Social anxiety disorder is a diagnosis of unreasonable fear of embarrassment in social situations. People with social anxiety disorder often avoid social situations, thereby limiting the quality of their lives. Cognitive-Behavioral Therapy (CBT) uses cognitive reappraisal to reduce social anxiety through questioning irrational beliefs about feared outcomes. Mindfulness-Based Stress Reduction (MBSR) stresses the acceptance of thoughts, rather than altering them.
While CBT and MBSR are both effective in treating social anxiety disorder, it is not clear whether their benefits are due to unique or shared therapeutic elements. Goldin et al. [JAMA Psychiatry] conducted a randomized controlled trial of CBT and MBSR to test the efficacy of each program on anxiety among people with social anxiety disorder, and tested the neural activity associated with each program.
The researchers randomly assigned 108 unmedicated generalized social anxiety disorder patients (56% female; average age=33 years; 44% White; 39% Asian-American, 9% Latino, 9% Other) to CBT, MBSR, or a waitlist control. Patients completed self-report measures of anxiety symptoms at baseline, posttreatment, and one year follow-up, and an fMRI task at baseline and posttreatment.
CBT and MBSR were delivered in 12 weekly 2.5-hour group sessions. CBT included cognitive restructuring, exposure, and relapse prevention. MBSR used a standard 8-week protocol with four additional weekly sessions substituting for the all-day retreat.
Before undergoing functional brain imaging, participants wrote down scenarios for the social situations that personally caused them anxiety along with the negative self-beliefs associated with those scenarios. Participants then imagined the feared social situations and associated self-beliefs, and either reacted to, reappraised, or accepted them while undergoing imaging.
Brain regions selected for analysis were previously associated with cognitive restructuring and attentional regulation (e.g., prefrontal and anterior cingulate cortices).
Previously published results from this study showed CBT and MBSR both reduced social anxiety symptoms significantly more than waitlist controls at post-treatment and one-year follow-up. The effects of CBT and MBSR were equivalent in size.
CBT and MBSR groups showed similar significant reductions in negative emotions during reacting, reappraising, and accepting trials from pre- to post-testing (partial η2 range=0.38-0.53). These changes were significantly greater than changes in the control group.
Both treatment groups showed increased brain activation in regions of interest compared to controls, and these changes were similar across CBT and MBSR groups.
The study shows CBT and MBSR are similarly effective in reducing social anxiety compared to a wait-list control, and that improvement is maintained at one-year follow-up. It suggests that, despite contrasting models of therapeutic change, CBT and MBSR have overlapping effects on brain activity. Despite their application of differing strategies, they both refine awareness, weaken avoidant behavior, and decrease the influence of negative self-beliefs. Acceptance and reappraisal strategies may involve brain regions that share substantial overlap.
The study is limited by excluding other brain regions previously associated with MBSR that may differ from CBT.
Goldin, P. R., Thurston, M., Allende, S., Moodie, C., Dixon, M. L., Heimberg, R. G., & Gross, J. J. (2021). 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. JAMA Psychiatry.
Link to study