Brain Imaging Predicts Psychotherapy Success in Patients with Social Anxiety Disorder

Treatment for social anxiety disorder or social phobia has entered the personalized medicine arena—brain imaging can provide neuromarkers to predict whether traditional options such as cognitive behavioral therapy will work for a particular patient, reported a National Institute of Mental Health (NIMH)-funded study that was published in the January 2013 issue of JAMA Psychiatry. Background Social anxiety disorder (SAD)— the fear of being judged by others and humiliated— is the third most prevalent psychiatric disorder in Americans, after depression and alcohol dependence, according to the National Comorbidity Survey, a U.S. poll on mental health. This fear can be so strong that it interferes with daily life activities like going to work or school. If left untreated, some sufferers use alcohol, food, or drugs to reduce the fear at social events, which often leads to other disorders such as alcoholism, eating disorders, and depression. The NIMH claims that 6.8 percent of U.S. adults and 5.5 percent of 13- to 15-year-olds, the age of onset for this chronic disorder, are annually afflicted Social Worker Continuing Education Although psychotherapy and drugs, such as antidepressants and benzodiazepines, exist as treatments for SAD, current behavioral measures poorly predict which would work better for individual patients. “Half of social anxiety disorder patients have satisfactory response to treatment. There is little evidence about which patient would benefit from a particular form of treatment,” said John D. Gabrieli, Ph.D., lead author of the study. “Currently, there is no rational basis for prescribing one treatment over the other. Which treatment a patient gets depends on whom they see.” Enter personalized medicine, the use of genetic or other biological markers to tailor treatments to those who would actually benefit from them, thus sparing the expense and side effects for those who would not. Brain imaging could identify neuromarkers or targeted areas of the brain that could one day optimize treatment for individual patients. Neuromarkers are being used in other areas of mental illness, for instance, to predict the onset of psychosis in schizophrenia and the likelihood of relapse in drug addiction. In this study, Gabrieli, at the Massachusetts Institute of Technology in Cambridge, and his colleagues, used functional magnetic resonance imaging (fMRI) in 39 SAD patients before a 12-week course of cognitive behavioral therapy. The patients viewed angry versus neutral faces and scenes while undergoing fMRI examination (see first slide). Compared to neutral faces, angry faces convey disapproval and are likely to prompt excessive fear responses and negative connotations in SAD patients; cognitive behavioral therapy teaches these patients ways to downregulate their responses. The patients’ brain images were then compared to their scores on a conventional clinical measure, the Liebowitz Social Anxiety Scale (LSAS), a questionnaire which they took before and after therapy completion. Results of the Study SAD patients responded more to the images of faces and not scenes, which is characteristic for the social basis of this disorder. Patients whose brains reacted strongly to the facial images before treatment benefitted more from the therapy than those who reacted to these the least (see second slide). Specifically, changes in two occipitotemporal brain regions—areas involved in early processing of visual cues such as faces—correlated with positive cognitive behavioral therapy outcome. These neuromarkers predicted treatment outcome better than the currently used LSAS. Significance This study is the first of its kind to use neuroimaging to predict treatment response in SAD patients. Neuromarkers may become a practical clinical tool to guide the selection of optimal treatments for individual patients. Integration of neuromarkers with genetic, behavioral, and other biomarkers is likely to further refine the prediction. What’s Next A larger study comparing people with SAD with normal participants is needed to verify the results. fMRI studies using other facial expressions (disgust or fear) might be better predictors. Studies that look at other treatment options, such as drugs, are also needed to confirm which treatment is optimal. Researchers asked patients with social phobia to undergo functional magnetic resonance imaging (fMRI) while viewing images of neutral versus angry faces and scenes. The patients’ brains showed more activity when they viewed the faces. Source: Gabrieli Lab, MIT Patients with social phobia whose brains “lit” up the most, particularly in two regions towards the back of the brain that process what we see, responded the best to psychotherapy. Source: Gabrieli Lab, MIT Reference Doehrmann O, Ghosh SS, Polli FE, Reynolds GO, Horn F, Keshavan A, Triantafyllou C, Saygin ZM, Whitfield-Gabrieli S, Hofmann SG, Pollack M, Gabrieli JD. Predicting Treatment Response in Social Anxiety Disorder from Functional Magnetic Resonance Imaging. JAMA Psychiatry. January 2013. 70(1):87–97.

