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Pretreatment Dorsal Anterior Cingulate Cortex and Dorsolateral Prefrontal Cortex Activation Moderates Outcomes of
Dana E Díaz1, Luke J Norman2, Stefanie R Russman Block3
1Department of Psychiatry, Columbia University Irving Medical Center, New York, New York.
Background:
Cognitive behavioral therapy (CBT) for pediatric anxiety targets heightened emotional sensitivity and impaired cognitive control over emotion, core neurocognitive features of anxiety. Exposure is considered the most active component of CBT, but its efficacy varies. Pretreatment function of substrates for emotion processing and cognitive control may predict response to exposure relative to other CBT subcomponents, such as relaxation.
Methods:
Youth with clinical anxiety (N = 118, 7-17 years) completed a functional magnetic resonance imaging task probing emotion processing and cognitive control and then were randomized to 12 sessions of exposure-focused CBT (EF-CBT) or relaxation management training (RMT). Voxelwise linear mixed-effects models tested how pretreatment whole-brain activation was associated with symptom reduction over the course of treatment.
Results:
EF-CBT led to greater symptom reduction than RMT. Better EF-CBT response was predicted by lower pretreatment activation in the left dorsolateral prefrontal cortex during emotion processing and in the bilateral dorsal anterior cingulate cortex and inferior parietal lobe during cognitive control of emotion. Conversely, these patterns were associated with poorer outcomes of RMT. Direct comparisons revealed that EF-CBT was more effective than RMT for youth with low and mean activation in all regions, but not high activation.
Conclusions:
EF-CBT outperformed RMT for youth with low-to-mean activation in regions supporting emotional appraisal, cognitive control, and threat attention, indicating that these patterns may be biomarkers of exposure readiness. Conversely, high activation in these regions did not confer differential benefit and may reflect hypervigilance or overcontrol that could interfere with exposure-based learning. These findings support the value of preparatory interventions to optimize treatment readiness and personalize delivery of exposure-based CBT.
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