Cognitive-behavior therapy for anxiety disorders: new perspectives

Miquel Angel Fullana

mafr@copc.cat

•  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

CBT for anxiety disorders

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

•  Current status of CBT for anxiety disorders

•  Improving the outcome

•  Dissemination

CBT for anxiety disorders

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

ACQUISITION EXTINCTION

Fear conditioning

Extinction-based therapies (2)

- CBT for anxiety disorders based on exposure

-  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

- The effects of D-cycloserine may be attenuated in Met carriers

-  The effects of BDNF probably change across development…and so could the effects of CBT

•  Current status of CBT for anxiety disorders

•  Improving the outcome

•  Dissemination

CBT for anxiety disorders

CBT works…buts 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