals in the control condition (extinction only) was comparable to that in the original studies and provided an adequate baseline to reveal differences with the retrieval-extinction condition. Our null findings indicate that the effect sizes in the original paper may have been inflated and question the legitimacy of previously proposed moderators of the retrieval-extinction effect. We argue that direct experimental evaluation of purported moderators of the retrieval-extinction effect will be key to shed more light on its nature and prerequisites.

Computational Dysfunctions in Anxiety: Failure to Differentiate Signal From Noise

BACKGROUND

Differentiating whether an action leads to an outcome by chance or by an underlying statistical regularity that signals environmental change profoundly affects adaptive behavior. Previous studies have shown that anxious individuals may not appropriately differentiate between these situations. This investigation aims to precisely quantify the process deficit in anxious individuals and determine the degree to which these process dysfunctions are specific to anxiety.

METHODS

One hundred twenty-two subjects recruited as part of an ongoing large clinical population study completed a change point detection task. Reinforcement learning models were used to explicate observed behavioral differences in low anxiety (Overall Anxiety Severity and Impairment Scale score ≤ 8) and high anxiety (Overall Anxiety Severity and Impairment Scale score ≥ 9) groups.

RESULTS

High anxiety individuals used a suboptimal decision strategy characterized by a higher lose-shift rate. Computational models and simulations revealed that this difference was related to a higher base learning rate. These findings are better explained in a context-dependent reinforcement learning model.

CONCLUSIONS

Anxious subjects' exaggerated response to uncertainty leads to a suboptimal decision strategy that makes it difficult for these individuals to determine whether an action is associated with an outcome by chance or by some statistical regularity. These findings have important implications for developing new behavioral intervention strategies using learning models.

Effects of acute exercise on fear extinction in rats and exposure therapy in humans: Null findings from five experiments

BACKGROUND

Exposure therapy is an established learning-based intervention for the treatment of anxiety disorders with an average response rate of nearly 50%, leaving room for improvement. Emerging strategies to enhance exposure therapy in humans and fear extinction retention in animal models are primarily pharmacological. These approaches are limited as many patients report preferring non-pharmacological approaches in therapy. With general cognitive enhancement effects, exercise has emerged as a plausible non-pharmacological augmentation strategy. The present study tested the hypothesis that fear extinction and exposure therapy would be enhanced by a pre-training bout of exercise.

METHODS

We conducted four experiments with rats that involved a standardized conditioning and extinction paradigm and a manipulation of exercise. In a fifth experiment, we manipulated vigorous-intensity exercise prior to a standardized virtual reality exposure therapy session among adults with fear of heights.

RESULTS

In experiments 1-4, exercise did not facilitate fear extinction, long-term memory, or fear relapse tests. In experiment 5, human participants showed an overall reduction in fear of heights but exercise did not enhance symptom improvement.

CONCLUSIONS

Although acute exercise prior to fear extinction or exposure therapy, as operationalized in the present 5 studies, did not enhance outcomes, these results must be interpreted within the context of a broader literature that includes positive findings. Taken all together, this suggests that more research is necessary to identify optimal parameters and key individual differences so that exercise can be implemented successfully to treat anxiety disorders.

Evaluating an Adjunctive Mobile App to Enhance Psychological Flexibility in Acceptance and Commitment Therapy

The primary aims of this study were to evaluate the feasibility and potential efficacy of a novel adjunctive mobile app designed to enhance the acquisition, strengthening, and generalization of acceptance and commitment therapy (ACT) skills being taught in therapy. A sample of 14 depressed/anxious clients receiving ACT used the ACT Daily app for 2 weeks in a pre-post, open trial design. Participants reported a high degree of program satisfaction. Clients significantly improved over the 2-week period on depression and anxiety symptoms as well as a range of psychological inflexibility measures. Analyses of mobile app data indicated effects of ACT Daily skill coaching on in-the-moment measures of inflexibility and symptoms, with unique effects found for acceptance and mindfulness. Adjunctive ACT mobile apps appear promising in enhancing therapy effects on psychological inflexibility and outcomes. A tailored skill coaching approach like ACT Daily based on randomly prompted assessments may be especially promising.

