Kristoffer N.T. Månsson

Altered neural correlates of affective processing after internet-delivered cognitive behavior therapy for social anxiety disorder

Randomized controlled trials have yielded promising results for internet-delivered cognitive behavior therapy (iCBT) for patients with social anxiety disorder (SAD). The present study investigated anxiety-related neural changes after iCBT for SAD. The amygdala is a critical hub in the neural fear network, receptive to change using emotion regulation strategies and a putative target for iCBT. Twenty-two subjects were included in pre- and post-treatment functional magnetic resonance imaging at 3T assessing neural changes during an affective face processing task. Treatment outcome was assessed using social anxiety self-reports and the Clinical Global Impression-Improvement (CGI-I) scale. ICBT yielded better outcome than ABM (66% vs. 25% CGI-I responders). A significant differential activation of the left amygdala was found with relatively decreased reactivity after iCBT. Changes in the amygdala were related to a behavioral measure of social anxiety. Functional connectivity analysis in the iCBT group showed that the amygdala attenuation was associated with increased activity in the medial orbitofrontal cortex and decreased activity in the right ventrolateral and dorsolateral (dlPFC) cortices. Treatment-induced neural changes with iCBT were consistent with previously reported studies on regular CBT and emotion regulation in general.

Development and initial evaluation of an Internet-based support system for face-to-face cognitive behavior therapy: a proof of concept study.

Background Evidence-based psychological treatments, such as cognitive behavior therapy (CBT), have been found to be effective in treating several anxiety and mood disorders. Nevertheless, issues regarding adherence are common, such as poor patient compliance on homework assignments and therapists’ drifting from strictly evidence-based CBT. The development of Internet-delivered CBT (ICBT) has been intensive in the past decade and results show that guided ICBT can be as effective as face-to-face CBT but also indicate a need to integrate the two forms of CBT delivery. Objective In this study, we developed and tested a new treatment format in which ICBT and face-to-face therapy were blended. We designed a support system accessible via the Internet (using a computer or an Apple iPad) for patients and therapists delivering CBT face-to-face. The support system included basic CBT components and a library of interventions gathered from existing ICBT manuals. Methods The study involved 15 patients with mild to moderate anxiety or depression (or both). Eight therapists conducted the treatments. All participants were interviewed after the nine-week intervention. Further, patients provided self-reports on clinical measures pre- and post-trial, as well as at a 12-month follow-up. Results A reduction was found in symptom scores across all measures. The reliable change index ranged from 60% to 87% for depression and anxiety. Large effect sizes (Cohen’s d) ranging from 1.62 (CI 95% 0.59-2.66) to 2.43 (CI 95% 1.12-3.74) were found. There were no missing data and no treatment dropouts. In addition, the results had been maintained at the 12-month follow-up. Qualitative interviews revealed that the users perceived the support system as beneficial. Conclusions The results suggest that modern information technology can effectively blend with face-to-face treatments and be used to facilitate communication and structure in therapy, thus reducing therapist drift.

Predicting long-term outcome of Internet-delivered cognitive behavior therapy for social anxiety disorder using fMRI and support vector machine learning.

Cognitive behavior therapy (CBT) is an effective treatment for social anxiety disorder (SAD), but many patients do not respond sufficiently and a substantial proportion relapse after treatment has ended. Predicting an individual’s long-term clinical response therefore remains an important challenge. This study aimed at assessing neural predictors of long-term treatment outcome in participants with SAD 1 year after completion of Internet-delivered CBT (iCBT). Twenty-six participants diagnosed with SAD underwent iCBT including attention bias modification for a total of 13 weeks. Support vector machines (SVMs), a supervised pattern recognition method allowing predictions at the individual level, were trained to separate long-term treatment responders from nonresponders based on blood oxygen level-dependent (BOLD) responses to self-referential criticism. The Clinical Global Impression-Improvement scale was the main instrument to determine treatment response at the 1-year follow-up. Results showed that the proportion of long-term responders was 52% (12/23). From multivariate BOLD responses in the dorsal anterior cingulate cortex (dACC) together with the amygdala, we were able to predict long-term response rate of iCBT with an accuracy of 92% (confidence interval 95% 73.2–97.6). This activation pattern was, however, not predictive of improvement in the continuous Liebowitz Social Anxiety Scale—Self-report version. Follow-up psychophysiological interaction analyses revealed that lower dACC–amygdala coupling was associated with better long-term treatment response. Thus, BOLD response patterns in the fear-expressing dACC–amygdala regions were highly predictive of long-term treatment outcome of iCBT, and the initial coupling between these regions differentiated long-term responders from nonresponders. The SVM-neuroimaging approach could be of particular clinical value as it allows for accurate prediction of treatment outcome at the level of the individual.

Neuroplasticity in response to cognitive behavior therapy for social anxiety disorder.

