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Patients with posttraumatic stress disorder (PTSD) tend to overgeneralize threat to safe stimuli, potentially reflecting aberrant stimuli discrimination. Yet, it is not clear whether threat overgeneralization reflects general discrimination deficits, or rather a specific bias related to aversive stimuli. Here we tested this question and characterized the neural correlates of threat discrimination.One-hundred and eight participants (33 PTSD; 43 trauma-exposed controls; 32 healthy controls) completed an emotionally neutral complex shape discrimination task involving identifying in 42 similar pairs the previously observed shape; and an emotionally aversive discrimination task, involving providing risk ratings for an aversive conditioned stimulus (CS+), and for several stimuli gradually differing in size from the original CS+. Resting state functional connectivity (rsFC) was collected before completing the tasks.No group differences emerged on the emotionally neutral task. Conversely, on the emotionally aversive task, individuals with PTSD had steeper linear risk rating slopes as the stimuli more resembled the conditioned stimulus. Finally, lower rsFC of amygdala-default mode network (DMN) and DMN-salience network (SN) were associated with steeper risk slopes, while for hippocampus-SN, lower rsFC was found only among participants with PTSD.Individuals with PTSD show deficits in discrimination only when presented with aversive stimuli. Dysregulated discrimination pattern may relate to a lack of input from regulatory brain areas (e.g., DMN/hippocampus) to threat-related brain areas (e.g., SN/amygdala).

Eye-tracking-based attention research has shown attentional biases toward dysphoric and away from positive stimuli in depression. However, most research used prototypical stimuli (co-presented contrasting emotional faces/pictures), less reflective of real-life situations. The current study addressed this limitation by examining participants' attentional allocation patterns while freely viewing a news website containing dysphoric and positive news articles.Participants with high levels of depression (HD; n = 30) and with minimal levels of depression (MD; n = 30) freely viewed a fictitious news website for 3.5 min, containing six articles (picture + text) with dysphoric content and six with positive content. Gaze patterns on corresponding areas of interest (AOIs) were compared. Following the task, participants rated each article's valence, authenticity, and interest.Compared to MD participants, HD participants spent more time dwelling on dysphoric articles and less time dwelling on positive articles. Within group analyses showed that while HD participants spent more time dwelling on dysphoric compared to positive articles, MD participants showed no preference, allocating their attention equally to both article types. Echoing within-group gaze patterns, HD participants rated the dysphoric articles as being more interesting than the positive articles, while MD participants rated both types of articles as being equally interesting.Attentional biases in depression were also evident when using a more ecologically valid task such as viewing a news website, manifesting as increase attention allocation to dysphoric over positive content. This attention pattern may be related to corresponding differences in the level of interest participants found in each article type.

Choices and response times in two-alternative decision-making tasks can be modeled by assuming that individuals steadily accrue evidence in favor of each alternative until a response boundary for one of them is crossed, at which point that alternative is chosen. Prior studies have reported that evidence accumulation during decision-making tasks takes longer in adults with psychopathology than in healthy controls, indicating that slow evidence accumulation may be transdiagnostic. However, few studies have examined perceptual decision making in anxiety disorders, where hypervigilance might enhance performance. Therefore, this study used the Hierarchical Drift Diffusion model to investigate evidence accumulation in adults with social anxiety disorder (SAD) and healthy controls as they performed a probabilistic reward task (PRT), in which social rewards were delivered for correct perceptual judgments. Adults with SAD completed the PRT before and after gaze-contingent music reward therapy (GCMRT), which trains attention allocation and has shown efficacy for SAD. Healthy controls also completed the PRT twice. Results revealed excellent performance in adults with SAD, especially after GCMRT: relative to controls, they showed faster evidence accumulation, better discriminability, and earned more rewards. These data highlight a positive effect of attention training on performance in anxious adults and show how a behavioral trait that is typically problematic-hypervigilance in SAD-can nevertheless confer advantages in certain contexts. The data also indicate that, in contrast to other forms of psychopathology, SAD is not characterized by slow evidence accumulation, at least in the context of the social PRT. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) posits that OCD is associated with attenuated access to internal states. Here we explored the implications of this model in the realm of emotions. Participants with OCD, anxiety disorders, and nonclinical control participants completed the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT), assessing two domains of emotional intelligence: Experiential emotional intelligence (EI), reflecting the ability to perceive and feel emotions accurately, and Strategic EI, reflecting the ability to understand and manage emotions correctly. As only Experiential EI requires accurate perception of one’s emotions for adequate performance, we predicted an interaction between group and EI area. Specifically, we predicted that compared to both anxiety disorders and healthy control participants, OCD participants would show a larger deficit in Experiential area of the MSCEIT relative to the Strategic area. Results were fully in line with this prediction. Moreover, supporting the specificity of the hypothesized deficit to OCD, participants with anxiety disorders did not differ from nonclinical control participants in their performance, and findings were not attributable to anxiety or depression levels. These results replicate and extend previous findings obtained with analogue samples and suggest that OCD is associated with attenuated access to emotional states, which may be partially compensated for by reliance on semantic knowledge of emotion.

Social anxiety disorder (SAD) is associated with fear of negative evaluation and heightened performance monitoring. The best-established treatments help only a subset of patients, and there are no well-established predictors of treatment response. The current study investigated whether individual differences in processing errors might predict response to gaze-contingent music reward therapy (GC-MRT). At baseline, healthy control subjects (HC; n = 20) and adults with SAD (n = 29), ages 19–43 years, completed the Flanker Task while electroencephalography (EEG) data were recorded. SAD participants then received up to 12 sessions over 8 weeks of GC-MRT, designed to train participants’ attention away from threatening and toward neutral faces. Clinical assessments were completed 9- (post-treatment) and 20-weeks (follow-up) after initiating the treatment. At baseline, compared to HC, SAD performed the task more accurately and exhibited increased error-related negativity (ERN) and delta power to error commission. After controlling for age and baseline symptoms, more negative ERN and increased frontal midline theta (FMT) predicted reduced self-reported social anxiety symptoms at post-treatment, and FMT also predicted clinician-rated and self-reported symptom reduction at the follow-up assessment. Hypervigilance to error is characteristic of SAD and warrants further research as a predictor of treatment response for GC-MRT.

Background Threat-related attention bias has been implicated in the etiology and maintenance of social anxiety disorder (SAD), with attentional research increasingly using eye-tracking methodology to overcome the poor psychometric properties of response-time-based tasks and measures. Yet, extant eye-tracking research in social anxiety has mostly failed to report on psychometrics and attempts to replicate past results are rare. Therefore, we attempted to replicate a previously published eye-tracking study of gaze patterns in socially anxious and nonanxious participants as they viewed social threatening and neutral faces, while also exploring the psychometric properties of the attentional measures used. Methods Gaze was monitored as participants freely viewed 60 different matrices comprised of eight socially-threatening and eight neutral faces, presented for 6000 ms each. Gaze patterns directed at threat and neutral areas of interest (AOIs) were compared by group. Internal consistency and test-retest reliability were also evaluated. Results Relative to healthy controls, socially anxious patients dwelled significantly longer on threat faces, replicating prior findings with the same task. Internal consistency of total dwell time on threat and neutral AOIs was high, and two-week test-retest reliability was acceptable. Limitations Test-retest reliability was only examined for the control group, which had a small sample size. Conclusion Increased dwell time on socially threatening stimuli is a reliable, stable, and generalizable measure of attentional bias in adults with social anxiety.

