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Cognitive-behavior therapy for anxiety disorders: new perspectives

Miquel Angel Fullana mafr@copc.cat

CBT for anxiety disorders


Current status of CBT for anxiety disorders Improving the outcome Dissemination

CBT for anxiety disorders


Current status of CBT for anxiety disorders Improving the outcome Dissemination

Does it work?

Panic disorder

Generalized anxiety disorder

Post-traumatic stress disorder

Obsessive-compulsive disorder

Social phobia

Data on the efficacy of CBT are mainly based on RCTs in - specialized centers - with specialized therapists - working in special conditions

CBT=15 sessions (2 hours) every day for 3 weeks + 8 sessions (1 hour) once a week + Homework (2 hours/day) + 2 home visits

Does it work in the real life?

How good is it?


- 25-50 % of patients with anxiety disorders do not respond to CBT - Results on the long-term not so good

Old or new cbt ?

OLD vs NEW CBT (1): SOCIAL PHOBIA


OLD CBT Exposure Cognitive restructuring

NEW CBT Elimination of safety behaviors Modification of post-events rumination Attention retraining

OLD vs NEW CBT (2): PANIC DISORDER


OLD CBT Relaxation techniques Breathing retraining Exposure NEW CBT Exposure, focus on safety behaviors

CBT for anxiety disorders


Current status of CBT for anxiety disorders Improving the outcome Dissemination

Improving the outcome: - Extinction-based therapies - CBT genetics

Extinction-based therapies

What we know
- CBT works for anxiety disorders - Some drugs also work for anxiety disorders - but combining CBT and drugs is not better than CBT alone

Extinction-based therapies (1)


Fear conditioning
A neutral stimulus becomes conditioned after being paired with an aversive stimulus and elicits a conditioned response (anxiety)

Fear conditioning is involved in anxiety disorders: - development of PTSD after trauma - efficacy of exposure in phobic disorders

Fear conditioning
ACQUISITION EXTINCTION

Extinction-based therapies (2)

- BT for anxiety disorders based on exposure C - Exposure is a form of extinction training - Some drugs (NMDA agonists) facilitate extinction - Can drugs that facilitate extinction improve the effects of CBT?

D-Cicloserine

N=28

N=27

N=23

D-cicloserine and phobic disorders


Good translational basis Improves exposure in both animals and humans Positive (but modest) effects in specific phobia., OCD, social phobia

Other extinction-based therapies

Height phobia

Claustrophobia

CBTgenetics

What we know
- Not many reliable predictors for CBT outcome (in OCD) - Genetics may predict the effects of drug treatments - Are genes associated with CBT outcome?

Some genes may be involved in cbt processes

Variation in BDNF and CBT outcome in OCD: preliminary results

GOAL To test whether variation in the BDNF Val66Met polymorphism is related to treatment response to exposure-based cognitive-behavior therapy (CBT) in OCD

METHODS 106 OCD patients (Bellvitge Hospital, Barcelona) Standardized CBT treatment after partial/non-response to a 12-week pharmacological trial Genotyped for the BDNF Val66Met

Response to CBT and Genotype in OCD (n=98)

35 % of Met carriers were responders 60 % of Val carriers were responders (p=0.027)

Fullana et al., submitted

Response to CBT, symptoms and Genotype in OCD (n=98)

Fullana et al., submitted

Some ideas to test

- Patients with bad extinction genes (Met carriers) will need more exposure or non-exposure treatments - he effects of D-cycloserine may be attenuated in Met carriers T - The effects of BDNF probably change across developmentand so could the effects of CBT

CBT for anxiety disorders


Current status of CBT for anxiety disorders Improving the outcome Dissemination

CBT worksbuts is not popular!

IAPT program (Improving Access to Psychological Therapy) - Creation of 250 centers of evidence-based psychological treatment in UK - 3.500 new therapists - Budget: 200 millions in 6 years

New research

N=108

N=232

N=134

New ways of delivering CBT

N=72

Take-home messages

CBT works for anxiety but there is room for improvement Translational research may help improve the results of CBT An important focus for reseach will be how to diseminate these treatments

Thanks for your attention