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Objective: Alcohol misuse is common among military veterans affected by posttraumatic stress disorder (PTSD) and depression; however, research to date has provided mixed evidence concerning differential associations among PTSD and depressive symptoms in relation to alcohol misuse. Further, most available studies have examined primarily male samples or have dichotomously grouped participants as either having or not having an alcohol use disorder. Our study sought to explore relations among 2 aspects of alcohol misuse (that is, alcohol-related problems, and quantity or frequency of alcohol use) and symptoms of PTSD and depression in independent samples of female and male military veterans. Method: Canadian military veterans (1271 men and 72 women) completed a battery of self-report questionnaires as part of a broader health status assessment conducted by Veterans Affairs Canada. Results: Linear regression analyses suggested depressive symptoms accounted for unique variance in reported alcohol-related problems and quantity or frequency of alcohol use among male veterans. Additionally, PTSD hyperarousal symptoms accounted for unique variance in reported alcohol-related problems. In contrast, among female veterans neither PTSD nor depressive symptoms were found to account for significant variance in measures of alcohol-related problems or quantity or frequency of alcohol use. Conclusions: Findings suggest differing mechanisms are involved in influencing alcohol misuse among male and female veterans. Accordingly, female veterans may benefit from specialized assessment and intervention approaches to prevent and treat alcohol-related disorders, rather than applying the same strategies commonly used with male veterans. Comprehensive results, implications, and directions for future research are discussed.

Health anxiety disorders (e.g., hypochondriasis) are prevalent but understudied in older adults. Existing research suggests that severe health anxiety has a late age of onset, perhaps because of comorbidity with physical health conditions that are more likely to occur with aging. Despite being under diagnosed in later life due to a lack of age-appropriate diagnostic criteria, significant positive associations with age suggest that health anxiety disorders are more prevalent in older than younger adults. Preliminary research also highlights the complexity of these disorders in older adults and the potential importance of medical morbidity as a risk factor. This review explores the complexities of health anxiety disorders in later life with a focus on understanding defining features, prevalence rates, correlates, assessment, diagnosis, and treatment. We offer a theoretical model of the development of severe health anxiety among older adults to encourage further research on this important and under-studied topic.

The Pain Catastrophizing Scale (PCS) was developed in English to assess 3 components of catastrophizing (rumination, magnification, helplessness). It has been adapted for use and validated with Flemish-speaking children (Pain Catastrophizing Scale for Children (PCS-C)) and French-speaking adolescents. The PCS-C has been back-translated to English and used extensively in research with English-speaking children; however, the factorial validity of the English PCS-C has not been empiri- cally examined. This study assessed the factor structure of the English PCS-C among a community sample of 1,006 English-speaking children (aged 8-18 years). Exploratory factor analysis was conduct- ed using a random subsample (n = 504) to assess the underlying factor structure. Items with poor factor loadings were removed. Confirmatory factor analysis, using the second subsample (n = 502), was used to cross-validate the factor structure revealed by exploratory factor analysis and compare it to the original 3-factor model and other model variants. Exploratory factor analysis revealed that the original PCS-C and a revised 3-factor model comprising 11 of the original 13 PCS-C items, all loading on their original factors, provided adequate fit to the data. The revised model provided sta- tistically better fit to the data compared to all other model variants, suggesting that the English PCS-C may be better understood using a revised 11-item oblique 3-factor model. Perspective: This is the first examination of the factorial validity of the widely used English version of the PCS-C in a large community sample of English-speaking children. A revised 11-item, 3-factor model provided statistically better fit to the data compared to the original model and other model variants.

Background The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) is a commonly used freely available self-report measure of depressive symptoms. Despite its popularity, several recent investigations have called into question the robustness and suitability of the commonly used 4-factor 20-item CES-D model. The goal of the current study was to address these concerns by confirming the factorial validity of the CES-D. Methods and Findings Differential item functioning estimates were used to examine sex biases in item responses, and confirmatory factor analyses were used to assess prior CES-D factor structures and new models heeding current theoretical and empirical considerations. Data used for the analyses included undergraduate (n = 948; 74% women), community (n = 254; 71% women), rehabilitation (n = 522; 53% women), clinical (n = 84; 77% women), and National Health and Nutrition Examination Survey (NHANES; n = 2814; 56% women) samples. Differential item functioning identified an item as inflating CES-D scores in women. Comprehensive comparison of the several models supported a novel, psychometrically robust, and unbiased 3-factor 14-item solution, with factors (i.e., negative affect, anhedonia, and somatic symptoms) that are more in line with current diagnostic criteria for depression. Conclusions Researchers and practitioners may benefit from using the novel factor structure of the CES-D and from being cautious in interpreting results from the originally proposed scale. Comprehensive results, implications, and future research directions are discussed.

Research has shown that ‘fear of anxiety’ plays a significant role in the occurrence of panic and is predictive of both the development and severity of panic disorder. The most frequently used measures of fear of anxiety are the Anxiety Sensitivity Index (ASI), the Agoraphobic Cognitions Questionnaire (ACQ), and the Body Sensations Questionnaire (BSQ). In an attempt to further our understanding of fear of anxiety the present study sought to evaluate the extent to which these common measures assess unique aspects of the construct. Results of data collected from 48 panickers and 48 control Ss with no panic history indicate that: 1. (a) the measures of fear of anxiety are modestly correlated with each other and, in panickers, with trait anxiety; 2. (b) panickers score higher than control Ss on the ASI and the total score of the ACQ, but not on the Physical or Social/Behavioral Concerns Scales of the ACQ or on the BSQ; and 3. (c) the measures provide unique contributions to discriminant function classification of panickers and nonpanickers. These results suggest that, while the measures are associated with panic experiences, each may be measuring unique aspects of fear of anxiety. Theoretical and practical implications are discussed.

Recently, there has been increased interest in the extent to which chronic pain patients fear and avoid activities that are thought to be related to the experience of pain. To date, however, few studies have evaluated the nature and extent of nonpain fears in these patients. The purpose of the present study was to address this paucity. The Fear Questionnaire was administered to 130 patients with physically unexplained chronic pain and 93 patients with a chronic condition unrelated to pain. Results indicated that the chronic pain patients were more fearful and avoidant of social interactions/situations and blood/injury than were the patient controls. Agoraphobia was minimal and did not differ significantly between groups. As well, the proportions of chronic pain patients indicating definite avoidance of particular situations related to blood/injury phobia (i.e., injection/minor surgery, hospitals, sight of blood, and thoughts of injury/illness) and social phobia (i.e., being watched/stared at, and speaking/acting to an audience) were significantly greater when compared to the patient controls. These results indicate that nonpain fear and avoidance are common in patients with chronic pain. Implications regarding the significance of these fears and avoidance behaviours on the experience and maintenance of pain symptoms and related disability are discussed. Anxiety 2:28–33 (1996). © 1996 Wiley-Liss, Inc.