BackgroundMany healthcare workers do not seek help, despite their enormous stress and greater risk for anxiety, depression and post-traumatic stress disorder (PTSD).AimsThis study screened for psychopathology and evaluated the efficacy of a brief, social contact-based video intervention in increasing treatment-seeking intentions among healthcare workers (trial registration: NCT04497415). We anticipated finding high rates of psychopathology and greater treatment-seeking intentions post-intervention.MethodHealthcare workers (n = 350) were randomised to (a) a brief video-based intervention at day 1, coupled with a booster video at day 14; (b) the video at day 1 only; or (c) a non-intervention control. In the 3 min video, a female nurse described difficulty coping with stress, her anxieties and depression, barriers to care and how therapy helped her. Assessments were conducted pre- and post-intervention and at 14- and 30-day follow-ups.ResultsOf the 350 healthcare workers, 281 (80%) reported probable anxiety, depression and/or PTSD. Participants were principally nurses (n = 237; 68%), physicians (n = 52; 15%) and emergency medical technicians (n = 30; 9%). The brief video-based intervention yielded greater increases in treatment-seeking intentions than the control condition, particularly among participants in the repeat-video group. Exploratory analysis revealed that in both video groups, we found greater effect among nurses than non-nurses.ConclusionsA brief video-based intervention increased treatment-seeking intention, possibly through identification and emotional engagement with the video protagonist. A booster video magnified that effect. This easily disseminated intervention could increase the likelihood of seeking care and offer employers a proactive approach to encourage employees to search for help if needed.

Background While effective treatments for posttraumatic stress disorder (PTSD) exist, many individuals, including military personnel and veterans fail to respond to them. Equine‐assisted therapy (EAT), a novel PTSD treatment, may complement existing PTSD interventions. This study employs longitudinal neuro‐imaging, including structural magnetic resonance imaging (sMRI), resting state‐fMRI (rs‐fMRI), and diffusion tensor imaging (DTI), to determine mechanisms and predictors of EAT outcomes for PTSD. Method Nineteen veterans with PTSD completed eight weekly group sessions of EAT undergoing multimodal MRI assessments before and after treatment. Clinical assessments were conducted at baseline, post‐treatment and at 3‐month follow‐up. Results At post‐treatment patients showed a significant increase in caudate functional connectivity (FC) and reduction in the gray matter density of the thalamus and the caudate. The increase of caudate FC was positively associated with clinical improvement seen immediately at post‐treatment and at 3‐month follow‐up. In addition, higher baseline caudate FC was associated with greater PTSD symptom reduction post‐treatment. Conclusions This exploratory study is the first to demonstrate that EAT can affect functional and structural changes in the brains of patients with PTSD. The findings suggest that EAT may target reward circuitry responsiveness and produce a caudate pruning effect from pre‐ to post‐treatment., This study employs longitudinal neuro‐imaging, including structural magnetic resonance imaging (sMRI), resting state‐fMRI (rs‐fMRI), and diffusion tensor imaging (DTI), to determine mechanisms and predictors of EAT outcomes for PTSD.

People with obsessive-compulsive disorder (OCD) tend to distrust their memory, perception, and other cognitive functions, and many OCD symptoms can be traced to diminished confidence in one's cognitive processes. For example, poor confidence in recall accuracy can cause doubt about one's memory and motivate repeated checking. At the same time, people with OCD also display performance deficits in a variety of cognitive tasks, so their reduced confidence must be evaluated in relation to their actual performance. To that end, we conducted an exhaustive review and meta-analysis of studies in which OCD participants and non-clinical control participants performed cognitive tasks and reported their confidence in their performance. Our search resulted in 19 studies that met criteria for inclusion in the quantitative analysis, with all studies addressing either memory or perception. We found that both performance and reported confidence were lower in OCD than in control participants. Importantly, however, confidence was more impaired than performance in participants with OCD. These findings suggest that people with OCD are less confident in their memory and perception than they should be, indicating a genuineunder-confidencein this population. We discuss potential mechanisms that might account for this finding and suggest avenues for further research into under-confidence and related meta-cognitive characteristics of OCD.

While impaired fear generalization is known to underlie a wide range of psychopathology, the extent to which exposure to trauma by itself results in deficient fear generalization and its neural abnormalities is yet to be studied. Similarly, the neural function of intact fear generalization in people who endured trauma and did not develop significant psychopathology is yet to be characterized. Here, we utilize a generalization fMRI task, and a network connectivity approach to clarify putative behavioral and neural markers of trauma and resilience. The generalization task enables longitudinal assessments of threat discrimination learning. Trauma-exposed participants (TE; N = 62), compared to healthy controls (HC; N = 26), show lower activity reduction in salience network (SN) and right executive control network (RECN) across the two sequential generalization stages, and worse discrimination learning in SN measured by linear deviation scores (LDS). Comparison of resilient, trauma-exposed healthy control participants (TEHC; N = 31), trauma exposed individuals presenting with psychopathology (TEPG; N = 31), and HC, reveals a resilience signature of network connectivity differences in the RECN during generalization learning measured by LDS. These findings may indicate a trauma exposure phenotype that has the potential to advance the development of innovative treatments by targeting and engaging specific neural dysfunction among trauma-exposed individuals, across different psychopathologies.

This report examines the relationship between pediatric anxiety disorders and implicit bias evoked by threats. To do so, the report uses two tasks that assess implicit bias to negative-valence faces, the first by eye-gaze and the second by measuring body-movement parameters. The report contrasts task performance in 51 treatment-seeking, medication-free pediatric patients with anxiety disorders and 36 healthy peers. Among these youth, 53 completed an eye-gaze task, 74 completed a body-movement task, and 40 completed both tasks. On the eye-gaze task, patients displayed longer gaze duration on negative relative to non-negative valence faces than healthy peers, F(1, 174) = 8.27, p = .005. In contrast, on the body-movement task, patients displayed a greater tendency to behaviorally avoid negative-valence faces than healthy peers, F(1, 72) = 4.68, p = .033. Finally, implicit bias measures on the two tasks were correlated, r(38) = .31, p = .049. In sum, we found an association between pediatric anxiety disorders and implicit threat bias on two tasks, one measuring eye-gaze and the other measuring whole-body movements. Converging evidence for implicit threat bias encourages future research using multiple tasks in anxiety.

Background In the network approach to psychopathology, psychiatric disorders are considered networks of causally active symptoms (nodes), with node centrality hypothesized to reflect symptoms’ causal influence within a network. Accordingly, centrality measures have been used in numerous network-based cross-sectional studies to identify specific treatment targets, based on the assumption that deactivating highly central nodes would proliferate to other nodes in the network, thereby collapsing the network structure and alleviating the overall psychopathology (i.e., the centrality hypothesis). Methods Here, we summarize three types of evidence pertaining to the centrality hypothesis in psychopathology. First, we discuss the validity of the theoretical assumptions underlying the centrality hypothesis in psychopathology. We then summarize the methodological aspects of extant studies using centrality measures as predictors of symptom change following treatment, while delineating their main findings and several of their limitations. Finally, using a specific dataset of 710 treatment-seeking patients with posttraumatic stress disorder (PTSD) as an example, we empirically examine node centrality as a predictor of therapeutic change, replicating the approach taken by previous studies, while addressing some of their limitations. Specifically, we investigated whether three pre-treatment centrality indices (strength, predictability, and expected influence) were significantly correlated with the strength of the association between a symptom’s change and the change in the severity of all other symptoms in the network from pre- to post-treatment (Δnode-Δnetwork association). Using similar analyses, we also examine the predictive validity of two simple non-causal node properties (mean symptom severity and infrequency of symptom endorsement). Results Of the three centrality measures, only expected influence successfully predicted how strongly changes in nodes/symptoms were associated with change in the remainder of the nodes/symptoms. Importantly, when excluding the amnesia node, a well-documented outlier in the phenomenology of PTSD, none of the tested centrality measures predicted symptom change. Conversely, both mean symptom severity and infrequency of symptom endorsement, two standard non-network-derived indices, were found to be more predictive than expected influence and remained significantly predictive also after excluding amnesia from the network analyses. Conclusions The centrality hypothesis in its current form is ill-defined, showing no consistent supporting evidence in the context of cross-sectional, between-subject networks.

