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The adverse childhood experiences (ACEs) literature has substantially grown over the last two decades. We have learned that ACEs are related to a number of poor developmental and health outcomes as well as the continuation of violence in adulthood. Additionally, we now understand that ACEs prevention needs to be a global public health priority. Although many advances have been made in our understanding of the impact of ACEs across the lifespan, there still remain areas that require further work and innovation. This chapter identifies five critical areas for future directions to advance the ACEs field, including: (1) development and validation of ACEs measurement tools, (2) use of empirical evidence to guide definitions of ACEs, (3) evidence-based methods to assess harms and benefits of ACEs screening, (4) continued development and evaluation of ACEs interventions, and (5) an increase in upstream public health approaches and ACEs prevention.

Adverse childhood experiences (ACEs) have been shown in multiple studies to be associated with compromised physical health across the developmental spectrum. The purpose of this chapter is severalfold. First, we provide an overview of the potential mechanisms underlying the linkage between ACEs and poor physical health. Second, we provide an overview of the specific risky health behaviors, physical health conditions, and mediators of poor physical health associated with childhood adversity. Third, we explore various implications of current knowledge for health service utilization, therapeutic intervention, and prevention. Finally, we conclude with a brief consideration of policy implications as well as a summary of areas that we believe to be in need of further investigation.

Event centrality, as measured by the Centrality of Event Scale (CES), refers to the degree to which a salient traumatic memory becomes central to individual identity. The current investigation modified the CES to capture valence (positive vs. negative) of event centrality (i.e., CES-V) and determine whether the valence of event centrality for traumatic events differentially relates to trauma responses (i.e., posttraumatic stress disorder [PTSD], posttraumatic growth [PTG]). Trauma-exposed community members (n = 512) completed measures of trauma experiences, PTSD, PTG, and the CES-V. Exploratory factor analysis supported the use of the CES-V. Trauma outcome response profiles were compared between event centrality valence group (i.e., central-positive, not central, central-negative) and factors influencing event centrality valence were explored. Most participants appraised their trauma as central and positive (54.7%), while others appraised their trauma as central and negative (32.8%) or not central (12.5%). Central-positive event centrality ratings were positively related to PTG and inversely related to PTSD, whereas central-negative event centrality ratings were positively related to PTSD and inversely related to PTG. The central-positive group reported the most PTG, and the central-negative group reported the most PTSD. Future research should explore the clinical utility of using event centrality valence to predict trauma responses and track treatment progress.

Major depressive disorder (MDD) frequently co-occurs with social anxiety disorder (SAD), and their comorbidity (MDD-SAD) increases clinical severity and functional impairment. Still, the specific psychological vulnerabilities of individuals with MDD-SAD are poorly understood. Individual attachment characteristics develop early in life through interactions with primary caregivers, and tend to persist throughout life. Early trauma can worsen attachment insecurity, increasing the risk for future anxiety and depression. The purpose of this study is to examine differences in individual attachment and history of trauma in depressed individuals with or without comorbid SAD and controls. One hundred sixty-two participants were categorized into three groups based on SCID-I interview: healthy controls (HC), individuals with current MDD without SAD (MDD), and individuals with current MDD comorbid with SAD (MDD-SAD). MDD-SAD group had significantly greater attachment anxiety and attachment avoidance compared to the MDD and HC groups. MDD-SAD group had greater clinician-rated depression severity and dysfunction compared to MDD group. In summary, the study further supports the clinical risks associated with MDD-SAD and suggests that insecure attachment might represent an associated vulnerability and a possible pathway which warrants further research and clinical attention.

Objectives Intolerance of uncertainty (IU) underlies several psychological disorders, and religion may help some individuals cope with IU and/or protect against psychological symptoms. It was hypothesized that IU would moderate the relations between coping motives for being religious, as well as religiosity, and common psychological disorder symptoms: Depression and social evaluation fears. Methods Study 1 included 473 self-reporting community members (M age = 48, 48% female, 80% Protestant/Catholic). Study 2 included 412 self-reporting undergraduates ( M age = 19, 71% female, 76% Protestant/Catholic). Results For Study 1, coping-based motives related to greater depression for young adults with above-average IU and to lower depression for young adults with below-average IU. For Study 2, religiosity related to lower depression and fear of negative evaluation for individuals with above-average IU and to greater fear of positive evaluation for individuals with below-average IU. Conclusion IU may be an important mechanism between aspects of religion and psychological disorder symptoms.

Substantial media attention has focused on suicide among Canadian Public Safety Personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police). The attention has raised significant concerns about the mental health impact of public safety service, as well as interest in the correlates for risk of suicide. There have only been two published studies assessing lifetime suicidal behaviors among Canadian PSP. The current study was designed to assess past-year and lifetime suicidal ideation, plans, and attempts amongst a large diverse sample of Canadian PSP. Estimates of suicidal ideation, plans, and attempts were derived from self-reported data from a nationally administered online survey. Participants included 5,148 PSP (33.4% women) grouped into six categories (i.e., Call Centre Operators/Dispatchers, Correctional Workers, Firefighters, Municipal/Provincial Police, Paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported past-year and lifetime suicidal ideation (10.1%, 27.8%), planning (4.1%, 13.3%), or attempts (0.4%, 4.6%). Women reported significantly more lifetime suicidal behaviors than men (ORs = 1.15 to 2.62). Significant differences were identified across PSP categories in reports of past-year and lifetime suicidal behaviors. The proportion of Canadian PSP reporting past-year and lifetime suicidal behaviors was substantial. The estimates for lifetime suicidal behaviors appear consistent with or higher than previously published international PSP estimates, and higher than reports from the general population. Municipal/Provincial Police reported the lowest frequency for past-year and lifetime suicidal behaviors, whereas Correctional Workers and Paramedics reported the highest. The results provide initial evidence that substantial portions of diverse Canadian PSP experience suicidal behaviors, therein warranting additional resources and research. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

