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Fluctuations of endogenous estrogen modulates fear extinction, but the influence of exogenous estradiol is less studied. Moreover, little focus has been placed on the impact of estradiol on broad network connectivity beyond the fear extinction circuit. Here, we examined the effect of acute exogenous estradiol administration on fear extinction-induced brain activation, whole-brain functional connectivity (FC) during the fear extinction task and post-extinction resting-state. Ninety healthy women (57 using oral contraceptives [OC], 33 naturally cycling [NC]) were fear conditioned on day 1. They ingested an estradiol or placebo pill prior to extinction learning on day 2 (double-blind design). Extinction memory was assessed on day 3. Task-based functional MRI data were ascertained on days 2 and 3 and resting-state data were collected post-extinction on day 2 and pre-recall on day 3. Estradiol administration significantly modulated the neural signature associated with fear extinction learning and memory, consistent with prior studies. Importantly, estradiol administration induced significant changes in FC within multiple networks, including the default mode and somatomotor networks during extinction learning, post-extinction, and during extinction memory recall. Exploratory analyses revealed that estradiol impacted ventromedial prefrontal cortex (vmPFC) activation and FC differently in the NC and OC women. The data implicate a more diffused and significant effect of acute estradiol administration on multiple networks. Such an effect might be beneficial to modulating attention and conscious processes in addition to engaging neural processes associated with emotional learning and memory consolidation.

The aim of this study was to determine the relationship between opioid prescriptions and number of chronic pain conditions in women with interstitial cystitis (IC).This was a cross-sectional study. Women diagnosed with IC based on International Classification of Diseases, Ninth Revision/Tenth Revision codes over an 11-year period (2010-2020) were identified from electronic medical records. Data on comorbidities and ambulatory opioid prescriptions were also extracted. Univariable and multivariable logistic regressions were used to assess the relationship between opioid prescriptions and the number and type of coexisting chronic pain conditions.Of the 1,219 women with IC, 207 (17%) had received at least 1 opioid prescription. The proportions of women with opioid prescriptions for no, 1, 2, and 3 or more coexisting chronic pain conditions were 13%, 20%, 28%, and 32%, respectively. On univariable analysis, factors significantly associated with opioid use were higher body mass index ( P0.001), depression ( P0.001), sleep disorder ( P0.001), endometriosis ( P0.05), chronic pelvic pain ( P0.001), fibromyalgia ( P0.05), joint pain ( P0.001), and number of coexisting chronic pain diagnoses ( P0.001). On multivariable analysis, opioid prescriptions remained significantly associated with the number of coexisting chronic pain diagnoses: 1 diagnosis (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.3-2.7), 2 diagnoses (aOR, 2.6; 95% CI, 1.6-4.3), 3 or more diagnoses (aOR, 2.5; 95% CI, 1.1-5.5), diagnosis of chronic pelvic pain (aOR, 2.1; 95% CI, 1.3-3.5), endometriosis (aOR, 2.4; 95% CI, 1.4-4.3), chronic joint pain (aOR, 1.8; 95% CI, 1.1-2.9), and sleep disorders (aOR, 2.4; 95% CI, 1.6-3.6).The likelihood of opioid prescriptions in women with IC increases with the number and type of coexisting chronic pain conditions and sleep disorders.

Objective To evaluate the psychometric and predictive performance of the Columbia-Suicide Severity Rating Scale (C-SSRS) in emergency department (ED) patients with suicidal ideation or attempts (SI/SA). Methods Participants (n = 1,376, mean age 36.8, 55% female, 76.8% white) completed the C-SSRS during the ED visit and were followed for one year. Reliability analyses, exploratory structural equation modeling, and prediction of future SA were explored. Results Reliability of the Suicidal Ideation subscale was adequate, but was poor for the Intensity of Ideation and Suicidal Behavior subscales. Three empirically derived factors characterized the C-SSRS. Only Factor 1 (Suicidal Ideation and Attempts) was a reliable predictor of subsequent SA, though odds ratios were small (ORs: 1.09-1.10, CI95% : 1.04, 1.15). The original C-SSRS Suicidal Ideation and Suicidal Behavior subscales and the C-SSRS ED screen predicted subsequent SA, again with small odds ratios (ORs: 1.07-1.19, CI95% : 1.01, 1.29). In participants without a SA history, no C-SSRS subscale predicted subsequent SA. History of any SA (OR: 1.98, CI95% : 1.43, 2.75) was the strongest predictor of subsequent SA. Conclusions The psychometric evidence for the C-SSRS was mixed. History of a prior SA, as measured by the C-SSRS, provided the most parsimonious and powerful assessment for predicting future SA.

