Neural response during attentional control and emotion processing predicts improvement after cognitive behavioral therapy in generalized social anxiety disorder

Pre-COVID brain network topology prospectively predicts social anxiety alterations during the COVID-19 pandemic

Background

Social anxiety (SA) is a negative emotional response that can lead to mental health issues, which some have experienced during the coronavirus disease 2019 (COVID-19) pandemic. Little attention has been given to the neurobiological mechanisms underlying inter-individual differences in SA alterations related to COVID-19. This study aims to identify neurofunctional markers of COVID-specific SA development.

Methods

110 healthy participants underwent resting-state magnetic resonance imaging and behavioral tests before the pandemic (T1, October 2019 to January 2020) and completed follow-up behavioral measurements during the pandemic (T2, February to May 2020). We constructed individual functional networks and used graph theoretical analysis to estimate their global and nodal topological properties, then used Pearson correlation and partial least squares correlations examine their associations with COVID-specific SA alterations.

Results

In terms of global network parameters, SA alterations (T2-T1) were negatively related to pre-pandemic brain small-worldness and normalized clustering coefficient. In terms of nodal network parameters, SA alterations were positively linked to a pronounced degree centrality pattern, encompassing both the high-level cognitive networks (dorsal attention network, cingulo-opercular task control network, default mode network, memory retrieval network, fronto-parietal task control network, and subcortical network) and low-level perceptual networks (sensory/somatomotor network, auditory network, and visual network). These findings were robust after controlling for pre-pandemic general anxiety, other stressful life events, and family socioeconomic status, as well as by treating SA alterations as categorical variables.

Conclusions

The individual functional network associated with SA alterations showed a disrupted topological organization with a more random state, which may shed light on the neurobiological basis of COVID-related SA changes at the network level.

Neural evidence of face processing in social anxiety disorder: A systematic review with meta-analysis

Numerous previous studies have used event-related potentials (ERPs) to examine facial processing deficits in individuals with social anxiety disorder (SAD). However, researchers still need to determine whether the deficits are general or specific and what the dominant factors are behind different cognitive stages. Meta-analysis was performed to quantitatively identify face processing deficits in individuals with SAD. Ninety-seven results in 27 publications involving 1032 subjects were calculated using Hedges' g. The results suggest that the face itself elicits enlarged P1 amplitudes, threat-related facial expressions induce larger P2 amplitudes, and negative facial expressions lead to enhanced P3/LPP amplitudes in SAD individuals compared with controls. That is, there is face perception attentional bias in the early phase (P1), threat attentional bias in the mid-term phase (P2), and negative emotion attentional bias in the late phase (P3/LPP), which can be summarized into a three-phase SAD face processing deficit model. These findings provide an essential theoretical basis for cognitive behavioral therapy and have significant application value for the initial screening, intervention, and treatment of social anxiety.

Weathering the storm of emotions: immediate and lasting effects of reinterpretation and distancing on event-related potentials and their association with habitual use of cognitive reappraisal

Reinterpretation and distancing, two cognitive reappraisal tactics, are known to effectively reduce negative feelings and event-related potentials (ERPs), such as the P300 and the late positive potential (LPP), in the short-term. Less is known about differential and lasting effects on ERPs as well as their association with habitual reappraisal. Fifty-seven participants were instructed to passively view or reappraise (reinterpretation, distancing) pictures that were repeatedly presented with the same instruction (active regulation phase). Thirty minutes later, these pictures were shown again without instruction for the assessment of lasting effects (re-exposure phase). ERPs were recorded and participants rated the intensity of negative feelings following picture presentation. Reappraisal led to an attenuation of the LPP, and both tactics decreased negative feelings during active regulation, whereby reinterpretation had a stronger impact on the subjective level. Passive re-exposure resulted in reduced negative feelings for previously reappraised pictures but had no lasting effects on ERPs. Higher habitual reappraisal was associated with higher P300 and early LPP amplitudes for emotional reactivity during the active regulation phase. During the re-exposure phase, higher habitual reappraisal was not related to ERPs. The current findings emphasize the effectiveness of both tactics in the short-term and lasting effects on the subjective experience of negative feelings. Enhanced emotional reactivity on the electrocortical level in individuals with a more frequent habitual use of reappraisal might indicate a higher preparedness to regulate.

Triple network model of brain connectivity changes related to adverse mood effects in an oral contraceptive placebo-controlled trial

Combined oral contraceptives (COC) are among the most commonly used contraceptive methods worldwide, and mood side effects are the major reason for discontinuation of treatment. We here investigate the directed connectivity patterns associated with the mood side effects of an androgenic COC in a double-blind randomized, placebo-controlled trial in women with a history of affective COC side effects (n = 34). We used spectral dynamic causal modeling on a triple network model consisting of the default mode network (DMN), salience network (SN) and executive control network (ECN). Within this framework, we assessed the treatment-related changes in directed connectivity associated with adverse mood side effects. Overall, during COC use, we found a pattern of enhanced connectivity within the DMN and decreased connectivity within the ECN. The dorsal anterior cingulate cortex (SN) mediates an increased recruitment of the DMN by the ECN during treatment. Mood lability was the most prominent COC-induced symptom and also arose as the side effect most consistently related to connectivity changes. Connections that were related to increased mood lability showed increased connectivity during COC treatment, while connections that were related to decreased mood lability showed decreased connectivity during COC treatment. Among these, the connections with the highest effect size could also predict the participants' treatment group above chance.

Neural predictors of cognitive-behavior therapy outcome in anxiety-related disorders: a meta-analysis of task-based fMRI studies

BACKGROUND

Cognitive-behavior therapy (CBT) is a well-established first-line intervention for anxiety-related disorders, including specific phobia, social anxiety disorder, panic disorder/agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. Several neural predictors of CBT outcome for anxiety-related disorders have been proposed, but previous results are inconsistent.

METHODS

We conducted a systematic review and meta-analysis of task-based functional magnetic resonance imaging (fMRI) studies investigating whole-brain predictors of CBT outcome in anxiety-related disorders (17 studies, n = 442).

RESULTS

Across different tasks, we observed that brain response in a network of regions involved in salience and interoception processing, encompassing fronto-insular (the right inferior frontal gyrus-anterior insular cortex) and fronto-limbic (the dorsomedial prefrontal cortex-dorsal anterior cingulate cortex) cortices was strongly associated with a positive CBT outcome.

CONCLUSIONS

Our results suggest that there are robust neural predictors of CBT outcome in anxiety-related disorders that may eventually lead (probably in combination with other data) to develop personalized approaches for the treatment of these mental disorders.

Dorsal anterior cingulate cortex activity during cognitive challenge in social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) is associated with aberrant emotional information processing while little is known about non-emotional cognitive processing biases. The dorsal anterior cingulate cortex (dACC) has been implicated in SAD neuropathology and is activated both by emotional and non-affective cognitive challenges like the Multisource Interference Task (MSIT).

METHODS

Here, we used fMRI to compare dACC activity and test performance during MSIT in 69 SAD patients and 38 healthy controls. In addition to patient-control comparisons, we examined whether neural activity in the dACC correlated with social anxiety, trait anxiety or depression levels.