Latent variable analysis of positive and negative valence processing focused on symptom and behavioral units of analysis in mood and anxiety disorders

BACKGROUND

Mood and anxiety disorders are highly heterogeneous and their underlying pathology is complex. The Research Domain Criteria (RDoC) approach seeks to establish dimensionally and neuroscience-based descriptions of psychopathology that may inform better classification and treatment approaches. The current investigation sought to determine the latent variables underlying positive and negative valence processing in terms of symptoms and behavioral units of analysis.

METHOD

As part of an ongoing study, individuals with mood and anxiety problems were recruited largely from primary care clinics at UCLA (n=62) and UCSD (n=58). These participants underwent a comprehensive symptomatic and behavioral assessment. An implicit approach avoidance task and a modified dot probe detection task were used to measure positive and negative valence processing.

RESULTS

Principal components analysis with varimax rotation identified four symptom components, three behavioral components for the dot probe task, and two behavioral components for the implicit approach avoidance task. These components yielded two meta-components consisting of: negative valence symptoms, negative approach bias, and high sustained, selective attention; and positive valence symptoms, positive approach bias, and slow selective or sustained attention. The components did not differ between males and females, nor by age or medication status.

LIMITATIONS

The limitations are: (1) relatively small sample, (2) exploratory analysis strategy, (3) no test/re-test data, (4) no neural circuit analysis, and (5) limited reliability of behavioral data.

CONCLUSIONS

These preliminary data show that positive and negative valence processing domains load on independent dimensions. Taken together, multi-level assessment approaches combined with advanced statistical analyses may help to identify distinct positive and negative valence processes within a clinical population that cut across traditional diagnostic categories.

Study protocol for a randomised controlled trial of cognitive processing therapy for post-traumatic stress disorder among Japanese patients: the Safety, Power, Intimacy, Esteem, Trust (SPINET) study

INTRODUCTION

Cognitive processing therapy (CPT) is widely regarded as a safe and effective first-line treatment for individuals with post-traumatic stress disorder (PTSD); however, no comparative studies have been conducted to examine the treatment outcomes in an Asian population. The aim of the present trial is to investigate the efficacy of CPT (individual format) as a treatment for PTSD in a population of Japanese patients.

METHODS AND ANALYSIS

A 16-week, single-centre, assessor-masked, randomised, parallel-group superiority trial has been designed to compare the efficacy of CPT in conjunction with treatment as usual (mostly pharmacotherapy and clinical monitoring) versus treatment as usual alone. The Clinician-Administered PTSD Scale for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) will be our primary outcome measure of the post-traumatic stress symptoms at 17 weeks, whereas the PTSD Checklist for DSM-5 and determination of the operationally defined responder status will be used to assess the secondary outcomes. An estimated sample size of 29 participants in each group will be required to detect an expected effect size of 1.4 (95% CI 0.85 to 1.95).

ETHICS AND DISSEMINATION

The institutional review board at the National Center of Neurology and Psychiatry in Japan approved this study. The results of this clinical trial will be presented at conferences and disseminated through publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

UMIN000021670 (registered on 1 April 2016).

Optimizing exposure-based CBT for anxiety disorders via enhanced extinction: Design and methods of a multicentre randomized clinical trial

Exposure-based psychological interventions currently represent the empirically best established first line form of cognitive-behavioural therapy for all types of anxiety disorders. Although shown to be highly effective in both randomized clinical and other studies, there are important deficits: (1) the core mechanisms of action are still under debate, (2) it is not known whether such treatments work equally well in all forms of anxiety disorders, including comorbid diagnoses like depression, (3) it is not known whether an intensified treatment with more frequent sessions in a shorter period of time provides better outcome than distributed sessions over longer time intervals. This paper reports the methods and design of a large-scale multicentre randomized clinical trial (RCT) involving up to 700 patients designed to answer these questions. Based on substantial advances in basic research we regard extinction as the putative core candidate model to explain the mechanism of action of exposure-based treatments. The RCT is flanked by four add-on projects that apply experimental neurophysiological and psychophysiological, (epi)genetic and ecological momentary assessment methods to examine extinction and its potential moderators. Beyond the focus on extinction we also involve stakeholders and routine psychotherapists in preparation for more effective dissemination into clinical practice.