OBJECTIVE: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theory to describe temporal patterns associated with multiple dimensions of suicidal ideation in a treatment-seeking sample of military personnel diagnosed with PTSD. METHOD: We performed a secondary analysis of archived data from 742 active duty military personnel (90% male, 57% white, mean age = 33 ± 7.4 years) enrolled in three clinical trials to examine the dimensional measurement properties of the first 5 items of the Scale for Suicidal Ideation (SSI). RESULTS: Findings indicated two change dynamics for suicidal ideation: homeostatic (i.e., the tendency for suicidal ideation to return to a stable point) and cyclical (i.e., the tendency for suicidal ideation to switch back and forth between higher and lower values). Cycling was the dominant dynamic, and was related to variables other from suicidal ideation. CONCLUSION: The cyclic nature of suicidal ideation suggests that assessment timing and context could influence observed associations with other variables. Analytic approaches and clinical methods that do not account for the temporal dynamics of suicide risk could miss these properties, thereby hindering efforts to identify mechanisms underlying the relationship between PTSD and suicidal thoughts and behaviors, and limiting opportunities for proactive and timely intervention. CLINICAL IMPACT STATEMENT: Suicidal ideation is multidimensional, with each dimension following different time courses. Cycling of suicidal ideation is pronounced among military personnel receiving treatment for PTSD. Recognizing these patterns could improve assessment and treatment by identifying critical periods of time during treatment that warrant suicide-focused interventions.

There is a relative lack of data regarding how patients weigh various factors when choosing a treatment strategy for interstitial cystitis/bladder pain syndrome (IC/BPS). Our aim is to describe patient experience with their current and prior treatments and discuss factors they consider when choosing a treatment. Twenty-one women with IC/BPS participated in five focus groups moderated by a psychologist. Focus groups were conducted until thematic saturation was reached. Group discussions were transcribed and independently coded by two reviewers. Emergent themes and concepts were identified using grounded theory methodology. Data on symptoms and beliefs regarding medications were collected using validated questionnaires: Interstitial Cystitis Symptom and Problem Index (ICSI and ICPI) and Beliefs in Medications Questionnaire-Specific (BMQ-S). The median age of participants was 42 years, and all had some college education. Median score (range) for the ICSI was 12 (4, 20) and for the ICPI was 10 (3, 16), indicating moderate symptom burden. Most patients had tried only first- or second-line treatments. The median BMQ-S score was 2, indicating a neutral attitude toward medication. Several themes were identified. Patients expressed interest in self-management of symptoms using a structured care plan that incorporates guided self-care practices and care that can be delivered virtually. Patients desired to minimize treatment side effects by reducing prescription medications and avoiding surgical procedures. Finally, patients had considerable interest in alternative treatments; however, they wanted these treatments to be evidence-based. Women with IC/BPS have a strong interest in guided programs that teach self-care practices and deliver alternative treatments through remote platforms.

The efficacy of prolonged exposure (PE) on suicide ideation (SI) as a secondary outcome among individuals with posttraumatic stress disorder (PTSD) is unclear. The purpose of this study was to compare the efficacy of PE in two formats (spaced, S-PE, 10 sessions over 8 weeks, and massed, M-PE, 10 sessions over 2 weeks) to Present Centered Therapy (PCT) and minimal contact control (MCC) on SI exacerbation among patients without suicide intent or plans. Active duty military personnel (n = 335) were randomized to: (1) S-PE vs. PCT and (2) M-PE vs. MCC. All participants completed the Beck Scale for Suicide Ideation and the Beck Depression Inventory (Suicide item) at baseline, posttreatment, and follow-ups. S-PE and PCT had significant and comparable reductions in SI during treatment. M-PE had significantly steeper reductions in SI during treatment compared to MCC. Specifically, more participants in M-PE compared to MCC had reliable improvement versus reliable exacerbation. Reduction in PTSD symptoms was significantly associated with reduction of SI. PE was associated with significant reductions in SI over time that were comparable to PCT and superior to MCC. These findings suggest that both trauma- and non-trauma-focused treatments are associated with reductions in SI, and that trauma-focused treatments improve SI relative to waitlist.

Background Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study. Methods Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported. Results The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts. Limitations The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study. Discussion OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Background Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and behavior. However, less is known about how the PTSD symptom clusters, namely alterations in arousal and reactivity (AAR), negative alterations in cognitions and mood (NACM), avoidance, and intrusion, uniquely relate to suicidal ideation. This study aimed to characterize the associations among suicidal ideation and these symptom clusters. Methods Study 1 (n = 346) and Study 2 (n = 194) included community members and treatment-seeking adults at an anxiety specialty clinic, respectively. Participants completed measures of trauma exposure, PTSD symptoms, and suicidal ideation. Results In both studies, suicidal ideation significantly and positively correlated with all PTSD factors. In Study 1, Wald tests of parameter constraints indicated that NACM and AAR had the strongest associations with suicidal ideation, followed by intrusion and avoidance. Results were replicated when restricting the sample to individuals with probable PTSD. In Study 2, suicidal ideation significantly and positively correlated with all PTSD factors; there were no differences in the strength of the suicidal ideation-PTSD factors relations. Limitations The studies were cross-sectional and relied on a single-item measure of suicidal ideation. Discussion All PTSD factors significantly and positively correlated with suicidal ideation, and the NACM and AAR PTSD clusters were most strongly associated with suicidal ideation in Study 1. Therefore, clinicians should be cautious to thoroughly screen patients with elevations on these PTSD cluster scores for suicide risk.