Patients with anxiety disorders exhibit excessive neural reactivity in the amygdala, which can be normalized by effective treatment like cognitive behavior therapy (CBT). Mechanisms underlying the brain’s adaptation to anxiolytic treatments are likely related both to structural plasticity and functional response alterations, but multimodal neuroimaging studies addressing structure–function interactions are currently missing. Here, we examined treatment-related changes in brain structure (gray matter (GM) volume) and function (blood–oxygen level dependent, BOLD response to self-referential criticism) in 26 participants with social anxiety disorder randomly assigned either to CBT or an attention bias modification control treatment. Also, 26 matched healthy controls were included. Significant time × treatment interactions were found in the amygdala with decreases both in GM volume (family-wise error (FWE) corrected PFWE=0.02) and BOLD responsivity (PFWE=0.01) after successful CBT. Before treatment, amygdala GM volume correlated positively with anticipatory speech anxiety (PFWE=0.04), and CBT-induced reduction of amygdala GM volume (pre–post) correlated positively with reduced anticipatory anxiety after treatment (PFWE⩽0.05). In addition, we observed greater amygdala neural responsivity to self-referential criticism in socially anxious participants, as compared with controls (PFWE=0.029), before but not after CBT. Further analysis indicated that diminished amygdala GM volume mediated the relationship between decreased neural responsivity and reduced social anxiety after treatment (P=0.007). Thus, our results suggest that improvement-related structural plasticity impacts neural responsiveness within the amygdala, which could be essential for achieving anxiety reduction with CBT.

Internet-delivered cognitive-behavioral therapy for social anxiety disorder in Romania: a randomized controlled trial.

Background and Aims Internet-based cognitive-behavioral therapy (iCBT) for social anxiety disorder has been found effective, as attested by independently conducted randomized controlled trials in four languages. The study aim is to test the efficacy of an iCBT program in a culture where it was not tested before (i.e. Romania). Methods Participants (n = 76) were recruited, screened and randomized to either a nine-week guided iCBT or a wait-list control group in April and May 2012. Self-report measures were collected before (April 2012) and after the intervention (July 2012), as well as six months later (January 2013). Although social anxiety was assessed with multiple measures, the Liebowitz Social Anxiety Scale - Self Report version (LSAS-SR) and Social Phobia Inventory (SPIN) were used as the primary outcome measures. Results A significant difference with a large between-group effect size in favor of iCBT was found (Cohen´s d = 1.19 for LSAS-SR and d = 1.27 for SPIN). Recovery rates show that 36.8% (n = 14) in the treatment group score below the SPIN clinical cut-off compared to only 2.6% (n = 1) in the wait-list control group. Post-intervention clinical interviews also revealed that 34.2% (n = 13) of the treatment group was completely recovered (full remission) while additionally 36.8% (n = 14) retained some social anxiety symptoms (partial remission). However, an important study limitation is that post-intervention interviewers were not blinded to the study conditions. The program also effectively reduced depression and dysfunctional thinking (between-group Cohen´s d = 0.84 for depression and d = 0.63 for dysfunctional thinking). Moreover, the iCBT intervention appears to have a long-term impact for participants’ functioning, as the treatment gains were maintained six months later. Conclusions Internet-delivered interventions display a high potential to quickly and widely disseminate effective evidence-based programs around the world. This study provides support for guided iCBT as a promising treatment approach in Romania. Trial Registration ClinicalTrials.gov NCT01557894

Structural but not functional neuroplasticity one year after effective cognitive behaviour therapy for social anxiety disorder

&NA; Effective psychiatric treatments ameliorate excessive anxiety and induce neuroplasticity immediately after the intervention, indicating that emotional components in the human brain are rapidly adaptable. Still, the interplay between structural and functional neuroplasticity is poorly understood, and studies of treatment‐induced long‐term neuroplasticity are rare. Functional and structural magnetic resonance imaging (using 3 T MRI) was performed in 13 subjects with social anxiety disorder on 3 occasions over 1 year. All subjects underwent 9 weeks of Internet‐delivered cognitive behaviour therapy in a randomized cross‐over design and independent assessors used the Clinically Global Impression‐Improvement (CGI‐I) scale to determine treatment response. Gray matter (GM) volume, assessed with voxel‐based morphometry, and functional blood‐oxygen level‐dependent (BOLD) responsivity to self‐referential criticism were compared between treatment responders and non‐responders using 2 × 2 (group × time; pretreatment to follow‐up) ANOVA. At 1‐year follow‐up, 7 (54%) subjects were classified as CGI‐I responders. Left amygdala GM volume was more reduced in responders relative to non‐responders from pretreatment to 1‐year follow‐up (Z = 3.67, Family‐Wise Error corrected p = 0.02). In contrast to previous short‐term effects, altered BOLD activations to self‐referential criticism did not separate responder groups at follow‐up. The structure and function of the amygdala changes immediately after effective psychological treatment of social anxiety disorder, but only reduced amygdala GM volume, and not functional activity, is associated with a clinical response 1 year after CBT. HighlightsLong‐term amygdala gray matter volume reduction corresponds to less social anxiety.In contrast, amygdala response alterations are not present at 1‐year follow‐up.Decreased anxiety cannot solely be explained by attenuated neural activation.The interplay between amygdala volume and function might be a treatment mechanism.