Parental Involvement in Cognitive Behavior Therapy for Children with Anxiety Disorders: 3-Year Follow-Up

Parental factors have been linked to childhood anxiety, hence, parental involvement in cognitive behavioral therapy (CBT) for anxious children has been examined. However, findings do not consistently show added effects of parent-enhanced CBT, longitudinal investigations are scarce and long-term effects unclear. In the present study, 40 out of 54 families who, 3 years previously, completed one of two types of CBT treatment: with limited or active parental involvement, were assessed using semi-structured diagnostic interviews. Diagnostic status at 3-years follow-up was compared between groups. Changes in diagnostic status across assessment points: posttreatment, 6-month and 3-year follow-up were analyzed within groups. Diagnostic change from 6-month to 3-year follow-up was compared between groups. Intent-to-treat analyses revealed no significant difference in diagnostic status between groups at 3-year follow-up. Nonetheless, children whose parents actively participated in treatment showed significantly more remission from 6-month to 3-year follow-up than children with limited parental participation.

Public speaking avoidance as a treatment moderator for social anxiety disorder

BACKGROUND AND OBJECTIVES

Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) have both garnered empirical support for the effective treatment of social anxiety disorder. However, not every patient benefits equally from either treatment. Identifying moderators of treatment outcome can help to better understand which treatment is best suited for a particular patient.

METHODS

Forty-nine individuals who met criteria for social anxiety disorder were assessed as part of a randomized controlled trial comparing 12 weeks of CBT and ACT. Pre-treatment avoidance of social situations (measured via a public speaking task and clinician rating) was investigated as a moderator of post-treatment, 6-month follow-up, and 12-month follow-up social anxiety symptoms, stress reactivity, and quality of life.

RESULTS

Public speaking avoidance was found to be a robust moderator of outcome measures, with more avoidant individuals generally benefitting more from CBT than ACT by 12-month follow-up. In contrast, clinician-rated social avoidance was not found to be a significant moderator of any outcome measure.

LIMITATIONS

Results were found only at 12-month follow-up. More comprehensive measures of avoidance would be useful for the field moving forward.

CONCLUSIONS

Findings inform personalized medicine, suggesting that social avoidance measured behaviorally via a public speaking task may be a more robust factor in treatment prescription compared to clinician-rated social avoidance.

Anxiety disorders

Anxiety disorders constitute the largest group of mental disorders in most western societies and are a leading cause of disability. The essential features of anxiety disorders are excessive and enduring fear, anxiety or avoidance of perceived threats, and can also include panic attacks. Although the neurobiology of individual anxiety disorders is largely unknown, some generalizations have been identified for most disorders, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis and genetic factors. In addition, general risk factors for anxiety disorders include female sex and a family history of anxiety, although disorder-specific risk factors have also been identified. The diagnostic criteria for anxiety disorders varies for the individual disorders, but are generally similar across the two most common classification systems: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Edition (ICD-10). Despite their public health significance, the vast majority of anxiety disorders remain undetected and untreated by health care systems, even in economically advanced countries. If untreated, these disorders are usually chronic with waxing and waning symptoms. Impairments associated with anxiety disorders range from limitations in role functioning to severe disabilities, such as the patient being unable to leave their home.