COVID-19 pandemic is a global calamity posing an unprecedented opportunity to study resilience. We developed a brief resilience survey probing self-reliance, emotion-regulation, interpersonal-relationship patterns and neighborhood-environment, and applied it online during the acute COVID-19 outbreak (April 6–15, 2020), on a crowdsourcing research website (www.covid19resilience.org) advertised through social media. We evaluated level of stress (worries) regarding COVID-19: (1) contracting, (2) dying from, (3) currently having, (4) family member contracting, (5) unknowingly infecting others with (6) experiencing significant financial burden following. Anxiety (GAD7) and depression (PHQ2) were measured. Totally, 3042 participants (n = 1964 females, age range 18–79, mean age = 39) completed the resilience and COVID-19-related stress survey and 1350 of them (mean age = 41, SD = 13; n = 997 females) completed GAD7 and PHQ2. Participants significantly endorsed more distress about family contracting COVID-19 (48.5%) and unknowingly infecting others (36%), than getting COVID-19 themselves (19.9%), p 10, 22.2%) and depression (PHQ2 > 2, 16.1%) did not differ between healthcare providers and non-healthcare providers. Higher resilience scores were associated with lower COVID-19 related worries (main effect F1,3054 = 134.9; p

OBJECTIVE Machine learning algorithms in electronic medical records can classify patients by suicide risk, but no research has explored clinicians' perceptions of suicide risk flags generated by these algorithms, which may affect algorithm implementation. The objective of this study was to evaluate clinician perceptions of suicide risk flags. METHODS Participants (n = 139; 68 with complete data) were mental health clinicians recruited to complete online surveys from October 2018 to April 2019. RESULTS Most participants preferred to know which features resulted in a patient receiving a suicide flag (94.12%) and reported that knowing those features would influence their treatment (88.24%). Clinicians were more likely to report that some algorithm features (increased thoughts of suicide) would alter their clinical decisions more than others (age, physical health conditions; χ² = 270.84, P < .001). Clinicians were more likely to report that they would create a safety/crisis response plan in response to a suicide risk flag compared to other interventions (χ² = 227.02, P < .001), and 21% reported that they would complete a no-suicide contract following a suicide risk flag. CONCLUSIONS Clinicians overwhelmingly reported that suicide risk flags in electronic medical records would alter their clinical decision making. However, clinicians' likelihood of acting in response to a suicide risk flag was tied to which features were highlighted rather than the presence of the risk flag alone. Thus, the utility of a suicide risk algorithm will be reduced if clinical features underlying the algorithm are hidden from clinicians or if clinicians do not view the clinical features as intuitively meaningful predictors of suicide risk.

While psychiatric disorder prevalence is higher among patients living with HIV (PLWH), there are no prior studies on rates of psychiatric diagnosis documentation in electronic medical records (EMRs) of PLWH, which was the goal of this study. Participants (n = 2,336) were enrolled in the Center for AIDS Research (CFAR) Longitudinal Database study. Diagnostic codes were extracted to assess the prevalence rates of depressive, alcohol/substance use, PTSD, sleep, and adjustment disorders. Prevalence rates for psychiatric disorders were extracted from national epidemiological studies for comparison. Rates of Major Depressive Disorder in the EMR were comparable to prior epidemiological reports in PLWH. In contrast, rates of PTSD, substance use, alcohol use, adjustment, and insomnia disorders were all markedly lower compared to epidemiological studies. While clinicians appropriately documented depression, other psychiatric comorbidities were largely overlooked. This indicates a potential bias in the detection or documentation of psychiatric disorders in PLWH.

Suicide rates among youths in foster care are among the highest in the United States. Despite this fact, many foster-care agencies do not perform universal suicide-risk assessments as part of routine care. This commentary includes an argument for the importance of implementing universal suicide-risk assessments for youths in foster care. Important contextual information that prevents behavioral-health clinicians from implementing universal suicide screenings of youths in foster care is discussed. Several possible strategies for implementing universal suicide-risk assessments are offered; the pros and cons of each strategy are discussed. The perspectives of multiple stakeholders should be included in the consideration of universal suicide screening for youths in foster care, including behavioral-health providers, primary-care doctors, supervisors, directors of agencies, foster parents, and case managers. Although each of these stakeholders can improve suicide prevention, youths in foster care may not have regular access to each stakeholder. Case managers may be the optimal stakeholders for implementing universal suicide screening because of their frequent access to youths in foster care; therefore, case managers should receive training in suicide-risk assessment and prevention strategies.

BackgroundFew studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT).MethodsParticipants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership.ResultsFive classes, namely rapid responder (7–17%), steep linear responder (14–22%), gradual responder (30–34%), non-responder (27–33%), and symptom exacerbation (7–13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT.ConclusionsDistinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.

