Impact of Cognitive Behavioral Therapy for Social Anxiety Disorder on the Neural Dynamics of Cognitive Reappraisal of Negative Self-beliefs: Randomized Clinical Trial
Open accessAbstract
IMPORTANCE: Cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) is thought to enhance cognitive reappraisal in patients with SAD. Such improvements should be evident in cognitive reappraisal-related prefrontal cortex responses. OBJECTIVE: To determine whether CBT for SAD modifies cognitive reappraisal-related prefrontal cortex neural signal magnitude and timing when implementing cognitive reappraisal with negative self-beliefs. DESIGN Randomized clinical trial of CBT for SAD vs wait-list control group during a study that enrolled patients from 2007 to 2010. SETTING: University psychology department. PARTICIPANTS: Seventy-five patients with generalized SAD randomly assigned to CBT or wait list. INTERVENTION: Sixteen sessions of individual CBT for SAD. MAIN OUTCOME MEASURES: Negative emotion ratings and functional magnetic resonance imaging blood oxygen-level dependent signal when reacting to and cognitively reappraising negative self-beliefs embedded in autobiographical social anxiety situations. RESULTS During reactivity trials, compared with wait list, CBT produced (1) greater reduction in negative emotion ratings and (2) greater blood oxygen-level dependent signal magnitude in the medial prefrontal cortex. During cognitive reappraisal trials, compared with wait list, CBT produced (3) greater reduction in negative emotion ratings, (4) greater blood oxygen level-dependent signal magnitude in the dorsolateral and dorsomedial prefrontal cortex, (5) earlier temporal onset of dorsomedial prefrontal cortex activity, and (6) greater dorsomedial prefrontal cortex-amygdala inverse functional connectivity. CONCLUSIONS AND RELEVANCE: Modulation of cognitive reappraisal-related brain responses, timing, and functional connectivity may be important brain changes that contribute to the effectiveness of CBT for social anxiety. This study demonstrates that clinically applied neuroscience investigations can elucidate neurobiological mechanisms of change in psychiatric conditions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00380731.
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Altered connectivity between the amygdala and dorsomedial prefrontal cortex, medial orbitofrontal cortex, and ventrolateral/dorsolateral prefrontal cortex has been observed following cognitive behavioral therapy.
“studies demonstrating altered connectivity following CBT between amygdala and dmPFC, mOFC and vl/dlPFC (Goldin et al., 2013; Goldin et al., 2014; Månsson et al., 2013)”
From Neural connectivity during affect labeling predicts treatment response to psychological therapies for social anxiety disorder. (2019) · cites this paper as Goldin et al., 2013
The Results and Discussion sections on cognitive reappraisal report greater inverse connectivity between the dorsomedial prefrontal cortex and left amygdala after CBT, compared with waitlist. They describe connectivity with medial and dorsolateral prefrontal regions as connections to the dorsomedial prefrontal cortex, not to the amygdala; they do not establish the claimed amygdala connections with medial orbitofrontal or ventrolateral prefrontal cortex. Page numbers were not available in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredCBT has been shown to increase activity in the reappraisal-associated dorsolateral, ventrolateral, and medial prefrontal cortical regions.
“CBT has been shown to increase activity in the reappraisalassociated dorsolateral, ventrolateral, and medial prefrontal cortical regions.17”
From Evaluation of Cognitive Behavioral Therapy vs Mindfulness Meditation in Brain Changes During Reappraisal and Acceptance Among Patients With Social Anxiety Disorder: A Randomized Clinical Trial (2021) · cites this paper as [17]
The Results section reports CBT-related increases in reappraisal-related activity in dorsomedial prefrontal cortex and left dorsolateral prefrontal cortex. It identifies these as the only two regions with corrected between-group differences; it does not support the claimed increase in ventrolateral prefrontal activity. Page numbers were not supplied with the passages. (LLM, conf=0.90)
Experimental — accuracy not yet measuredEvidence suggests that both CBT and MBSR for social anxiety disorder increase recruitment of emotion regulatory brain regions.
“Evidence suggests that both CBT and MBSR for SAD increase recruitment of emotion regulatory brain regions.”
From Evaluation of Cognitive Behavioral Therapy vs Mindfulness Meditation in Brain Changes During Reappraisal and Acceptance Among Patients With Social Anxiety Disorder: A Randomized Clinical Trial (2021) · cites this paper as [17]
The Discussion (Clinical Implications; page not provided) reports greater and quicker recruitment of a reappraisal-related brain region following CBT for social anxiety disorder. Our copy does not report that MBSR increases recruitment of emotion-regulatory brain regions, so it supports only the CBT part of the claim. (LLM, conf=0.88)
Experimental — accuracy not yet measuredTwo studies comparing cognitive behavioral therapy to wait-list groups of social anxiety disorder patients found treatment-related increases in inverse connectivity between dorsomedial prefrontal cortex and left amygdala during reappraisal of negative self-beliefs, and positive connectivity among prefrontal regions during reappraisal of social criticism.