Chronic pain during childhood and adolescence can lead to persistent pain problems and mental health disorders into adulthood. Posttraumatic stress disorders and depressive and anxiety disorders are mental health conditions that co-occur at high rates in both adolescent and adult samples, and are linked to heightened impairment and disability. Comorbid chronic pain and psychopathology has been explained by the presence of shared neurobiology and mutually maintaining cognitive-affective and behavioral factors that lead to the development and/or maintenance of both conditions. Particularly within the pediatric chronic pain population, these factors are embedded within the broader context of the parent–child relationship. In this review, we will explore the epidemiology of, and current working models explaining, these comorbidities. Particular emphasis will be made on shared neurobiological mechanisms, given that the majority of previous research to date has centered on cognitive, affective, and behavioral mechanisms. Parental contributions to co-occurring chronic pain and psychopathology in childhood and adolescence will be discussed. Moreover, we will review current treatment recommendations and future directions for both research and practice. We argue that the integration of biological and behavioral approaches will be critical to sufficiently address why these comorbidities exist and how they can best be targeted in treatment.

It has been proposed that high anxiety sensitivity amplifies a number of fears and anxiety reactions. The purpose of this study was to examine whether anxiety sensitivity influences pain-related anxiety and associated cognitive and affective reactions in patients with physically unexplained chronic back pain. Seventy patients with chronic back pain without demonstrable organic pathology completed a battery of questionnaires prior to admission to a multidisciplinary treatment centre. Fourteen patients (20.0%) were classified as high, 44 (62.9%) as medium and 12 (17.1%) as low anxiety sensitive. Multivariate analysis of variance indicated that the high anxiety sensitive patients were more negatively affected by their experience with pain. Specifically, high anxiety sensitivity patients exhibited greater cognitive disruption and anxiety in response to pain, greater fear of negative consequences of pain, and greater negativity of affect than the other groups. Groups did not differ in the intensity of pain that they were experiencing. The proportion of high anxiety sensitive patients reporting current use of analgesic medication was, however, significantly greater than the medium and low anxiety sensitive patients. Correlational analyses indicated significant associations between anxiety sensitivity and pain-related cognitive/affective variables that were independent of pain severity. These results suggest that chronic back pain patients with high anxiety sensitivity, despite equal levels of pain severity, are more likely to be negatively affected by their pain experiences than those with medium and low anxiety sensitivity.

PsycLIT and Medline, two computerized databases, were used to determine the number of articles on anxiety disorders published each year from 1981–1990. The results showed that the proportion of articles on anxiety disorders listed in PsycLIT and Medline increased dramatically during the 1980s, especially during the last half of the decade. The anxiety disorders most frequently researched were panic disorder, obsessive compulsive disorder, and posttraumatic stress disorder. Far fewer abstracts were associated with generalized anxiety disorder, social phobia, and simple phobia. Factors that might have been instrumental in the increased research activity on anxiety disorders are discussed.

The aim of this study was to examine the relationship between perpetration and victimization of physical and sexual intimate partner violence (IPV) in the past year and substance use disorders (SUDs) in the past year, including alcohol, sedatives/tranquilizers, cocaine, cannabis, and nicotine stratified according to sex. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions. A series of adjusted logistic regression models were conducted. Among men and women, all types of SUDs were associated with increased odds of IPV perpetration (odds ranging from 1.4 to 8.5 adjusting for sociodemographic variables). IPV victimization increased the odds of having all types of SUDs for male and female victims, with the exception of sedatives/tranquilizer abuse/dependence among women (odds ranging from 1.5 to 6.0 adjusting for sociodemographic variables). Substances that had the most robust relationship with perpetration and victimization of IPV included alcohol and cannabis, after adjusting for sociodemographic variables, mood disorders, anxiety disorders, personality disorders, and mutual violence.

Fear of injury has been posited as crucial in pain-related anxiety and in the development of chronic pain; however, research has only measured fear of injury indirectly through other constructs (eg, fear of illness and fear of movement). The current study tested fear of injury as an independent contributor to pain-related anxiety and impairment. Patients (n = 78; 37% women) in a work-hardening treatment program for chronic low back pain completed self-report measures of pain-related anxiety, anxiety sensitivity, fear of injury, current pain, and impairment. Behavioral measures of impairment included lifting capacity, treatment outcomes, and days absent from treatment. Structural equation modeling tested the role of fear of injury within contemporary theory. Fit for the theoretical model was excellent and superior to an alternative model. Variance accounted for in pain-related anxiety by fear of injury, anxiety sensitivity, and current pain was 64%, while pain-related anxiety and current pain predicted 49% of variance in latent impairment. Fear of injury directly predicted pain-related anxiety (β = .42) and indirectly predicted impairment through pain-related anxiety (β = .19). Fear of injury may warrant theoretical and clinical consideration as an important contributor to pain-related anxiety and impairment; however, research is needed to explore how it may be causally related with other constructs. Perspective Fear of injury directly predicts pain-related anxiety and indirectly predicts self-reported and behavioral impairment. Fear of injury may warrant inclusion in contemporary theories of chronic pain. Clinicians may benefit from considering the construct in interventions for chronic pain.