INTRODUCTION: Distress intolerance (DI), one’s perceived or behavioral incapacity to withstand distress, is implicated in psychopathology and smoking. This study evaluated the effect of DI on smoking reinforcement in the context of a carbon dioxide (CO(2)) biological challenge. METHODS: Adult daily smokers (n = 90; 48.9% female) were randomized to receive a single inhalation/breath of 35% CO(2)-enriched air (n = 45) or compressed room air (n = 45). Perceived DI was assessed before the challenge. Smoking reinforcement was examined via average post-challenge puff volume across puffs and at the puff-to-puff level. RESULTS: Higher DI was associated with an increased average puff volume (b = −4.7, p = .031). CO(2) produced decreased average puff volume compared with room air (b = −7.7, p = .018). There was a DI* condition interaction (ƒ(2) = 0.02), such that CO(2) decreased average puff volume compared with room air in smokers with higher DI (b = −13.9, t = −3.06, p = .003), but not lower DI. At the puff-to-puff level, there was a significant interaction between DI, condition, and cubic time (b = 0.0003, p =. 037). Specifically, room air produced large initial puff volumes that decreased from puff to puff over the cigarette for high- and low-DI smokers. CO(2) produced persistent flat volumes from puff to puff over the cigarette for higher DI smokers, whereas CO(2) produced puff volumes like that of room air in lower DI smokers. DISCUSSION: Findings suggest DI heightens smoking reinforcement generally, and in the context of intense cardiorespiratory distress, is associated with stable and persistent smoking. DI is a promising therapeutic target that, if addressed through psychological intervention, may improve cessation outcomes by decreasing smoking reinforcement. IMPLICATIONS: This study contributes to our understanding of the relationship between DI and smoking reinforcement, via examining these processes in response to acute cardiorespiratory distress. Specifically, we found that smokers who are less tolerant of distress, as opposed to those who are more tolerant, evince a decrease in average puff volume, and consistently low puff-to-puff volume, in response to a biological stressor. These findings suggest that smokers high in DI alter smoking behavior following acute cardiorespiratory distress, perhaps to reduce overstimulation, yet also persist in smoking in a manner that suggests an inability to achieve satiation.

While several empirically supported treatments for posttraumatic stress disorder (PTSD) have been developed, these treatments are neither widely available nor universally efficacious. This pilot, proof of concept study evaluated a computerized imaginal exposure Script-Driven Imagery Training (SDI-T) for individuals with elevated trauma reactivity. The training was supplemented with two forms of linguistic processing, affect labeling (SDI-T + AL) and distraction (SDI-T + D), to determine whether linguistic inhibitory regulation augmented the effects of SDI-T.Participants (n = 64) with trauma-related distress were randomized to SDI-T, SDI-T + AL, or SDI-T + D. Physiology and self-reported trauma distress were measured at pre- and post-training.The training was acceptable to participants and effective at reducing self-reported distress (d = -0.41), and physiological activation from pre- to post-training (d = -0.49, ps .01), with some evidence that linguistic processing (SDI-T + AL and SDIT-T + D) conferred a benefit over SDI-T. The linguistic processing groups had significantly steeper reduction in physiology relative to the non-linguistic processing group (p .05, d = 0.59). There was no benefit of SDI-T + AL over SDI-T + D.This pilot study provides initial support for the acceptability and efficacy of computerized imaginal exposure training for PTSD. Clinical implications and future directions are discussed.

Background Most individuals experience more than one trauma. Hence, it is important to consider the count and types of traumas (polytraumatization) in relation to post-trauma mental health. Method The current study examined the relation of polytraumatization patterns to PTSD clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], and alterations in arousal and reactivity [AAR]), depression, and impulsivity facets (lack of perseverance, lack of premeditation, negative urgency, sensation seeking) using a web-based sample of 346 participants. Age, gender, race, and ethnicity were covariates. Results Results of latent class analyses indicated a three-class solution: Low Experience, Moderate Experience – Predominent Threat/Indirect PTEs (Moderate Experience), and High Experience – Predominant Interpersonal PTEs (High/Interpersonal). Multinomial logistic regression results indicated that ethnicity and gender were significant covariates in predicting Low versus High/Interpersonal Class, and Moderate Experience versus High/Interpersonal Class membership, respectively. The High/Interpersonal Class had higher scores on most PTSD clusters, depression, and the impulsivity facets of lack of perseverance and negative urgency compared to the other classes. The Low and Moderate Experience Classes differed on PTSD's avoidance and AAR clusters (lower in the former). Conclusions Individuals exposed to multiple PTE types, particularly interpersonal traumas, may be at risk for more severe post-trauma symptoms.

Background Little is known about panic attacks and puffing topography, a behavioral index of the value of smoking reinforcement. This study examined smoking style during the course of smoking of a single cigarette among adult daily smokers with and without a history of panic attacks. Method Participants (n = 124, Mage = 43.9, SD = 9.7; 44.4% female) were non-treatment seeking daily smokers. Lifetime panic attack history was assessed via diagnostic assessment; 28.2% (n = 35) of the sample had a panic attack history. Participants smoked one cigarette during an ad libitum smoking trial. Puff volume, duration, and inter-puff interval were measured using the Clinical Research Support System (CReSS) pocket device. Results Regression analyses revealed that panic attack status was not associated with significant differences in average puff volume, duration, or inter-puff interval. Multi-level modeling was used to examine puffing trajectories. Puff-level data revealed that there was a significant quadratic time x panic effect for puff volume and duration. Those with a panic attack history demonstrated relatively sustained levels of both puff volume and duration over time, whereas those without a history of panic attacks demonstrated an increase followed by a decrease in volume and duration over time. These effects were not accounted for by the presence of general psychopathology. Discussion Smokers with a panic attack history demonstrate more persistent efforts to self-regulate the delivery of nicotine, and thus may be at risk for continued smoking and dependence. Tailored treatment may be needed to address unique vulnerabilities among this group.