The relative health of a field of research can be approximated by assessing peer-reviewed journal publication trends for articles pertinent to that field. The most recent comprehensive assessment of publication trends in the anxiety disorders indicated that the field was on a continuing trajectory of growth (Boschen, 2008). We conducted an updated search of Medline for publications on each of the anxiety disorders from 2006 to 2016. Results indicated that there was continuing growth in anxiety disorders research overall and, particularly, for posttraumatic stress disorder, social anxiety disorder, generalized anxiety disorder, and obsessive compulsive disorder. Publication trends observed in Medline were also reflected in the focus of papers published in the Journal of Anxiety Disorders over the past 3 years; yet, a substantive number of papers in the journal also dealt with multiple anxiety disorders, anxiety-related constructs, transdiagnostic issues, and conditions with significant overlap with the anxiety disorders. Observed publication trends, shifts in the focus of research attention, and probable future research directions are discussed briefly.

Abstract. Posttraumatic stress disorder (PTSD) and chronic musculoskeletal pain (CMP) are highly prevalent ( Breslau, 2002 ) and comorbid disorders ( Otis, Keane, & Kerns, 2003 ). The shared vulnerability model explains this overlap in part through a common attentional bias toward threat ( Asmundson, Coons, Taylor, & Katz, 2002 ). The current study made use of the acoustic startle to assess cognitive bias to threat in participants (n = 106; 64% women) who reported experiencing a motor vehicle accident (MVA). Participants were divided into five groups based on their diagnoses: PTSD, CMP, both PTSD and CMP, any general (i.e., non-PTSD) anxiety disorder with no CMP, and a no-disorder Control group. Self-report measures were used to assess psychological symptoms, trauma response, and pain-related factors. Word stimuli (i.e., trauma, sensory pain, health, pleasant, neutral) were presented visually prior to onset of the acoustic startle probe to assess for diagnosis-congruent attentional biases (e.g., persons with PTSD respond differently to trauma words). Relative to the general anxiety and control group, persons with PTSD or chronic pain demonstrated delayed startle peak and greater startle intensity across all word stimuli types; the results suggest there may be psychophysiologically measurable differences associated with PTSD and pain. The startle probe paradigm remains relatively nascent for such research, but has potential utility for assessment and treatment monitoring. Comprehensive results, discussion, and implications are analyzed.

Interventions that reduce anxiety sensitivity (AS) may have far reaching benefits for the prevention and treatment of mental disorders. Exercise, even when limited to a single session, appears to be an efficacious intervention for reducing AS. This effect has been largely examined using moderate intensity continuous (i.e., without rest) training (MICT). High intensity exercise protocols, such as sprint interval training (SIT), have not been investigated as a strategy for reducing AS or related constructs. We examined the effects of a single session of either SIT or MICT on AS, distress tolerance (DT), and intolerance of uncertainty (IU). A total of 56 participants were randomized into either a 50-min MICT group, a 10-min SIT group, or a waitlist control group. AS, DT, and IU were measured at baseline, post-exercise session, and at 3-day and 7-day follow-ups. Both exercise groups experienced similar reductions in AS; however, these changes appeared attributable to reductions across different AS dimensions. Specifically, significant reductions in the AS Physical Concerns were noted in the SIT group whereas the MICT group experienced significant reductions in both the AS Social and Cognitive Concerns dimensions. Both DT and IU were not changed by either exercise protocol. These findings suggest that exercise protocols varying in intensity and duration can reduce AS. This knowledge could help contribute to the optimization of exercise strategies for reducing AS. Furthermore, as lack of time is frequently reported as a barrier to exercising regularly, findings that SIT reduces overall AS to a similar extent as MICT in a fraction of the time, could inform both research and practice aimed at increasing adherence to exercise protocols for psychological wellbeing.

Background: Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP. Methods: An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures. Results: There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure. Interpretation: The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.

Copyright © The Author(s) 2019. Published by SAGE. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/). The current study was designed to assess whether cognitive risk factors (i.e. anxiety sensitivity (AS), intolerance of uncertainty (IU)) explained variance in mental disorder symptoms in Canadian police officers beyond variance explained by demographic variables (i.e. sex, marital status, education, years of service). Police participants (708 men; 271 women) completed measures assessing posttraumatic stress disorder, panic disorder, social anxiety disorder, major depressive disorder, generalized anxiety disorder, IU and AS. Multivariate analysis of variance demonstrated that only main effects of sex were significant for all symptom variables, except SAD. Hierarchical multiple regressions demonstrated that AS and IU accounted for greater variance than sex on all mental disorder symptom measures, which suggests that cognitive risk factors explain more variance in mental disorder symptoms than sex. Efforts to reduce AS and IU may be beneficial for improving police mental health. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: R Nicholas Carleton’s research is supported by the Canadian Institutes of Health Research (CIHR) through a New Investigator Award (FRN: 285489) and a Catalyst Grant (FRN: 162545). This research was also funded in part by the Ministry of Public Safety and Emergency Preparedness through the Policy Development Contribution Program. Faculty yes

The Posttraumatic Growth Inventory (PTGI; Tedeschi and Calhoun, 1996) is the most commonly used measure of posttraumatic growth. Although the original five factor structure has extensive psychometric support, evidence exists for alternate PTGI models. The current study assessed the validity of oblique and hierarchical factor structures of five PTGI models. Confirmatory factor analyses were performed among a heterogeneous community sample with a diverse trauma history. The oblique models provided a better fit to the data compared with their respective hierarchical models. Three oblique variants provided good fit to the data on two fit indices and all five oblique variants met the recommended criteria for at least one fit index. The 10-item model demonstrated the lowest Expected Cross-Validation Index (ECVI) values and is a brief and useful measure when examining PTGI total scores; however, current results suggest that consideration of the specific subscales may be more meaningful than total scores. Researchers and clinicians interested in subscale scores should consider using the 18- or 21-item variants due to a higher number of items per factor and, therefore, greater factor stability. Future directions in refining and measuring posttraumatic growth are discussed.

