title: Predicting long-term outcome of Internet-delivered cognitive behavior therapy for social anxiety disorder using fMRI and support vector machine learning.
abstract: Cognitive behavior therapy (CBT) is an effective treatment for social anxiety disorder (SAD), but many patients do not respond sufficiently and a substantial proportion relapse after treatment has ended. Predicting an individual's long-term clinical response therefore remains an important challenge. This study aimed at assessing neural predictors of long-term treatment outcome in participants with SAD 1 year after completion of Internet-delivered CBT (iCBT). Twenty-six participants diagnosed with SAD underwent iCBT including attention bias modification for a total of 13 weeks. Support vector machines (SVMs), a supervised pattern recognition method allowing predictions at the individual level, were trained to separate long-term treatment responders from nonresponders based on blood oxygen level-dependent (BOLD) responses to self-referential criticism. The Clinical Global Impression-Improvement scale was the main instrument to determine treatment response at the 1-year follow-up. Results showed that the proportion of long-term responders was 52% (12/23). From multivariate BOLD responses in the dorsal anterior cingulate cortex (dACC) together with the amygdala, we were able to predict long-term response rate of iCBT with an accuracy of 92% (confidence interval 95% 73.2-97.6). This activation pattern was, however, not predictive of improvement in the continuous Liebowitz Social Anxiety Scale-Self-report version. Follow-up psychophysiological interaction analyses revealed that lower dACC-amygdala coupling was associated with better long-term treatment response. Thus, BOLD response patterns in the fear-expressing dACC-amygdala regions were highly predictive of long-term treatment outcome of iCBT, and the initial coupling between these regions differentiated long-term responders from nonresponders. The SVM-neuroimaging approach could be of particular clinical value as it allows for accurate prediction of treatment outcome at the level of the individual.
authors.affiliation: Division of Psychology, Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
authors.forename: K N T
authors.initials: KN
authors.lastname: Månsson
authors.affiliation: Department of Psychology, Uppsala University, Uppsala, Sweden.
authors.forename: A
authors.identifier: 0000000325169075
authors.initials: A
authors.lastname: Frick
authors.affiliation: 1] Centre for Population Studies, Ageing and Living Conditions, Umeå University, Umeå, Sweden [2] Umeå Center for Functional Brain Imaging (UFBI), Umeå University, Umeå, Sweden.
authors.forename: C-J
authors.initials: CJ
authors.lastname: Boraxbekk
authors.affiliation: 1] Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands [2] Department of Neuroimaging, Centre for Neuroimaging Sciences, Institute of Psychiatry, King's College London, London, UK.
authors.forename: A F
authors.initials: AF
authors.lastname: Marquand
authors.affiliation: Department of Neuroimaging, Centre for Neuroimaging Sciences, Institute of Psychiatry, King's College London, London, UK.
authors.forename: S C R
authors.initials: SC
authors.lastname: Williams
authors.affiliation: Department of Psychology, Stockholm University, Stockholm, Sweden.
authors.forename: P
authors.initials: P
authors.lastname: Carlbring
authors.affiliation: 1] Division of Psychology, Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden [2] Psychiatry Section, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
authors.forename: G
authors.initials: G
authors.lastname: Andersson
authors.affiliation: Department of Psychology, Uppsala University, Uppsala, Sweden.
authors.forename: T
authors.initials: T
authors.lastname: Furmark
mesh_terms: D000328:Adult; D001008:Anxiety Disorders / Q000503:physiopathology / Q000628:therapy*; D001921:Brain / Q000503:physiopathology*; D001931:Brain Mapping / Q000379:methods; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D020407:Internet; D000069550:Machine Learning; D008279:Magnetic Resonance Imaging; D008297:Male; D013813:Therapy, Computer-Assisted / Q000379:methods; D016896:Treatment Outcome