Enhancing exposure therapy for anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder

Abstract

Translating findings from basic science, several compounds have been identified that may enhance therapeutic outcomes and/or expedite treatment gains when administered alongside exposure-based treatments. Four of these compounds (referred to as cognitive enhancers) have been evaluated in the context of randomized controlled trials for anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), obsessive compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). These cognitive enhancers include D-cycloserine, yohimbine hydrochloride, glucocorticoids and cortisol, and brain derived neurotrophic factor. There is consistent evidence that cognitive enhancers can enhance therapeutic outcomes and/or expedite treatment gains across anxiety disorders, OCD, and PTSD. Emerging evidence has highlighted the importance of within-session fear habituation and between-session fear learning, which can either enhance fear extinction or reconsolidate of fear responses. Although findings from these trials are promising, there are several considerations that warrant further evaluation prior to wide-spread use of cognitive enhancers in exposure-based treatments. Consistent trial design and large sample sizes are important in future studies of cognitive enhancers.

Bothersome tics in patients with chronic tic disorders: Characteristics and individualized treatment response to behavior therapy

“…Finally, some tics may be more challenging to treat with current behavioral approaches due to their specific nature, minimal awareness, and/or lack of an adequate competing response. Future research should examine the differential benefit of specific competing responses for individual tics and explore other pharmacological or behavioral augmentation strategies that have shown promise in related conditions (McGuire, Lewin, & Storch, 2014). …”

“…Although there is some variation between HRT and CBIT due to the incorporation of specific therapeutic components (e.g., relaxation training, functional analysis), both include the core therapeutic components of awareness training and competing response training (Peterson, 2007; Woods, Miltenberger, & Lumley, 1996). Randomized controlled trials consistently demonstrate the acceptability, efficacy, and safety of these behavioral interventions (Deckersbach, Rauch, Buhlmann, & Wilhelm, 2006; Piacentini et al, 2010; Wilhelm et al, 2003; Wilhelm et al, 2012), with a recent meta-analysis identifying moderate-to-large treatment effects (McGuire, Piacentini, et al, 2014). Indeed, treatment guidelines recommend behavior therapy as a first-line intervention for youths with CTDs (Murphy, Lewin, Storch, & Stock, 2013; Steeves et al, 2012; Verdellen, van de Griendt, Hartmann, & Murphy, 2011).…”

Extinction learning in childhood anxiety disorders, obsessive compulsive disorder and post-traumatic stress disorder: implications for treatment

“…These approaches include increasing SRI dosage, augmenting existing evidence-based treatment with additional pharmacological agents (e.g., clomipramine, antipsychotics) [10,11], or using cognitive enhancers to augment therapeutic learning in CBT [15]. Although augmentation of CBT with SRI medications is recommended for youths with severe symptoms [10,11], SRI medications are not a preferred treatment option by their parents [16,17].…”

“…Broadly, cognitive enhancers are pharmacological compounds that influence signaling pathways involved in synaptic plasticity of brain regions associated with threat acquisition and thereby enhance the neurocircuity of extinction learning [19]. Several cognitive enhancers have been examined across fear-based psychiatric disorders [15]. Findings suggest that cognitive enhancers do not universally expedite and/or enhance CBT outcomes.…”

“…Findings suggest that cognitive enhancers do not universally expedite and/or enhance CBT outcomes. The most well-studied cognitive enhancer, d-cycloserine (DCS), has demonstrated the most consistent benefit for augmenting CBT in anxiety disorders [15,20,21]. However, evidence suggests that its effects may be influenced by specific characteristics (e.g., comorbid psychiatric conditions, psychiatric medication) [20] and/or therapeutic mechanisms (e.g., extinction learning, extinction retention) [22-24].…”