Background Exaggerated anticipatory anxiety is common in social anxiety disorder (SAD). Neuroimaging studies have revealed altered neural activity in response to social stimuli in SAD, but fewer studies have examined neural activity during anticipation of feared social stimuli in SAD. The current study examined the time course and magnitude of activity in threat processing brain regions during speech anticipation in socially anxious individuals and healthy controls (HC). Method Participants (SAD n=58; HC n=16) underwent functional magnetic resonance imaging (fMRI) during which they completed a 90 s control anticipation task and 90 s speech anticipation task. Repeated measures multi-level modeling analyses were used to examine group differences in time course activity during speech vs. control anticipation for regions of interest, including bilateral amygdala, insula, ventral striatum, and dorsal anterior cingulate cortex. Results The time course of amygdala activity was more prolonged and less variable throughout speech anticipation in SAD participants compared to HCs, whereas the overall magnitude of amygdala response did not differ between groups. Magnitude and time course of activity was largely similar between groups across other regions of interest. Limitations Analyses were restricted to regions of interest and task order was the same across participants due to the nature of deception instructions. Conclusions Sustained amygdala time course during anticipation may uniquely reflect heightened detection of threat or deficits in emotion regulation in socially anxious individuals. Findings highlight the importance of examining temporal dynamics of amygdala responding.

OBJECTIVE: Adolescents with posttraumatic stress disorder (PTSD) are at higher risk for suicide compared to adolescents without PTSD. This study aimed to explore whether PTSD treatment reduces suicidal ideation in adolescents, and whether the degree of reduction in PTSD was associated with reduction in suicidal ideation. METHODS: Adolescent females with PTSD from a sexual assault (55% Black, 15.3 years, SD = 1.5) were randomized to either prolonged exposure therapy for adolescents (PE-A, n = 31) or client-centered therapy (CCT, n = 30). They reported on suicidal ideation, depression and PTSD at pre- and post-treatment, every therapy session, and follow-up, and about 40% endorsed suicidal ideation at baseline. RESULTS: There was a significant reduction in a single-item measure of suicidal ideation during treatment across all participants. The Time in Treatment × Condition interaction was significant (p < .05, d = 0.52), indicating a significantly steeper reduction in suicidal ideation in PE-A compared to in CCT. The degree of reduction in PTSD (ps < .05, d = 0.26 – 0.54) and depression symptoms (ps < .05, d = 0.54 – 0.81) in treatment and follow-up was associated with the speed of suicidal ideation reduction in treatment and follow-up. CONCLUSIONS: Adolescents randomized to PE-A had significantly faster reductions in suicidal ideation compared to those randomized to CCT. Greater reduction in PTSD and depression symptoms was associated with faster reduction in suicidal ideation. Clinically, this study demonstrates that adolescents who have suicidal ideation without current intent may benefit from PE-A.

Self-referential processing is critical to understanding social anxiety disorder (SAD). This study examined neural differences in self-referential processing in healthy controls (HC) and participants with SAD at pre- and post-treatment. Participants (n = 64) underwent fMRI scanning while viewing a video of themselves (“Self”) or another person (“Other”). SAD participants were randomized to cognitive behavior therapy (CBT), acceptance and commitment therapy (ACT), or waitlist, and were re-scanned at post-treatment. In SAD vs. HC, the fusiform face area (FFA) showed significantly more activation during Self vs. Other, and greater SAD severity was associated with significantly more activation during Self vs. Other in the right FFA and the left extrastriate body area (EBA). Greater reduction in SAD severity was associated with stronger connectivity between the amygdala and FFA during Self vs. Other at post-treatment, whereas the strength of connectivity during Self and Other was comparable at post-treatment for those with less SAD reduction. Thus, there were significant differences in activation and functional connectivity of brain regions implicated in self-referential processing in SAD. Change in connectivity between the amygdala and FFA were observed as a function of change in SAD severity, suggesting that improvements in SAD severity may correct this altered functional connectivity.

Violation of unconditioned stimulus (US) expectancy during extinction training may enhance associative learning and result in improved long-term extinction retention compared to within-session habituation. This experiment examines variation in US expectancy (i.e., expectancy violation) as a predictor of long-term extinction retention. It also examines within-session habituation of fear-potentiated startle (electromyography, EMG) and fear of conditioned stimuli (CS) throughout extinction training as predictors of extinction retention. Participants (n = 63) underwent fear conditioning, extinction and retention and provided continuous ratings of US expectancy and EMG, as well as CS fear ratings before and after each phase. Variation in US expectancy throughout extinction and habituation of EMG and fear was entered into a regression as predictors of retention and reinstatement of levels of expectancy and fear. Greater variation in US expectancy throughout extinction training was significantly predictive of enhanced extinction performance measured at retention test, although not after reinstatement test. Slope of EMG and CS fear during extinction did not predict retention of extinction. Within-session habituation of EMG and self-reported fear is not sufficient for long-term retention of extinction learning, and models emphasizing expectation violation may result in enhanced outcomes.