Objective Many acute coronary syndrome (ACS) patients are nonadherent to cardiovascular medications despite their known benefits for lowering risk of recurrent cardiovascular events. Research suggests that greater cardiac-related fear of recurrence (FoR) may be associated with higher nonadherence to cardiovascular medications and avoidance of physical activity. We aim to test the effect of an intervention that targets FoR as a potentially modifiable mechanism underlying nonadherence to recommended health behaviors among patients with suspected ACS. Method The INFORM trial ("INvestigating Fear Of Recurrence as a modifiable Mechanism of behavior change to improve medication adherence in acute coronary syndrome patients") is a double-blind, parallel-group randomized clinical trial. It compares an 8-session, at-home, electronic tablet-delivered, cognitive bias modification training (CBMT) intervention with a sham control. Patients who experience high perceived threat at the time of presentation to the emergency department (ED) with a suspected ACS are enrolled and randomized within 6 weeks of their ED visit. The primary outcome, FoR, is measured by the adapted Concerns about Recurrent ACS Scale. The trial also tests the intervention's effect on a potential mechanism of health behavior change that is inversely correlated with fear: an expansive future time perspective. Additional outcomes include electronically measured adherence to a cardiovascular medication and self-reported physical activity. Conclusions This study takes a mechanistic approach to addressing the dangerous problem of poor health behaviors after ACS. The trial will test whether targeting FoR or future time perspective by CBMT is a promising approach to improving nonadherence after ACS. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Comorbidity between posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) has been commonly overlooked by studies examining resting-state functional connectivity patterns in PTSD. The current study used a data-driven approach to identify resting-state functional connectivity biomarkers to 1) differentiate individuals with PTSD (with or without MDD) from trauma-exposed healthy control subjects (TEHCs), 2) compare individuals with PTSD alone with those with comorbid PTSD+MDD, and 3) explore the clinical utility of the identified biomarkers by testing their associations with clinical symptoms and treatment response.Resting-state magnetic resonance images were obtained from 51 individuals with PTSD alone, 52 individuals with PTSD+MDD, and 76 TEHCs. Of the 103 individuals with PTSD, 55 were enrolled in prolonged exposure treatment. A support vector machine model was used to identify resting-state functional connectivity biomarkers differentiating individuals with PTSD (with or without MDD) from TEHCs and differentiating individuals with PTSD alone from those with PTSD+MDD. The associations between the identified features and symptomatology were tested with Pearson correlations.The support vector machine model achieved 70.6% accuracy in discriminating between individuals with PTSD and TEHCs and achieved 76.7% accuracy in discriminating between individuals with PTSD alone and those with PTSD+MDD for out-of-sample prediction. Within-network connectivity in the executive control network, prefrontal network, and salience network discriminated individuals with PTSD from TEHCs. The basal ganglia network played an important role in differentiating individuals with PTSD alone from those with PTSD+MDD. PTSD scores were inversely correlated with within-executive control network connectivity (p.001), and executive control network connectivity was positively correlated with treatment response (p.001).Results suggest that unique brain-based abnormalities differentiate individuals with PTSD from TEHCs, differentiate individuals with PTSD from those with PTSD+MDD, and demonstrate clinical utility in predicting levels of symptomatology and treatment response.

Studies have searched for neurobiological markers of trauma exposure, posttraumatic stress disorder (PTSD) diagnosis, and resilience to trauma to identify therapeutic targets for PTSD. Despite some promising results, findings are inconsistent.The present study adopted a data-driven approach to systematically explore whether structural brain markers of trauma, PTSD, or resilience emerge when all are explored.Differences between clusters in the proportion of PTSD, healthy controls (HC), and trauma-exposed healthy controls (TEHC) served to indicate the presence of PTSD, trauma, and resilience markers, respectively. A total of 129 individuals, including 46 with PTSD, 49 TEHCs, and 34 HCs not exposed to trauma were scanned. Volumes, cortical thickness, and surface areas of interest were obtained from T1 structural MRI and used to identify data-driven clusters.Two clusters were identified, differing in the proportion of TEHCs but not of PTSDs or HCs. The cluster with the higher proportion of TEHCs, referred to as the resilience cluster, was characterized by higher volume in brain regions implicated in trauma exposure, especially the thalamus and rostral middle frontal gyrus. Cross-validation established the robustness and consistency of the identified clusters.Findings support the existence of structural brain markers of resilience.

BackgroundEmerging cross-sectional data indicate that healthcare workers (HCWs) in the COVID-19 era face particular mental health risks. Moral injury – a betrayal of one’s values and beliefs, is a potential concern for HCWs who witness the devastating impact of acute COVID-19 illness while too often feeling helpless to respond. This study longitudinally examined rates of depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and moral injury among United States HCWs in the COVID-19 era. We anticipated finding high levels of clinical symptoms and moral injury that would remain stable over time. We also expected to find positive correlations between clinical symptoms and moral injury.MethodsThis three-wave study assessed clinical symptoms and moral injury among 350 HCWs at baseline, 30, and 90 days between September and December 2020. Anxiety, depression, PTSD, and moral injury were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Primary Care PTSD Screen (PC-PTSD), and Moral Injury Events Scale (MIES).ResultsOf the 350 HCWs, 72% reported probable anxiety, depression, and/or PTSD disorders at baseline, 62% at day 30, and 64% at day 90. High level of moral injury was associated with a range of psychopathology including suicidal ideation, especially among healthcare workers self-reporting COVID-19 exposure.ConclusionsFindings demonstrate broad, persisting, and diverse mental health consequences of the COVID-19 pandemic among United States HCWs. This study is the first to longitudinally examine the relationships between moral injury and psychopathology among HCWs, emphasizing the need to increase HCWs’ access to mental healthcare.

BACKGROUND Psychotherapy noncompletion rates for veterans and their families are high. This study sought to (a) measure noncompletion rates of such patients at a university-based treatment center, (b) compare veteran and family member attrition rates, (c) identify dropout predictors, and (d) explore clinicians' perspectives on treatment noncompletion. METHOD Using quantitative and qualitative approaches, we analyzed demographic and clinical characteristics of 141 patients (90 military veterans; 51 family members) in a university treatment center. We defined dropout as not completing the time-limited therapy contract. Reviewing semistructured interview data assessing clinicians' perspectives on their patients' dropout, three independent raters agreed on key themes, with interrater coefficient kappa range .74 to 1. RESULTS Patient attrition was 24%, not differing significantly between veterans and family members. Diagnosis of major depression (MDD) and exposure-based therapies predicted noncompletion, as did higher baseline Hamilton Depression Rating Scale (HDRS) total scores, severe depression (HDRS > 20), lack of Beck Depression Inventory weekly improvement, and history of military sexual trauma. Clinicians mostly attributed noncompletion to patient difficulties coping with intense emotions, especially in exposure-based therapies. CONCLUSION Noncompletion rate at this study appeared relatively low compared to other veteran-based treatment centers, if still unfortunately substantial. Patients with comorbid MDD/PTSD and exposure-based therapies carried greater noncompletion risk due to the MDD component, and this should be considered in treatment planning. Ongoing discussion of dissatisfaction and patient discontinuation, in the context of a strong therapeutic alliance, might reduce noncompletion in this at-risk population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective: As veterans have high rates of posttraumatic stress disorder (PTSD) and historically poor treatment outcomes and high attrition, alternative treatments have gained much popularity despite lack of rigorous research. In this study, a recently developed and manualized 8-session group Equine-Assisted Therapy for PTSD (EAT-PTSD) was tested in an open trial to assess its preliminary feasibility, acceptability, and outcomes for military veterans. Methods: The study was conducted from July 2016 to July 2019. Sixty-three treatment-seeking veterans with PTSD enrolled. PTSD diagnosis was ascertained using the Structured Clinical Interview for DSM-5, Research Version (SCID-5-RV) and confirmed using the Clinician-Administered PTSD Scale (CAPS-5). Mean age was 50 years, and 23 patients (37%) were women. Clinician and self-report measures of PTSD and depression were assessed at pretreatment, midtreatment, and posttreatment and at a 3-month follow-up. An intent-to-treat analysis and a secondary analysis of those who completed all 4 clinical assessments were utilized. Results: Only 5 patients (8%) withdrew from treatment, 4 before midtreatment and 1 afterward. Posttreatment assessment revealed marked reductions in both clinician-rated and self-reported PTSD and depression symptoms, which persisted at 3-month follow-up. Specifically, mean (SD) CAPS-5 scores fell from 38.6 (8.1) to 26.9 (12.4) at termination. Thirty-two patients (50.8%) showed clinically significant change (≥ 30% decrease in CAPS-5 score) at posttreatment and 34 (54.0%) at follow-up. Conclusions: Manualized EAT-PTSD shows promise as a potential new intervention for veterans with PTSD. It appears safe, feasible, and clinically viable. These preliminary results encourage examination of EAT-PTSD in larger, randomized controlled trials. Trial Registration: ClinicalTrials.gov identifier: NCT03068325.