Predicting cognitive behavioral therapy response in social anxiety disorder with anterior cingulate cortex and amygdala during emotion regulation

Background

Cognitive Behavioral Therapy (CBT) for social anxiety disorder (SAD) and other internalizing conditions attempts to improve emotion regulation. Accumulating data indicate anterior cingulate cortex (ACC), and to a lesser extent amygdala, activation in various tasks predicts treatment outcome. However, little is known about ACC and amygdala activation to emotion regulation in predicting clinical improvement following CBT in SAD.

Methods

Before treatment, 38 SAD patients completed implicit and explicit emotion regulation paradigms during fMRI. Implicit regulation involved attentional control over negative distractors. Explicit regulation comprised cognitive reappraisal to negative images. Pre-CBT brain activity was circumscribed to anatomical-based ACC sub-regions (rostral, dorsal) and amygdala masks, which were submitted to ROC curves to examine predictive validity as well as correlational analysis to evaluate prognostic change in symptom severity.

Results

More rostral (rACC) activity in implicit regulation and less rACC activity during explicit regulation distinguished responders (34%) from non-responders. Greater amygdala response in implicit regulation also foretold responder status. Baseline rACC and amygdala activity during attentional control correlated with pre-to-post CBT change in symptom severity such that more activation was related to greater decline in symptoms. No significant correlations were observed for explicit regulation.

Conclusions

Across forms of regulation, rACC activity predicted responder status whereas amygdala as a neuromarker was limited to implicit regulation. While the direction of effects (enhanced vs. reduced) in rACC activity was task-dependent, results suggest SAD patients with deficient regulation benefited more from CBT. Findings support previous studies involving patients with depression and suggest the rACC may be a viable marker of clinical improvement in SAD.

•

Anterior cingulate cortex is a replicated treatment neuromarker in depression.

•

Cognitive behavioral therapy (CBT) is evidence-based psychotherapy for social phobia.

•

CBT attempts to improve emotion regulation ability.

•

Baseline anterior cingulate cortex activity in regulation predicted CBT response.

•

Baseline amygdala activity during regulation also predicted CBT response.

Emotion regulation related neural predictors of cognitive behavioral therapy response in social anxiety disorder

Social anxiety disorder (SAD) is characterized by aberrant prefrontal activity during reappraisal, an adaptive cognitive approach aimed at downregulating the automatic response evoked by a negative event. Cognitive behavioral therapy (CBT) is first-line psychotherapy for SAD, however, many remain symptomatic after treatment indicating baseline individual differences in neurofunctional activity may factor into CBT outcome. An emotion regulation strategy practiced in CBT is cognitive restructuring, a proxy for reappraisal. Therefore, neural response during reappraisal may serve as a brain-based predictor of CBT success. Prior to 12weeks of individual CBT, 34 patients with SAD completed a validated emotion regulation task during fMRI. Task instructions included 'Reappraise,' that is, use a cognitive approach to reduce affective state to a negative image, which was contrasted with looking at a negative image ('Look'). Regression results for Reappraise (vs. Look) revealed greater reduction in symptom severity was predicted by less pre-CBT activation in the dorsolateral prefrontal cortex (DLPFC). Regarding predictive validity, DLPFC significantly classified responder status. Post-hoc analysis revealed DLPFC activity, but not demographic data, baseline clinical measures, or reappraisal-related affective state during fMRI, significantly accounted for the variance in symptom reduction. Findings indicate patients with SAD are more likely to benefit from CBT if there is less pre-treatment DLPFC recruitment, a region strongly implicated in emotion regulation. Patients with reduced baseline frontal activation when reappraising negative stimuli may be especially helped by explicit cognitive interventions. Further research is necessary to establish DLPFC as a stable brain-based marker of treatment outcome.

Separate and combined effects of genetic variants and pre-treatment whole blood gene expression on response to exposure-based cognitive behavioural therapy for anxiety disorders

OBJECTIVES

Exposure-based cognitive behavioural therapy (eCBT) is an effective treatment for anxiety disorders. Response varies between individuals. Gene expression integrates genetic and environmental influences. We analysed the effect of gene expression and genetic markers separately and together on treatment response.