The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.

Conceptual models of health anxiety stem from a diverse array of theoretical positions; however, to date, cognitive behavioral models have garnered the greatest empirical support and are the focus of this chapter. An initial cognitive behavioral model of health anxiety has since been elaborated and extended upon by several research groups. At present, there is not enough research on a single cognitive behavioral model of health anxiety to suggest that one model is a preferred over other models. Nonetheless, there is existing research supporting central tenets of many aspects of existing cognitive behavioral models of health anxiety. For these reasons, a variety of potential causal and maintaining factors of health anxiety are reviewed in this chapter. The reviewed factors are not meant to be an exhaustive list; rather, they are ones commonly implicated in extant cognitive behavioral models and are factors that have received, at least some, empirical support. This chapter commences through a consideration of biological vulnerability, before describing how learning experiences may contribute to health anxiety. Cognitive factors, inclusive of attention, beliefs, memory, and processing of somatosensory information, are then considered, followed by a discussion of the role of behavioral factors in the pathogenesis of health anxiety. The chapter concludes with a summation of the reviewed factors.

Health anxiety occurs when perceived bodily sensations or changes are interpreted as symptoms of a serious disease. Everyone experiences health anxiety at some point in their lives, and in some cases, it can be persistent and distressing. Contemporary cognitive behavioral models conceptualize health anxiety as existing along a continuum, ranging from mild to severe, and as being a core facet of several psychiatric diagnoses. Maladaptive presentations of health anxiety, often referred to as severe health anxiety, are associated with various dysfunctional beliefs and several forms of health-related checking behavior. These maladaptive presentations are often personally debilitating and associated with considerable societal costs. The purpose of this chapter is to introduce contemporary cognitive behavioral models proposed to understand health anxiety, to provide an overview of its clinical profile, to describe the core features associated with its etiology and maintenance, and to introduce considerations for assessment and treatment.

In this chapter, we have four specific goals. First, we provide a brief overview of pain and chronic pain. Second, we define the construct of anxiety sensitivity, introduce models proposed to explain the association between it and persistent presentations of pain, and review the current evidence from related empirical investigations. Third, we provide an overview of clinical strategies as well as concrete and actionable clinical recommendations for optimizing pain outcomes through the application of techniques designed to reduce anxiety sensitivity. Finally, given that research in this area remains in its infancy, we provide a potential agenda to guide future research efforts.

Background There is considerable evidence of widespread emotional distress associated with the COVID-19 pandemic. A growing number of studies have assessed posttraumatic growth related to the current pandemic; but, none have considered whether reported growth is real or illusory (i.e., characterized by avoidant or defensive coping that results in higher levels of distress). The purpose of this study was to extend this literature by assessing growth specific to the pandemic in people reporting high levels of COVID-related stress and estimating the extent of real and illusory COVID-19-related growth. Methods Participants were 893 adults from Canada and the United States with high levels of COVID-related stress who provided complete responses on measures of posttraumatic growth, disability, and measures of general and COVID-related distress as part of a larger longitudinal survey. Results Approximately 77 % of participants reported moderate to high growth in at least one respect, the most common being developing greater appreciation for healthcare workers, for the value of one’s own life, for friends and family, for each day, as well as changing priorities about what is important in life and greater feelings of self-reliance. Consistent with predictions, cluster analysis identified two clusters characterized by high growth, one comprising 32 % of the sample and reflective of real growth (i.e., reporting little disability and stable symptoms across time) and the other comprising 17 % of the sample and reflective of illusory growth (i.e., reporting high disability and worsening symptoms). These clusters did not differ in terms of socially desirable response tendencies; but, the illusory growth cluster reported greater increases in alcohol use since onset of the pandemic. Conclusion Consistent with research regarding personal growth in response to prior pandemics and COVID-19, we found evidence to suggest moderate to high levels of COVID-related growth with respect to appreciation for healthcare workers, life, friends and family, and self-reliance. Findings from our cluster analysis support the thesis that many reports of COVID-related personal growth reflect ineffectual pandemic-related coping as opposed to true growth. These findings have important implications for developing strategies to optimize stress resilience and posttraumatic growth during chronically stressful events such as pandemics.

© 2021 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. Comorbid posttraumatic stress disorder (PTSD) and substance use (SU) is a growing health concern among Canadian veterans. Veterans are increasingly seeking symptom relief for PTSD and comorbid SU by engaging service dogs (SDs). Despite promising results, the efficacy of SDs in aiding veterans warrants further investigation. An exploratory patientoriented, longitudinal, time-series, mixed-methods research design was employed with a sample of five Canadian veterans matched with SDs from AUDEAMUS, Inc. PTSD and SU were measured at six time points over 1 year with the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual for Mental Disorders, 5th Edition (PCL-5), Drug Use Screening Inventory Revised Substance Use Subscale (DUSI-R SU), and one-onone semi-structured interviews. There were clinically significant decreases in the veterans’ PTSD scores with the PCL-5. Interview content complemented these results. Veterans offered accounts of ways in which their SDs directly supported and helped manage their PTSD and related symptoms. While DUSI-R SU scale changes were non-significant, during interviews each veteran reported a decrease in their use of opioids and alcohol, while some reported an increase in their use of medical cannabis. However, veterans also highlighted ways in which their SDs sometimes contributed to increases in their PTSD and related symptoms, as well as their SU. This was particularly evident during the early stages of training and bonding. This study makes an important contribution to the emerging field examining the potential benefit of SDs for veterans diagnosed with PTSD. Additionally, this study is novel in its identification of the SDs beneficial contributions to veterans’ comorbid problematic use of substances. Faculty yes