This study examined different variables as predictors of treatment entry and treatment dropout among veterans with military-related posttraumatic stress disorder (PTSD). First, we examined predictors of treatment entry versus refusal of treatment. Among the veterans who started therapy, we examined predictors of treatment completion. Symptom severity of PTSD, depression, and anxiety at baseline were measured. Daily functioning at baseline was also measured. Results indicate that the younger the veterans were, the more likely they were to refuse treatment. Dropout from treatment was also predicted by younger age at referral, as well as by past treatment, higher number of years of education, and higher depression levels at baseline. Two conclusions can be drawn from the results. First, it may be beneficial to increase awareness of treatment options for PTSD among younger veterans as this may increase treatment consent rates. Second, to reduce treatment dropout in veteran patients with PTSD, therapists should take into consideration both past treatment and baseline depression levels as risk factors for dropout.

BackgroundThe hippocampus plays an important role in psychopathology and treatment outcome. While posterior hippocampus (PH) may be crucial for the learning process that exposure-based treatments require, affect-focused treatments might preferentially engage anterior hippocampus (AH). Previous studies have distinguished the different functions of these hippocampal sub-regions in memory, learning, and emotional processes, but not in treatment outcome. Examining two independent clinical trials, we hypothesized that anterior hippocampal volume would predict outcome of affect-focused treatment outcome [Interpersonal Psychotherapy (IPT); Panic-Focused Psychodynamic Psychotherapy (PFPP)], whereas posterior hippocampal volume would predict exposure-based treatment outcome [Prolonged Exposure (PE); Cognitive Behavioral Therapy (CBT); Applied Relaxation Training (ART)].MethodsThirty-five patients with posttraumatic stress disorder (PTSD) and 24 with panic disorder (PD) underwent structural magnetic resonance imaging (MRI) before randomization to affect-focused (IPT for PTSD; PFPP for PD) or exposure-based treatments (PE for PTSD; CBT or ART for PD). AH and PH volume were regressed with clinical outcome changes.ResultsBaseline whole hippocampal volume did not predict post-treatment clinical severity scores in any treatment. For affect-focused treatments, but not exposure-based treatments, anterior hippocampal volume predicted clinical improvement. Smaller AH correlated with greater affect-focused treatment improvement. Posterior hippocampal volume did not predict treatment outcome.ConclusionsThis is the first study to explore associations between hippocampal volume sub-regions and treatment outcome in PTSD and PD. Convergent results suggest that affect-focused treatment may influence the clinical outcome through the ‘limbic’ AH, whereas exposure-based treatments do not. These preliminary, theory-congruent, therapeutic findings require replication in a larger clinical trial.

The Military Family Wellness Center at Columbia University Irving Medical Center provides cost-free, confidential mental health services to military service members, veterans, and their families in a nongovernmental setting, with an emphasis on addressing gaps in available care. Partnerships with academic institutions and collaboration with veteran organizations, regional stakeholders, and local Veterans Administration centers facilitate cross-site referrals, enhance knowledge and expertise, and advance shared goals. This article describes the development of these relationships, focusing on key priorities, barriers overcome, and lessons learned. Future directions are discussed.

IntroductionBoth trauma exposure and post-traumatic stress disorder (PTSD) are associated with increased risk of cardiovascular disease (CVD), the leading cause of death in the USA. Endothelial dysfunction, a modifiable, early marker of CVD risk, may represent a physiological mechanism underlying this association. This mechanism-focused cohort study aims to investigate the relationship between PTSD (both in terms of diagnosis and underlying symptom dimensions) and endothelial dysfunction in a diverse, community-based sample of adult men and women.Methods and analysisUsing a cohort design, 160 trauma-exposed participants without a history of CVD are designated to the PTSD group (n=80) or trauma-exposed matched control group (n=80) after a baseline diagnostic interview assessment. Participants in the PTSD group have a current (past month) diagnosis of PTSD, whereas those in the control group have a history of trauma but no current or past psychiatric diagnoses. Endothelial dysfunction is assessed via flow-mediated vasodilation of the brachial artery and circulating levels of endothelial cell-derived microparticles. Two higher order symptom dimensions of PTSD—fear and dysphoria—are measured objectively with a fear conditioning paradigm and attention allocation task, respectively. Autonomic imbalance, inflammation, and oxidative stress are additionally assessed and will be examined as potential pathway variables linking PTSD and its dimensions with endothelial dysfunction. Participants are invited to return for a 2-year follow-up visit to reassess PTSD and its dimensions and endothelial dysfunction in order to investigate longitudinal associations.Ethics and disseminationThis study is conducted in compliance with the Helsinki Declaration and University of California, Los Angeles Institutional Review Board. The results of this study will be disseminated via articles in peer-reviewed journals and presentations at academic conferences and to community partners.Trial registration numberNCT03778307; pre-results.

Eye-tracking-based attention research has consistently shown a lack of a normative attentional bias away from dysphoric face stimuli in depression, characterizing the attention system of non-depressed individuals. However, this more equal attention allocation pattern could also be related to biased emotion identification, namely, an inclination of depressed individuals to attribute negative emotions to non-negative stimuli when processing mood-congruent stimuli. Here, we examined emotion identification as a possible mechanism associated with attention allocation when processing emotional faces in depression. Attention allocation and emotion identification of participants with high (HD; n = 30) and low (LD; n = 30) levels of depression symptoms were assessed using two corresponding tasks previously shown to yield significant findings in depression, using the same face stimuli (sad, happy, and neutral faces) across both tasks. We examined group differences on each task and possible between-task associations. Results showed that while LD participants dwelled longer on relatively positive faces compared with relatively negative faces on the attention allocation task, HD participants showed no such bias, dwelling equally on both. Trait anxiety did not affect these results. No group differences were noted for emotion identification, and no between-task associations emerged. Present results suggest that depression is characterized by a lack of a general attention bias toward relatively positive faces over relatively negative faces, which is not related to a corresponding bias in emotion identification.