METHODS

Adult participants (n ≤ 181) diagnosed with panic disorder or a specific phobia underwent eCBT as part of standard care. Percentage decrease in the Clinical Global Impression severity rating was assessed across treatment, and between baseline and a 6-month follow-up. Associations with treatment response were assessed using expression data from 3,233 probes, and expression profiles clustered in a data- and literature-driven manner. A total of 3,343,497 genetic variants were used to predict treatment response alone and combined in polygenic risk scores. Genotype and expression data were combined in expression quantitative trait loci (eQTL) analyses.

RESULTS

Expression levels were not associated with either treatment phenotype in any analysis. A total of 1,492 eQTLs were identified with q < 0.05, but interactions between genetic variants and treatment response did not affect expression levels significantly. Genetic variants did not significantly predict treatment response alone or in polygenic risk scores.

CONCLUSIONS

We assessed gene expression alone and alongside genetic variants. No associations with treatment outcome were identified. Future studies require larger sample sizes to discover associations.

A novel perceptual discrimination training task: Reducing fear overgeneralization in the context of fear learning

Generalization is an adaptive learning mechanism, but it can be maladaptive when it occurs in excess. A novel perceptual discrimination training task was therefore designed to moderate fear overgeneralization. We hypothesized that improvement in basic perceptual discrimination would translate into lower fear overgeneralization in affective cues. Seventy adults completed a fear-conditioning task prior to being allocated into training or placebo groups. Predesignated geometric shape pairs were constructed for the training task. A target shape from each pair was presented. Thereafter, participants in the training group were shown both shapes and asked to identify the image that differed from the target. Placebo task participants only indicated the location of each shape on the screen. All participants then viewed new geometric pairs and indicated whether they were identical or different. Finally, participants completed a fear generalization test consisting of perceptual morphs ranging from the CS + to the CS-. Fear-conditioning was observed through physiological and behavioural measures. Furthermore, the training group performed better than the placebo group on the assessment task and exhibited decreased fear generalization in response to threat/safety cues. The findings offer evidence for the effectiveness of the novel discrimination training task, setting the stage for future research with clinical populations.

What good are positive emotions for treatment? Trait positive emotionality predicts response to Cognitive Behavioral Therapy for anxiety

OBJECTIVE

Cognitive behavioral therapy (CBT) is empirically supported for the treatment of anxiety disorders; however, not all individuals achieve recovery following CBT. Positive emotions serve a number of functions that theoretically should facilitate response to CBT - they promote flexible patterns of information processing and assimilation of new information, encourage approach-oriented behavior, and speed physiological recovery from negative emotions. We conducted a secondary analysis of an existing clinical trial dataset to test the a priori hypothesis that individual differences in trait positive emotions would predict CBT response for anxiety.

METHOD

Participants meeting diagnostic criteria for panic disorder (n = 28) or generalized anxiety disorder (n = 31) completed 10 weekly individual CBT sessions. Trait positive emotionality was assessed at pre-treatment, and severity of anxiety symptoms and associated impairment was assessed throughout treatment.

RESULTS

Participants who reported a greater propensity to experience positive emotions at pre-treatment displayed the largest reduction in anxiety symptoms as well as fewer symptoms following treatment. Positive emotions remained a robust predictor of change in symptoms when controlling for baseline depression severity.

CONCLUSIONS

Initial evidence supports the predictive value of trait positive emotions as a prognostic indicator for CBT outcome in a GAD and PD sample.