RESULTS

The MSIT activated the dACC as expected but with no differences in task performance or neural reactivity between SAD patients and controls. There were no significant correlations between dACC activity and social or trait anxiety symptom severity. In patients, there was a significant negative correlation between dACC activity and depressive symptoms.

CONCLUSIONS

In absence of affective challenge, we found no disorder-related cognitive profile in SAD patients since neither MSIT task performance nor dACC neural activity deviated in patients relative to controls.

Neuroscience-based psychotherapy: A position paper

In the recent years, discoveries in neuroscience have greatly impacted upon the need to modify therapeutic practice starting from the evidence showing some cerebral mechanisms capable of coping with mental health crisis and traumatic events of the individual's life history by redesigning the narrative plot and the person's sense of the Self. The emerging dialogue between neuroscience and psychotherapy is increasingly intense and modern psychotherapy cannot ignore the heritage deriving from studies about neuropsychological modification of memory traces, neurobiology of attachment theory, cognitive mechanisms involved in psychopathology, neurophysiology of human empathy, neuroimaging evidence about psychotherapeutic treatment, and somatoform disorders connecting the brain and the body. In the present article, we critically examined sectorial literature and claimed that psychotherapy has to referred to a neuroscience-based approach in order to adopt the most tailored interventions for specific groups of patients or therapy settings. We also provided recommendations for care implementation in clinical practice and illustrated challenges of future research.

Functional neural changes associated with psychotherapy in anxiety disorders - A meta-analysis of longitudinal fMRI studies

Successful psychotherapy for anxiety disorders is thought to be linked to functional neural changes in prefrontal control areas and fear-related limbic regions. Thus, discovering such therapy-associated neural changes might point to relevant mechanisms of action. Using AES-SDM, we conducted a coordinate-based meta-analysis of 22 whole-brain datasets (n = 419 anxiety patients) from 18 studies identified by our systematic literature search following PRISMA criteria (preregistration available at OSF: https://osf.io/dgc4p). In these studies, fMRI data was collected in response to negative stimuli during cognitive-emotional tasks before and after psychotherapy. Post-psychotherapy, activation decreased in the right insula, the anterior cingulate cortex, and the dorsolateral prefrontal cortex; no region had increased activation. A subgroup analysis for CBT revealed additional decrease in the supplementary motor area. Reduced activation in limbic and frontal regions might indicate therapy-associated normalization regarding the perception of internal and external threat, subsequent allocation of cognitive resources, and changes in effortful cognitive control. Due to the integration of diverse treatments and experimental tasks, these changes presumably reflect global effects of successful psychotherapy.

ERPs in Children and Adolescents with Generalized Anxiety Disorder: Before and after an Intervention Program

According to DSM 5, generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry about various topics that occupies the majority of the subject’s time for a period of at least six months. The aforementioned state causes distress and/or functional impairments. This paper presents the outcomes of a pilot study that evaluated the implementation of cognitive behavioral therapy (CBT) and CBT with an SSRIs intervention program. The participants comprised 16 children and adolescents with GAD (8 males and 8 females) matched with 16 typically developing peers (8 males and 8 females) aged from 10 to 16 years old (M = 12.56 SD = 2.18). Baseline assessment consisted of event related potentials (ERPs), which indicated that participants with GAD presented cognitive deficits in attention and memory, as they exhibited longer P300 latencies. Following treatment with the CBT program and/or medication, children and adolescents with GAD did not present statistically significantly longer P300 latencies and reaction times in comparison to the control group. Lastly, children and adolescents who followed the CBT program or the CBT program with psychopharmacological assistance did not reveal statistically significant differences in 13 out of 15 topographic brain areas and in reaction time.

Anterior cingulate cortex activation during attentional control as a transdiagnostic marker of psychotherapy response: a randomized clinical trial

Anterior cingulate cortex (ACC) response during attentional control in the context of task-irrelevant emotional faces is a promising biomarker of cognitive behavioral therapy (CBT) outcome in patients with social anxiety disorder (SAD). However, it is unclear whether this biomarker extends to major depressive disorder (MDD) and is specific to CBT outcome. In the current study, 72 unmedicated patients with SAD (n = 39) or MDD (n = 33) completed a validated emotional interference paradigm during functional magnetic resonance imaging before treatment. Participants viewed letter strings superimposed on task-irrelevant threat and neutral faces under low perceptual load (high interference) and high perceptual load (low interference). Biomarkers comprised anatomy-based rostral ACC (rACC) and dorsal ACC (dACC) response to task-irrelevant threat (>neutral) faces under low and high perceptual load. Patients were randomly assigned to 12 weeks of CBT or supportive therapy (ST) (ClinicalTrials.gov identifier: NCT03175068). Clinician-administered measures of social anxiety and depression severity were obtained at baseline and every 2 weeks throughout treatment (7 assessments total) by an assessor blinded to the treatment arm. A composite symptom severity score was submitted to latent growth curve models. Results showed more baseline rACC activity to task-irrelevant threat>neutral faces under low, but not high, perceptual load predicted steeper trajectories of symptom improvement throughout CBT or ST. Post-hoc analyses indicated this effect was driven by subgenual ACC (sgACC) activation. Findings indicate ACC activity during attentional control may be a transdiagnostic neural predictor of general psychotherapy outcome.

Neurocircuitry of Treatment in Anxiety Disorders

Background:

Methods:

Results:

Conclusions:

Amygdala connectivity and implications for social cognition and disorders

The amygdala is a hub of subcortical region that is crucial in a wide array of affective and motivation-related behaviors. While early research contributed significantly to our understanding of this region's extensive connections to other subcortical and cortical regions, recent methodological advances have enabled researchers to better understand the details of these circuits and their behavioral contributions. Much of this work has focused specifically on investigating the role of amygdala circuits in social cognition. In this chapter, we review both long-standing knowledge and novel research on the amygdala's structure, function, and involvement in social cognition. We focus specifically on the amygdala's circuits with the medial prefrontal cortex, the orbitofrontal cortex, and the hippocampus, as these regions share extensive anatomic and functional connections with the amygdala. Furthermore, we discuss how dysfunction in the amygdala may contribute to social deficits in clinical disorders including autism spectrum disorder, social anxiety disorder, and Williams syndrome. We conclude that social functions mediated by the amygdala are orchestrated through multiple intricate interactions between the amygdala and its interconnected brain regions, endorsing the importance of understanding the amygdala from network perspectives.