The COVID Stress Scales (CSS) were designed to assess stress related to the COVID-19 pandemic. Emerging evidence indicates that people with anxiety disorders (ADs) and obsessive-compulsive disorder (OCD) may be more negatively impacted by COVID-19 than those with mood disorders or healthy individuals. Accordingly, this study sought to validate the Persian CSS (Persian-CSS) and to compare COVID-19-related stress reactions among patients with specific ADs and OCD. Patients with OCD (n = 300) and ADs (n = 310) completed the Persian-CSS and other scales developed to assess anxiety-related traits and COVID-19-related distress. The Persian-CSS replicated a five-factor structure similar to the original CSS in OCD and ADs. The total CSS and its scales had good reliability and validity. Patients with generalized anxiety disorder, panic disorder, and OCD had higher COVID-19 stress reactions than patients with social anxiety disorder and specific phobia. Patients with panic disorder had higher danger and contamination fears and xenophobia than patients with OCD. The study suggests that the Persian-CSS is a valid scale to be used in patients with OCD and ADs, each of whom differs in their specific patterns of COVID-19-related stress reactions., Highlights • The Persian COVID Stress Scales were validated in patients with OCD and anxiety-related disorders. • The Persian-CSS replicated the five-factor structure with good reliability and validity. • Patients with OCD and generalized anxiety and panic disorders had higher COVID-19 stress responses. • Patients with panic disorder had more danger and contamination fears and xenophobia than patients with OCD.

Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) are highly comorbid (Collimore et al., 2010). Trauma may present a shared environmental factor contributing to the development of comorbidity; however, existent research has been hampered by use of restrictive samples and limitations in the range of traumas investigated. The current study examines the relationship between a broad range of potentially traumatic events and the comorbidity between PTSD and SAD using Wave 2 of the National Epidemiological Survey of Alcohol and Related Conditions (n=34,653). Multiple logistic regressions and cross-tabulations were used to evaluate differences in the prevalence of potentially traumatic events among those who met criteria for comorbid PTSD-SAD compared to those with PTSD without SAD and SAD without PTSD. Those in the comorbid PTSD-SAD group were significantly more likely than those in the PTSD without SAD or SAD without PTSD groups to report experiencing specific types of assaultive violence, childhood maltreatment, and other shocking events. Associations between comorbidity and childhood maltreatment were significant for females only. Individuals diagnosed with comorbid PTSD-SAD are more likely than those diagnosed with either disorder alone to report exposure to specific types of traumatic events within their lifetime.

Previous research on bully perpetration and psychiatric outcomes has been limited to examination of lifetime associations and has not included evaluation of posttraumatic stress disorder (PTSD), despite previously reported correlations between PTSD and anger and aggression. The purpose of the present study was to provide a comprehensive evaluation of the association between bullying behaviour and mental disorders within a past-year framework. Data was obtained from Wave 2 of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC; n=34,653), a nationally-representative survey of American adults. Cross-tabulations and logistic regression analyses were conducted to evaluate the relationship between bullying behaviour and psychiatric diagnosis. A total of 239 individuals (138 males, 101 females) reported engaging in bullying behaviour within the past-year. Mood, anxiety, substance use, and personality disorders were all more common among bully perpetrators compared to others. Of note, strong associations were found between PTSD and bully perpetration. Findings from the current study demonstrate strong associations between bullying perpetration and mental health concerns. The proximity of bullying behaviors and mental health concerns may be important, suggesting avenues for efforts at intervention and bullying prevention.

Introduction Contemporary models of pain and smoking posit a cyclical relationship wherein smoking reduces pain in the short term but, ultimately, serves to exacerbate it in the long term. Such models were influenced by initial experimental findings suggesting situational pain is sufficient to increase smoking-urge and behavior. The initial experimental findings have not yet been replicated and potential mediating smoking motives and anxiety variables have not been explored. Methods The current investigation was designed with the aims of exploring whether (a) electrical heat-pain is sufficient to increase smoking-urge, (b) pain intensity, anxiety sensitivity, and smoking expectancies for pain relief account for variance in post-pain smoking-urge, and (c) individuals are more likely to smoke following a pain experience. Results Participants in the heat-pain condition (n = 16) reported greater smoking-urge than those in the no-pain control condition (n = 16). In the heat-pain condition, approximately 31% of variance in smoking-urge was accounted for by the belief that smoking would help with pain coping or relief. Anxiety sensitivity and pain intensity ratings were not significant predictors of smoking-urge. Significantly more individuals in the heat-pain condition attempted to smoke (100%) after the pain manipulation than those in the no-pain control condition (62.5%). Conclusions Acute heat-pain increases smoking-urge and behavior, especially for individuals with expectancies that smoking will help with pain coping. Pain and pain-related smoking expectancies may serve as barriers to smoking cessation for those experiencing pain. Findings provide support for smoking cessation interventions strategies aimed at pain management and challenging smoking expectancies for pain coping/relief.