OBJECTIVE: Military service members and veterans have high rates of posttraumatic stress disorder (PTSD), as do military family members. Exposure-based, cognitive-behavioral approaches have received ample research; other PTSD therapies require further empirical attention. Interpersonal psychotherapy (IPT), targeting affective awareness, life circumstances, and social support, has demonstrated efficacy for civilians with PTSD but awaits rigorous testing in military personnel: only two small military pilot studies and two case reports have been published. Military family members have received minimal clinical outcomes research. Addressing these gaps, this open trial is the first to examine IPT for PTSD in veterans, service members, and family members, including a subsample of patients with comorbid PTSD/depression. METHODS: Fifty U.S. military service members, veterans, and family members were offered 14 sessions of IPT for PTSD. Psychosis, bipolar disorder, moderate or greater substance use disorder, and high suicide risk were exclusion criteria. PTSD and depressive symptoms were assessed at baseline, mid-treatment, post-treatment, and three-month follow-up. RESULTS: Clinician-assessed PTSD (Clinician-Administered PTSD Scale) and depression (Hamilton Depression scale) symptoms decreased over time in the full sample and the comorbid PTSD/depression subset (ps

Accurate assessment is crucial for determining appropriate therapeutic interventions for social anxiety and conducting sound clinical research. While self-report measures of social anxiety are widely used in both research and clinical settings, they have several drawbacks inherent to their textual nature. Here, we describe the development and initial validation of the Visual Social Anxiety Scale (VSAS), a novel picture-based self-report measure of social anxiety, based on the well-established widely-used Liebowitz Social Anxiety Scale (LSAS). Specifically, the 24 items of the LSAS were used as the basis for social situations to be included in the VSAS. First, pictures to serve as VSAS items were selected using a rigorous two-phase process (four pilot studies; n = 225). Next, reliability (internal consistency, test-retest) and validity (convergent, discriminant) were explored with new participants (n = 304) who completed the VSAS and a battery of additional self-report questionnaires, delivered in a random order. The VSAS was completed again a month later (n = 260/304). The VSAS showed high internal consistency and test-retest reliability, and good convergent and discriminant validities. VSAS correlations with convergent measures were significantly greater than its correlations with discriminant measures. Thus, the VSAS shows initial promise as a novel picture-based self-report measure of social anxiety.

Cognitive bias modification (CBM) is a class of mechanised psychological interventions designed to target specific aberrant cognitive processes considered key in the aetiology and/or maintenance of specific psychiatric disorders. In this review, we outline a multistage translational process that allows tracking progress in CBM research. This process involves four steps: (1) the identification of reliable cognitive targets and establishing their association with specific disorders; (2) clinical translations designed to rectify the identified cognitive targets; (3) verification of effective target engagement and (4) testing of clinical utility in randomised controlled trials. Through the prism of this multistage process, we review progress in clinical CBM research in two cognitive domains: attention and interpretation; in six psychiatric conditions: anxiety disorders, major depressive disorder, post-traumatic stress disorder, addictive disorders, eating disorders and obsessive–compulsive disorder. The review highlights achievement as well as shortcomings of the CBM approach en route to becoming a recognised evidence-supported therapy for these disorders.

Social networking sites (SNSs) are an increasingly used medium for social interactions. For socially anxious individuals, SNS-based communication is often preferred over traditional face-to-face socializing. Yet, research on SNSs usage and social anxiety is still less common, with extant studies being mostly correlational among healthy nonanxious participants. Conversely, here, we examined differences in actual gaze patterns to social and nonsocial stimuli between socially anxious and nonanxious individuals while using Facebook. Socially anxious and nonanxious student participants freely viewed a genuine Facebook profile page designed for the present study, for 3.5 minutes, containing 12 social and 12 nonsocial picture stimuli. Gaze patterns on social and nonsocial areas of interest (AOIs) were explored. Subjective uneasiness experienced when viewing the social pictures and state anxiety were also assessed. Finally, 2 weeks following the task, we evaluated participants’ willingness to participate in a follow-up (fictitious) study that required them to passively view their own Facebook profile, and then to actively use it. Results showed that compared with nonanxious participants, socially anxious participants demonstrated a viewing pattern less favoring social pictures, reflecting an attentional avoidance tendency. A significant inverse correlation between subjective uneasiness and percent of dwell time spent on the social AOI emerged. Socially anxious participants also reported higher levels of state anxiety, which was significantly positively correlated with uneasiness scores. Finally, socially anxious participants were also less willing to actively use their Facebook profile page. This study suggests that social anxious individuals are characterized by attentional and behavioral avoidance tendencies when using Facebook.

BACKGROUND. Despite extensive research, symptom structure of posttraumatic stress disorder (PTSD) is highly debated. The network approach to psychopathology offers a novel method for understanding and conceptualizing PTSD. However, extant studies have mainly used small samples and self-report measures among sub-clinical populations, while also overlooking comorbid depressive symptoms. METHODS. PTSD symptom network topology was estimated in a sample of 1489 treatment-seeking veteran patients based on a clinician-rated PTSD measure. Next, clinician-rated depressive symptoms were incorporated into the network to assess their influence on PTSD network structure. The PTSD-symptom network was then contrasted with the network of 306 trauma-exposed (TE) treatment-seeking patients not meeting full criteria for PTSD to assess corresponding network differences. Finally, a directed acyclic graph (DAG) was computed to estimate potential directionality among symptoms, including depressive symptoms and daily functioning. RESULTS. The PTSD symptom network evidenced robust reliability. Flashbacks and getting emotionally upset by trauma reminders emerged as the most central nodes in the PTSD network, regardless of the inclusion of depressive symptoms. Distinct clustering emerged for PTSD and depressive symptoms within the comorbidity network. DAG analysis suggested a key triggering role for re-experiencing symptoms. Network topology in the PTSD sample was significantly distinct from that of the TE sample. CONCLUSIONS. Flashbacks and psychological reactions to trauma reminders, along with their strong connections to other re-experiencing symptoms, have a pivotal role in the clinical presentation of combat-related PTSD among veterans. Depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems.

Background Heightened attention allocation toward negative-valanced information and reduced attention allocation toward positive-valanced information represent viable targets for attention bias modification in major depressive disorder. Accordingly, we conducted a randomized controlled trial testing the efficacy of a novel gaze-contingent attention bias modification procedure for major depressive disorder. Method Sixty patients with major depressive disorder were randomly assigned to either eight training sessions of feedback-based gaze-contingent music reward therapy designed to divert patients' gaze toward positive over sad stimuli, or to a control condition which entailed eight sessions of gaze-noncontingent music. Clinician-rated and self-reported measures of depression, and proportion of dwell-time on sad faces, were assessed pretreatment, posttreatment, and at a 3-month follow-up. Results Gaze-contingent music reward therapy produced a greater reduction in dwell-time on sad faces compared with the control condition, but it failed to generalize to novel faces. Both groups manifested similarly significant reductions in depression symptoms from pre- to posttreatment that were maintained at follow-up. Exploratory analyses suggest that first-episode patients may benefit more from this therapy than patients with a history of multiple episodes. Conclusions Gaze-contingent music reward therapy can modify attention biases in depression, but clear differential clinical effects did not emerge. Theoretical and practical implications are discussed.

BACKGROUND: Recent research suggests that posttraumatic stress disorder (PTSD) is associated with altered amygdala and hippocampal resting-state functional connectivity (rsFC). However, less research has examined whether Prolonged Exposure (PE), a first line exposure-based treatment for PTSD, has the potential to alter resting state neural networks. METHODS: Twenty-four patients with PTSD and 26 matched trauma-exposed healthy controls (TEHCs) underwent resting-state functional magnetic resonance imaging (fMRI) at baseline. PTSD patients were scanned a second time after completing 10-session PE in which patients narrated a detailed trauma account (imaginal exposure) and confronted trauma reminders (in vivo exposure) to extinguish trauma-related fear responses. TEHC were scanned again following a 10-week waiting period. Seed regions of interest (ROIs) included centromedial amygdala (CMA), basolateral amygdala (BLA), and the hippocampus. RESULTS: Post- versus pre-treatment comparisons indicated increased rsFC of the BLA and CMA with the orbitofrontal cortex (OFC), and hippocampus-medial prefrontal cortex (mPFC) among patients with PTSD, but not among TEHC participants. CONCLUSIONS: Enhanced amygdala and hippocampus rsFC with prefrontal cortical regions following PE could underlie improved capacity for inhibition and re-evaluation of threat, and heightened memory encoding and retrieval ability, respectively. These findings encourage further investigation of this circuitry as a therapeutic target in PTSD.