Neural mechanisms and predictors of SSRI and CBT treatment of anxiety: A randomized trial focused on emotion and cognitive processing

Anxiety disorders (ADs) are common and difficult to treat. While research suggests ADs are characterized by an imbalance between bottom-up and top-down attention processes and that effective treatments work by correcting this dysfunction, there is insufficient data to explain how and for whom treatments work. The late positive potential (LPP), an event-related potential reflecting elaborative processing of motivationally salient stimuli, is sensitive to both bottom-up and top-down processes. The present study examines the LPP in healthy controls (HC) and patients with ADs under low and high working memory (WM) load to assess its utility as a predictor and index of symptom reduction in patients who underwent cognitive behavioral therapy (CBT) or selective serotonin reuptake inhibitor (SSRI) treatment. The LPP when viewing negative and neutral distractor images and WM performance were assessed in 96 participants (40 HC, 32 CBT, 24 SSRI) during a letter recall task at Week 0 and in a subset of the study sample (23 CBT, 16 SSRI) at Week 12. Patients were randomly assigned to twelve weeks of CBT or SSRI treatment. Participants completed self-reported symptom measures at each time point. Greater Week 0 LPP to negative images under low WM load predicted greater symptom reduction in the SSRI, but not the CBT, group. Regression analyses examining the LPP to negative images as an index of symptom reduction revealed a smaller decrease in the LPP to negative images under low WM load was associated with less anxiety reduction across treatment modalities. Findings suggest the LPP during low WM load may serve as a cost-effective predictor and index of treatment outcome in ADs. Clinical Trials Registration: ClinicalTrials.gov (Identifier: NCT01903447).

Attentional Processing and Interpretative Bias in Functional Neurological Disorder

OBJECTIVE

Altered attentional processing (automatically attending to negative or illness-relevant information) and interpretative biases (interpreting ambiguous information as negative or illness relevant) may be mechanistically involved in functional neurological disorder (FND). Common mechanisms between FND and chronic fatigue syndrome (CFS) have been proposed but not compared experimentally.

METHODS

We compared the cognitive task performance of FND, CFS, and healthy control (HC) groups. The tasks assessed attentional bias toward illness-relevant stimuli (visual probe task), attentional control (attention network task), and somatic interpretations (interpretative bias task), alongside self-reported depression, anxiety, fatigue, and general health.

RESULTS

Thirty-seven participants diagnosed with FND, 52 participants diagnosed with CFS, and 51 HC participants were included. Although participants with CFS showed attentional bias for illness-relevant stimuli relative to HC (t = -3.13, p = .002, d = 0.624), individuals with FND did not (t = -1.59, p = .118, d = 0.379). Both the FND (t = 3.08, p = .003, d = 0.759) and CFS (t = 2.74, p = .007, d = 0.548) groups displayed worse attentional control than did the HC group. Similarly, the FND (t = 3.63, p < .001, d = 0.801) and CFS groups (t = 4.58, p < .001, d = 0.909) showed more somatic interpretative bias than did the HC group.

CONCLUSIONS

Similar attentional control deficits and somatic interpretative bias in individuals with FND and CFS support potential shared mechanisms underlying symptoms. Interpretative bias toward somatic and illness-relevant stimuli in functional disorders may prove a therapeutic target.

Neural correlates of cognitive behavioral therapy response in youth with negative valence disorders: A systematic review of the literature

BACKGROUND

Cognitive-behavioral therapy (CBT) is the gold-standard psychotherapeutic treatment for pediatric negative valence disorders. However, some youths do not respond optimally to treatment, which may be due to variations in neural functioning.

METHODS

We systematically reviewed functional magnetic resonance imaging studies in youths with negative valence disorders to identify pre- and post-treatment neural correlates of CBT response.

RESULTS

A total of 21 studies were identified, of overall weak to moderate quality. The most consistent findings across negative valence disorders consisted of associations of treatment response with pre- and post-treatment task-based activation and/or functional connectivity within and between the prefrontal cortex, the medial temporal lobe, and other limbic regions. Associations of CBT response with baseline and/or post-treatment activity in the striatum, precentral and postcentral gyri, medial and posterior cingulate cortices, and parietal cortex, connectivity within and between the default-mode, cognitive control, salience, and frontoparietal networks, and metrics of large-scale brain network organization, were also reported, although less consistently.

LIMITATIONS

The poor quality and limited number of studies and the important heterogeneity of study designs and results considerably limit the conclusions that can be drawn from this literature.

CONCLUSIONS

Despite these limitations, these findings provide preliminary evidence suggesting youths presenting certain patterns of brain function may respond better to CBT, whereas others may benefit from alternative or augmented forms of treatment.

Brain-gut-microbiome interactions in obesity and food addiction

Normal eating behaviour is coordinated by the tightly regulated balance between intestinal and extra-intestinal homeostatic and hedonic mechanisms. By contrast, food addiction is a complex, maladaptive eating behaviour that reflects alterations in brain-gut-microbiome (BGM) interactions and a shift of this balance towards hedonic mechanisms. Each component of the BGM axis has been implicated in the development of food addiction, with both brain to gut and gut to brain signalling playing a role. Early-life influences can prime the infant gut microbiome and brain for food addiction, which might be further reinforced by increased antibiotic usage and dietary patterns throughout adulthood. The ubiquitous availability and marketing of inexpensive, highly palatable and calorie-dense food can further shift this balance towards hedonic eating through both central (disruptions in dopaminergic signalling) and intestinal (vagal afferent function, metabolic endotoxaemia, systemic immune activation, changes to gut microbiome and metabolome) mechanisms. In this Review, we propose a systems biology model of BGM interactions, which incorporates published reports on food addiction, and provides novel insights into treatment targets aimed at each level of the BGM axis.

Exposure to food in anorexia nervosa and brain correlates of food-related anxiety: findings from a pilot study

BACKGROUND

Although the primary target of treatment for anorexia nervosa (AN) is weight gain, established psychological interventions focus on maintaining factors of AN, and do not specifically address eating behaviours. We have previously reported results of a case series investigating in-vivo food exposure in AN, demonstrating the feasibility and acceptability of this treatment together with evidence of significant clinical change (Cardi, Leppanen, Mataix-Cols, Campbell, & Treasure, 2019). The current study examined the neural circuitry of food-related anxiety.

METHODS

We examined neural reactivity (fMRI) to food images pre- and post-food exposure therapy (n=16), and compared it to a group of healthy control participants (HC n=21) who were scanned on two occasions.

RESULTS

Prior to treatment, the AN group (compared to HC) showed less reactivity in the anterior cingulate cortex (ACC). Following exposure treatment, patients (compared to HC), show increased activity in the dorsolateral prefrontal cortex, decreased activity in the superior parietal lobe and no differences in the ACC. The level of activation of the insula (pre-treatment) predicted the degree of post-treatment reduction in self-reported food anxiety in AN. Changes in food-related anxiety were also associated with changes in neural activation in a cluster located in the middle temporal gyrus/lateral parietal cortex.

LIMITATIONS

The primary limitations of this work are the small sample size and lack of patient comparison group.

CONCLUSIONS

Exposure to food in AN may be associated with changes in neural circuitries implicated in emotion regulation and attentional processes. However, these findings need replication in larger and controlled studies.