Panic attacks occurring outside of Panic Disorder are not well-understood despite their inclusion as a diagnostic specifier in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). This study compares panic attacks in the context of Panic Disorder compared to social anxiety in terms of their symptom frequency, severity, and clinical correlates. Method: Participants ( n =404) were interviewed using the Anxiety Disorders Interview Schedule (ADIS-IV-L; Brown et al., 1994), from which we analyzed interviewer ratings of panic attacks and panic attack symptoms, as well as other demographic and clinical characteristics. Results: Panic attacks in the context of Panic Disorder were characterized by a greater number and severity of symptoms compared to panic attacks in the context of Social Anxiety Disorder, and were associated with a history of traumatization, inpatient psychiatric treatment, and benzodiazepine use. Social anxiety panic attacks were associated with reduced physical health concerns. Cognitive panic attack symptoms were more prevalent in Panic Disorder and were associated with a variety of poor clinical correlates. Conclusions: Panic attacks in the context of Panic Disorder are more severe than those in social anxiety, and this may be driven by cognitive disturbances during those attacks.

Posttraumatic stress disorder (PTSD) is associated with significantly greater risk for suicidal ideation (SI). In civilians, the negative alterations in cognitions and mood (NACM) and alterations in arousal and reactivity (AAR) clusters are most strongly associated with SI. This study sought to examine the association between PTSD symptom clusters and SI in a large sample of veterans. Veterans (n = 1,789) completed the PTSD Checklist for DSM-5 and the Patient Health Questionnaire (PHQ) during primary care visits. Wald chi-square tests of parameter constraints were computed to test hypothesized relations between PTSD factors and the PHQ-9 suicidal ideation item. Each of the PTSD symptom clusters were significantly associated with SI. The NACM cluster was more strongly associated with SI than AAR and marginally more strongly associated with SI than the avoidance symptom clusters. In a restricted sample of only veterans with PTSD, NACM remained more strongly associated with SI than avoidance. Each of the NACM symptoms were significantly associated with SI. Changes in cognitions and mood were most strongly associated with SI in this large sample of veterans. These findings suggest that directly targeting the NACM symptom cluster may be an important goal for suicide prevention efforts among veterans with PTSD.

The current study examined the role of trauma-related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present-centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check-in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178-.387, ds = -0.02-0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = -0.19 to -0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = -0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma-related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.

Background Anxiety disorders commonly co-occur with suicidal ideation (SI). To our knowledge, no studies have reported on the baseline prevalence of SI and the reduction in SI in a naturalistic sample receiving cognitive behavior therapy (CBT) for anxiety-related disorders. Methods Participants (n = 355) recruited from an anxiety specialty clinic reported SI at pre-, mid-, and post-CBT. Multilevel mixed effects logistic regression models compared differences in SI endorsement over Time. Results Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) were associated with significantly elevated baseline SI relative to specific phobia. PTSD and unspecified anxiety-related disorders were associated with significant reductions in SI, whereas reductions in SAD, GAD, OCD, and panic disorder did not reach significance. Rates of new onset and exacerbation of SI were low. Discussion CBT for anxiety disorders was associated with significant reductions in SI over time, with no evidence for exacerbation of suicide risk. Clinical implications are discussed, as well as future research directions to further understand the effect of anxiety disorder treatments on SI.

Background Natural disasters are associated with a variety of negative health consequences, including enhanced suicide risk. Factors that moderate the relationship between disaster exposure and enhanced suicide risk are unknown. The aim of the current study was to determine whether pre-disaster PTSD moderates the association between change over time in thoughts of death, suicidal ideation (SI), suicide plans, and suicide attempts (SA) from pre- to post-disaster. Methods Participants (n = 2832) were recruited from Chile as part of the larger PREDICT study and completed a measure of lifetime PTSD and panic disorder at baseline and a lifetime death/suicide measure at baseline in 2003 and again 6, 12, and 24 months later (i.e. “pre-disaster”). One year following a major earthquake and tsunami in 2010 (i.e., “post-disaster”), participants completed another death/suicide measure. Results Both those with and without pre-disaster PTSD experienced significant increases in SI from pre- to post-disaster. However, pre-disaster PTSD was associated with significantly accelerated increases in thoughts of death and SI from pre-to post-disaster. At nearly all time-points, pre-disaster PTSD was associated with higher thoughts of death and SI, suicide planning, and SA. In contrast, panic disorder did not moderate the association between time and changes in SI. Limitations There was a long time-gap between pre-disaster and post-disaster, with limited data about what occurred during this time. Conclusion Pre-disaster PTSD is an important predictor of increased SI following a natural disaster, and groups with pre-disaster PTSD should be prioritized for receipt of mental health resources following a natural disaster.