Internet treatment for social anxiety disorder in Romania: study protocol for a randomized controlled trial

BackgroundSocial anxiety disorder (SAD) is one of the most common anxiety disorders and is associated with marked impairments. However, a small proportion of individuals with SAD seek and receive treatment. Internet-administrated cognitive behavior therapy (iCBT) has been found to be an effective treatment for SAD. This trial will be the first Internet-delivered guided self-help intervention for SAD in Romania.MethodsParticipants with social anxiety disorder (N = 96) will be recruited via newspapers, online banners and Facebook. Participants will be randomized to either: a) an active treatment, or b) a waiting list control group.The treatment will have a guided iCBT format and will last for nine weeks. Self-report questionnaires on social phobia, anxiety, depression, treatment credibility and irrational thinking will be used. All assessments will be collected pre, post and at follow-up (six months after intervention). Liebowitz Social Anxiety Scale – Self-Report version (LSAS-SR) will be the primary outcome measure and will be administrated on a weekly basis in both conditions.DiscussionThe present randomized controlled trial investigates the efficacy of an Internet-administered intervention in reducing social anxiety symptoms in a culture where this form of treatment has not been tested. This trial will add to the body of knowledge on the efficacy of iCBT, and the results might lead to an increase of the accessibility of evidence-based psychological treatment in Romania.Trial registrationClinicalTrials.gov: NCT01557894

Prediction of outcome in internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A machine learning approach

There are no consistent predictors of treatment outcome in paediatric obsessive–compulsive disorder (OCD). One reason for this might be the use of suboptimal statistical methodology. Machine learning is an approach to efficiently analyse complex data. Machine learning has been widely used within other fields, but has rarely been tested in the prediction of paediatric mental health treatment outcomes.

Voxel-based morphometry multi-center mega-analysis of brain structure in social anxiety disorder

Social anxiety disorder (SAD) is a prevalent and disabling mental disorder, associated with significant psychiatric co-morbidity. Previous research on structural brain alterations associated with SAD has yielded inconsistent results concerning the direction of the changes in gray matter (GM) in various brain regions, as well as on the relationship between brain structure and SAD-symptomatology. These heterogeneous findings are possibly due to limited sample sizes. Multi-site imaging offers new opportunities to investigate SAD-related alterations in brain structure in larger samples. An international multi-center mega-analysis on the largest database of SAD structural T1-weighted 3T MRI scans to date was performed to compare GM volume of SAD-patients (n = 174) and healthy control (HC)-participants (n = 213) using voxel-based morphometry. A hypothesis-driven region of interest (ROI) approach was used, focusing on the basal ganglia, the amygdala-hippocampal complex, the prefrontal cortex, and the parietal cortex. SAD-patients had larger GM volume in the dorsal striatum when compared to HC-participants. This increase correlated positively with the severity of self-reported social anxiety symptoms. No SAD-related differences in GM volume were present in the other ROIs. Thereby, the results of this mega-analysis suggest a role for the dorsal striatum in SAD, but previously reported SAD-related changes in GM in the amygdala, hippocampus, precuneus, prefrontal cortex and parietal regions were not replicated. Our findings emphasize the importance of large sample imaging studies and the need for meta-analyses like those performed by the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Consortium.

The initial evaluation of an Internet-based support system for audiologists and first-time hearing aid clients

Objectives Audiologists provide professional contact and support between appointments to clients with hearing impairment using telephone and e-mail, but more advanced and flexible technological platforms are also possible. The present study aimed to evaluate the clinical application of an Internet-based support system for audiologists and their first-time hearing aid clients. Design An Internet-based support system developed by Månsson et al. (2013) for psychologists and their clients was adapted for audiologic purposes. Three audiologic clinics in Sweden tested the support system with their clients. Study sample Twenty-three clients managed by four audiologists used and evaluated the support system. In addition, five of the clients and all four audiologists were interviewed and their responses were analyzed using content analysis. Results The clients and the audiologists reported positive experiences and overall satisfaction but audiologists reported that the support system did not address the needs of all clients. More positive experiences and greater satisfaction with the support system were associated with reductions on self-reported consequences of hearing loss and positive hearing aids outcomes. Conclusions An Internet-based support system can be used in audiologic rehabilitation. Both audiologists and clients recognized the systems potential value to offer an online support to the provision of audiologic services.