A mechanistic model for individualised treatment of anxiety disorders based on predictive neural biomarkers

Increased amygdala responsiveness is the hallmark of fear and a characteristic across patients with anxiety disorders. The amygdala is embedded in a complex regulatory circuit. Multiple different mechanisms may elevate amygdala responsiveness and lead to the occurrence of an anxiety disorder. While top-down control by the prefrontal cortex (PFC) downregulates amygdala responses, the locus coeruleus (LC) drives up amygdala activation via noradrenergic projections. This indicates that the same fearful phenotype may result from different neural mechanisms. We propose a mechanistic model that defines three different neural biomarkers causing amygdala hyper-responsiveness in patients with anxiety disorders: (a) inherent amygdala hypersensitivity, (b) low prefrontal control and (c) high LC drive. First-line treatment for anxiety disorders is exposure-based cognitive behavioural therapy, which strengthens PFC recruitment during emotion regulation and thus targets low-prefrontal control. A treatment response rate around 50% (Loerinc et al., 2015, Clinical Psychological Reviews, 42, 72-82) might indicate heterogeneity of underlying neurobiological mechanisms among patients, presumably leading to high variation in treatment benefit. Transforming insights from cognitive neuroscience into applicable clinical heuristics to categorise patients based on their underlying biomarker may support individualised treatment selection in psychiatry. We review literature on the three anxiety-related mechanisms and present a mechanistic model that may serve as a rational for pathology-based diagnostic and biomarker-guided treatment selection in psychiatry.

Nucleus accumbens volume as a predictor of anxiety symptom improvement following CBT and SSRI treatment in two independent samples

Structural variations of neural regions implicated in fear responses have been well documented in the pathophysiology of anxiety and may play an important role in treatment response. We examined whether gray matter volume of three neural regions supporting fear and avoidance responses [bilateral amygdala, nucleus accumbens (NAcc), and ventromedial prefrontal cortex (PFC)] predicted cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) treatment outcome in two independent samples of patients with anxiety disorders. Study 1 consisted of 81 adults with anxiety disorders and Study 2 included 55 children and adolescents with anxiety disorders. In both studies, patients completed baseline structural MRI scans and received either CBT or SSRI treatment. Clinician-rated interviews of anxiety symptoms were assessed at baseline and posttreatment. Among the adult sample, greater pre-treatment bilateral NAcc volume was associated with a greater reduction in clinician-rated anxiety symptoms pre-to-post CBT and SSRI treatment. Greater left NAcc volume also predicted greater decreases in clinician-rated anxiety symptoms pre-to-post CBT and SSRI treatment among youth with current anxiety. Across studies, results were similar across treatments, and findings were maintained when adjusting for patient's age, sex, and total intracranial brain volume. We found no evidence for baseline amygdala or ventromedial PFC volume serving as treatment predictors across the two samples. Together, these findings provide promising support for the role of NAcc volume as an objective marker of anxiety treatment improvement that spans across development. Future studies should clarify the specific mechanisms through which NAcc volume exerts its therapeutic effects.

Amygdala volume and social anxiety symptom severity: Does segmentation technique matter?

The amygdala factors prominently in neurobiological models of social anxiety (SA), yet amygdala volume findings regarding SA have been inconsistent and largely focused on case-control characterization. One source of discrepant findings could be variability in volumetric techniques. Therefore, we compared amygdala volumes derived via an automated technique (Freesurfer) against a manually corrected approach, also involving Freesurfer. Additionally, we tested whether the relationship between volume and SA symptom severity would differ across volumetric techniques. We pooled participants (n = 76) from archival studies. SA severity was assessed with the Liebowitz Social Anxiety Scale; scores ranged from non-clinical to clinical levels. Freesurfer produced significantly larger amygdalar volumes for participants with poor image quality. Even after excluding such participants, paired sample t-tests showed Freesurfer's boundaries produced significantly larger amygdalar volumes than manually corrected ones, bilaterally. Yet, intra-class correlation coefficients between the two methods were high, which suggests that Freesurfer's over-estimation of amygdala volume was systemic. Regardless of segmentation technique, volumes were not associated with SA symptom severity. Potentially, amygdala sub-regions may yield clearer patterns regarding SA symptoms. Further, our study underscores the importance of image quality for segmentation of the amygdala, and image quality may be particularly valuable when examining anatomical data for subtle inter-individual differences.

Neuroimaging, genetic, clinical, and demographic predictors of treatment response in patients with social anxiety disorder

BACKGROUND

Correct prediction of treatment response is a central goal of precision psychiatry. Here, we tested the predictive accuracy of a variety of pre-treatment patient characteristics, including clinical, demographic, molecular genetic, and neuroimaging markers, for treatment response in patients with social anxiety disorder (SAD).

METHODS

Forty-seven SAD patients (mean±SD age 33.9 ± 9.4 years, 24 women) were randomized and commenced 9 weeks' Internet-delivered cognitive behavior therapy (CBT) combined either with the selective serotonin reuptake inhibitor (SSRI) escitalopram (20 mg daily [10 mg first week], SSRI+CBT, n = 24) or placebo (placebo+CBT, n = 23). Treatment responders were defined from the Clinical Global Impression-Improvement scale (CGI-I ≤ 2). Before treatment, patients underwent functional magnetic resonance imaging and the Multi-Source Interference Task taxing cognitive interference. Support vector machines (SVMs) were trained to separate responders from nonresponders based on pre-treatment neural reactivity in the dorsal anterior cingulate cortex (dACC), amygdala, and occipital cortex, as well as molecular genetic, demographic, and clinical data. SVM models were tested using leave-one-subject-out cross-validation.

RESULTS

The best model separated treatment responders (n = 24) from nonresponders based on pre-treatment dACC reactivity (83% accuracy, P = 0.001). Responders had greater pre-treatment dACC reactivity than nonresponders especially in the SSRI+CBT group. No other variable was associated with clinical response or added predictive accuracy to the dACC SVM model.

LIMITATIONS

Small sample size, especially for genetic analyses. No replication or validation samples were available.

CONCLUSIONS

The findings demonstrate that treatment outcome predictions based on neural cingulate activity, at the individual level, outperform genetic, demographic, and clinical variables for medication-assisted Internet-delivered CBT, supporting the use of neuroimaging in precision psychiatry.

Alterações do córtex cingulado anterior como um preditor de resposta à terapia cognitivo-comportamental

RESUMO Objetivo A terapia cognitivo-comportamental (TCC) tem eficácia bem-documentada na literatura científica para transtornos relacionados aos sintomas da ansiedade. No entanto, há uma parcela de pacientes que não responde ao tratamento psicoterápico. Por isso, os estudos sobre as alterações no córtex cingulado anterior (CCA) como preditoras neurais do tratamento têm contribuído para encontrar respostas sobre as diferenças nas respostas ao tratamento. O objetivo do presente estudo é descrever, por meio de revisão sistemática, os estudos encontrados até o ano de 2018 sobre o papel do CCA na predição de resposta à terapia. Métodos Foram realizadas buscas nas bases PsycInfo, Web of Science e PubMed com termos referentes ao tema “córtex cingulado anterior”, “terapia cognitivo-comportamental” e “predição de respostas”, incluindo estudos com neuroimagem estrutural e funcional. Resultados As buscas apresentaram 14 artigos sobre “transtorno de estresse pós-traumático (TEPT)”, “transtorno obsessivo-compulsivo (TOC)” e “transtorno de ansiedade social (TAS)”. Os estudos com neuroimagem estrutural apresentaram resultados promissores. A maior espessura do CCA foi preditora de melhor resposta ao tratamento para TEPT e TOC. Os resultados de neuroimagem funcional foram promissores para maior ativação como preditora de melhor resposta para TAS. Por outro lado, os resultados para TEPT apontaram que a menor ativação pode ser preditora de melhores respostas. Conclusão As alterações nos estudos de neuroimagem sugerem que o CCA tenha um papel de predição de resposta ao tratamento com TCC. Estudos posteriores com amostras maiores podem contribuir para a ampliação da eficácia nos tratamentos de tais transtornos.