Tackling maladaptive memories through reconsolidation: From neural to clinical science

Behavioral neuroscience has greatly informed how we understand the formation, persistence, and plasticity of memory. Research has demonstrated that memory reactivation can induce a labile period, during which previously consolidated memories are sensitive to change, and in need of restabilization. This process is known as reconsolidation. Such findings have advanced not only our basic understanding of memory processes, but also hint at the prospect of harnessing these insights for the development of a new generation of treatments for disorders of emotional memory. However, even in simple experimental models, the conditions for inducing memory reconsolidation are complex: memory labilization appears to result from the interplay of learning history, reactivation, and also individual differences, posing difficulties for the translation of basic experimental research into effective clinical interventions. In this paper, we review a selection of influential animal and human research on memory reconsolidation to illustrate key insights these studies afford. We then consider how these findings can inform the development of new treatment approaches, with a particular focus on the transition of memory from reactivation, to reconsolidation, to new memory formation, as well as highlighting possible limitations of experimental models. If the challenges of translational research can be overcome, and if reconsolidation-based procedures become a viable treatment option, then they would be one of the first mental health treatments to be directly derived from basic neuroscience research. This would surely be a triumph for the scientific study of mind and brain.

Anxiety

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions-including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal-is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Timing matters: Endogenous cortisol mediates benefits from early-day psychotherapy

OBJECTIVE

No simple way to augment fear extinction has been established. Cortisol has shown to enhance memory extinction and preliminary evidence suggest that extinction learning maybe more successful in the morning when cortisol is high. The aim was to determine whether exposure sessions conducted earlier in the day are associated with superior therapeutic gains in extinction-based psychotherapy. We also examined the role of cortisol levels as a mediator between time of day and therapeutic gains.

METHOD

Participants were 24 individuals meeting DSM-IV criteria for panic disorder with agoraphobia. Participants received 3 weekly in-vivo exposure sessions, yielding 72 total sessions for analysis of time of day effects. Session start times were evenly distributed across the day. The outcome measures were reductions in panic symptom severity (avoidance behaviors, threat misappraisal, perceived control, and panic disorder symptom severity).

RESULTS

Sessions starting earlier in the day were associated with superior therapeutic gains by the next therapy session. Earlier sessions were also associated with higher pre-exposure cortisol levels, which in turn were related to greater clinical improvement by the next session. Cortisol thus was found to mediate the effect of time of day on subsequent outcome, providing a link between earlier exposure sessions and greater clinical improvement.

CONCLUSION

The data suggest that early-day extinction-based therapy sessions yield better outcomes than later-day sessions, partly due to the enhancing effect of higher cortisol levels.

Treatment for Anhedonia: A Neuroscience Driven Approach

Anhedonia, or loss of interest or pleasure in usual activities, is characteristic of depression, some types of anxiety, as well as substance abuse and schizophrenia. Anhedonia is a predictor of poor long-term outcomes, including suicide, and poor treatment response. Because extant psychological and pharmacological treatments are relatively ineffective for anhedonia, there is an unmet therapeutic need for this high-risk symptom. Current psychological and drug treatments for anxiety and depression focus largely on reducing excesses in negative affect rather than improving deficits in positive affect. Recent advances in affective neuroscience posit that anhedonia is associated with deficits in the appetitive reward system, specifically the anticipation, consumption, and learning of reward. In this paper, we review the evidence for positive affect as a symptom cluster, and its neural underpinnings, and introduce a novel psychological treatment for anxiety and depression that targets appetitive responding. First, we review anhedonia in relation to positive and negative valence systems and current treatment approaches. Second, we discuss the evidence linking anhedonia to biological, experiential, and behavioral deficits in the reward subsystems. Third, we describe the therapeutic approach for Positive Affect Treatment (PAT), an intervention designed to specifically target deficits in reward sensitivity.