Anxiety disorders are associated with pervasive functional impairment. The cost to society in income or productivity loss for patients who meet criteria for one of these disorders was $46.6 billion in 1990 (DuPont et al. 1996). In addition to the financial burden, patients with anxiety disorders experience interpersonal problems such as marital discord and other family and social problems (Markowitz et al. 1989; Lochner et al. 2003), education problems (Stein et al. 1997; Wittchen et al. 2000), and increased use of non-prescription drugs (Lochner et al. 2003). Thus, the functional impairment associated with anxiety disorders is as important to understand and address as the symptoms of anxiety. Throughout this paper, for the sake of clarity, symptoms will be referred to throughout as anxiety and depression characteristics that are operationalized in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), including physical, behavioral, and cognitive disturbances. Functioning will refer to activities of daily living such as the ability to work or attend school, or fulfill social or familial obligations. The relationship between symptom severity and functional impairment in patients with anxiety disorders is not as straightforward as might be expected. For instance, while the majority of studies demonstrate that the frequency of panic attacks or number of depression symptoms is predictive of disability (Katerndahl & Realini, 1997; Rubin et al. 2000; Chan et al. 2009), others have found that the frequency of panic attacks is not correlated with functioning (Michelson et al. 1998). In addition, the number of anxiety symptoms endorsed accounts for only a small percentage of variance in quality of life or functioning (Leon et al. 1992; Michelson et al. 1998; Rapaport et al. 2005). These data suggest that improvements in functioning are unlikely to occur merely through symptom reduction. Improvement in functioning is often measured as a sign of treatment effectiveness. A number of studies of pharmacological treatment report significant improvements on measures of functioning alongside improvements on symptom measures for anxiety disorders (Jacobs et al. 1997; Lecrubier & Judge, 1997; Mavissakalian et al. 1998; Michelson et al. 1998; Malik et al. 1999; Stein et al. 1999). However, the situation is complicated by other studies that fail to find differences in functioning between patients receiving medication versus placebo (Hoehn-Saric et al. 1993) or find differences on self-report measures of functioning but fail to find differences on clinician-rated measures of functioning (Michelson et al. 1998). Evidence for changes in functioning from pre- to post- cognitive behavior therapy (CBT) is more limited, particularly compared to other active treatments, but several studies indicate improved quality of life for patients with anxiety disorders following CBT (Safren et al. 1996; Moritz et al. 2005; Arch et al. 2012). Some studies indicate equivalent improvements in functioning following CBT compared to pharmacotherapy (Kilic, Noshirvani, Basoglu, & Marks, 1997). Few studies have attempted to parse the complicated relationship between symptom levels and functional impairment. Those that have only examine unidirectional relationships, typically by examining whether improvements in symptom levels predict improvements in functioning. The results from such studies have been contradictory. On the one hand, several studies show that symptom improvements are associated with, or predict, functional improvement, following pharmacotherapy (Jacobs et al. 1997) and CBT (Telch et al. 1995; Moritz et al. 2005). On the other hand, other studies fail to substantiate the link between symptom and functional impairment outcomes (Tenney et al. 2003; Monson et al. 2006). No study to our knowledge has simultaneously analyzed the predictive role of symptom improvement on functioning while examining the role of functional improvement on symptom alleviation. This is an essential question that has clear implications for treatment development. If functional improvement is a stronger predictor of symptom reduction than the converse, then clinicians would be encouraged to target ways of improving functioning in patients’ daily lives early in the treatment process. Alternatively, if symptom alleviation more strongly predicts functional improvement, clinicians would be justified in dedicating more time to targeting symptom alleviation from the onset of treatment. The current study aimed to evaluate the bidirectional nature of the relationship between symptoms and functioning. We used data from a sample of patients with principal anxiety disorders presenting to their primary care physicians as part of the Coordinated Anxiety Learning and Management (CALM; Roy-Byrne et al. 2010; Craske et al. 2011) study. Analyses were conducted on data covering an 18-month period, providing an extended time period to capture changes in both functioning and symptoms. The primary hypothesis was that symptom levels at a given time point would predict functioning at the subsequent time point, and simultaneously that functioning at a given time point would predict symptom levels at a subsequent time point.

Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of behavioral activation and acceptance and commitment therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to 6 months of Acceptance-Based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through posttreatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.

Although the relationships between PTSD, abuse history, and suicidal behaviors are well-established in military and outpatient samples, little data is available on this relationship in inpatient samples. This study examines the relationships between these variables and related demographic and clinical correlates in a sample of psychiatric inpatients with a diagnosis of major depressive disorder using electronic medical record (EMR) data. Controlling for relevant demographic and clinical variables, PTSD diagnosis and history of abuse were both significantly associated with history of suicide attempt, but in a combined model, only history of abuse remained as a significant predictor. Whereas history of abuse was associated with a history multiple suicide attempts, PTSD diagnosis was not. Both insurance status and gender acted as significant moderators of the relationship between history of abuse and history of suicide attempt, with males and those with public/no insurance having greater associations with history of suicide attempts when an abuse history was present. These data indicate the importance of documentation of PTSD, abuse history, and history of suicide attempts. The results also suggest that in the presence of an abuse history or PTSD diagnosis, additional time spent on safety and aftercare planning following hospital discharge may be indicated.

Critical thinking is assumed to be an important factor in the promotion of evidence-based treatment practices. However, little is known about attitudinal and other dispositional factors that may influence critical thinking in psychotherapists specifically. The aim of the current study was to identify factors associated with critical thinking abilities in psychotherapists. A total of 143 licensed psychotherapists completed an Internet-based survey that assessed their critical thinking ability. Hierarchical regression analyses indicated that critical thinking ability was associated with theoretical orientation, reliance on intuition in decision-making, and endorsement of erroneous beliefs about health. Implications for improving critical thinking skills in psychotherapists are discussed.