Neuroimaging findings as predictors of treatment outcome of psychotherapy in anxiety disorders

Anxiety disorders are the largest group of mental disorders and a leading cause of impairment, implicating in high costs for health systems and society. Effective pharmacological and psychological treatments are available, but a significant fraction of these patients does not respond adequately to these treatments. The objective of this study is to identify neuroimaging findings that could predict response to psychotherapy in anxiety disorders.

METHODS

The authors reviewed psychotherapy clinical trials with neuroimaging conducted with patients with anxiety disorders. A systematic review was performed in MEDLINE database through PubMed, the Cochrane Collaboration's Clinical Trials Register (CENTRAL), PsycINFO and Thomson Reuters's Web of Science.

RESULTS

From the studies included in this review, 24 investigated anxiety disorder patients, and findings in the amygdala, dorsolateral prefrontal cortex (dlPFC), anterior cingulate cortex (ACC) and insula predicted response to psychotherapy in social anxiety disorder. Findings in ACC, hippocampus, insula, dlPFC, amygdala and inferior frontal gyrus (iFG) predicted response to psychotherapy in panic disorder and generalized anxiety disorder.

LIMITATIONS

There was great heterogeneity between the included studies regarding neuroimaging techniques and the tasks performed during functional neuroimaging.

CONCLUSION

Neuroimaging studies suggest that abnormalities in hippocampus, amygdala, iFG, uncus and areas linked with emotional regulation (dlPFC and ACC), predict a good outcome to psychotherapy in anxiety disorders.

Neural connectivity during affect labeling predicts treatment response to psychological therapies for social anxiety disorder

BACKGROUND

Although psychological treatments for social anxiety disorder (SAD) can be highly effective, many individuals do not respond to treatment. Identifying factors associated with improved outcomes can facilitate individualized treatment choices. We investigated whether patterns of neural connectivity predicted treatment responses and whether treatment type, cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT), moderated this effect.

METHODS

Participants with SAD (n = 34) underwent fMRI prior to treatment and completed implicit and explicit emotion regulation tasks. Neural connectivity measures were estimates of amygdala-prefrontal cortex connectivity. Treatment responder status was defined using the 'clinically significant change index' (Loerinc et al., 2015).

RESULTS

Right amygdala-right ventrolateral prefrontal cortex connectivity during implicit emotion regulation was a significant predictor of treatment response (OR = 9.01, 95% CI = 1.77, 46.0, p = .008). Stronger inverse connectivity was associated with greater likelihood of treatment response. There were no significant neural moderators of treatment response to CBT versus ACT.

LIMITATIONS

The primary limitation of this work was the small sample size which restricted the power to detect significant moderation effects, and results should be interpreted as preliminary.

CONCLUSIONS

Amygdala-vlPFC connectivity during affect labeling predicted treatment responder status following CBT or ACT for social anxiety disorder. This suggests that the functioning of neural circuitry supporting emotion regulation capacities may be a 'gateway' to receiving benefit from psychological treatments. Future work should aim to replicate this effect in a larger sample and consider methods for enhancing functional connectivity within this circuitry as a potential treatment adjunct.

Unconscious Psychological Treatments for Physiological Survival Circuits

The idea of targeting unconscious or implicit processes in psychological treatments is not new, but until recently it has not been easy to manipulate these processes without also engaging consciousness. Here we review how this is possible, using various modern cognitive neuroscience methods including a technique known as Decoded Neural-Reinforcement. We discuss the general advantages of this approach, such as how it can facilitate double-blind placebo-controlled studies, and minimize premature patient dropouts in the treatment of fear. We also speculate how this may generalize to other similar physiological survival processes.

Meta-analyses of the neural mechanisms and predictors of response to psychotherapy in depression and anxiety

Understanding the neural mechanisms underlying psychological therapy could aid understanding of recovery processes and help target treatments. The dual-process model hypothesises that psychological therapy is associated with increased emotional-regulation in prefrontal brain regions and decreased implicit emotional-reactivity in limbic regions; however, research has yielded inconsistent findings. Meta-analyses of brain activity changes accompanying psychological therapy (22 studies, n = 352) and neural predictors of symptomatic improvement (11 studies, n = 293) in depression and anxiety were conducted using seed-based d mapping. Both resting-state and task-based studies were included, and analysed together and separately. The most robust findings were significant decreases in anterior cingulate/paracingulate gyrus, inferior frontal gyrus and insula activation after therapy. Cuneus activation was predictive of subsequent symptom change. The results are in agreement with neural models of improved emotional-reactivity following therapy as evidenced by decreased activity within the anterior cingulate and insula. We propose compensatory as well as corrective neural mechanisms of action underlie therapeutic efficacy, and suggest the dual-process model may be too simplistic to account fully for treatment mechanisms. More research on predictors of psychotherapeutic response is required to provide reliable predictors of response.

Neuroimaging Predictors and Mechanisms of Treatment Response in Social Anxiety Disorder: an Overview of the Amygdala

PURPOSE OF REVIEW

Aberrant amygdala activity is implicated in the neurobiology of social anxiety disorder (SAD) and is, therefore, a treatment target. However, the extent to which amygdala predicts clinical improvement or is impacted by treatment has not been critically examined. This review highlights recent neuroimaging findings from clinical trials and research that test links between amygdala and mechanisms of action.

RECENT FINDINGS

Neuropredictor studies largely comprised psychotherapy where improvement was foretold by amygdala activity and regions beyond amygdala such as frontal structures (e.g., anterior cingulate cortex, medial prefrontal cortex) and areas involved in visual processes (e.g., occipital regions, superior temporal gyrus). Pre-treatment functional connectivity between amygdala and frontal areas was also shown to predict improvement signifying circuits that support emotion processing and regulation interact with treatment. Pre-to-post studies revealed decreases in amygdala response and altered functional connectivity in amygdala pathways regardless of treatment modality. In analogue studies of fear exposure, greater reduction in anxiety was predicted by less amygdala response to a speech challenge and amygdala activity decreased following exposures. Yet, studies have also failed to detect amygdala effects reporting instead treatment-related changes in regions and functional systems that support sensory, emotion, and regulation processes. An array of regions in the corticolimbic subcircuits and extrastriate cortex appear to be viable sites of action. The amygdala and amygdala pathways predict treatment outcome and are altered following treatment. However, further study is needed to establish the role of the amygdala and other candidate regions and brain circuits as sites of action.