Anger is associated with the development of posttraumatic stress disorder (PTSD) and with poor treatment outcomes. The Dimensions of Anger Reactions Scale-5 (DAR-5) has demonstrated preliminary evidence of unitary factor structure and sound psychometric properties. Gender-based differences in psychometric properties have not been explored. The current study examined gender-based factor structure invariance and differential item functioning of the DAR-5 and gender differences in PTSD symptoms as a function of anger severity using a community sample of adults who had been exposed to trauma. Data were collected from 512 trauma-exposed community-dwelling adults (47.9% women). Confirmatory factor analyses, Mantel-Haenszel χ(2) tests and a comparison of characteristic curves, and 2-way analyses of variance, respectively, were used to assess gender-based factor structure invariance, gender-based response patterns to DAR-5 items, and gender differences in PTSD symptoms as a function of anger. The unitary DAR-5 factor structure did not differ between men and women. Significant gender differences in the response pattern to the DAR-5 items were not present. Trauma-exposed individuals with high anger reported greater overall PTSD symptoms (p < .001), regardless of gender. The DAR-5 can be used to assess anger in trauma-exposed individuals without concern of gender biases influencing factor structure or item functioning. Findings further suggested that the established relationship between anger and PTSD severity did not differ by gender.

Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided. Canadian Institutes of Health Research, The Mayday Fund

A well-established body of literature supports the role of physical activity in maintaining mental health. Conversely, lack of physical activity has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and high anxiety sensitivity. Emerging research has investigated and found promising support for aerobic exercise in reducing symptoms of PTSD and anxiety sensitivity through exposure to feared bodily sensations; however, little is known regarding whether factors such as cardiorespiratory fitness predict who will most benefit from such interventions. We explored the role of cardiorespiratory fitness in predicting reductions in PTSD symptoms and anxiety sensitivity following aerobic exercise. Thirty-two individuals from a previously published trial (Fetzner & Asmundson, 2015) were enrolled in a 2-week aerobic exercise program consisting of six sessions of moderate to vigorous intensity stationary cycling and were assessed for cardiorespiratory fitness. Results suggested that aerobic exercise was generally effective in reducing symptoms of PTSD and anxiety sensitivity, regardless of individuals' fitness levels; however, individuals with lower pre-treatment levels of cardiorespiratory fitness experienced greater reductions in avoidance and hyperarousal symptoms of PTSD, as well as total, physical, and social symptoms of anxiety sensitivity. With the exception of re-experiencing symptoms of PTSD and cognitive symptoms of anxiety sensitivity, symptom reduction generally decelerated or returned toward pre-treatment levels following post-treatment. Aerobic exercise may be particularly effective in targeting specific symptoms related to PTSD and anxiety sensitivity in individuals with lower levels of cardiorespiratory fitness and sustained physical activity may be required to maximize maintenance of treatment gains. (C) 2015 Elsevier Ltd. All rights reserved.

Highlights • Little is known about healthcare worker stigmatization (HCWS) during COVID-19. • HCWS involves fear and avoidance of healthcare workers, for fear of infection. • Our research indicates that HCWS is a widespread, under-recognized problem. • HCWS is associated with the COVID Stress Syndrome. • Interventions that reduce the COVID Stress Syndrome may reduce HCWS., Background During past disease outbreaks, healthcare workers (HCWs) have been stigmatized (e.g., shunned, ostracized) by members in their community, for fear that HCWs are sources of infection. There has been no systematic evaluation of HCW stigmatization during the COVID-19 pandemic. Methods Non-HCW adults from the United States and Canada (N = 3551) completed an online survey, including measures of HCW stigmatization, COVID Stress Syndrome, and avoidance. Results Over a quarter of respondents believed that HCWs should have severe restrictions placed on their freedoms, such as being kept in isolation from their communities and their families. Over a third of respondents avoided HCWs for fear of infection. Participation in altruistic support of HCWs (i.e., evening clapping and cheering) was unrelated to stigmatizing attitudes. Demographic variables had small or trivial correlations with HCW stigmatization. People who stigmatized HCWs also tended to avoid other people, avoid drug stores and supermarkets, and avoid leaving their homes. Factor analysis suggested that HCW stigmatization is linked to the COVID Stress Syndrome. Conclusion Fear and avoidance of HCWs is a widespread, under-recognized problem during the COVID-19 pandemic. It is associated with the COVID Stress Syndrome and might be reduced by interventions targeting this syndrome.

Highlights • Participants with anxiety-related disorders exhibited higher COVID-related stress than those with no mental health disorder. • Those with anxiety-related disorders exhibited higher COVID-related stress than those with mood disorders. • Those with anxiety-related or mood disorders were more likely to self-isolate than those with no mental health disorder. • Mental health interventions for COVID-19 need to be tailored to the needs of people with pre-existing mental health conditions., Background People with pre-existing mental health conditions may be more susceptible to stressors associated with COVID-19 relative to the general population; however, no studies have assessed whether susceptibility differs between classes of mental health disorders. We assessed COVID-19-related stress, self-isolation stressors, and coping in those with a primary anxiety-related disorder diagnosis, a primary mood disorder diagnosis, and no mental health disorder. Methods Adults from a population-representative sample from the United States and Canada who reported current (past year) anxiety-related (n = 700) or mood (n = 368) disorders were compared to a random sample of respondents who did not report a current mental health diagnosis (n = 500) on COVID-19-related stress, self-isolation stress, and coping. Results The anxiety-related disorders group exhibited higher COVID Stress Scales total scores and higher scores on its fears about danger and contamination, socioeconomic consequences, xenophobia, and traumatic stress symptoms scales than the other groups. The mood disorders group had higher scores on the traumatic stress symptoms and socioeconomic consequences scales than those with no current mental disorder. Those with current anxiety-related or mood disorders were more likely to voluntarily self-isolate and were more likely to report greater self-isolation stressors and distress than those without a mental health disorder. Yet, there were no major differences in perceived effectiveness of coping strategies across groups. Conclusion People with anxiety-related or mood disorders were more negatively affected by COVID-19 compared to those with no mental health disorder; however, adding to psychological burden, those with anxiety-related disorders reported greater fears about danger and contamination, socioeconomic consequences, xenophobia, and traumatic stress symptoms than the other groups. These findings suggest the need for tailoring COVID-19-related mental health interventions to meet the specific needs of people with pre-existing mental health conditions.