BackgroundAlthough it has been posited that exposure to adverse childhood experiences (ACEs) increases vulnerability to deployment stress, previous literature in this area has demonstrated conflicting results. Using a cross-sectional population-based sample of active military personnel, the present study examined the relationship between ACEs, deployment related stressors and mood and anxiety disorders.MethodData were analyzed from the 2002 Canadian Community Health Survey – Canadian Forces Supplement (CCHS-CFS; n = 8340, age 18–54 years, response rate 81%). The following ACEs were self-reported retrospectively: childhood physical abuse, childhood sexual abuse, economic deprivation, exposure to domestic violence, parental divorce/separation, parental substance abuse problems, hospitalization as a child, and apprehension by a child protection service. DSM-IV mood and anxiety disorders [major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic attacks/disorder and social phobia] were assessed using the Composite International Diagnostic Interview (CIDI).ResultsEven after adjusting for the effects of deployment-related traumatic exposures (DRTEs), exposure to ACEs was significantly associated with past-year mood or anxiety disorder among men [adjusted odds ratio (aOR) 1.34, 99% confidence interval (CI) 1.03–1.73, p p = 0.01]. Participants exposed to both ACEs and DRTEs had the highest prevalence of past-year mood or anxiety disorder in comparison to those who were exposed to either ACEs alone, DRTEs alone, or no exposure.ConclusionsACEs are associated with several mood and anxiety disorders among active military personnel. Intervention strategies to prevent mental health problems should consider the utility of targeting soldiers with exposure to ACEs.

In a study of the prevalence of panic and other anxiety disorders in persons with complaints of dizziness, 87 patients referred to a clinic for vestibular disorders completed self-rating measures of anxiety and depression; 32 also underwent a structured diagnostic interview. Thirteen (14.9%) of the patients met the DSM-III-R criteria for panic disorder, agoraphobia, or both. They rated themselves as much more disabled by their dizziness than the patients with no psychiatric disorder. Panic disorder was equally prevalent among patients with and without vestibular disease. In some cases panic disorder may provide an explanation for the dizziness, whereas in others it may be a comorbid condition compounding the disability attributable to the vestibular disorder.

There is a growing body of evidence to suggest that clinical anxiety is associated with cognitive biases that favour the processing of threat-related information specific to particular anxiety syndromes. Several cognitive psychology paradigms have been used to demonstrate that anxiety disorder patients selectively attend to threatening material that is specifically related to their particular disorder. The present investigation was an attempt to support preliminary reports suggesting that patients with social phobia selectively process social threat information. Twenty-four patients with social phobia (generalized type) and 20 healthy control subjects completed a computerized task designed to assess allocation of visual attention for specific stimuli (neutral, physically threatening, or socially threatening) via measurement of response latencies for dots that immediately followed their presentation. It was found that, when attention was allocated in the spatial location of a stimulus cue, patients with social phobia responded faster to probes that followed social threat cues than probes following either neutral cues of physical threat cues. This effect was not observed among control subjects. These results support the view that patients with social phobia selectively process threat cues that are social-evaluative in nature. The theoretical relevance and clinical implications of these results are outlined.

A number of cognitive psychology paradigms have been used to demonstrate that panic disorder patients selectively process stimuli that are related to themes of physical threat and catastrophe. The present investigation was an attempt to replicate and extend initial findings obtained with the dot-probe paradigm, a visual attention paradigm which allows for the assessment of allocation of visual attention to stimuli of varied emotional valence via the measurement of detection latencies for visual probes that follow their presentation. Twenty-two panic disorder patients and 20 healthy control subjects were tested using neutral, social threat, and panic symptom/fear cues. No between-group differences were observed in detection latencies for visual probes that followed neutral, social threat, or panic symptom/fear cues. These results represent a failure to replicate previous reports of selective processing in panic disorder and suggest that panic disorder patients may not selectively process cues related to bodily sensation and panic-related fears. Implications of this finding are discussed.

Background and objectives Physiological arousal serves to maintain social anxiety disorder by skewing self-perception. Anxiety sensitivity is associated with the disorder and exaggerated perceptions of arousal, but has not been tested as explaining exaggerated perceived arousal in social contexts. The aim of this investigation was to address this issue. Methods A total of 42 individuals participated in three tasks associated with potential social threat (i.e., a speech, typing task, hyperventilation) and completed measures of trait social anxiety and anxiety sensitivity. State anxiety, perceived arousal, and objective arousal were assessed during each task. Results Trait social anxiety and anxiety sensitivity were correlated with state anxiety and perceived arousal, but not objective arousal, during the tasks. Anxiety sensitivity mediated the relationships between trait social anxiety and perceived arousal and between trait social anxiety and state anxiety for the typing and hyperventilation tasks. Limitations Although the sample likely included a number of individuals with social anxiety disorder, the sample was mostly comprised of individuals without a diagnosis. The current results can be extended to clinical presentations to some extent, but future research is needed to further explore the demonstrated relationships in samples of individuals with social anxiety disorder. Conclusions Anxiety sensitivity may play a crucial role in perceptions of arousal and state anxiety in the context of potential social threats, warranting attention from researchers and clinicians focussing on social anxiety disorder.

Background Clinical data has indicated that exposure to trauma and meeting diagnostic criteria for posttraumatic stress disorder (PTSD) are common among individuals with a history of conduct disorder. However, these relationships have not been adequately examined in a population-based sample. Methods Data were drawn from Wave 2 of the U.S. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) collected in 2004–2005 (n = 34,653, response rate = 86.7%). Multivariate logistic regression analyses were conducted to examine relations between conduct disorder, traumatic life events, and PTSD in the full sample, and separately for males and females. Results The main findings indicate that childhood maltreatment was associated with conduct disorder (Adjusted Odds Ratio [AOR] ranging from 2.4 to 4.7) after adjustment for sociodemographic variables. Additionally, respondents with a history of conduct disorder compared to respondents without conduct disorder were more likely to report experiencing any traumatic event (AOR = 2.7, 95% CI = 2.0–3.6) and PTSD (AOR = 2.2, 95% CI = 1.8–2.7) after adjusting for sociodemographic variables. Although sex differences were noted, conduct disorder was associated with the greatest odds of assaultive violence for males and females. The majority of individuals (72.9%) diagnosed with both conduct disorder and PTSD developed conduct disorder symptoms before PTSD symptoms. Conclusions Results of this study provide the first known sex-stratified examination of the relationship between conduct disorder, traumatic events, and PTSD in a large, population-based sample of adults and are consistent with clinical impressions. Policy and clinical implications are discussed.