“Two studies comparing CBT to wait-list groups of SAD patients demonstrated treatment-related increases in i) inverse connectivity between the dmPFC and left amygdala while reappraising negative self-beliefs (Goldin et al., 2013), and ii) positive connectivity among prefrontal regions including medial PFC, dmPFC, left dACC, left dlPFC and left vlPFC when reappraising social criticism (Goldin et al.”
From Treatment for social anxiety disorder alters functional connectivity in emotion regulation neural circuitry (2017) · cites this paper as Goldin et al., 2013
After CBT, individuals with SAD showed stronger inverse amygdala-dmPFC connectivity while reappraising negative self-beliefs.
“Individuals with SAD demonstrated strengthened inverse connectivity (i.e., negative correlation in activity between two regions) between the amygdala and the dmPFC while reappraising negative self-beliefs after cognitive behavioral therapy (Goldin et al., 2013).”
From Changes in functional connectivity with cognitive behavioral therapy for social anxiety disorder predict outcomes at follow-up (2020) · cites this paper as Goldin et al., 2013
The present results agree with treatment studies showing strengthened dmPFC activation and inverse amygdala connectivity during reappraisal after CBT.
“Our results are consistent with treatment studies, which have found strengthened dmPFC activation as well as inverse connectivity with the amygdala during reappraisal after cognitive behavioral therapy (Goldin et al., 2013).”
From Changes in functional connectivity with cognitive behavioral therapy for social anxiety disorder predict outcomes at follow-up (2020) · cites this paper as Goldin et al., 2013
Prior studies using the autobiographical social situation emotion regulation fMRI task have found similar reductions in negative emotion when reacting and reappraising negative self-beliefs following CBT for SAD and when implementing breath-focused and meta-cognitive attention regulation following MBSR for SAD.
“Prior studies using the autobiographical social situation emotion regulation fMRI task have found similar reductions in negative emotion when reacting and reappraising negative self-beliefs following CBT for SAD 17 and when implementing breath-focused and meta-cognitive attention regulation following MBSR for SAD.19,22”
Both the amygdala and rostral ACC/mPFC are putative neural targets of psychosocial and pharmacological treatments known to be effective in generalized social anxiety disorder.
“Both the amygdala and rostral ACC/mPFC are putative neural 'targets' of psychosocial and pharmacological treatments known to be effective in GSAD (Evans et al, 2009;Goldin et al, 2013;Klumpp et al, 2013a;Phan et al, 2013).”
From Modulation of Resting-State Amygdala-Frontal Functional Connectivity by Oxytocin in Generalized Social Anxiety Disorder (2014) · cites this paper as Goldin et al, 2013
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“Two studies comparing CBT to wait-list groups of SAD patients demonstrated treatment-related increases in i) inverse connectivity between the dmPFC and left amygdala while reappraising negative self-beliefs (Goldin et al., 2013), and ii) positive connectivity among prefrontal regions including medial PFC, dmPFC, left…”
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- Authors
- Goldin, P. R., Ziv, M., Jazaieri, H., Hahn, K., Heimberg, R., & Gross, J. J.
- Affiliations
- Stanford University (US)
- Temple University (US)
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2013-10-01
- Volume
- 70
- Issue
- 10
- Pages
- 1048
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC4141477
- OpenAlex
- W2153734379
- Semantic Scholar
- 4680b233cbaeda4704483fc44cbe3e45d43f2ec4
- Cited by
- 174
- References
- 44
- Citations by year
- 2026: 14 · 2025: 12 · 2024: 5 · 2023: 11 · 2022: 14 · 2021: 12 · 2020: 10 · 2019: 10 · 2018: 21 · 2017: 12 · 2016: 19 · 2015: 17 · 2014: 16
- FWCI
- 23.48
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R01MH076074)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- cognitive behavioral therapy, social anxiety disorder, cognitive reappraisal, negative self-beliefs, prefrontal cortex, dorsomedial prefrontal cortex, dorsolateral prefrontal cortex, amygdala, negative emotions
- MeSH terms
- Anxiety Disorders, Brain Mapping, Cognition, Emotions, Humans, Psychomotor Performance, Cognitive Behavioral Therapy, Prefrontal Cortex
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