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) proposes an account of OCD symptoms in terms of two core components: attenuation of access to internal states and seeking proxies for internal states. Specifically, the SPIS model posits that OCD is associated with difficulty in accessing various internal states, including feelings, preferences, memories, and even physiological states. This difficulty drives obsessive-compulsive individuals seek and rely on compensatory proxies, or substitutes, for their internal states. These proxies are perceived by the individual with OCD to be more easily discernible or less ambiguous compared to the internal states for which they substitute, and can take the form of fixed rules, rituals, or reliance on external sources of information. In the present article we first provide a detailed explanation of the SPIS model, and then review empirical studies that examined the model in a variety of domains, including bodily states, emotions, and decision-making. Next, we elaborate on the SPIS model's novel account of compulsive rituals, obsessions and doubt and relate them to extant theoretical accounts of OCD. To conclude, we highlight open questions that can guide future research and discuss the model's clinical implications.

BackgroundCognitive–behavioral group therapy (CBGT) is a first-line treatment for social anxiety disorder (SAD). However, since many patients remain symptomatic post-treatment, there is a need for augmenting procedures. This randomized controlled trial (RCT) examined the potential augmentation effect of attention bias modification (ABM) for CBGT.MethodsFifty patients with SAD from three therapy groups were randomized to receive an 18-week standard CBGT with either ABM designed to shift attention away from threat (CBGT + ABM), or a placebo protocol not designed to modify threat-related attention (CBGT + placebo). Therapy groups took place in a large mental health center. Clinician and self-report measures of social anxiety and depression were acquired pre-treatment, post-treatment, and at 3-month follow-up. Attention bias was assessed at pre- and post-treatment.ResultsPatients randomized to the CBGT + ABM group, relative to those randomized to the CBGT + placebo group, showed greater reductions in clinician-rated SAD symptoms post-treatment, with effects maintained at 3-month follow-up. Group differences were not evident for self-report or attention-bias measures, with similar reductions in both groups. Finally, reduction in attention bias did not mediate the association between group and reduction in Liebowitz Social Anxiety Scale Structured Interview (LSAS) scores.ConclusionsThis is the first RCT to examine the possible augmenting effect of ABM added to group-based cognitive–behavioral therapy for adult SAD. Training patients’ attention away from threat might augment the treatment response to standard CBGT in SAD, a possibility that could be further evaluated in large-scale RCTs.

Current attention bias modification (ABM) procedures are designed to implicitly train attention away from threatening stimuli with the hope of reducing stress reactivity and anxiety symptoms. However, the mechanisms underlying effective ABM delivery are not well understood, with awareness of the training contingency suggested as one possible factor contributing to ABM efficacy. Here, 45 high-anxious participants were trained to divert attention away from threat in two ABM sessions. They were randomly assigned to one of three training protocols: an implicit protocol, comprising two standard implicit ABM training sessions; an explicit protocol, comprising two sessions with explicit instruction as to the attention training contingency; and an implicit-explicit protocol, in which participants were not informed of the training contingency in the first ABM session and informed of it at the start of the second session. We examined learning processes and stress reactivity following a stress-induction task. Results indicate that relative to implicit instructions, explicit instructions led to stronger learning during the first training session. Following rest, the explicit and implicit groups exhibited consolidation-related improvement in performance, whereas no such improvement was noted for the implicit-explicit group. Finally, although stress reactivity was reduced after training, contingency awareness did not yield a differential effect on stress reactivity measured using both self-reports and skin conductance, within and across sessions. These results suggest that explicit ABM administration leads to greater initial learning during the training protocol while not differing from standard implicit administration in terms of off-line learning and stress reactivity.

Patients with social anxiety disorder exhibit increased attentional dwelling on social threats, providing a viable target for therapeutics. This randomized controlled trial examined the efficacy of a novel gaze-contingent music reward therapy for social anxiety disorder designed to reduce attention dwelling on threats.Forty patients with social anxiety disorder were randomly assigned to eight sessions of either gaze-contingent music reward therapy, designed to divert patients' gaze toward neutral stimuli rather than threat stimuli, or to a control condition. Clinician and self-report measures of social anxiety were acquired pretreatment, posttreatment, and at 3-month follow-up. Dwell time on socially threatening faces was assessed during the training sessions and at pre- and posttreatment.Gaze-contingent music reward therapy yielded greater reductions of symptoms of social anxiety disorder than the control condition on both clinician-rated and self-reported measures. Therapeutic effects were maintained at follow-up. Gaze-contingent music reward therapy, but not the control condition, also reduced dwell time on threat, which partially mediated clinical effects. Finally, gaze-contingent music reward therapy, but not the control condition, also altered dwell time on socially threatening faces not used in training, reflecting near-transfer training generalization.This is the first randomized controlled trial to examine a gaze-contingent intervention in social anxiety disorder. The results demonstrate target engagement and clinical effects. This study sets the stage for larger randomized controlled trials and testing in other emotional disorders.

Background The Seeking Proxies for Internal States (SPIS) model of OCD asserts that obsessive-compulsive (OC) tendencies are associated with attenuated access to internal states. Here we explore the implications of this model for awareness of emotional valence. Methods In Study 1, participants with high and low OC tendencies (n = 30 in each group) rated how they felt while viewing different pictures with positive, neutral, or negative valence taken from the International Affective Picture System. Study 2 replicated Study 1 among non-selected participants (n = 99) that rated positive and negative pictures chosen from the recently developed Basic-Emotions Nencki Affective Picture System. In both studies, mean deviation from norm ratings (of each picture system) served as the primary outcome measure. Results Study 1 showed that high OC participants’ mean deviation score was significantly higher, compared with low OC participants, across positive, neutral, and negative pictures (p=.01). Follow-up analyses revealed that while no group difference emerged for mean valence rating (p=.16), groups differed on the mean standard deviation of ratings within each valence category (p=.002). In Study 2, only OC tendencies, not depressive or anxiety symptoms, were positively correlated with mean deviation from norm ratings (p=.026). Dividing the sample to high and low OC groups based on an OC cutoff score yielded similar group differences to those observed in Study 1 (p Limitations Analog samples and a relative small sample size (Study 1). Conclusions This study suggests that OC symptoms are associated with reduced awareness of emotional valence, possibly emanating from a noisier emotional perception.

Background and objectives These days, a growing number of social interactions occur through video-mediated communication (VMC). However, little is known about how socially anxious individuals use this technology. Here, we examined the visual attention patterns of high and low socially anxious individuals during a live interaction with a study confederate using a typical online VMC setup. Methods High (n = 30) and low (n = 30) socially anxious participants completed a VMC-based social interaction task comprised of two parts: A one-on-one acquaintance interview followed by a one-on-one short presentation assignment. State anxiety was measured before and after the task, and gaze data was collected throughout. Results High socially anxious participants experienced elevated anxiety following the interaction task, whereas no elevation was observed for low socially anxious participants. Gaze data revealed that high socially anxious participants dwelled longer on the confederate's image during the acquaintance interview compared with the presentation task, and dwelled longer on non-face areas during the presentation relative to during the acquaintance interview. This task-related gaze pattern was not observed among low socially anxious participants. Limitations An analog sample was used in this study and future research should replicate its findings in a clinical sample. Future studies may also wish to counterbalance confederate's gender and task order across participants. Conclusions The results suggest that during VMC, socially anxious individuals observe their environment differently than non-socially anxious individuals, depending on the context of the interaction. This context-dependency might help explain mixed findings in previous studies. Further theoretical implications of these findings are discussed.

