Cognitive Behavioural Therapy vs the Agoraphobic Brain

Even though it is the season to be jolly and all, there are still many that cannot leave their homes and join in with all the celebrations. Agoraphobia doesn't take a break for the holidays and neither do we. This last couple of weeks we have finished the first draft of the research project that we will complete with Agoraphobia Free once we finish it. We have also been writing the script for the app itself so we can show it to all those who have agreed to help us develop it so we can get their thoughts on our ideas.

As part of all that we have been reading all the science papers about the treatment of agoraphobia we can get our hands on. Cognitive behavioural therapy (CBT) using exposure (i.e. getting sufferers to confront gradually the thing that they fear as part of the therapy) is still the undisputed best way to get people suffering from agoraphobia better. Unfortunately it doesn't work for everyone. One of the papers I came across tries to find out why exactly some people do get better with this method while others don't. They use functional magnetic resonance imaging (fMRI) to try to get the answer.

Researchers lead by Ulrike Lueken from the Institute of Clinical Psychology and Psychotherapy, Technische Universität, Dresden, Germany recruited 49 people with agoraphobia who were not taking any tablets for their condition and gave them exposure-based CBT to help with their agoraphobia. All improved quite a bit but about 50% got much better. Looking at their scans it turned out that the ones who got very much better had a permanent change in the connection between the anterior cingulate cortex and the amygdala. The anterior cingulate was able to switch off the amygdala quite effectively as compared to those who did not do so well in the therapy. There seemed to already be a good connection between these two before the treatment started. Also when learning tricks to deal with fear responders used their right hippocampus more than those who did not benefit so much. By way of very quick and very simplistic explanation the hippocampus is used in memory, the amygdala is active when we are scared and the anterior cingulate is involved in solving problems where the person has the impulse of doing one thing, but doing it would result in making a mistake. It helps us stop ourselves from doing stuff we don't mean to do.

Here's a couple of pics of the protagonists:

 Anterior Cingulate

Anterior Cingulate



The researchers reason that people who don't do so well with exposure therapy tend to have brain networks that are overactive when detecting threat and are not able to inhibit the fear response so well when the situation is essentially 'safe'. Also, stopping oneself from being scared requires to use the tricks learned to stop the fear consciously and those who where able to remember the tricks and use them when scared did better.


Those whose anterior cingulate was better at switching off the amygdala and those who were able to activate their hippocampus when feeling anxious (i.e. remember the tricks to deal with anxiety and use them) after going through the therapy benefited more from it. However, for me the main message is that it seems that everyone in the study benefited from the therapy to some extent and that the activation pattens changed in everyone after the treatment.

So it isn't a case of looking at brain scans to decide who should have the treatment and who shouldn't. However, the scans may give as a clue as to what changes to aim for with therapy and maybe therapy delivered in a different way may train those important networks even in people who normally would not benefit so much from the standard treatment.

Here's a link to the study in case you want to read it.