The Future of CBT in the Age of the DSM-5. Stefan G. Hofmann, Ph.D. Professor of Psychology Boston University

Transcription

1 The Future of CBT in the Age of the DSM-5 Stefan G. Hofmann, Ph.D. Professor of Psychology Boston University 1

2 Carving Nature at Its Joints

3 Reasons for Classifying Mental Disorders Common language to reliably assess patients (code disorders for insurance etc) Advance science and further understanding in psychopathology Optimize and tailor existing treatments and develop new treatments 3

4 Some Controversies Clinical utility but no concurrent/predictive validators. RDoC: Basic dimensions of functioning across multiple units of analysis cutting across DSM disorders; goal is to translate progress in behavioral and neuroscience to improve understanding of psychopathology and develop new and tailored treatments. 4

5 Hofmann, S. G., Asnaani, A., Vonk, J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36,

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7 Placebo-controlled Effect Sizes of CBT on anxiety (red bars) and depression (green bars). Acute Stress Dis. Obsessive-Compulsive Dis. Post-traumatic Stress Dis. Social Anxiety Dis. Generalized Anxiety Dis. Panic Disorder Anxiety Depression Effect Size (Hedges' g) Hofmann, S. G., & Smits, J. A. (2008). Cognitive behavioral therapy for adult anxiety disorders: A meta-analysis of randomized controlled trials. Journal of Clinical Psychiatry, 69,

8 Percent responders Efficacy of Pharmacotherapy Example: SSRI for Social Anxiety Disorder PAR PLA Post acute Bouwer, C., & Stein, D. J. (1998). Use of selective serotonine reptake inhibitor citalopram in the treatment of generalize social anxiety disorder. J Affective Dis, 49,

9 How Good are Combination Treatments for Anxiety Disorders? Meta-analysis of RCTs comparing CBT plus Med vs. CBT plus PLA Effect sizes at post-treatment: PD and GAD: moderate OCD and SAD: small and not significant. Hofmann, S. G., Sawyer, A. T., Korte, K. J., & Smits, J. A. J. (2009). Is it beneficial to add pharmacotherapy to cognitive-behavioral therapy when treating anxiety disorders? A meta-analytic review. International Journal of Cognitive Therapy, 2,

10 Percent responders Social Anxiety Disorder Post CBT FLUOX CBT+FLUOX CBT+PLA PLA Davidson J. R. T., Foa, E. B., Huppert, J. D., Keefe, F., Franklin, M., Compton, J., Zhao, N., Connor, K., Lynch, T. R., & Kishore, G. (2004). Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Archives of General Psychiatry, 61,

11 Why is Combination Therapy Not Doing Better? State-dependent learning? Attribution? Turtle race? 11

12 Why is Combination Therapy Not Doing Better? State-dependent learning? Attribution? Turtle race? 12

13 GOAL 13

14 GOAL 14

15 Ways to Further Improve Treatment Effects Augmentation Prediction 15

16 Ways to Further Improve Treatment Effects Augmentation Prediction 16

17 NMDA Receptor Glutamate Glycine Extracellular Intracellular Hofmann, S. G. (2007). Enhancing exposure-based therapy from a translational research perspective. Behaviour Research & Therapy, 45,

18 NMDA Receptor Ca2+ Glutamate Glycine Extracellular NMDA Receptor Intracellular LTP 18

19 NMDA Receptor Ca2+ Glutamate D-cycloserine Extracellular NMDA Receptor Intracellular LTP 19

20 Social Anxiety Disorder SPAI Scores 140 Placebo (N = 13) D-cycloserine (N = 10) 120 SPAI -total Scores Pre-Test Post-Test 1-mo FU Hofmann S. G., Meuret, A. E., Smits, J. A. J., Simon, N. M., Pollack, M. H., Eisenmenger, K., Shiekh, M., & Otto, M. W. (2006). Augmentation of exposure therapy for social anxiety disorder with d-cycloserine. Archives of General Psychiatry, 63,

21 Social Anxiety Disorder Hofmann, S. G., Smits, A. J., Rosenfield, D., Simon, N., Otto, M. W., Meuret, A. E., Marques, L., Fang, A., Tart, C., & Pollack, M. H. (2013). D-cycloserine as an augmentation strategy of cognitive behavioral therapy for social anxiety disorder. American Journal of Psychiatry,170,

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23 Smits, J. A. J., Rosenfield, D., Otto, M. W., Marques, L, Davis, M. L., Meuret, A. E., Simon, N. M., Pollack, M., & Hofmann, S. G. (2013). D-cycloserine Enhancement of exposure therapy for social anxiety disorder depends on the success of exposure sessions. Journal of Psychiatric Research, 47,

24 Height Phobia Smits, J. A. J., Rosenfield, D., Otto, M. W., Powers, M. B., Hofmann, S. G., Telch, M. J., Pollack, M. H., & Tart, C. D. (2013). D-cycloserine enhancement of fear extinction is specific to successful exposure sessions: Evidence from the treatment of height phobia. Biological Psychiatry, 73,

25 PTSD (Iraq) Litz, B. T., Salters-Pedneault, K., Steenkamp, M., Hermos, J. A., Bryant, R. A., Otto, M. W., & Hofmann, S. G. (2012). A randomized placebo-controlled trial of d- cycloserine and exposure therapy for post-traumatic stress disorder. Journal of Psychiatric Research, 46,

26 Ways to Further Improve Treatment Effects Augmentation Prediction 26

27 Using fmri to predict CBT response 51 SAD patients (generalized subtype); 28.8 years average age. Doehrmann, O., Ghosh, S. S., Polli, F. E., Reynolds, G. O., Whitfield-Gabrieli, S., Hofmann, S. G., Pollack, M., & Gabrieli, J. D. (2013). Predicting treatment response in social anxiety disorder from functional magnetic resonance imaging. JAMA Psychiatry, 70,

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29 LSAS change associated with activation in dorsal occipital cluster LSAS change associated with activation in ventral occipital cluster

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31 Doehrmann, O., Ghosh, S. S., Polli, F. E., Reynolds, G. O., Whitfield-Gabrieli, S., Hofmann, S. G., Pollack, M., & Gabrieli, J. D. (2013). Predicting treatment response in social anxiety disorder from functional magnetic resonance imaging. JAMA Psychiatry, 70,

32 Summary Augmentation: Speed up your turtle! Cognitive enhancers, such as DCS, can augment CBT. Prediction: fmri at pre-test can predict CBT response. 32

33 The Future is. Actively participating in the scientific progress that moves mental health care forward Expanding (and possibly changing) our paradigm Letting go of turf battles (cognitive vs. behavioral therapy; CBT vs. third wave, etc) Closely working with our neighboring disciplines (e.g., neuroscience and biology) Rethinking the way we classify and treat disorders 33