Recent advances in the treatment of anxiety disorders

Cognitive behavioral therapy (CBT) is the first-line psychological treatment for anxiety disorders. Although effective, partial or non-response to treatment remains an all-too-common occurrence, with over half of patients failing to respond fully to first-line cognitive behavioral therapy. The same is true for pharmacological interventions for anxiety disorders. Combining CBT with conventional anxiolytic medication is typically not more effective than unimodal therapy for treating anxiety disorders. This presentation will examine strategies to augment and modify CBT to enhance its efficacy. Recently, the search for new strategies to augment CBT has turned to a unique model of combination therapy. Rather than using pharmacotherapy as an anxiolytic in its own right, it is used to augment the core learning processes of cognitive-behavior therapy and exposure procedures. Moreover, recent work in emotion research points to new intervention strategies for anxiety disorders, such as mindfulness-based therapies and meditation practices.

The first half of this presentation will review the current literature on conventional and novel combination strategies. A particularly successful prototype of a novel augmentation strategy of CBT is the use of d-cycloserine (DCS), a partial agonist at the glycine recognition site of the glutametergic N-methyl-D-aspartate receptor, to facilitate extinction learning. The second half the presentation will review novel and adaptive emotion regulation strategies, including mindfulness and loving-kindness mediation.

The efficacy of CBT for anxiety disorders can be enhanced by (1) augmenting the treatment with the cognitive enhancers such as DCS, and (2) modifying the intervention using novel emotion regulation strategies. The augmentation strategies are based on the fact that exposure-based treatments in humans partly rely on extinction to reduce the fear response in anxiety disorders. In fact, animal studies have consistently shown that DCS facilitates extinction learning. Similarly, recent human trials have shown that DCS enhances fear reduction during exposure therapy of some anxiety disorders. Positive findings so far have been reported in placebo-controlled trials for specific phobia, social anxiety disorder, panic disorder, and obsessive compulsive disorder. The strongest effects were observed in studies in which patients receive a small dose of DCS (50 mg) acutely 1 hour before the exposure trials with no more than 5 administrations weekly. The modification strategies of CBT have primarily focused on enhancing adaptive emotion regulation strategies, beyond traditional reappraisal strategies. Whereas cognitive reappraisal strategies are antecedent focused, these novel strategies are primarily emotion response focused. Although these strategies have only recently been studied as treatments for anxiety disorders, they are rooted in ancient Eastern and Buddhist practices. CBT is an evolving science that integrates traditional and modern approaches and is in line with modern emotion and neuroscience theories.