For patients with social anxiety disorder (SAD), current behavioral and pharmaceutical treatments work about half the time. After weeks of investment in therapy, about half of patients will likely still suffer with symptoms of anxiety, and have little choice but to try again with something else. This trial-and-error process — inevitable due to an absence of tools to guide treatment selection — is time-consuming and expensive, and some patients eventually just give up.
But new MIT research suggests that it may be possible to do better than a coin toss when choosing psychiatric therapies for patients. The study, which performed brain scans on 38 SAD patients, found that these scans contain clues that indicate, with about 80 percent accuracy, which SAD patients will do well in cognitive behavioral therapy (CBT), an intervention designed to help patients change thinking patterns. Use of the scans to predict treatment outcomes improved predictions fivefold over use of a clinician’s assessment alone.
The researchers used a form of brain imaging that scans patients in a state of rest. Resting-state images can be done quickly, in about 15 minutes, and reliably, since they don’t require patients to follow instructions, so they have the potential to be used in a clinical setting as a tool that helps doctors select the best treatments for patients.
The findings are reported in the current issue of the journal Molecular Psychiatry.
Social anxiety disorder affects approximately 6.8 percent of Americans, about 15 million individuals, and is the country’s third-most-common mental health disorder, according to the National Institutes of Mental Health.
Its symptoms include extreme anxiety in social settings that can interfere with work and quality of life. Patients living with this disorder are also at higher risk of other psychiatric disorders, such as depression and substance abuse.
The study analyzed SAD patients from the Center for Anxiety and Related Disorders at Boston University and the Center for Anxiety and Traumatic Stress at Massachusetts General Hospital. The patients were scanned prior to participation in 12 weeks of group-based CBT. They also were evaluated using a behavioral assessment tool called the Liebowitz Social Anxiety Scale (LSAS) before and after CBT to determine who had improved.
In 2013, the researchers studied task-based scans of this same group of patients. They found that scans of patients’ brains as they responded to angry or neutral faces and emotional or neutral scenes predicted CBT outcomes.
Behavioral differences among patients can affect performance. Also, task-based scans can only be used on patients who can follow a task, which excludes infants and some elderly or very ill patients.
So they followed this earlier research with a study of the predictive power of resting-state imaging, which they had also performed prior to CBT. During a resting-state scan, the patient just lies there.
Resting-state imaging provides a look at the way a patient’s brain is wired, both structurally and functionally. For instance, resting-state functional magnetic resonance imaging (fMRI) shows which parts of the brain synchronize with one another during rest, suggesting that they are functionally connected. In addition, analysis of diffusion-weighted magnetic resonance imaging (dMRI) shows the underlying anatomy of the white matter tracts that interconnect distant brain regions.
Based on findings from their earlier research, they first used resting-state fMRI to look at connections to the amygdala, the seat of fear in the brain. They found that patients with higher connectivity to the amygdala from certain other regions were more likely to have lower anxiety after CBT.
They then performed a second analysis of the resting-state fMRI data, this time looking across the entire brain for patterns of connectivity. This analysis revealed additional markers that were predictive of treatment. The researchers also analyzed dMRI data and found that more robust connectivity in the tract that connects visual cues with emotional responses is also predictive of improvement with CBT.
Higher LSAS scores, which indicate more severe SAD, correlate modestly with larger improvements after CBT. In this study, each brain scan analysis had predictive value beyond the LSAS, and the three analyses together produced a fivefold improvement in predictive power over the LSAS alone.
The next step is to validate their predictive model on hundreds or possibly thousands of patients. Such a large-scale study may be possible because resting-state scans are comparable even when performed in different labs or by different researchers. Such comparisons weren’t feasible using task-based scans, which tend to vary from lab to lab.
About Social anxiety disorder:
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by an intense fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life. These fears can be triggered by perceived or actual scrutiny from others.
Physical symptoms often accompanying social anxiety disorder include excessive blushing, excess sweating, trembling, palpitations and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events.
SAD is sometimes referred to as an ‘illness of lost opportunities’ where ‘individuals make major life choices to accommodate their illness.’
About Cognitive behavioral therapy (CBT):
Cognitive behavioral therapy (CBT) is a form of psychotherapy. It was originally designed to treat depression, but is now used for a number of mental illnesses.
The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles. CBT is “problem focused” (undertaken for specific problems) and “action oriented” (therapist tries to assist the client in selecting specific strategies to help address those problems),or directive in its therapeutic approach.
It is different from the more traditional, psychoanalytical approach, where therapists look for the unconscious meaning behind the behaviors and then diagnose the patient.