Context There has been increasing concern about the impact of the global economic recession on mental health. To date, findings on the relationship between income and mental illness have been mixed. Some studies have found that lower income is associated with mental illness, while other studies have not found this relationship. Objective To examine the relationship between income, mental disorders, and suicide attempts. Design Prospective, longitudinal, nationally representative survey. Setting United States general population. Participants A total of 34 653 noninstitutionalized adults (aged ≥20 years) interviewed at 2 time points 3 years apart. Main Outcomes Lifetime DSM-IV Axis I and Axis II mental disorders and lifetime suicide attempts, as well as incident mental disorders and change in income during the follow-up period. Results After adjusting for potential confounders, the presence of most of the lifetime Axis I and Axis II mental disorders was associated with lower levels of income. Participants with household income of less than $20 000 per year were at increased risk of incident mood disorders during the 3-year follow-up period in comparison with those with income of $70 000 or more per year. A decrease in household income during the 2 time points was also associated with an increased risk of incident mood, anxiety, or substance use disorders (adjusted odds ratio, 1.30; 99% confidence interval, 1.06-1.60) in comparison with respondents with no change in income. Baseline presence of mental disorders did not increase the risk of change in personal or household income in the follow-up period. Conclusions Low levels of household income are associated with several lifetime mental disorders and suicide attempts, and a reduction in household income is associated with increased risk for incident mental disorders. Policymakers need to consider optimal methods of intervention for mental disorders and suicidal behavior among low-income individuals.

Significant controversy exists as to whether soldiers are at increased risk for suicide and suicidal behaviors compared with civilians. Furthermore, little is known about whether risk factors for suicidal behaviors in civilian populations are generalizable to soldiers. The aim of the current study is to determine whether the prevalence and correlates of past-year suicidal ideation and suicide attempts differ in Canadian soldiers when compared with Canadian civilians. The current study utilized data from the Canadian Community Health Survey Cycle 1.2Canadian Forces Supplement in conjunction with the 2001–2002 Canadian Community Health Survey Cycle 1.2. Logistic regression interaction models were used to explore differences between correlates of suicidal ideation and suicide attempts comparing Canadian soldiers with civilians. Although there was no significant difference between the 2 samples on prevalence of past-year suicidal ideation, the prevalence of past-year suicide attempts was significantly lower in the Canadian forces sample compared with the civilian population (odds ratio ¼ 0.41, 95% confidence interval: 0.25, 0.67). Findings suggest that suicide attempts are less common in Canadian active military personnel than in the civilian population. Possible mechanisms for these differences are discussed. Canada; military personnel; psychology, military; risk factors; social problems; suicide Abbreviations: AOR, adjusted odds ratio; CCHS 1.2, Canadian Community Health Survey Cycle 1.2; CCHS-CFS, Canadian Community Health Survey Cycle 1.2-Canadian Forces Supplement; CI, confidence interval; CIDI, Composite International Diagnostic Interview; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; OR, odds ratio (unadjusted); PTSD, posttraumatic stress disorder; UK, United Kingdom.

Objective: To systematically review the literature on the association between deployment to a peacekeeping mission and distress, mental disorders, and suicide. Methods: Peer-reviewed English publications were found through key word searches in MEDLINE, PsycINFO, Scopus, and Embase, and by contacting authors in the field. Sixty-eight articles were included in this review. Results: Some studies have found higher levels of postdeployment distress and posttraumatic stress disorder (PTSD) symptoms. Most studies have not shown an increased risk of suicide in former peacekeepers. Correlates of distress and PTSD symptoms included level of exposure to traumatic events during deployment, number of deployments, predeployment personality traits or disorder, and postdeployment stressors. Perceived meaningfulness of the mission, postdeployment social supports, and positive perception of homecoming were associated with lower likelihood of distress. Conclusions: Most peacekeepers do not develop high levels of distress or symptoms of PTSD. As postdeployment distress is consistently shown to be associated with high levels of exposure to combat during deployment, targeted interventions for peacekeepers who have been exposed to high levels of combat should be considered.

To (1) use structural equation modeling (SEM) to examine relationships proposed in Turk's diathesis-stress model of chronic pain and disability as well as (2) investigate what role, if any, posttraumatic stress symptoms (PTSS) play in predicting pain disability, relative to some of the other factors in the model.The study sample consisted of 208 patients scheduled for general surgery, 21 to 60 years of age (mean age=47.18 y, SD=9.72 y), who reported experiencing persistent pain for an average of 5.56 years (SD=7.90 y). At their preadmission hospital visit, patients completed the Anxiety Sensitivity Index, Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale-20, Pain Disability Index, posttraumatic stress disorder Checklist, and rated the average intensity of their pain (0 to 10 numeric rating scale). SEM was used to test a model of chronic pain disability and to explore potential relationships between PTSS and factors in the diathesis-stress model.SEM results provided support for a model in which anxiety sensitivity predicted fear of pain and catastrophizing, fear of pain predicted escape/avoidance, and escape/avoidance predicted pain disability. Results also provided support for a feedback loop between disability and fear of pain. SEM analyses provided preliminary support for the inclusion of PTSS in the diathesis-stress model, with PTSS accounting for a significant proportion of the variance in pain disability.Results provide empirical support for aspects of Turk's diathesis-stress model in a sample of patients with persistent pain. Findings also offer preliminary support for the role of PTSS in fear-avoidance models of chronic pain.

Anxiety sensitivity (AS) was initially conceptualized as existing along a continuum; however, emerging evidence from taxometric analyses is mixed as to whether the latent structure of AS is dimensional or taxonic. The purpose of the present study was to further evaluate the latent structure of AS in an effort to clarify the contrasting findings reported in the literature. To do so, we examined the latent structure of AS in two large independent samples unselected with regard to AS level (comprising undergraduate respondents and/or community residents). MAXEIG and MAMBAC analyses were performed with indicator sets drawn from distinct self-report measures of AS within either sample. MAXEIG and MAMBAC, as well as comparison analyses utilizing simulated taxonic and dimensional datasets, yielded converging evidence that AS has a dimensional latent structure. Implications of these finding for the conceptualization and measurement of AS are discussed and future research directions are highlighted.

The present investigation sought to examine the relation between specific types of chronic musculoskeletal pain and cigarette smoking among a large representative sample of adolescents and adults residing in Canada. Specifically, we examined the relations between chronic back pain, arthritis, and daily smoking status. As predicted, individuals with chronic back pain were more likely to smoke than those without chronic back pain or arthritis; this association remained significant after controlling for sociodemographics and any lifetime anxiety or mood disorder. An opposite, albeit less robust, association was evident for the prescence of lifetime arthritis and smoking. Future work is needed to better understand the mechainisms underlying the association between chronic pain and smoking.

