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Integrating best practices for health disparities to adapt evidence-based treatments is imperative to adequately meet the needs of diverse cultures, particularly ones that therapists can apply flexibility across multiple diverse communities.Using a mixed-methods, community-engaged approach, we examined how a range of community participants (N = 169) defined mental health, perceived barriers to treatment, and used culturally based coping methods to manage their mental health. Phase 1 (n = 49) included qualitative focus group data from five distinct racial/ethnic communities (African immigrants/refugees, Black/African Americans, Hispanics, Pacific Islanders, and American Indians). Phase 2 included quantitative surveys from members of four of these communities (n = 59) and the frontline providers serving them (n = 61).The communities and providers highlighted chronic worry and distress related to daily activities as primary treatment concerns. Further, this mixed-methods data informed our proposed best practice treatment adaptation framework using chronic worry as an example.The main aims of this study were to exemplify best practices for addressing mental health inequities in communities of color in terms of (a) conducting health disparities research and (b) applying a treatment adaptation framework for culturally responsive clinical care. Specific features of how this framework was conceived and applied provide a unique and critical view into integrating best practices to address health disparities in diverse communities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Purpose To describe Lifestyle Coach perceptions of dyads (i.e., family members and/or friends) in the National Diabetes Prevention Program (NDPP). Design Qualitative evaluation of cross-sectional survey responses. Setting Online. Participants Lifestyle Coaches (n=253) with experience teaching at least one in-person year-long NDPP cohort at a CDC-recognized organization. Measures Survey included items on background and experience with dyadic approach, as well as open-ended items on the benefits and challenges observed when working with dyads in the NDPP. Analysis Lifestyle Coach background and experience were analyzed descriptively in SPSS. Open-ended responses were content coded in ATLAS.ti using qualitative description, and then grouped into categories. Results Most Lifestyle Coaches (n=210; 83.0%) reported experience delivering the NDPP to dyads. Benefits of a dyadic approach included having a partner in lifestyle change, superior outcomes and increased engagement, and positive “ripple effects.” Challenges included difficult relationship dynamics, differences between dyad members, negative “ripple effects,” and logistics. Conclusion Lifestyle Coaches described a number of benefits, as well as some challenges, with a dyadic approach to the NDPP. Given the concordance between close others in lifestyle and other risk factors for type 2 diabetes, utilizing a dyadic approach in the NDPP has the potential to increase engagement, improve outcomes, and extend the reach of the program.

The COVID-19 pandemic has exacerbated disparities in mental health treatment for people of color in the USA. Meeting the needs of those most burdened by this disparity will require swift and tactical action in partnership with these communities. The purpose of this paper is to describe how a community-based participatory research approach was employed to assess the priorities and needs of four communities of color (African immigrant, Hispanic/Latino, Black/African American, and Pacific Islander) in a major U.S. city. A brief quantitative survey devised jointly by community leaders and the research team was deployed to community members (N = 59) in the fall of 2020. The most endorsed mental health issues across the communities were excessive worry (51%) and stress regarding COVID-19, racism, and immigration policies (49%). The most endorsed physical health concerns included sleep difficulties (44%), headaches, and backaches (each 39%). Physical symptoms predicted the endorsement of a mental health issue above and beyond COVID-19-related hardships, multiplying the odds of reporting an issue by 1.73 per physical health concern endorsed. Based on these findings, the community-research team conceptualized and proposed an evidence-based, effectiveness-implementation hybrid type-2 intervention approach for chronic worry and daily stress. This paper highlights detail on how the community-research team arrived at the proposed multilevel intervention that addresses community-stated barriers to mental health treatment (e.g., preferring trusted health workers to deliver emotional health treatments) and considers the burden of the additional stressful context of COVID-19.Diverse community members and university researchers collaborated on the development of an equitable intervention approach for community members’ mental health needs.