BackgroundEstablishing neurobiological markers of posttraumatic stress disorder (PTSD) is essential to aid in diagnosis and treatment development. Fear processing deficits are central to PTSD, and their neural signatures may be used as such markers.MethodsHere, we conducted a meta-analysis of seven Pavlovian fear conditioning fMRI studies comparing 156 patients with PTSD and 148 trauma-exposed healthy controls (TEHC) using seed-basedd-mapping, to contrast neural correlates of experimental phases, namely conditioning, extinction learning, and extinction recall.ResultsPatients with PTSD, as compared to TEHCs, exhibited increased activation in the anterior hippocampus (extending to the amygdala) and medial prefrontal cortex during conditioning; in the anterior hippocampus-amygdala regions during extinction learning; and in the anterior hippocampus-amygdala and medial prefrontal areas during extinction recall. Yet, patients with PTSD have shown an overall decreased activation in the thalamus during all phases in this meta-analysis.ConclusionFindings from this metanalysis suggest that PTSD is characterized by increased activation in areas related to salience and threat, and lower activation in the thalamus, a key relay hub between subcortical areas. If replicated, these fear network alterations may serve as objective diagnostic markers for PTSD, and potential targets for novel treatment development, including pharmacological and brain stimulation interventions. Future longitudinal studies are needed to examine whether these observed network alteration in PTSD are the cause or the consequence of PTSD.

This multiple-baseline open pilot trial examined feasibility, compliance, acceptability, and preliminary indices of efficacy of Gaze-Contingent Music Reward Therapy (GC-MRT) for anxious 7-to 10-year-old children. GC-MRT is a novel therapy for anxiety disorders that relies on eye-tracking technology and operant conditioning principles to divert attention toward neutral over threat stimuli, with music serving as a reward. Using a multiple-baseline design, 12 children (M(age) = 8.3 years, SD = .72, range = 7–10; 4 girls) with social anxiety disorder, generalized anxiety disorder, or separation anxiety disorder received 8 therapy sessions. Clinical status was determined via semistructured interviews and questionnaires. Patients were randomized to wait 1, 3, or 5 weeks between initial assessment and beginning of therapy. Self-reported anxiety was recorded weekly, and comprehensive clinical assessments were obtained pre- and posttreatment. All 12 patients completed the full course of GC-MRT within the allocated therapy period. Therapy credibility rates were moderate to high as reported by both children and parents. Clinician-rated anxiety levels remained consistent during baseline measurement and decreased significantly following treatment. Parent-reports also yielded significant reductions in child anxiety symptoms from pre- to posttreatment. However, child-reported anxiety did not change significantly. The results provide preliminary evidence for feasibility, acceptability, and efficacy of GC-MRT for young children with anxiety disorders. Efficacy should now be tested in randomized controlled trials.

Background and objective People's feelings are not always accessible to them, and this might be especially the case for some individuals and in some situations. Based on our model of obsessive-compulsive disorder, we predicted that obsessive-compulsive (OC) tendencies and situationally induced doubt would be associated with decreased access to one's own emotions. Methods In the first two studies we examined the relationships between OC tendencies and performance on the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). In Study 3 we undermined participants' confidence in their ability to accurately assess their own emotions and assessed the effect of this manipulation on MSCEIT performance. Results As predicted, OC tendencies were associated with lower scores on the Experiential area of the MSCEIT, which relies on access to experienced emotions, but not on the Strategic area, which relies on semantic knowledge about emotions. Similarly, undermining participants' confidence in their own emotions reduced their scores on the Experiential, but not on the Strategic area of the MSCEIT. Limitations The findings should be replicated with a clinical OCD population and with other measures of emotional experience. Conclusion These studies suggest that impaired access to emotional states may be caused by doubting those states, that it characterizes people with high OC tendencies, and that it might be a manifestation of a more general difficulty in accessing internal states.

BackgroundRandomized control trials (RCTs) comparing attention control training (ACT) and attention bias modification (ABM) in posttraumatic stress disorder (PTSD) have shown mixed results. The current RCT extends the extant literature by comparing the efficacy of ACT and a novel bias-contingent-ABM (BC-ABM), in which direction of training is contingent upon the direction of pre-treatment attention bias (AB), in a sample of civilian patients with PTSD.MethodsFifty treatment-seeking civilian patients with PTSD were randomly assigned to either ACT or BC-ABM. Clinician and self-report measures of PTSD and depression, as well as AB and attention bias variability (ABV), were acquired pre- and post-treatment.ResultsACT yielded greater reductions in PTSD and depressive symptoms on both clinician-rated and self-reported measures compared with BC-ABM. The BC-ABM condition successfully shifted ABs in the intended training direction. In the ACT group, there was no significant change in ABV or AB from pre- to post-treatment.ConclusionsThe current RCT extends previous results in being the first to apply ABM that is contingent upon AB at pre-treatment. This personalized BC-ABM approach is associated with significant reductions in symptoms. However, ACT produces even greater reductions, thereby emerging as a promising treatment for PTSD.

BackgroundCognitive models of posttraumatic stress disorder (PTSD) implicate threat-related attentional biases in the etiology and phenomenology of the disorder. However, extant attentional research using reaction time (RT)-based paradigms and measures has yielded mixed results. Eye-tracking methodology has emerged in recent years to overcome several inherent drawbacks of RT-based tasks, striving to better delineate attentional processes.MethodsA systematic review of experimental studies examining threat-related attention biases in PTSD, using eye-tracking methodology and group-comparison designs, was conducted conforming to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies were selected following a systematic search for publications between 1980 and December 2017 in PsycINFO, MEDLINE and the National Center for PTSD Research's Published International Literature on Traumatic Stress (PILOTS) database. Additional records were identified by employing the Similar Articles feature in PubMed, and the Cited Reference Search in ISI Web of Science. Reference sections of review articles, book chapters and studies selected for inclusion were searched for further studies. Ongoing studies were also sought through Clinicaltrials.gov.ResultsA total of 11 studies (n= 456 participants in total) were included in the final review. Results indicated little support for enhanced threat detection, hypervigilance and attentional avoidance. However, consistent evidence emerged for sustained attention on threat (i.e. attention maintenance) in PTSD.ConclusionsThis review is the first to systematically evaluate extant findings in PTSD emanating from eye-tracking studies employing group-comparison designs. Results suggest that sustained attention on threat might serve as a potential target for therapeutic intervention.

Background Identification of reliable targets for therapeutic interventions is essential for developing evidence-based therapies. Attention biases toward negative-valenced information and lack of protective positive bias toward positive-valenced stimuli have been implicated in depression. However, extant research has typically used tasks with narrow stimuli arrays and unknown or poor psychometric properties. Here, we recorded eye-tracking data of depressed and non-depressed participants during a free viewing task to address these limitations. Methods Patients with major depressive disorder (MDD; n = 20) and undergraduate students with high (n = 23) and low (n = 20) levels of depression freely viewed 60 different face-based matrices for six seconds each. Each matrix included eight sad and eight happy facial expressions. Gaze patterns on sad and happy areas of interest (AOIs) were explored. Internal consistency for the entire sample and one-week test-retest reliability in the student sub-sample were assessed. Results Compared to undergraduates with low levels of depression, patients with MDD and students with high levels of depression dwelled significantly longer on sad faces. Results also showed a significantly longer dwell time on the happy AOI relative to the sad AOI only in the low depression group. The two depressed groups dwelled equally on the two AOIs. The task demonstrated high internal consistency and acceptable one-week test-retest reliability. Limitations Only sad and happy facial expressions were used. Relative small sample size. Conclusion Relative to non-depressed participants, depressed participants showed prolonged dwelling on sad faces and lack of bias toward happy faces. These biases present viable targets for gaze-contingent attention bias modification therapy.