New avenues for treating emotional memory disorders: towards a reconsolidation intervention for posttraumatic stress disorder

The discovery that fear memories may change upon retrieval, a process referred to as memory reconsolidation, opened avenues to develop a revolutionary new treatment for emotional memory disorders. Reconsolidation is a two-phase process in which retrieval of a memory initiates a transient period of memory destabilization, followed by a protein synthesis-dependent restabilization phase. This reconsolidation window offers unique opportunities for amnesic agents to interfere with the process of memory restabilization, thereby weakening or even erasing the emotional expression from specific fear memories. Here we present four uncontrolled case descriptions of patients with symptoms of posttraumatic stress disorder (PTSD) who received a reconsolidation intervention. The intervention basically involves a brief reactivation of the trauma memory aimed to trigger memory destabilization, followed by the intake of one pill of 40 mg propranolol HCl (i.e. a noradrenergic beta-blocker) that should disrupt the process of memory restabilization. We present three cases who showed a steep decline of fear symptoms after only one or two intervention sessions. To illustrate that the translation from basic science to clinical practice is not self-evident, we also present a description of a noneffective intervention in a relatively complex case. Even though the reconsolidation intervention is very promising, the success of the treatment depends on whether the memory reactivation actually triggers memory reconsolidation. Obviously the uncontrolled observations described here warrant further study in placebo-controlled designs.

Predicting Response Trajectories during Cognitive-Behavioural Therapy for Panic Disorder: No Association with the BDNF Gene or Childhood Maltreatment

BACKGROUND

Anxiety disorders are highly prevalent and result in low quality of life and a high social and economic cost. The efficacy of cognitive-behavioural therapy (CBT) for anxiety disorders is well established, but a substantial proportion of patients do not respond to this treatment. Understanding which genetic and environmental factors are responsible for this differential response to treatment is a key step towards "personalized medicine". Based on previous research, our objective was to test whether the BDNF Val66Met polymorphism and/or childhood maltreatment are associated with response trajectories during exposure-based CBT for panic disorder (PD).

METHOD

We used Growth Mixture Modeling to identify latent classes of change (response trajectories) in patients with PD (N = 97) who underwent group manualized exposure-based CBT. We conducted logistic regression to investigate the effect on these trajectories of the BDNF Val66Met polymorphism and two different types of childhood maltreatment, abuse and neglect.

RESULTS

We identified two response trajectories ("high response" and "low response"), and found that they were not significantly associated with either the genetic (BDNF Val66Met polymorphism) or childhood trauma-related variables of interest, nor with an interaction between these variables.

CONCLUSIONS

We found no evidence to support an effect of the BDNF gene or childhood trauma-related variables on CBT outcome in PD. Future studies in this field may benefit from looking at other genotypes or using different (e.g. whole-genome) approaches.

An investigation of general predictors for cognitive-behavioural therapy outcome for anxiety disorders in a routine clinical setting

INTRODUCTION

Cognitive-behavioural therapy (CBT) is effective for treating anxiety disorders and is offered in most mental health services around the world. However, a relatively large number of patients with anxiety disorders do not benefit from CBT, experience relapses or drop out. Reliable predictors of treatment effects are lacking. The aim of this study is to investigate the predictive value of emotion regulation and attentional control for CBT outcome in a routine setting.

METHODS AND ANALYSIS

In this prospective and practice-based study, 112 patients with anxiety disorders referred for manual-based group CBT at two psychiatric outpatient clinics will be recruited. Emotion regulation, severity of anxiety and attentional control will be assessed with self-report measures and with an experimental computer-based attentional control task at baseline, post-treatment and at a 6-month follow-up. Emotion regulation will be measured with Difficulties in Emotion Regulation Questionnaire, severity of anxiety will be assessed with Beck Anxiety Inventory and attentional control will be measured with the self-report questionnaire, Attention Control Scale, and with an experimental computer-based attentional control task based on theory of visual attention. Data will be analysed using multilevel mixed-effects modelling.

ETHICS AND DISSEMINATION

The study is approved by the Danish National Ethical Board, the Department of Psychology Ethical Board, University of Copenhagen and by the Danish Data Protection Agency. Study findings will be disseminated through peer-reviewed journal publications and conference presentations. The Danish Committee System on Health Research Ethics has been notified about the project.

TRIAL REGISTRATION NUMBER

NCT02638363.