professor fullana
Post on 10-Mar-2015
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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
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