Objective: There is increasing concern about mental health problems and need for mental health care among soldiers after deployment. This study examined correlates of self-perceived need for mental health care among active military personnel. Methods: Data were from a 2002 crosssectional population-based survey of 8,441 active Canadian military personnel (2,592 women) aged 16 to 54 (response rate 81%). A fully structured lay-administered interview for past-year DSM-IV mental disorders and perceived need for mental health care was conducted. Five domains of self-perceived need were assessed: information, medication, counseling, social intervention, and skills training. Several deployment factors were assessed (length of deployment, number of deployments, and exposure to deployment-related traumatic events), as were longterm restriction in activities because of disability and suicidal ideation. Multiple logistic regression models were used to determine correlates of perceived need. Results: After adjustment for mental disorders, the strongest and most consistent correlates of perceived need were longterm restriction in activities, suicidal ideation, female gender, and regular service status (versus reserve status) (adjusted odds ratios ranging from 1.28 to 4.37). Deployment and exposure to combat and witnessing atrocities were moderately associated with an increase in self-perceived need for mental health care. Conclusions: The findings suggest that a range of issues beyond the presence of common mental disorders need to be considered in understanding the factors that contribute to a sense of need for mental health treatment. Postdeployment screening programs should consider systematically assessing self-perceived need for mental health treatment. (Psychiatric Services 61:50–57, 2010)

Contains fulltext : 90743.pdf (Publisher’s version ) (Closed access) Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) are frequently camorbid among veteran and community samples. Several studies have demonstrated significant camorbidity between trauma, PTSD, and social anxiety (SA), and a growing number of studies have explored the nature of this association. Although a diagnosis of either PTSD or SAD alone can result in significant impairment in social and occupational functioning, these difficulties are often magnified in persons suffering from both disorders. This review describes the current state-of-the-art regarding the co-occurrence of trauma, PTSD, and SA. First, we provide an overview of empirical data on the prevalence of co-occurring trauma, PTSD, and SAD. Second, we describe possible explanatory models of the co-occurrence, with a specific focus on the shared vulnerability model. Third, we review the available empirical data addressing the postulates of this model, including both genetic and psychological vulnerabilities. Fourth, we describe additional factors guilt, shame, and depressive symptoms that may help to explain the co-occurrence of PTSD and SA. A better understanding of this complex relationship will improve the efficacy of treatment for individuals suffering from both disorders. We conclude with key areas for future research.

This review covers the current cognitive behavioural treatments available to address fear-avoidance beliefs in patients with chronic musculoskeletal pain (CMP). Four types of treatment protocols were identified for inclusion in the review: (a) graded in vivo exposure (GivE); (b) graded activity (GA); (c) acceptance and commitment therapy (ACT); and (d) mixed cognitive behavioural protocols. Most of the research suggests that GivE and ACT result in the best outcomes for treating fear-avoidance beliefs in patients with CMP. There is also a readily apparent paucity of research from North America; indeed, most of the available studies were conducted in the Netherlands and Scandinavia. This relative absence of North American research raises potentially important questions about the role of compensation status and access to care, which differ between countries, on treatment outcome. Implications and directions for future research are discussed. ispartof: Cognitive Behaviour Therapy vol:39 issue:1 pages:46-63 ispartof: location:England status: published

Introduction: Individuals with chronic pain problems are at an increased risk for certain types of substance abuse and dependence. Recent work suggests that there is a signifi cant association between chronic pain and cigarette smoking; however, it is unclear as to whether pain – smoking effects are evident above and beyond sociodemographic factors and cooccurring substance use disorders. The present investiga-tion examined the relation between lifetime and current (past year) chronic pain and cigarette smoking status and nicotine dependence. Methods: This investigation comprised a large representative sample of English-speaking adults ( n = 9,282) residing in the United States. Data were collected primarily through face-to-face interviews conducted between February 2001 and April 2003. Results: After adjusting for sociodemographic variables and the presence of a lifetime substance use disorder, individuals with a lifetime history of chronic neck or back pain were signifi cantly more likely to be current smokers and to be diag-nosed with lifetime as well as current nicotine dependence. Although there was no signifi cant incremental relation between current chronic neck and back pain and being a current smoker, there was a signifi cant association with lifetime and current nicotine dependence. Similar relations were evident among those with and without medically unexplained chronic pain in regard to smoking status and lifetime and current nicotine dependence. Discussion: Findings are discussed in terms of better under-standing the chronic pain – smoking association.

Behavioral-genetic (twin) methods are important tools for understanding the etiology of trauma exposure and posttraumatic stress disorder (PTSD). The purpose of the present article is to synthesize the results obtained from twin studies and outline important avenues for further investigation. Twin research to date suggests that: (1) exposure to assaultive trauma is moderately heritable whereas exposure to non-assaultive trauma is not, (2) PTSD symptoms are moderately heritable, and (3) comorbidity of PTSD with other disorders may be partly due to shared genetic and environmental influences. Remarkably little is known about whether the observed comorbidity of PTSD with particular personality traits and poor physical health is due to shared genetic or environmental factors. Similarly, little is known about whether gene-environment interactions play an important role in trauma exposure and PTSD. Further research is required to clarify these issues and to determine whether findings to date, obtained mostly from male combat veterans, generalize to other populations. Research programs that integrate behavioral-genetics with molecular genetics and with cognitive-behavioral conceptualizations and research methods may deepen our understanding of the complex links among genes, brain, cognition, emotion, and the environment.

The purpose of this article is to describe the current state-of-the-art regarding the co-occurrence of the anxiety disorders and chronic pain. First, we describe the core characteristics of chronic pain and its co-occurrence with the anxiety disorders. Second, we review data on the prevalence of co-occurrence. Third, we describe the mutual maintenance and shared vulnerability models, both of which have been offered to explain the co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain and may have applicability to various other anxiety disorders. Fourth, we provide an integrative review of available research addressing the postulates of these models specific to the mechanisms of anxiety sensitivity, selective attention to threat, and reduced threshold for alarm. We conclude with general recommendations for improving assessment and treatment of patients who present with an anxiety disorder accompanied by clinically significant pain. Given that most of the available evidence has come from studies of PTSD and chronic pain, we provide a detailed agenda for future investigation of the co-occurrence of chronic pain and other anxiety disorders. Depression and Anxiety, 2009. © 2009 Wiley-Liss, Inc.