Many university students suffer from test anxiety that is severe enough to impair performance. Given mixed efficacy results of previous cognitive-behavior therapy (CBT) trials and a theoretically driven rationale, an acceptance-based behavior therapy (ABBT) approach was compared to traditional CBT (i.e., Beckian cognitive therapy; CT) for the treatment of test anxiety. In this pilot study, 16 university students with test anxiety were randomly assigned to receive either a CT or ABBT 2-hr group workshop. The two treatments produced markedly different effects on test performance (measured by exam scores), with those receiving ABBT experiencing improvements in performance, whereas those receiving CT exhibited reduced performance. In addition, there was a suggestion that ABBT might have been more effective at reducing subjectively experienced test anxiety (i.e., a nonsignificant but medium-sized group by time interaction effect). Implications of these results for the treatment of test anxiety and for theoretical notions related to cognitive change strategies are discussed.

ObjectiveThe presence of anxiety disorders is associated with poorer alcohol use disorder treatment outcomes, but little is known about the impact of alcohol use problems on anxiety disorder treatment outcomes despite their high comorbidity. The current study examined the impact of alcohol use symptom severity on anxiety disorder treatment outcomes in a multi-site primary care effectiveness study of anxiety disorder treatment.MethodData came from the Coordinated Anxiety Learning and Management (CALM) effectiveness trial. Participants (N=1004) were randomized to an evidence-based anxiety intervention (including cognitive behavioral therapy and medications) or usual care in primary care. Participants completed measures of alcohol use, anxiety, and depression at baseline, 6-, 12-, and 18-month follow-up periods. Patients with alcohol dependence were excluded.ResultsThere were no significant moderating (Treatment Group × Alcohol Use Severity) interactions. The majority of analyses revealed no predictive effects of alcohol use severity on outcome; however, alcohol problems at baseline were associated with somewhat higher anxiety and depression symptoms at the 18-month follow-up.ConclusionsThese data indicate that patients with alcohol problems in primary care can be effectively treated for anxiety disorders. Baseline alcohol problems were associated with some poorer long-term outcomes, but this was evident across CALM and usual care. These findings provide preliminary evidence that there may be no need to postpone treatment of anxiety disorders until alcohol problems are addressed, at least among those who have mild to moderate alcohol problems. Replication with more severe alcohol use disorders is needed.

There has been much discussion in the literature recently regarding the conceptual and technical differences between so-called second- (e.g., Beckian cognitive therapy) and third-wave (e.g., acceptance and commitment therapy) behavioral therapies. Previous research has not addressed the potential similarities and differences among the practitioners of these types of approaches. The current study examined possible differences in the characteristics of second-wave ( n = 55) and third-wave cognitive-behavioral therapists ( n = 33) using an Internet-based survey. There were differences found at the technical level between the two groups. As expected, third-wave therapists reported greater use of mindfulness/acceptance techniques. Also, third-wave therapists reported greater use of exposure techniques and second-wave therapists reported greater use of cognitive restructuring and relaxation techniques. In general, third-wave clinicians were more eclectic at the technical level and demonstrated significantly greater use of family systems techniques, existential/humanistic techniques, and the total number of techniques. No significant differences were found on the attitudinal measures administered, including reliance on an intuitive thinking style, acceptance of complementary and alternative therapies and related health beliefs, or most attitudes toward evidence-based practices. The authors did not identify many differences between second-wave and third-wave therapists other than in terms of the techniques they employ. The clinical and research implications for these findings are discussed.

Despite increasing dissemination efforts, many psychotherapists still do not use treatments that are supported by research. Some have claimed that psychotherapists rely more on their clinical intuition than scientific evidence when making treatment decisions, but there is a paucity of research on this topic. The aim of the study was to examine the relationship between intuition and therapists' attitudes towards evidence-based practices (EBPs).Psychotherapists from diverse professional backgrounds completed an Internet-based survey that assessed EBP attitudes, reliance on an intuitive thinking style, attitudes about alternative therapies and endorsement of erroneous health beliefs that are not supported by scientific evidence.Regression analyses showed that an intuitive thinking style was associated with several dimensions of EBP attitudes, including more negative attitudes towards research, less openness to research-based treatments, and less willingness to use evidence-based treatments if required to do so, even after controlling for background factors such as education level. Furthermore, a tendency to rely on intuition was associated with more positive attitudes towards alternative therapies and the endorsement of erroneous health beliefs.Most dissemination efforts targeted at psychotherapists focus only on education about EBPs. However, results of this study suggest that dissemination efforts may need to more directly address the potential barriers to using EBPs (i.e. reliance on intuition) to be optimally effective in changing therapists' attitudes and behaviours.

The purpose of this study was to determine if anxiety-mediated gait adaptations can reduce the risk for falling among younger and older adults. Fourteen younger adults (23.14 ± 3.08 years) and 14 older adults (69.28 ± 5.41 years) participated in this study. Participants were asked to walk the length of a 7.20 m walkway and avoid contact with an obstacle that appeared suddenly underfoot at either 25% or 75% of the gait cycle duration. Testing was conducted in four conditions of postural threat. The obstacle was presented as a light beam and did not jeopardize balance when contacted. Fall risk was inferred from the frequency of obstacle contacts. Our findings indicated that obstacle contact frequency decreased when conservative gait patterns emerged. These findings imply that anxiety-mediated gait adaptations are beneficial in reducing the risk for falling among older adults and present the possibility that fear of falling may offer protective benefits for postural control. One possibility is that the beneficial effects of anxiety can only be realized among older adults who do not fear falling.