Impact of cognitive-behavioral therapy for social anxiety disorder on the neural bases of emotional reactivity to and regulation of social evaluation

Abstract

We examined whether Cognitive-Behavioral Therapy (CBT) for social anxiety disorder (SAD) would modify self-reported negative emotion and functional magnetic resonance imaging brain responses when reacting to and reappraising social evaluation, and tested whether changes would predict treatment outcome in 59 patients with SAD who completed CBT or waitlist groups. For reactivity, compared to waitlist, CBT resulted in (a) increased brain responses in right superior frontal gyrus (SFG), inferior parietal lobule (IPL), and middle occipital gyrus (MOG) when reacting to social praise, and (b) increases in right SFG and IPL and decreases in left posterior superior temporal gyrus (pSTG) when reacting to social criticism. For reappraisal, compared to waitlist, CBT resulted in greater (c) reductions in self-reported negative emotion, and (d) increases in brain responses in right SFG and MOG, and decreases in left pSTG. A linear regression found that after controlling for CBT-induced changes in reactivity and reappraisal negative emotion ratings and brain changes in reactivity to praise and criticism, reappraisal of criticism brain response changes predicted 24% of the unique variance in CBT-related reductions in social anxiety. Thus, one mechanism underlying CBT for SAD may be changes in reappraisal-related brain responses to social criticism.

Clinicaltrialsgov identifier: NCT00380731. http://www.clinicaltrials.gov/ct2/show/NCT00380731?term=social+anxiety+cognitive+behavioral+therapy+Stanford&rank=1.

Keywords: Cognitive-behavioral therapy; Emotion; Emotion regulation; Neuroimaging; Reappraisal; Social anxiety.

Conflict of interest statement

None of the authors of this manuscript have any biomedical financial interests or potential conflicts of interest.

Copyright © 2014 Elsevier Ltd. All rights reserved.

Figures

Figure 1

Experimental Design: structure of one social evaluation trial. Cued instruction, 12s video clip, emotion ratings button responses from 1=not negative to 5=extremely negative. Thick bar indicates the 7.5s period of each trial that was used for BOLD signal analysis.

Figure 2

Negative Emotion Ratings When Reacting to Praise or Criticism, and Reappraising Criticism Pre- and Post-Cognitive-Behavioral Therapy and Waitlist * group × time interaction p < .05

Figure 3

Differential Pre-to-Post-CBT vs. Waitlist Changes in Whole-Brain BOLD Responses for React Praise, React Criticism, and Reappraise Criticism A. React praise: 1= right anterior medial prefrontal cortex, 2=right inferior parietal lobule, 3=right medial prefrontal cortex, 4=right middle occipital cortex, B. React criticism: 5= right anterior medial prefrontal cortex, 6= right inferior parietal lobule, 7= left posterior superior temporal gyrus, 8 = right inferior parietal lobule, and C. Reappraise criticism: 9 = right medial prefrontal cortex, 10 = left posterior superior temporal gyrus, 11 = right inferior temporal gyrus/middle occipital gyrus. L = left, R = right, Z = superior (+) to inferior (−).

Figure 3

Differential Pre-to-Post-CBT vs. Waitlist Changes in Whole-Brain BOLD Responses for React Praise, React Criticism, and Reappraise Criticism A. React praise: 1= right anterior medial prefrontal cortex, 2=right inferior parietal lobule, 3=right medial prefrontal cortex, 4=right middle occipital cortex, B. React criticism: 5= right anterior medial prefrontal cortex, 6= right inferior parietal lobule, 7= left posterior superior temporal gyrus, 8 = right inferior parietal lobule, and C. Reappraise criticism: 9 = right medial prefrontal cortex, 10 = left posterior superior temporal gyrus, 11 = right inferior temporal gyrus/middle occipital gyrus. L = left, R = right, Z = superior (+) to inferior (−).

Figure 4

Right Anterior Medial Prefrontal Cortex-Seeded Differential Context-Dependent Functional Connectivity for Reappraise vs. React Social Criticism Post-CBT Reappraise > React: 1 = left dorsolateral and ventrolateral prefrontal cortex, 2 = left medial prefrontal cortex, 3 = left dorsal anterior cingulate cortex, 4 = left posterior superior temporal cortex, 5 = left anterior temporal pole, 6 = left supramarginal gyrus, 7 = left lingual gyrus, 8 = left caudate, 9 = left lentiform / putamen, 10 = left culmen, 11 = right culmen, 12 = left posterior middle temporal gyrus.