Objective: To determine whether exposure to particular types of traumatic events was differentially associated with suicide attempts in a representative sample of active military personnel. Method: Data came from the Canadian Community Health Survey: Mental Health and Well-Being Canadian Forces Supplement (CCHS-CFS), a cross-sectional survey that provided a comprehensive examination of mental disorders, health, and the well-being of currently active Canadian military personnel ( n = 8441; aged 16 to 54 years; response rate 81.1%). Respondents were asked about exposure to 28 traumatic events that occurred during their lifetime. Suicide attempts were measured using a question about whether the person ever “attempted suicide or tried to take [his or her] own life.” Results: The prevalence of lifetime suicide attempts for currently active Canadian military men and women was 2.2% and 5.6%, respectively. Sexual and other interpersonal traumas (for example, rape, sexual assault, spousal abuse, child abuse) were significantly associated with suicide attempts in both men (adjusted odds ratios [AORs] ranging from 2.31 to 4.43) and women (AORs ranging from 1.73 to 3.71), even after adjusting for sociodemographics and mental disorders. Additionally, the number of traumatic events experienced was positively associated with increased risk of suicide attempts, indicating a dose–response effect of exposure to trauma. Conclusions: The current study is the first to demonstrate that sexual and other interpersonal traumatic events are associated with suicide attempts in a representative sample of active Canadian military men and women.

Background: Tonic immobility (TI) is a temporary state of motor inhibition believed to be a response to situations involving extreme fear. Limited attention has been directed to studying TI in humans; however, the phenomenon has been well documented in the animal literature. In humans, TI is believed to occur during sexual assault, and there have been reports of fear-induced freezing in the contexts of air, naval, and other disasters. Methods: This study had three main purposes: (1) to assess the factor structure of a new self-report measure— the Tonic Immobility Questionnaire [1] —designed to assess human TI in a range of traumatic events; (2) to explore associations among discovered TIQ factors and a measure of posttraumatic symptoms in the context of trauma type; and (3) to determine whether TI is related to suspected and empirically supported predictors of posttraumatic stress disorder. Participants were a subset of undergraduate students (n 578) who reported a TI experience in the context of a traumatic event. Results: No differences were found in frequency or severity of TI reported across trauma types. Exploratory factor analysis of Tonic Immobility Questionnaire item responses resulted in a three-factor solution (i.e., physical immobility, fear, and dissociation). Significant positive correlations were found between the Tonic Immobility Questionnaire and measures of posttraumatic symptoms, dissociation, anxiety sensitivity, and absorption. Regression analysis revealed that peritraumatic dissociation scores alone accounted for 51% of the variance in TI scores. Conclusions: TI may represent an extreme behavioral expression of trauma-induced peritraumatic dissociation. Implications and directions for future research are discussed. Depression and Anxiety 26:550–556, 2009. r 2009 Wiley-Liss, Inc.

Background: The Social Interaction Anxiety Scale and Social Phobia Scale [6] are companion measures for assessing symptoms of social anxiety and social phobia. The scales have good reliability and validity across several samples, [3,6] however, exploratory and confirmatory factor analyses have yielded solutions comprising substantially different item content and factor structures. These discrepancies are likely the result of analyzing items from each scale separately or simultaneously. The current investigation sets out to assess items from those scales, both simultaneously and separately, using exploratory and confirmatory factor analyses in an effort to resolve the factor structure. Methods: Participants consisted of a clinical sample (n5353; 54% women) and an undergraduate sample (n5317; 75% women) who completed the Social Interaction Anxiety Scale and Social Phobia Scale, along with additional fear-related measures to assess convergent and discriminant validity. Results: A three-factor solution with a reduced set of items was found to be most stable, irrespective of whether the items from each scale are assessed together or separately. Items from the Social Interaction Anxiety Scale represented one factor, whereas items from the Social Phobia Scale represented two other factors. Conclusion: Initial support for scale and factor validity, along with implications and recommendations for future research, is provided. Depression and Anxiety 26:E71–E81, 2009. r 2009 Wiley-Liss, Inc.

OBJECTIVE To examine the relationship between household income and psychological distress, suicidal ideation and attempts, and mood, anxiety, and substance use disorders. METHOD Data came from the Collaborative Psychiatric Epidemiology Surveys, a collection of 3 nationally representative surveys of American adults conducted between 2001 and 2003. Psychological distress, suicidal ideation, suicide attempts, and mood, anxiety, and substance use disorders were examined in relation to household income after adjusting for sex, marital status, race, age, and employment status. RESULTS Analyses revealed an inverse association between income and psychological distress as measured by the Kessler Psychological Distress Scale, with those in the lowest income quartile demonstrating significantly more distress than any of the remaining 3 income quartiles (P < .05). Subsequent analysis of DSM-IV-diagnosed psychological disorders revealed a similar pattern of results, which were particularly strong for substance use disorders (adjusted odds ratio [AOR] = 1.74; 95% CI, 1.39-2.18), suicidal ideation (AOR = 1.77; 95% CI, 1.46-2.13), and suicide attempts (AOR = 2.15; 95% CI, 1.55-2.98). The association between income and mood and anxiety disorders was less consistent, and the relationship between income and suicidal ideation differed among the 5 race categories (non-Hispanic white, Hispanic, Asian American, black, and other). Non-Hispanic white persons showed a strong, negative relationship between income and suicidal ideation (AOR = 2.15; 95% CI, 1.66-2.80), while the association was considerably weaker or nonexistent for the other races. CONCLUSIONS Although conclusions cannot be drawn concerning causation, the strength of associations between income, suicidal ideation, suicide attempts, and substance abuse points to the need for secondary prevention strategies among low-income, high-risk populations.

The Whiteley Index [WI; Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal of Psychiatry, 113, 89-93] is a widely used self-report measure of health anxiety, hypochondriasis, and illness phobia; however, the factor structure of the WI has proven unstable. Moreover, factorial investigations of the WI persist in the original true/false response format despite criticisms of dichotomous scales and the availability of a Likert scale version [Barsky, A. J., Cleary, P. D., Wyshak, G., Spitzer, R. L., Williams, J. B. W., & Klerman, G. L. (1992). A structured diagnostic interview for hypochondriasis: a proposed criterion standard. The Journal of Nervous and Mental Disease, 180, 20-27]. The current investigation explores the factor structure of the 5-point Likert scale version of the WI using a sample of 287 students (64 men, ages 18-34 [M=20.6; SD=3.2]; 223 women ages 18-45 [M=20.2; SD=3.2]) divided into two sex-matched groups. A 2-factor 8-item model was extracted from the first group using exploratory factor analysis. However, confirmatory factor analysis with the second group showed superior fit to the data using a precedent 2-factor 6-item model, demonstrating factorial invariance across response options. Comprehensive results, implications, and directions for future research are discussed.