Background and objectives We have previously reported that obsessive-compulsive individuals perform more poorly on tasks that require accurate perception of internal states. As these individuals are also characterized by elevated levels of doubt regarding internal states, the causal relationship between doubt and accurate perception remained unclear. The presented study examines whether undermining participants' confidence in their ability to accurately produce a specific internal state would affect their performance on a task that requires accurate perception of this state. Methods Participants were trained to produce specific levels of forearm muscle tension and then required to produce various tension levels in four experimental phases. The first three alternated in terms of whether the participants viewed a biofeedback monitor while the fourth offered participants several times the choice to view the monitor. Prior to the task, half of the participants received instructions that undermined their confidence in their ability to accurately assess their own muscle tension. We measured participants' accuracy in producing the required muscle tension levels and the number of times they requested to view the monitor in the final phase. Results Undermined confidence participants were less accurate in producing the required muscle tension levels in the absence of biofeedback, and were also more likely to request the monitor in the final phase. Conclusions Doubt can affect performance on tasks that require perceiving and experiencing internal states. This finding supports the possibility that access to internal states in OCD is attenuated due to elevated levels of doubt regarding these states.

Sex differences in the epidemiology and clinical presentation of trauma-related psychopathology have long been documented. Multiple underlying mechanisms have been examined, both psychosocial and biological. Among the most promising biological mechanisms are neural substrates of trauma-related psychopathology that have been uncovered in recent years. Neuroimaging studies of sex-related heterogeneity published over the past 3 years (2014–2017) demonstrate an interaction between sex and type, timing, and load of trauma exposure. These studies suggest that, for males, early trauma exposure may involve a loss of gray matter in the limbic system, including the prefrontal cortex (PFC), amygdala, and hippocampus, and an over-activity and increased connectivity of salience hubs, and particularly dorsal anterior cingulate cortex (dACC). For females, however, early trauma exposure may involve overactive and possibly an enlarged amygdala, as well as decreased connectivity of salience hubs such as the dACC. Underlying mechanisms may include interaction with several endocrine systems and result in differential neural response to naturally occurring and added endocrine ligands, as well as sex-specific genetic and epigenetic risk and resilience factors. This complex interaction between multiple biological systems may be associated with sex-specific behavioral patterns, in turn associated with trauma-related psychopathology. While substantial number of published studies present preliminary evidence for neural mechanisms of sex-specific posttraumatic responses, there is a paucity of research directly designed to examine sex as a biological factor in trauma-related psychopathology. Specific foci for future studies aiming to bridge current gaps in the literature are discussed.

Background Social anxiety disorder (SAD) is characterized by intense fear when facing a crowd. Processing biases of crowd-related information have been suggested as contributing to the etiology and maintenance of the disorder. Here we tested whether patients with SAD display aberrant patterns of extracting the mean emotional tone from sets of faces. Methods Twenty-one participants with SAD and 24 unanxious control participants had to determine the average emotion expression of sets of six different morphed faces ranging from happy to angry. In 20% of trials the six faces were randomly sampled from the entire happy-angry range. The remaining 80% of trials, considered the critical trials, had an emotional outlier: five faces were sampled from one-half of the emotional range, whereas the sixth face was sampled from the opposite emotional range. Results Participants with SAD were less accurate than controls in extracting the mean emotional tone from sets of faces. Unanxious participants underweighted negative outliers and overweighed positive outliers when extracting the mean, whereas participants with SAD exhibited no such biases. Conclusions Results suggest a possible mechanism associated with the anxiety experienced by socially anxious individuals when facing a crowd.

Patients with anorexia nervosa (AN) have been shown to display both elevated anxiety and attentional biases in threat processing. In this study, we compared threat-related attention patterns of patients with AN restricting type (AN-R; n = 32), AN binge/purge type (AN-B/P; n = 23), and healthy controls (n = 19). A dot-probe task with either eating disorder-related or general and social anxiety-related words was used to measure attention patterns. Severity of eating disorder symptoms, depression, anxiety, and stress were also assessed. Patients with AN-R showed vigilance to both types of threat words, whereas patients with AN-B/P showed avoidance of both threat types. Healthy control participants did not show any attention bias. Attention bias was not associated with any of the demographic, clinical, and psychometric parameters introduced. These findings suggest that there are differential patterns of attention allocation in patients with AN-R and AN-B/P. More research is needed to identify what causes/underlies these differential patterns.

Posttraumatic stress disorder (PTSD) has been associated with altered resting-state functional connectivity (rs-FC) of several brain regions within the salience (SN) and default-mode (DMN) networks, including the hippocampus. However, most rs-FC studies have not focused primarily on the hippocampus, nor have they appreciated its structural heterogeneity, despite clear evidence for a dissociation between posterior and anterior hippocampal connectivity. Here, we examine rs-FC of anterior and posterior hippocampus with key regions in the SN (amygdala, insula, and dorsal anterior cingulate cortex/pre-supplementary motor area) and DMN (ventromedial prefrontal cortex, posterior cingulate cortex, and precuneus) previously implicated in PTSD, using a seed-based approach. Resting-state magnetic resonance images were obtained from 48 PTSD patients and 34 trauma-exposed healthy participants (TEHC). Results indicated no group differences when examining the hippocampus as a whole. However, examining the anterior and posterior hippocampus revealed a loss of anterior to posterior connectivity differentiation in PTSD patients. The PTSD group also demonstrated lower negative connectivity of the posterior hippocampus-precuneus pathway compared with the TEHC group. Finally, as differences in anterior and posterior hippocampus connectivity have been also related to age, we performed a secondary analysis exploring the association between age and posterior- and anterior-hippocampus connectivity in both groups. Results showed that among PTSD patients, increased age had the effect of normalizing posterior hippocampus-precuneus and hippocampus-posterior cingulate cortex connectivity, whereas no such effect was noted for the control group. These findings highlight the need for PTSD connectivity research to consider sub-parts of the hippocampus and to account for age-related connectivity differences.

Pervasive doubts are a central feature of obsessive-compulsive disorder (OCD). We have theorized that obsessive doubts can arise in relation to any internal state and lead to compensatory reliance on more discernible substitutes (proxies), including rules and rituals. Previous findings corroborated this hypothesis, but were based on students with high and low OCD tendencies and did not control for anxiety. The present study tested our hypothesis in OCD participants using both anxiety disorders and nonclinical controls. Twenty OCD participants, 20 anxiety disorders participants, and 20 nonclinical participants underwent 2 experimental procedures. In the first, participants had to produce specific levels of muscle tension with and without the aid of biofeedback. In the second, participants were asked to subjectively assess their own muscle tension after viewing preprogrammed false feedback showing either increasing or decreasing levels of muscle tension. As predicted, OCD participants were less accurate than anxiety disorder and nonclinical participants in producing designated levels of muscle tension when biofeedback was not available and more likely to request the biofeedback when given the opportunity to do so. In the false feedback procedure, OCD participants were more influenced by the false biofeedback when judging their own level of muscle tension compared with the 2 controls groups. In both procedures, anxiety disorder participants did not differ from the nonclinical controls. These results support the hypothesis that individuals with OCD have attenuated access to and reduced confidence in their internal states, and that this deficit is specific to OCD and not attributable to anxiety.

Background and objectives Obsessive-compulsive (OC) patients typically display reduced metacognitive confidence, but findings regarding the scope of this phenomenon and factors that mediate it have been inconsistent. This study aimed to further the understanding of reduced metacognitive confidence in obsessive-compulsive disorder (OCD) by exploring the relationship between metacognitive processes and OC tendencies. Methods High and low OC participants answered a general-knowledge questionnaire, rated their confidence in each answer, and decided whether or not to report each answer. Results High and low OC participants did not differ either in their performance (general knowledge) or in their subjective estimations or confidence regarding their performance. The two groups also did not differ in the effectiveness of their metacognitive monitoring or in the relationship between monitoring and report-control decisions (control sensitivity). However, the two groups did differ in response criterion, with high OC participants less willing to report answers held with low-to-medium levels of subjective confidence. Limitations The study was conducted with non-clinical participants, which limits generalization to OCD. Conclusions These results suggest that conservative response criterion among OC individuals might be the critical factor underlying feelings of doubt and uncertainty endemic in OCD.