The optimistic brain: Trait optimism mediates the influence of resting-state brain activity and connectivity on anxiety in late adolescence

As a hot research topic in the field of psychology and psychiatry, trait optimism reflects the tendency to expect positive outcomes in the future. Consistent evidence has demonstrated the role of trait optimism in reducing anxiety among different populations. However, less is known about the neural bases of trait optimism and the underlying mechanisms for how trait optimism protects against anxiety in the healthy brain. In this investigation, we examined these issues in 231 healthy adolescent students by assessing resting-state brain activity (i.e., fractional amplitude of low-frequency fluctuations, fALFF) and connectivity (i.e., resting-state functional connectivity, RSFC). Whole-brain correlation analyses revealed that higher levels of trait optimism were linked with decreased fALFF in the right orbitofrontal cortex (OFC) and increased RSFC between the right OFC and left supplementary motor cortex (SMC). Mediation analyses further showed that trait optimism mediated the influence of the right OFC activity and the OFC-SMC connectivity on anxiety. Our results remained significant even after excluding the impact of head motion, positive and negative affect and depression. Taken together, this study reveals that fALFF and RSFC are functional neural markers of trait optimism and provides a brain-personality-symptom pathway for protection against anxiety in which fALFF and RSFC affect anxiety through trait optimism.

Anterior cingulate activation to implicit threat before and after treatment for pediatric anxiety disorders

BACKGROUND

Research suggests that individuals with anxiety have difficulty ignoring threat distractors when completing tasks with competing stimuli. Studies examining the neural correlates of these emotional processing difficulties in youth anxiety highlight reduced recruitment of regions associated with goal-directed attention, such as the anterior cingulate cortex (ACC). In the current study, we examined neural activation during an emotional conflict task in youth with anxiety disorders before and after treatment.

METHODS

Twenty-five youth (ages 9-19 years) with generalized, separation, and/or social anxiety disorder and 25 healthy controls underwent 2 functional magnetic resonance imaging scans approximately 13 weeks apart. At each scan, participants completed a task in which they matched shapes in the context of emotional distractors (happy and threatening faces). Between scans, anxious youth were treated with the selective serotonin reuptake inhibitor (SSRI) sertraline or cognitive behavior therapy (CBT).

RESULTS

Prior to treatment, anxious youth exhibited reduced activation of the medial prefrontal cortex, encompassing the rostral ACC, when matching shapes in the context of threat distractors relative to healthy controls. Activation in this region increased in anxious youth after treatment, but remained unchanged in the healthy control group. Increases in rostral ACC activation were related to greater reductions in social anxiety and avoidance symptoms following treatment.

CONCLUSIONS

Effective treatments for pediatric anxiety may enhance rostral ACC response during attempts to filter out threat-relevant stimuli. Enhanced recruitment of this region may constitute one manner in which CBT and SSRI treatment reduce youth anxiety symptoms, particularly social anxiety and avoidance.

Vantage sensitivity: a framework for individual differences in response to psychological intervention

PURPOSE

People differ significantly in their response to psychological intervention, with some benefitting more from treatment than others. According to the recently proposed theoretical framework of vantage sensitivity, some of this variability may be due to individual differences in environmental sensitivity, the inherent ability to register, and process external stimuli. In this paper, we apply the vantage sensitivity framework to the field of psychiatry and clinical psychology, proposing that some people are more responsive to the positive effects of psychological intervention due to heightened sensitivity.

METHODS

After presenting theoretical frameworks related to environmental sensitivity, we review a selection of recent studies reporting individual differences in the positive response to psychological intervention.

RESULTS

A growing number of studies report that some people benefit more from psychological intervention than others as a function of genetic, physiological, and psychological characteristics. These studies support the vantage sensitivity proposition that treatment response is influenced by factors associated with heightened sensitivity to environmental influences. More recently, studies have also shown that sensitivity can be measured with a short questionnaire which appears to predict the response to psychological intervention.

CONCLUSIONS

Vantage sensitivity is a framework with significant relevance for our understanding of widely observed heterogeneity in treatment response. It suggests that variability in response to treatment is partly influenced by people's differing capacity for environmental sensitivity, which can be measured with a short questionnaire. Application of the vantage sensitivity framework to psychiatry and clinical psychology may improve our knowledge regarding when, how, and for whom interventions work.

Social anxiety disorder exhibit impaired networks involved in self and theory of mind processing

Most previous studies regarding social anxiety disorder (SAD) have focused on the role of emotional dysfunction, while impairments in self- and theory of mind (ToM)-processing have relatively been neglected. This study utilised functional connectivity density (FCD), resting-state functional connectivity (RSFC) and discriminant analyses to investigate impairments in self- and ToM-related networks in patients with SAD. Patients with SAD exhibited decreased long-range FCD in the right rostral anterior cingulate cortex (rACC) and decreased short-range FCD in the right superior temporal gyrus (STG)—key nodes involved in self- and ToM-processing, respectively. Decreased RSFC of the right rACC and STG with widespread frontal, temporal, posteromedial, sensorimotor, and somatosensory, regions was also observed in patients with SAD. Altered RSFC between the right rACC and bilateral superior frontal gyrus, between the right rACC and right middle frontal gyrus, and within the right STG itself provided the greatest contribution to individual diagnoses of SAD, with an accuracy of 84.5%. These results suggest that a lack of cognitive inhibition on emotional self-referential processing as well as impairments in social information integration may play critical roles in the pathomechanism of SAD and highlight the importance of recognising such features in the diagnosis and treatment of SAD.

Predictive Neuroimaging Markers of Psychotherapy Response: A Systematic Review

INTRODUCTION

Predictive neuroimaging markers of treatment response are increasingly sought in order to inform the treatment of major depressive and anxiety disorders. We review the existing literature regarding candidate predictive neuroimaging markers of psychotherapy response and assess their potential clinical utility.

METHODS

We searched Embase, PsycINFO, and PubMed up to October 2014 for studies correlating pretreatment neuroimaging parameters with psychotherapy response in major depressive and anxiety disorders. Our search yielded 40 eligible studies.

RESULTS

The anterior cingulate cortex, amygdala, and anterior insula emerged as potential markers in major depressive disorder and some anxiety disorders. Results across studies displayed a large degree of variability, however, and to date the findings have not been systematically validated in independent clinical cohorts and have not been shown capable of distinguishing between medication and psychotherapy responders. Also limited is the examination of how neuroimaging compares or might add to other prognostic clinical variables.

CONCLUSION

While the extant data suggest avenues of further investigation, we are still far from being able to use these markers clinically. Future studies need to focus on longitudinal testing of potential markers, determining their prescriptive value and examining how they might be integrated with clinical factors.

The relation between parent depressive symptoms and neural correlates of attentional control in offspring: A preliminary study

Offspring of depressed parents are at significantly elevated risk for depressive disorders themselves; however, the specific mechanisms associated with this risk are not well known. Given the well-established link between parental depression and biased attention for negative stimuli in children, this preliminary study sought to examine the neural correlates of directing attention toward and away from emotional faces in children and adolescents in association with parent's current depressive symptoms. Forty-two youth (age 7-18 years) completed a task with conditions that manipulated whether participants were instructed to match emotional faces (explicit emotion processing) or match shapes in the context of emotional face distractors (implicit emotion processing) during functional magnetic resonance imaging. Results revealed a positive correlation between parent depressive symptoms and youths' recruitment of the dorsal anterior cingulate cortex (ACC) during attempts to direct attention away (implicit processing) from negative faces. These findings were maintained after accounting for current anxiety and depressive symptoms among youth suggesting that the findings were not fully attributable to offspring's psychopathology. These preliminary findings suggest that altered dorsal ACC function may contribute to the biased attention for negative information typically demonstrated in youth at high risk for depression by disrupting efficient inhibition of negative stimuli.

