How Does Therapy for Anxiety Change the Brain?

By Grant H. Brenner

How does therapy work? We don’t exactly know how, though there are many factors: changing underlying emotional responses, desensitization to trauma, reworking ways of thinking about things, improving coping, increasing self-awareness and insight, understanding how developmental factors influence us in the present, optimizing factors related to lifestyle and outlook, and even epigenetic changes related to resolving traumatic experiences.

Because anxiety is such a common and growing problem, and a key part of many psychiatric conditions, including generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), personality disorders and traits including neurosis and turning anxiety inward, mood disorders including depression and bipolar disorder, ADHD (attention-deficit/hyperactivity disorder), OCD (obsessive-compulsive disorder), social anxiety, phobias, and many other conditions—and because anxiety is a powerful driver of behavior and coping—it’s crucial for us to understand what is happening in the brain when therapy works.

How we deal with anxiety makes or breaks whether we’ll be able to thrive and enjoy satisfaction in many areas of life. Excessive or poorly handled anxiety can interfere with therapy. For example, prior research identifies four pillars of effective therapy: self-acceptance, self-knowledge, better relationship quality, and increased consideration of others. High anxiety can undermine all of these processes in a variety of ways.

Neurobiological understanding also allows us to refine future therapeutic efforts, and identify common targets for therapy, biological treatments including psychiatric medications, and emerging interventions including transcranial magnetic stimulation (TMS) and other forms of non-invasive brain stimulation (NIBS), which may be used to turbo-charge therapy at some future-state.

Your Brain on Therapy

A recent review and synthesis of the literature on how treatment of anxiety with psychotherapy, therefore, comes at an opportune time. Researchers Shrammen and colleagues published in the journal Neuroscience and Biobehavioral Reviews (2022) the results of an extensive meta-analysis, pointing to the participation of prefrontal control areas (foundational for executive function) and fear-related limbic regions (ancient areas of the brain related to basic function and behavior).

Authors culled the literature on anxiety treatment with therapy and neuroimaging for references, distilling them down to a collection of high-quality research papers. Data from the research was pooled into a large set, which was statistically analyzed for significant correlations. The final sample included 22 data sets, including 419 participants, focusing on CBT (cognitive behavior therapy) or exposure therapy (used to treat fear by introducing triggers in smaller to large doses to extinguish exaggerated responses). The average number of sessions of therapy was about 8.5, and all studies reported significant anxiety symptom reduction, with a strong effect size of 1.24.

In terms of brain activity, differences were found in four areas: the anterior cingulate cortex (ACC), the right insula, and the left and right middle frontal gyrus (MFG), with peak activity in the dorsolateral prefrontal cortex (dlPFC) (incidentally the region targeted in TMS treatment of depression and anxiety).

In addition, significant correlations with anxiety reduction and decreased activity in the left supplementary motor area (SMA) were found. This area is one of the regions targeted in TMS for the treatment of OCD: Slowing down activity here is thought to interrupt rapidly looping neural circuits associated with both repetitive physical behaviors as well as intrusive, recurrent thoughts.

What Does It Mean?

These findings are important because they synthesize and confirm the prior work, setting the stage for future studies. Patients treated with therapy who show reduced anxiety have decreased activity in the limbic system, which includes brain areas like the amygdala known to be overactive in situations of threat and distress. Memory systems, notably the hippocampus, are negatively impacted by chronic elevated anxiety and stress, closely related with amygdala activity.

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Likewise, activity in the insula also decreased, an area of the brain related to physical and emotional disgust, both of oneself and things outside of oneself. In addition to anxiety, the authors note, these same brain areas are involved with depression, OCD, and PTSD. Together, the ACC and insula may network to increase how much attention—via the "salience network"—one pays to negatives related to anxiety sensitivity, excessive monitoring of aversive inner states, and related problems including body image distortions.

The ACC is important as a control mechanism, exerting “top-down” influence on emotional limbic regions to help regulate and suppress negative emotions when they threaten to spin out of control. Counterintuitively, activity in the executive dlPFC region was decreased—the proposed explanation is that this area may be hyperactive in regulating anxiety. Therefore, when anxiety is diminished, the PFC doesn’t need to be as active to keep the anxiety in check. This makes sense given that the ACC is more active, perhaps taking up some of the work the PFC was doing to compensate, but this requires further investigation.

Understanding that these brain regions work together as a network, rather than as standalone areas, is important in order to make sense of how therapy impacts the brain. There isn’t one “anxiety area"—the overall picture of anxiety for each of us depends on the complex interplay of many brain regions, both in terms of how strong we feel fear-based feelings, as well as how we cope and make sense of such experiences. Thinking of mental experience from the network perspective provides powerful conceptual tools for understanding wellness, illness, and treatment.

Future Directions

For people prone to anxiety—for example, those with neurotic personality traits—anxiety tends to be met with maladaptive coping. For instance, people who are prone to anxiety tend to use worry to cope with stress, rather than adopting a problem-solving mindset based in the reappraisal of the situation and identification of better choices. Therapy focuses on identifying such less resilient responses and learning more useful ways of approaching these challenges.

Over time, with effective treatment, how we deal with emotional dysregulation becomes more of a choice, a voluntary function, than an involuntary reaction. It’s not so different from learning how to perform a complicated physical activity, like dancing or juggling, but there’s nothing concrete to work with—making the emotional juggling act a bit more challenging conceptually.

Future study designs can look at how specific interventions impact brain activity directly in order to better understand which approaches have what effect on brain regions and networks. Understanding what works best, and for whom, is critical to personalizing treatment. In addition, the studies reviewed here focus on cognitive behavioral and exposure-based approaches. Furthermore, research suggests we can change personality traits by deliberate practice of preferred ways of behaving. Understanding how changing "personality habits" changes the brain is critical for helping people with personality disorders do and feel better in life and relationships.

However, traditional talk therapy ("psychodynamic therapy")—not covered in the above meta-analysis—focusing on understanding and insight, with less structure than CBT, also has been shown to be highly effective (Shedler, 2010). Psychodynamic therapy, rooted in psychoanalysis, addresses seven key domains:

1. Focus on affect and expression of emotion.
2. Exploration of attempts to avoid distressing thoughts and feelings.
3. Identification of recurring themes and patterns.
4. Discussion of past experiences (developmental focus).
5. Focus on interpersonal relations.
6. Focus on the therapy relationship.
7. Exploration of fantasy life.

Future research looking at a broader set of therapies to understand common pathways as well as ways they work differently is required to deeply understand and tailor treatments on an individual basis.

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