Background Adverse childhood experiences (ACEs) are common and related to substance use problems in adulthood. Less is known about these relationships in adolescence and if experiencing ACEs in addition to peer victimization (or bullying) would have an interaction or cumulative effect on the odds of adolescent substance use. Method Data were used from the Well-Being and Experiences Study (The WE Study), a cross-sectional survey of adolescents aged 14–17 years (n = 1002) in Manitoba, Canada collected between July 2017 and October 2018. Statistical methods included descriptive statistics and logistic regression models. Results The prevalence of experiencing any of the 12 ACEs was 75.1 %. The prevalence of any peer victimization (monthly or more often) was 24.1 %. All individual ACEs were associated with increased odds of substance use. No significant interaction effects between ACEs and peer victimization on substance use were found. Significant cumulative effects were found, indicating that experiencing both ACEs and peer victimization, compared with experiencing ACEs only, significantly increased the odds of substance use among adolescents. Conclusion The odds of substance use becomes significantly greater if the adolescent with a history of ACEs also experiences peer victimization. Further research aimed at effective prevention of ACEs, peer victimization, and substance use is needed.

Highlights • The Behavioral Immune System (BIS) contributes to pandemics anxiety. • A community sample in China (N = 908) was surveyed during the COVID-19 health crisis. • Disgust propensity and sensitivity was a moderator in fear of contracting COVID-19., The COVID-19 public health crisis has led to extensive recommendations by officials to contain its spread. Anxiety regarding contracting the virus is prominent in the public. Specific routes to anxiety over disease contraction are under studied. It is expected that a contributory feature of fear of contracting COVID-19 involve disgust propensity and sensitivity, emotional reactions that are part of a broader behavioral immune system (BIS). A total of N = 908 Chinese adults (mean age = 40.37 years, SD = 9.27; n = 752 female) participated in a survey distributed between February 24 and March 15, 2020. Participants completed measures of anxiety sensitivity, disgust propensity and sensitivity, and fear of contracting COVID-19. Results support a moderating relationship between both disgust propensity and sensitivity in the relationship between physical concerns associated with anxiety sensitivity and fear of contracting COVID-19. These results lend support for individual variation in the activation of the BIS. Recommendations for public education to target individuals who may experience mental health consequences from pandemics are provided.

Health anxiety can be defined as a multifaceted trait that is primarily characterised by a fear of, or preoccupation with, serious illness. Whereas low levels of health anxiety can be helpful, clinically significant levels are associated with personal suffering and substantial societal costs. As general anxiety is probably on the rise, and the Internet has increased access to health-related information, it is commonly speculated that health anxiety has increased over the past decades. We tested this hypothesis based on a systematic review and meta-analysis of birth cohort mean health anxiety in Western university student samples from 1985 to 2017. Sixty-eight studies with 22 413 student participants were included. The primary analysis indicated that the mean score on the Illness Attitudes Scales had increased by 4.61 points (95 % CI: 1.02, 8.20) from 1985 to 2017. The percentage of general population Internet users in the study year of data collection was not predictive of student mean health anxiety. In conclusion, this study corroborates the hypothesis of an increase in health anxiety, at least in the student population, over the past decades. However, this increase could not be linked to the introduction of the Internet.

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges’ g = 1.24) and follow-up (mean Hedges’ g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.

This chapter discusses the complex relationship between stress and physical health, with a focus on comorbid posttraumatic stress disorder (PTSD) and physical health conditions. There is a great deal of evidence that stress and mental health conditions, such as PTSD, often co-occur with physical health conditions. This chapter reviews this evidence, describes potential mechanisms underlying the comorbidity, and outlines theoretical frameworks for understanding the relationship between stress and physical health. It considers the ways in which stress leads to poor physical health, how physical health conditions can lead to stress, and how other factors may both increase stress and worsen physical health. Clinical implications of comorbid mental and physical health conditions and suggestions for future research in the area are also discussed.

Poor health outcomes associated with posttraumatic stress disorder (PTSD) may reflect engagement in unhealthy behaviors that increase morbidity risk and disengagement in healthy behaviors that decrease morbidity risk. Although research supports this pattern, findings are not definitive, particularly for healthy behaviors. Many studies have not controlled for effects of concurrent generalized anxiety and depression, which might explain conflicting findings. To address this limitation, we used an online cross-sectional research design and multivariate multilevel modelling to evaluate associations between a multitude of health behaviors (i.e. sedentary behavior, sleep quality, physical activity, eating habits, alcohol use and substance use) and PTSD, while adjusting for comorbid generalized anxiety and depression, in a sample of trauma-exposed individuals (N = 246). Our results indicate that PTSD and comorbid generalized anxiety and depression symptoms were differentially associated with specific health constructs. Specifically, sedentary behavior and poor sleep quality were associated with PTSD, whereas low physical activity, poor sleep quality, and unhealthy eating habits were associated with depression. Both increased alcohol and substance use were associated with generalized anxiety. Results from our study highlight the need to conceptualize associations between health behaviors and specific psychological symptoms in a comprehensive manner as part of clinical presentations of PTSD.