Epigenetic and Neural Circuitry Landscape of Psychotherapeutic Interventions

The science behind psychotherapy has garnered considerable interest, as objective measures are being developed to map the patient's subjective change over the course of treatment. Prenatal and early life influences have a lasting impact on how genes are expressed and the manner in which neural circuits are consolidated. Transgenerationally transmitted epigenetic markers as well as templates of enhanced thought flexibility versus evasion can be passed down from parent to child. This influences gene expression/repression (impacting neuroplasticity) and kindling of neurocircuitry which can perpetuate maladaptive cognitive processing seen in a number of psychiatric conditions. Importantly, genetic factors and the compounding effects of early life adversity do not inexorably lead to certain fated outcomes. The concepts of vulnerability and resilience are becoming more integrated into the framework of "differential susceptibility," speaking to how corrective environmental factors may promote epigenetic change and reconfigure neural templates, allowing for symptomatic improvement. Psychotherapy is one such factor, and this review will focus on our current knowledge of its epigenetic and neurocircuitry impact.

Neural correlates of explicit and implicit emotion processing in relation to treatment response in pediatric anxiety

BACKGROUND

Approximately 40%-45% of youth with anxiety disorders do not achieve remission (or a substantial reduction in symptoms) following treatment, highlighting the need to identify predictors of treatment response. Given the well-established link between attentional biases and anxiety disorders in youth and adults, this study examined the neural correlates of directing attention toward and away from emotional faces in relation to pediatric anxiety treatment response.

METHOD

Prior to beginning treatment with the selective serotonin reuptake inhibitor (SSRI) sertraline or cognitive behavior therapy (CBT), 37 youth (age 7-19 years) with generalized and/or social anxiety disorder completed a task with conditions that manipulated whether participants were instructed to match emotional faces (explicit emotion processing) or match shapes in the context of emotional face distractors (implicit emotion processing) during functional magnetic resonance imaging.

RESULTS

Results revealed that reduced activation in superior frontal gyrus (SFG), encompassing the dorsal anterior cingulate cortex (ACC) and dorsomedial prefrontal cortex (PFC), during implicit processing of emotional faces predicted a greater reduction in anxiety severity pre-to-post treatment. Post hoc analyses indicated that effects were not significantly moderated by the type of treatment or anxiety type.

CONCLUSIONS

Findings suggest that less recruitment of SFG, including the dorsal ACC and dorsomedial PFC, during implicit emotion processing predicts a greater reduction in youth anxiety symptoms pre-to-post treatment. Youth who exhibit reduced activation in these areas while matching shapes in the context of emotional face distractors may have more to gain from CBT and SSRI treatment due to preexisting deficits in attentional control. These findings suggest that neuroimaging may be a useful tool for predicting which youth are most likely to benefit from anxiety treatment.

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.

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Anterior cingulate cortex is a replicated treatment neuromarker in depression.

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

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CBT attempts to improve emotion regulation ability.

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Baseline anterior cingulate cortex activity in regulation predicted CBT response.

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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.

Neural responses to social threat and predictors of cognitive behavioral therapy and acceptance and commitment therapy in social anxiety disorder

Previous research has often highlighted hyperactivity in emotion regions to simple, static social threat cues in social anxiety disorder (SAD). Investigation of the neurobiology of SAD using more naturalistic paradigms can further reveal underlying mechanisms and how these relate to clinical outcomes. We used fMRI to investigate responses to novel dynamic rejection stimuli in individuals with SAD (N=70) and healthy controls (HC; N=17), and whether these responses predicted treatment outcomes following cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT). Both HC and SAD groups reported greater distress to rejection compared to neutral social stimuli. At the neural level, HCs exhibited greater activations in social pain/rejection regions, including dorsal anterior cingulate cortex and anterior insula, to rejection stimuli. The SAD group evidenced a different pattern, with no differences in these rejection regions and relatively greater activations in the amygdala and other regions to neutral stimuli. Greater responses in anterior cingulate cortex and the amygdala to rejection vs. neutral stimuli predicted better CBT outcomes. In contrast, enhanced activity in sensory-focused posterior insula predicted ACT responses.

Targeting Ruminative Thinking in Adolescents at Risk for Depressive Relapse: Rumination-Focused Cognitive Behavior Therapy in a Pilot Randomized Controlled Trial with Resting State fMRI

This pilot randomized control trial was designed to examine whether Rumination-Focused Cognitive Behavior Therapy (RFCBT) reduces rumination and residual depressive symptoms among adolescents with a history of Major Depressive Disorder (MDD) who are at risk for relapse. We also examined whether these changes in symptoms were associated with changes in functional connectivity of the posterior cingulate cortex (PCC), a key node in the default mode network (DMN). Thirty-three adolescents (ages 12–18) were randomized to eight weeks of RFCBT or an assessment only (AO) control. Twenty two adolescents successfully completed fMRI scans pre- and post-intervention. Adolescents were recruited from the clinic and community and met criteria for at least one previous episode of MDD and were currently in full or partial remission. An Independent Evaluator interviewed parent and child before and after the eight-week intervention. The left PCC (-5, -50, 36) seed was used to probe resting state functional connectivity of the DMN. Adolescents who received RFCBT demonstrated reduced rumination (F = -2.76, df = 112, p < .01, 95% CI [-4.72,-0.80]) and self-report depression across eight weeks (F = -2.58, df = 113, p < .01, 95% CI [-4.21, -0.94]). Youth who received RFCBT also demonstrated significant decreases in connectivity between the left PCC and the right inferior frontal gyrus (IFG) and bilateral inferior temporal gyri (ITG). Degree of change in connectivity was correlated with changes in self-report depression and rumination. These data suggest that rumination can be reduced over eight weeks and that this reduction is associated with parallel decreases in residual depressive symptoms and decreased functional connectivity of the left PCC with cognitive control nodes. These changes may enhance the ability of vulnerable youth to stay well during the transition to adulthood.

Trial Registration: ClinicalTrials.gov NCT01905267

Cognitive Mechanisms in Chronic Tinnitus: Psychological Markers of a Failure to Switch Attention

The cognitive mechanisms underpinning chronic tinnitus (CT; phantom auditory perceptions) are underexplored but may reflect a failure to switch attention away from a tinnitus sound. Here, we investigated a range of components that influence the ability to switch attention, including cognitive control, inhibition, working memory and mood, on the presence and severity of CT. Our participants with tinnitus showed significant impairments in cognitive control and inhibition as well as lower levels of emotional well-being, compared to healthy-hearing participants. Moreover, the subjective cognitive complaints of tinnitus participants correlated with their emotional well-being whereas complaints in healthy participants correlated with objective cognitive functioning. Combined, cognitive control and depressive symptoms correctly classified 67% of participants. These results demonstrate the core role of cognition in CT. They also provide the foundations for a neurocognitive account of the maintenance of tinnitus, involving impaired interactions between the neurocognitive networks underpinning attention-switching and mood.