Factor-analytic studies of the structure of posttraumatic stress disorder (PTSD) symptoms have yielded inconsistent results. One of the reasons for the inconsistency may be that PTSD is highly comorbid with other disorders; the observed factor structure might depend on the particular comorbid disorder. One such disorder is chronic pain. The goal of the present study was to investigate whether PTSD symptom structure differs between pain and pain-free patients scheduled to undergo major surgery. Four hundred and forty-seven patients who were approached 7 to 10 days prior to scheduled surgery completed the PTSD Checklist-Civilian (PCL-C) Version and the Current Pain and Pain History Questionnaire; the latter was used to divide patients into pain (N = 175) and pain-free (N = 272) groups. Results showed that in pain-free patients, PTSD symptoms were best expressed as 2 symptom clusters (re-experiencing/avoidance; emotional numbing/hyperarousal) accounting for 52.4% of the variance. In pain patients, PTSD symptoms were best expressed as a single symptom cluster accounting for 51.1% of the variance. These results suggest different interrelationships among PTSD symptoms in these 2 populations. Results reflect the need for (1) controlling for pain in studies looking at PTSD-symptom expression and (2) further research on PTSD-symptom expression in pain populations. Perspective These results may have important implications for research on the comorbidity between PTSD and chronic pain, as well as for treatment of PTSD symptoms in patients presenting with pain problems.

Little is known about the factors that predict the transition of acute, time limited pain to chronic pathological pain following postero-lateral thoracotomy. The aim of the present prospective, longitudinal study was to determine the extent to which (1) pre-operative pain intensity, pain disability, and post-traumatic stress symptoms (PTSS) predict post-thoracotomy pain disability 6 and 12 months later; and (2) if these variables, assessed at 6 months, predict 12 month pain disability. Fifty-four patients scheduled to undergo postero-lateral thoracotomy for intrathoracic malignancies were recruited before surgery and followed prospectively for one year. The incidence of chronic post-thoracotomy pain was 68.1% and 61.1% at the 6 and 12 month follow-ups, respectively. Multiple regression analyses showed that neither pre-operative factors nor acute movement-evoked post-operative pain predicted 6 or 12 month pain disability. However, concurrent pain intensity and emotional numbing, but not avoidance symptoms, made unique, significant contributions to the explanation of pain disability at each follow-up (total R(2)=76.3.0% and 63.9% at 6 and 12 months, respectively, both p

Introduction Waddell’s signs and symptoms have been described as patient presentations not within usual anatomic patterns of injury pathology. Waddell’s signs were thought to indicate psychological distress and were termed “non-organic findings”; similarly, Waddell’s symptoms were described as inappropriate and attributable to psychological features. Endorsement of more than two of Waddell’s symptoms is thought to be associated with psychological distress, disability, and poor treatment outcomes; however, this has not been empirically assessed. Methods The current study used a sample of patients (n = 108; 30% women) involved in a multi-disciplinary work hardening program provided by a third-party insurer. Patients who endorsed more than two of Waddell’s symptoms were compared with those who did not on demographic variables as well as self-report measures of psychological distress, disability, and treatment outcome. Results Patients who endorsed more than two of Waddell’s symptoms reported higher levels of psychological distress, perceived disability, pain intensity, and pain durations. Moreover, consistent with previous research on Waddell’s symptoms, patients endorsing more than two symptoms were also less likely to return to work. Conclusions Waddell’s symptoms were associated with increased perceived disability and pervasive pain interference. Patients who endorsed more than two symptoms were significantly less likely to return to work than those who endorsed zero, one, or two symptoms. Patients who endorsed more than two symptoms may indeed be affected by factors beyond tissue pathology that nonetheless warrant clinical attention. Waddell’s symptoms appear to have promise as a quick indicator of treatment complexity and outcome.

Prior studies have shown that anxiety sensitivity (AS) plays an important role in posttraumatic stress disorder (PTSD) symptom severity. The purpose of this study was to evaluate associations between empirically supported PTSD symptom clusters (i.e. reexperiencing, avoidance, numbing, hyperarousal) and AS dimensions (i.e. psychological concerns, social concerns, somatic concerns). Participants were 138 active-duty police officers (70.7% female; mean age = 38.9 years; mean time policing = 173.8 months) who, as a part of a larger study, completed measures of trauma exposure, PTSD symptoms, AS, and depressive symptoms. All participants reported experiencing at least one event that they perceived as traumatic, and 44 (31.9%) screened positive for PTSD. Officers with probable PTSD scored significantly higher on AS total as well as the somatic and psychological concerns dimensional scores than did those without PTSD. As well, a higher percentage of officers with probable PTSD scored positively on the AS-derived Brief Screen for Panic Disorder (Apfeldorf et al., 1994) compared with those without PTSD. A series of regression analyses revealed that depressive symptoms, number of reported traumas, and AS somatic concerns were significant predictors of PTSD total symptom severity as well as severity of reexperiencing. Avoidance was predicted by depressive symptoms and AS somatic concerns. Only depressive symptoms were significantly predictive of numbing and hyperarousal cluster scores. These findings contribute to understanding the nature of association between AS and PTSD symptom clusters. Implications for the treatment of individuals having PTSD with and without panic-related symptomatology are discussed.

Objectives. We sought to determine the fractions of psychiatric disorders and suicide ideation and attempts in a general population sample attributable to childhood physical abuse, sexual abuse, and witnessing domestic violence. Methods. Data were obtained from the US National Comorbidity Survey Replication. Population attributable fractions were calculated to determine the proportion of psychiatric disorders and suicide ideation and attempts attributable to adverse childhood experiences. The analysis was stratified by gender. Results. The estimated attributable fractions for psychiatric disorders attributable to having experienced any adverse childhood event ranged from 22% to 32% among women and 20% to 24% among men. Having experienced any adverse event accounted for a substantial proportion of suicide ideation and attempts among women (16% and 50%, respectively) and men (21% and 33%, respectively). Substantial proportions of poor mental health outcomes were also attributable to increasing number of adverse events. Conclusions. The estimated proportions of poor mental health outcomes attributed to childhood adversity were medium to large for men and women. Prevention efforts that reduce exposure to adverse childhood events could substantially reduce the prevalence of psychopathology and suicidal behavior in the general population.