Avatars may help children with social anxiety overcome fears

A principal standing in the hallway says, "You are one of my favorite students!" In class, a smart girl says, "You are the nicest person in our class!" Many children would smile and eagerly return those compliments, but some with social anxiety may be too terrified to respond. Researchers at the University of Central Florida's Anxiety Disorders Clinic and the Atlanta-based company Virtually Better want to give more children with social anxiety the practice they need to become comfortable in social situations. They have developed a new, one-of-a-kind computer simulation program that enables children to interact with avatars playing the roles of classmates, teachers and a principal. The simulation, designed for children ages 8 to 12, allows clinicians to play the roles of the avatars while the children sit at a computer in a different room and respond to situations they encounter routinely. The children practice greetings, giving and receiving compliments, being assertive and asking and answering questions. "These kids come in and say, 'I don't know how to make a friend,'" said Deborah Beidel, director of the Anxiety Disorders Clinic and a psychology professor at UCF. "We have to teach them the skills that most people learn from being around other people." The National Institute of Mental Health, part of the National Institutes of Health, provided a $500,000 grant to fund the development of the software and a 12-week study that will begin this summer. The study will involve 30 Central Florida children ages 8 to 12. Many children are nervous and slow to warm up in new social situations, but those with social anxiety disorders have severe distress that doesn't go away, Beidel said. "If a fear is so severe that it prevents a child from doing something he or she should be doing, such as going to school, playing on a sports team, being in a dance recital, going to birthday parties or making friends, then a parent should call a mental health professional," she said. Under Beidel's leadership, the UCF Anxiety Disorders Clinic has treated children with anxiety disorders for five years. The clinic offers what Beidel calls the "gold standard" of treatments. Children with anxiety disorders are paired with socially comfortable peers for outings to places such as bowling alleys, restaurants and miniature golf courses. The new study will give parents multiple treatment options at UCF. But parents in most communities aren't so fortunate. Many clinicians who treat children don't have the time or resources to recruit socially comfortable children and organize regular outings. Guiding clients through a simulation in the office may be the only feasible solution for them continuing education for counselors The simulation features a realistic school setting, designed with the help of elementary school teachers. The pre-programmed responses of the avatar classmates – which include a cool girl, a smart girl and a bully -- were recorded by children to ensure the language reflects how they talk. "The most important thing is that this was designed by clinicians with a very specific intention to help people get better. That's the big difference between this and a game, and there is nothing like this on the market," said Josh Spitalnick, clinical psychologist and director of research and clinical services at Virtually Better, an Atlanta-based company bringing interactive technologies to behavioral healthcare for treatment and training. The six characters and the varying levels of difficulty in the simulation allow clinicians to design scenarios appropriate for their patients. More challenging scenarios include dealing with a bully who is demanding that a child give up some of her lunch money. If the initial trial goes well, researchers hope to conduct a yearlong trial with more children. If that is successful, the simulation could then become available to clinicians. The program eventually could be expanded to include other settings, such as playgrounds, and to serve other children who need help improving social skills. ### For more information about UCF's Anxiety Disorders Clinic, go to http://anxietyclinic.cos.ucf.edu. For more information about Virtually Better Technologies, visit www.virtuallybetter.com.

Adding Psychotherapy to Medication Treatment Improves Outcomes in Pediatric OCD

Source: NIMH

Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association social worker continuing education

Background

Several studies have shown that, among adults with OCD, a form of CBT involving controlled exposure to feared situations plus training that helps the person refrain from compulsions is effective both alone and in combination with antidepressant medication. However, few studies of this type of combination therapy have been conducted among children. In addition, many children with OCD tend to respond only partially to antidepressant medication. Studies have found that among adults who only partially respond to antidepressant medication, adding CBT can be effective. However, until now, there have been no studies testing this same approach in youth.

Martin Franklin Ph.D., of the University of Pennsylvania, Jennifer Freeman Ph.D., of Brown University, John March M.D.,MPH, of Duke University, and colleagues set out to determine whether CBT can effectively augment antidepressant treatment in children who partially respond to the medication. Among 124 children ages 7-17, they compared three treatment options:
Medication management only (MM), prescribed and managed by a physician. All patients were taking a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI).
MM plus Instructional CBT (I-CBT), a shorter, less intensive version of CBT administered by the prescribing physician.
MM plus CBT provided by a trained CBT therapist. The CBT included a type of therapy called exposure plus response prevention (ERP), in which children are exposed to feared situations and taught how to respond to the resulting anxiety without engaging in compulsions.

Results

After 12 weeks of treatment, nearly 69 percent of those receiving MM+CBT had responded to treatment, compared to 34 percent receiving MM+I-CBT and 30 percent receiving MM. Those receiving MM+CBT showed more improvement in all respects, compared to those receiving MM and MM+I-CBT.

Significance

The findings are consistent with other studies demonstrating that ERP is an effective treatment strategy for OCD, both alone and in combination with SSRIs. The researchers conclude that the full version of CBT with ERP should be widely disseminated as opposed to a brief version that may not be effective.

What’s next

The researchers were unsure why there was so little difference in treatment response between the MM group and the MM+I-CBT group. They reasoned that the I-CBT was generally ineffective because it was brief and less intensive than the CBT. It also did not include key treatment components that are central to the full CBT protocol, such as exposure practices during the treatment sessions themselves. Future efforts should focus on making the full CBT with ERP more widely available in community settings, they concluded.

Citation

Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D, Moore P, Choate-Summers M, Garcia A, Edson AL, Foa EB, March JS. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive compulsive disorder: the Pediatric OCD Treatment Study (POTS II) randomized controlled trial. Journal of the American Medical Association. 21 Sept 2011

Social Phobia

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Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.

Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.

Social phobia affects about 15 million American adults.1 Women and men are equally likely to develop the disorder,10 which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4and substance abuse may develop if people try to self-medicate their anxiety.4,5

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.