Functional neuroimaging of psychotherapeutic processes in anxiety and depression: from mechanisms to predictions

PURPOSE OF REVIEW

The review provides an update of functional neuroimaging studies that identify neural processes underlying psychotherapy and predict outcomes following psychotherapeutic treatment in anxiety and depressive disorders. Following current developments in this field, studies were classified as 'mechanistic' or 'predictor' studies (i.e., informing neurobiological models about putative mechanisms versus aiming to provide predictive information).

RECENT FINDINGS

Mechanistic evidence points toward a dual-process model of psychotherapy in anxiety disorders with abnormally increased limbic activation being decreased, while prefrontal activity is increased. Partly overlapping findings are reported for depression, albeit with a stronger focus on prefrontal activation following treatment. No studies directly comparing neural pathways of psychotherapy between anxiety and depression were detected. Consensus is accumulating for an overarching role of the anterior cingulate cortex in modulating treatment response across disorders. When aiming to quantify clinical utility, the need for single-subject predictions is increasingly recognized and predictions based on machine learning approaches show high translational potential.

SUMMARY

Present findings encourage the search for predictors providing clinically meaningful information for single patients. However, independent validation as a crucial prerequisite for clinical use is still needed. Identifying nonresponders a priori creates the need for alternative treatment options that can be developed based on an improved understanding of those neural mechanisms underlying effective interventions.

Can cognitive behaviour therapy beneficially influence arousal mechanisms in psychosis?

Cognitive behavioural therapy for psychosis (CBTp) is an approved adjunct therapy for patients with psychotic disorders; however, we do not fully understand the neurobiological effects that this therapy may exert. Arousal, as measured by electroencephalography (EEG), provides a useful electrophysiological marker for assessing psychotic disorders. EEG studies may therefore serve as a useful measure for assessing the underlying effects of CBTp in psychotic disorders.

Prefrontal control and predictors of cognitive behavioral therapy response in social anxiety disorder

Generalized social anxiety disorder (gSAD) is associated with aberrant anterior cingulate cortex (ACC) response to threat distractors. Perceptual load has been shown to modulate ACC activity such that under high load, when demands on processing capacity is restricted, individuals with gSAD exhibit compensatory activation to threat distractors yet under low load, there is evidence of reduced activation. It is not known if neural predictors of response to cognitive behavioral therapy (CBT), based on such emotional conflict resolution, interact with demands on controlled processes. Prior to CBT, 32 patients with gSAD completed an fMRI task involving a target letter in a string of identical targets (low perceptual load) or a target letter in a mixed letter string (high perceptual load) superimposed on fearful, angry and neutral face distractors. Whole-brain voxel-wise analyses revealed better CBT outcome was predicted by more frontopartial activity that included dorsal ACC (dACC) and insula to threat (vs neutral) distractors during high, but not low, perceptual load. Psychophysiological interaction analysis with dACC as the seed region revealed less connectivity with dorsolateral prefrontal cortex to threat distractors during high load. Results indicate patients with less regulatory capability when demands on higher-order control are great may benefit more from CBT.

Temporal profile of brain response to alprazolam in patients with generalized anxiety disorder

This study investigated the temporal pattern of brain response to emotional stimuli during 28 days of alprazolam treatment among patients with generalized anxiety disorder (GAD) randomized 2:1 to drug or placebo in a double-blind design. Functional magnetic resonance imaging scans obtained during an emotion face matching task (EFMT) and an affective stimulus expectancy task (STIMEX) were performed at baseline, one hour after initial drug administration and 28 days later. Alprazolam significantly reduced scores on the Hamilton Anxiety Scale and the Penn State Worry Questionnaire after one week and 28 days of treatment. Brain activation in the amygdala during the EFMT and in the insula during the STIMEX was reduced one hour after alprazolam administration but returned to baseline levels at Day 28. Exploratory analyses revealed significant treatment differences in brain activity during the STIMEX on Day 28 in frontal lobe, caudate nucleus, middle temporal gyrus, secondary visual cortex, and supramarginal gyrus. These results are consistent with the notion that the neural mechanisms supporting sustained treatment effects of benzodiazepines in GAD differ from those underlying their acute effects.

The role of emotion and emotion regulation in social anxiety disorder

Many psychiatric disorders involve problematic patterns of emotional reactivity and regulation. In this review, we consider recent findings regarding emotion and emotion regulation in the context of social anxiety disorder (SAD). We first describe key features of SAD which suggest altered emotional and self-related processing difficulties. Next, we lay the conceptual foundation for a discussion of emotion and emotion regulation and present a common framework for understanding emotion regulation, the process model of emotion regulation. Using the process model, we evaluate the recent empirical literature spanning self-report, observational, behavioral, and physiological methods across five specific families of emotion regulation processes-situation selection, situation modification, attentional deployment, cognitive change, and response modulation. Next, we examine the empirical evidence behind two psychosocial interventions for SAD: cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR). Throughout, we present suggestions for future directions in the continued examination of emotion and emotion regulation in SAD.

Resting state amygdala-prefrontal connectivity predicts symptom change after cognitive behavioral therapy in generalized social anxiety disorder

BACKGROUND

Aberrant amygdala-prefrontal interactions at rest and during emotion processing are implicated in the pathophysiology of generalized social anxiety disorder (gSAD), a common disorder characterized by fears of potential scrutiny. Cognitive behavioral therapy (CBT) is first-line psychotherapy for gSAD and other anxiety disorders. While CBT is generally effective, there is a great deal of heterogeneity in treatment response. To date, predictors of success in CBT for gSAD include reduced amygdala reactivity and increased activity in prefrontal regulatory regions (e.g., anterior cingulate cortex, "ACC") during emotion processing. However, studies have not examined whether tonic (i.e., at rest) coupling of amygdala and these prefrontal regions also predict response to CBT.

RESULTS

Twenty-one patients with gSAD participated in resting-state functional magnetic resonance imaging (fMRI) before 12 weeks of CBT. Overall, symptom severity was significantly reduced after completing CBT; however, the patients varied considerably in degree of symptom change. Whole-brain voxel-wise findings showed symptom improvement after CBT was predicted by greater right amygdala-pregenual ACC ("pgACC") connectivity and greater left amygdala-pgACC coupling encompassing medial prefrontal cortex. In support of their predictive value, area under receiver operating characteristic curve was significant for the left and right amygdala-pgACC in relation to treatment responders.

CONCLUSIONS

Improvement after CBT was predicted by enhanced resting-state bilateral amygdala-prefrontal coupling in gSAD. Preliminary results suggest baseline individual differences in a fundamental circuitry that may underlie emotion regulation contributed to variation in symptom change after CBT. Findings offer a new approach towards using a biological measure to foretell who will most likely benefit from CBT. In particular, the departure from neural predictors based on illness-relevant stimuli (e.g., socio-emotional stimuli in gSAD) permits the development of biomarkers that reflect commonalities in the neurobiology of anxiety and mood disorders.