Few studies have examined why socially related fears and posttraumatic stress commonly, but not invariably, co-occur. It may be that only traumata of human agency (e.g., sexual assault), for which there is an interpersonal component, give rise to co-occurring socially related fears. These symptoms might also co-occur because of shared genetic factors. We investigated these issues using a sample of 882 monozygotic and dizygotic twins. No significant differences in socially related fear (i.e., fear of negative evaluation, fear of socially observable arousal symptoms) were found between participants reporting assaultive or nonassaultive trauma. However, significant differences in socially related fear were found when participants were grouped into probable PTSD and no PTSD groups. Participants with probable PTSD exhibited greater socially related fear (i.e., fear of negative evaluation) than those without PTSD. Using biometric structural equation modeling, trauma exposure was best explained by shared and nonshared environmental influences. The fear of socially observable arousal symptoms was influenced by genetic and nonshared environmental influences. Implications and directions for future research are discussed.

Recent findings from a sample of patients with acute and chronic musculoskeletal pain and headache indicate that fear of pain is characterized by latent continuity; that is, it is non-taxonic. It remains to be determined whether the latent structure of fear of pain is consistent between patients seeking treatment for pain versus those drawn from representative community samples. The purpose of the present investigation was to determine if the latent structure of fear of pain is characterized by latent continuity in a representative community sample of older adults. Using taxometric methods in a sample of 459 community dwelling older adults, we sought to evaluate the latent structure of fear of pain as indexed by the Pain Anxiety Symptoms Scale. Results from analyses of simulated Monte Carlo data, MAXEIG-HITMAX, and L-mode consistency tests indicated that the latent structure of fear of pain in this sample was the same as that previously reported in clinical samples, being non-taxonic and characterized by latent continuity. These findings confirm initial findings that fear of pain, at least as measured by the Pain Anxiety Symptoms Scale, is continuous, occurring along a latent continuum ranging from low to high. Results are discussed in relation to the conceptual understanding of fear of pain, implications for assessment and treatment, and future research directions.

Objective: The primary purpose of this study was to examine the role of fear of falling, fear of pain, and associated activity avoidance in the prediction of pain and falls. Method: A 6-month longitudinal study of older community-dwelling adults. Results: The authors found that fear of falling is a better predictor of falls than is activity avoidance. Moreover, fear of pain did not predict future pain-related avoidance or future pain in the sample of seniors. Discussion: The findings confirm the ability of fear of falling to predict falls but challenge preexisting models developed to account for the relationship between falls and fear. The findings also suggest limits on the generalizability of fear—avoidance models of pain. The authors conclude by suggesting mechanisms that could account for the relationship of fears with falls and pain. Unlike previous conceptualizations, these mechanisms do not rely on activity avoidance as an explanation.

Sleep paralysis (SP) occurs when rapid eye movement (REM) activity and concomitant paralysis of the skeletal muscles persist as an individual awakens and becomes conscious of his/her surroundings. SP is often accompanied by frightening hallucinations that some researchers suggest may be confounded with memories of childhood sexual abuse (CSA; [McNally, R. J., & Clancy, S. A. (2005). Sleep paralysis in adults reporting repressed, recovered, or continuous memories of childhood sexual abuse. Journal of Anxiety Disorders, 19, 595-602]). The purpose of this study was to evaluate relationships between CSA and SP. Based on self-report, participants (n=263) were categorized into three CSA groups: confirmed, unconfirmed, or no history of CSA. Relative to participants reporting no CSA history, those reporting CSA reported more frequent and more distressing episodes of SP. Post hoc analyses revealed that participants with clinically significant post-traumatic symptoms (irrespective of CSA history) also reported more frequent and more distressing episodes of SP. Significant correlations were found among SP indices and measures of post-traumatic symptoms, depression, dissociation, and absorption. Implications and future research directions are discussed. Language: en

The present investigation examined the impact of anxiety sensitivity (AS) and media exposure on posttraumatic stress disorder (PTSD) symptoms. Reactions from 143 undergraduate students in Hamilton, Ontario were assessed in the Fall of 2003 to gather information on anxiety, media coverage, and PTSD symptoms related to exposure to a remote traumatic event (September 11th). Regression analyses revealed that the Anxiety Sensitivity Index (ASI; [Peterson, R. A., & Reiss, S. (1992). Anxiety Sensitivity Index manual, 2nd ed. Worthington, Ohio: International Diagnostic Systems]) and State-Trait Anxiety Inventory trait form (STAI-T; [Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). State-trait anxiety inventory. Palo Alto, California: Consulting Psychologists Press]) total scores were significant predictors of PTSD symptoms in general. The ASI total score was also a significant predictor of hyperarousal and avoidance symptoms. Subsequent analyses further demonstrated differential relationships based on subscales and symptom clusters. Specifically, media exposure and trait anxiety predicted hyperarousal and re-experiencing symptoms, whereas the ASI fear of somatic sensations subscale significantly predicted avoidance and overall PTSD symptoms. Implications and directions for future research are discussed.

Some contemporary theorists and clinicians champion acceptance and mindfulness-based interventions, such as Acceptance and Commitment Therapy (ACT), over cognitive-behavioral therapy (CBT) for the treatment of emotional disorders. The objective of this article is to juxtapose these two treatment approaches, synthesize, and clarify the differences between them. The two treatment modalities can be placed within a larger context of the emotion regulation literature. Accordingly, emotions can be regulated either by manipulating the evaluation of the external or internal emotion cues (antecedent-focused emotion regulation) or by manipulating the emotional responses (response-focused emotion regulation). CBT and ACT both encourage adaptive emotion regulation strategies but target different stages of the generative emotion process: CBT promotes adaptive antecedent-focused emotion regulation strategies, whereas acceptance strategies of ACT counteract maladaptive response-focused emotion regulation strategies, such as suppression. Although there are fundamental differences in the philosophical foundation, ACT techniques are fully compatible with CBT and may lead to improved interventions for some disorders. Areas of future treatment research are discussed.