To better understand depression among adolescent university students, this study was designed to examine coping style as a potential mediator between perfectionism and depression. Participants comprised 510 undergraduate students from Malaysia. Structural Equation Modelling demonstrated that personal standards perfectionism and task-focused coping style were negatively associated with depression, while emotion-focused coping style, avoidant coping style, and evaluative concerns perfectionism were positively associated with depression. Multiple mediator modelling provided evidence that coping styles partially mediated the relationship between perfectionism and depression. These findings advance current knowledge by suggesting how perfectionism may contribute to depression and may inform the development of more effective prevention and intervention programs for depression.

Social Anxiety Disorder (SAD) models implicate social threat cue vigilance (i.e., attentional biases) in symptom development and maintenance. A modified dot-probe protocol has been shown to reduce SAD symptoms, in some but not all studies, presumably by modifying an attentional bias. The current randomized controlled trial was designed to replicate and extend such research. Participants included treatment-seeking adults (n = 108; 58% women) who met diagnostic criteria for SAD. Participants were randomly assigned to a standard (i.e., control) or modified (i.e., active) dot-probe protocol condition and to participate in-lab or at home. The protocol involved twice-weekly 15-min sessions, for 4 weeks, with questionnaires completed at baseline, post-treatment, 4-month follow-up, and 8-month follow-up. Symptom reports were assessed with repeated measures mixed hierarchical modeling. There was a main effect of time from baseline to post-treatment wherein social anxiety symptoms declined significantly (p.05) but depression and trait anxiety did not (p.05). There were no significant interactions based on condition or participation location (ps.05). Reductions were maintained at 8-month follow-up. Symptom reductions were not correlated with threat biases as indexed by the dot-probe task. The modified and standard protocol both produced significant sustained symptom reductions, whether administered in-lab or at home. There were no robust differences based on protocol type. As such, the mechanisms for benefits associated with modified dot-probe protocols warrant additional research.

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and suicide attempt; however, research has largely focused on specific samples and a limited range of traumas. We examined suicidal ideation and suicide attempt relating to 27 traumas within a nationally representative U.S. sample of individuals with PTSD. Data were from the National Epidemiologic Survey of Alcohol and Related Conditions (N = 34,653). Participants were assessed for lifetime PTSD and trauma history, suicidal ideation, and suicide attempt. We calculated the proportion of individuals reporting suicidal ideation or suicide attempt for each trauma and for the number of unique traumas experienced. Most traumas were associated with greater suicidal ideation and suicide attempt in individuals with PTSD compared to individuals with no lifetime trauma or with lifetime trauma but no PTSD. Childhood maltreatment, assaultive violence, and peacekeeping traumas had the highest rates of suicidal ideation (49.1% to 51.9%) and suicide attempt (22.8% to 36.9%). There was substantial variation in rates of suicidal ideation and suicide attempt for war and terrorism-related traumas. Multiple traumas increased suicidality, such that each additional trauma was associated with an increase of 20.1% in rate of suicidal ideation and 38.9% in rate of suicide attempts. Rates of suicidal ideation and suicide attempts varied markedly by trauma type and number of traumas, and these factors may be important in assessing and managing suicidality in individuals with PTSD. Language: en

Several mechanisms have been posited for the anxiolytic effects of exercise, including reductions in anxiety sensitivity through interoceptive exposure. Studies on aerobic exercise lend support to this hypothesis; however, research investigating aerobic exercise in comparison to placebo, the dose-response relationship between aerobic exercise anxiety sensitivity, the efficacy of aerobic exercise on the spectrum of anxiety sensitivity and the effect of aerobic exercise on other related constructs (e.g. intolerance of uncertainty, distress tolerance) is lacking. We explored reductions in anxiety sensitivity and related constructs following a single session of exercise in a community sample using a randomized controlled trial design. Forty-one participants completed 30 min of aerobic exercise or a placebo stretching control. Anxiety sensitivity, intolerance of uncertainty and distress tolerance were measured at baseline, post-intervention and 3-day and 7-day follow-ups. Individuals in the aerobic exercise group, but not the control group, experienced significant reductions with moderate effect sizes in all dimensions of anxiety sensitivity. Intolerance of uncertainty and distress tolerance remained unchanged in both groups. Our trial supports the efficacy of aerobic exercise in uniquely reducing anxiety sensitivity in individuals with varying levels of the trait and highlights the importance of empirically validating the use of aerobic exercise to address specific mental health vulnerabilities. Aerobic exercise may have potential as a temporary substitute for psychotherapy aimed at reducing anxiety-related psychopathology.

In June 2014 I had the honour and privilege of receiving the Donald O. Hebb Award for Distinguished Contributions to Psychology as a Science from the Canadian Psychological Association. Although I was the individual upon whom this award was bestowed, my career contributions to the science of psychology have required the labours of many. In this article I pay homage to the "village" that helped me tackle the complexities of various forms of fear and eventually shape current understanding of chronic and disabling pain and its associations with posttraumatic stress disorder. In the spirit of paying forward some of the wisdom graciously imparted on me by that village, and with hopes that this may in some small way benefit others venturing down the career path of Canadian academic psychology, I reflect on some of the most important learning experiences from childhood and throughout my training and early career. To conclude, I briefly comment on what I perceive to be a bright future for Canadian psychology.Keywords: Hebb, Asmundson, fear, pain, training, mentor, early careerResumeEn juin 2014, j'ai eu l'honneur et le privilege de recevoir, de la Societe canadienne de psychologie, le prix Donald-O.-Hebb pour contributions remarquables a la psychologie en tant que science. Si je suis la personne a qui on a remis ce prix, mes contributions a la science de la psychologie au fil de ma carriere resultent du travail de bien des gens. Dans cet article, je rends hommage au « village » qui m'a aide a explorer la complexite des diverses formes de peur et, ulterieurement, a comprendre la douleur chronique et debilitante ainsi que ses liens avec le trouble de stress post-traumatique. Dans le but de transmettre une part de la sagesse qui m'a ete genereusement communiquee par ce village, et dans l'espoir que mes propos pourront aider, meme un peu, d'autres personnes qui ont choisi de faire carriere dans le domaine de la recherche en psychologie au Canada, je decris certaines des plus precieuses lecons que j'ai apprises pendant mon enfance ainsi qu'au cours de ma formation et au debut de ma carriere. Je conclus par quelques remarques sur l'avenir prometteur que je percois pour la psychologie au Canada.Mots-cles : Hebb, Asmundson, peur, douleur, formation, mentor, debut de carriere.The only appropriate way to open this article is to express my gratitude and thrill in being selected as the 2014 recipient of the Donald O. Hebb Award for Distinguished Contributions to Psychology as a Science from the Canadian Psychological Association (CPA). I have been aware of the Hebb Award for more than 20 years and recall drawing inspiration as a graduate student from the innovative ideas of its namesake-Donald O. Hebb-and the award recipients of that time. The award has always been aspirational; thus, despite approaching personal unbelievability, it is an absolute honour and privilege to have my work recognised as having a quality and magnitude of impact deserving of this award.My teachers, mentors, and training opportunities have helped prepare me in the art of disseminating my ideas and research findings effectively, whether through the written or spoken word. What my experiences have not prepared me for is the process of providing a personal reflection that accurately and coherently captures the essence of how it is that I arrived on a CPA conference stage in June, 2014 to receive one of the most prestigious honours that can be bestowed on a Canadian psychologist. As unprepared as I am, this is the challenge I face.As I sat down to tackle this challenge, I recalled mentioning earlier in the day to the students in my fourth-year honours seminar that effective dissemination requires the delivery of a clear message that is relayed in a concise story with a beginning, middle, and an end. With that in mind, I quickly decided that my message should be one of gratitude to the "village" of many whose wisdom and labours ushered me along the path leading to that conference stage. …

© 2018 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). Canadian Public Safety Personnel (PSP; e.g., correctional service officers, dispatchers, firefighters, paramedics, police officers) regularly experience potentially traumatic, painful, and injurious events. Such exposures increase risk for developing mental disorders and chronic pain, which both involve substantial personal and social costs. The interrelationship between mental disorders and chronic pain is well-established, and both can be mutually maintaining; accordingly, understanding the relationship between mental health and chronic pain among PSP is important for improving health care. Unfortunately, the available research on such comorbidity for PSP is sparse. The current study was designed to provide initial estimates of comorbidities between mental disorders and chronic pain across diverse PSP. Participants included 5093 PSP (32% women) in six categories (i.e., Call Center Operators/Dispatchers, Correctional Workers, Firefighters, Municipal/Provincial Police, Paramedics, Royal Canadian Mounted Police) who participated in a large PSP mental health survey. The survey included established self-report measures for mental disorders and chronic pain. In the total sample, 23.1% of respondents self-reported clinically significant comorbid concerns with both mental disorders and chronic pain. The results indicated PSP who reported chronic pain were significantly more likely to screen positive for posttraumatic stress disorder (PTSD), major depressive disorder, generalized anxiety disorder, social anxiety disorder, and alcohol use disorder. There were differences between PSP categories; but, the most consistent indications of comorbidity were for chronic pain, PTSD, and major depressive disorder. Comorbidity between chronic pain and mental disorders among PSP is prevalent. Health care providers should regularly assess PSP for both symptom domains. R. N. Carleton’s research is supported by the Canadian Institutes of Health Research (CIHR) through a New Investigator Award (FRN: 285489). T.O. Afifi’s research is supported by a CIHR New Investigator Award and Foundation Scheme Award. R. El-Gabalawy’s research is supported by the CIHR Chronic Pain SPOR Network, and University of Manitoba Start-Up funding. Faculty yes

Background Chronic pain conditions and posttraumatic stress disorder (PTSD) commonly co-occur and are associated with opioid use disorder (OUD). The aims of this paper were to identify prevalence estimates of OUD among individuals with and without PTSD and assess independent and combined contributions of PTSD and chronic pain conditions on OUD in a nationally representative sample. Methods Data were extracted from 36,309 individuals from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. Past-year PTSD and OUD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 edition. Respondents reported physician-confirmed, past-year chronic pain conditions, categorized into musculoskeletal pain (e.g., arthritis), digestive pain (e.g., pancreatitis), and nerve pain (e.g., reflex sympathetic dystrophy). We examined the weighted prevalence of OUD among those with and without PTSD. Multiple logistic regressions examined the association between PTSD and chronic pain conditions on OUD. Results The prevalence of OUD was higher among those with PTSD than those without. Comorbid PTSD/musculoskeletal pain and PTSD/nerve pain conditions were associated with increased odds of OUD, compared to those with neither PTSD nor chronic pain conditions. Digestive pain conditions were not associated with OUD. Comorbid PTSD/musculoskeletal pain conditions demonstrated an additive relationship on OUD compared to musculoskeletal pain conditions and PTSD alone. Conclusions Results reveal that musculoskeletal pain and nerve pain conditions are associated with increased odds of OUD, but only musculoskeletal pain conditions display an additive relationship on OUD when combined with PTSD. These findings have implications for opioid management and screening among those with comorbid conditions.