Preliminary data suggest cognitive processing therapy (CPT) significantly reduces posttraumatic stress disorder (PTSD) symptom severity among military personnel and veterans when delivered over 12 days and combined with daily recreational activities (Bryan et al., 2018). The present study aimed to examine how therapy pace (i.e., daily vs. weekly sessions) and setting (i.e., clinic vs. recreational) impacts change in PTSD symptom severity. Forty-five military personnel and veterans diagnosed with PTSD chose to receive CPT (a) daily at a recreational facility with recreational programming, (b) daily on a university campus without recreational programming, and (c) weekly on a university campus without recreational programming. PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). Reductions in CAPS-5 and PCL-5 scores were large and statistically significant across all three settings (Cohen's ds2.1). As compared to reductions in CAPS-5 and PCL-5 scores in daily therapy at a recreational facility (CAPS-5: d = 1.63-2.40; PCL-5: d = 1.99-2.17), reductions in CAPS-5 and PCL-5 scores were significantly larger in daily therapy on campus, CAPS-5: t(80) = -2.9, p = .005, d = 2.23-2.69; PCL-5: t(78) = 2.6, p = .010, d = 2.54-4.43, but not weekly therapy on campus, CAPS-5: t(80) = 0.2, p = .883, d = 1.04-2.47; PCL-5: t(78) = 1.0, p = .310, d = 1.77-3.44. Participants receiving daily therapy on campus and weekly therapy on campus also had higher rates of clinically significant improvement and good end-state functioning. Results support the effectiveness of CPT across multiple treatment settings and formats and suggest that daily CPT may be less effective when delivered in combination with recreational activities.

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

Differences in cultural orientations, such as interdependent and independent self-construals, may influence social anxiety disorder (SAD) symptom presentations. However, prior research on the association between interdependent/independent self-construals and SAD was limited to non-clinical samples. Using a treatment-seeking population with clinical levels of anxiety, the current study extends prior research by examining whether the relationship between interdependent/independent self-construals and SAD is specific to SAD or indicative of a broader relationship with anxiety or depression more generally. We also expand upon prior work by examining the effect of self-construals on treatment outcomes and whether self-construals change over time. The results showed that endorsing a less independent self-construal was associated with greater SAD symptoms specifically, and was not associated with other anxiety or depression symptom measures. Additionally, while interdependent and independent self-construals did not moderate SAD treatment outcomes, there was a decrease in interdependent self-construal and increase in independent self-construal over a course of cognitive behavioral therapy. Notably, this change over time was tied to specific items that correlated strongly with SAD symptoms. Together, these results increase our understanding of the relationship between interdependent/independent self-construals and SAD symptoms in treatment-seeking anxiety patients.

Individuals from socioeconomically disadvantaged groups have lesser participation and success in the National Diabetes Prevention Program (NDPP). Barriers to NDPP participation and lifestyle change were examined from the perspective of Lifestyle Coaches serving lower versus higher income participants. Lifestyle Coaches (n = 211) who serve lower income (n = 82) or higher income (n = 129) participants reported on observed barriers to NDPP participation and lifestyle change and ranked the three most significant barriers to (a) NDPP participation and (b) lifestyle change. Group differences in number/type of barriers were examined using t-tests and chi-square analyses, and ranking differences were examined using multilevel cumulative logit models. Lifestyle Coaches of lower income (versus higher income) participants reported two additional barriers on average. Ranked barriers to participation were similar between groups, and notably included physical/emotional barriers. However, for lifestyle change, those serving lower income groups were more likely to rank lack of access to healthy grocery stores, but less likely to rank low motivation and lack of family support. Lifestyle Coaches of lower income participants were less likely to rank long wait period prior to enrollment as the most significant barrier to participation, and to rank lack of time off from work as the most significant barrier to lifestyle change. Despite more barriers observed among lower versus higher income participants, overlap in the most significant barriers highlights the potential utility of widely addressing common barriers among NDPP participants. In particular, physical and emotional barriers have been overlooked, yet deserve greater attention in future research and practice.The National Diabetes Prevention Program (NDPP) has less successfully reached and changed the lifestyles of lower income (versus higher income) adults in the USA who are at high risk for type 2 diabetes. In a nationwide online survey, we asked Lifestyle Coaches who deliver the NDPP to identify up to 37 potential barriers to participation and success that they had observed among their participants. We then compared the number, type, and rankings of the most significant barriers to participation and success in the NDPP from the perspective of Lifestyle Coaches estimating the majority of their participants had lower versus higher incomes. Lifestyle Coaches delivering the NDPP to lower income participants reported an average of two additional barriers to participation and success than those delivering the program to higher income participants. The barriers ranked among the most significant to NDPP participation and lifestyle change were generally similar among Lifestyle Coaches working with lower versus higher income participants. Top-ranked barriers included physical/emotional symptoms (e.g., anxiety, depression) as well as barriers previously reported in studies focused on NDPP participants. It is critical that barriers be carefully evaluated and addressed to improve the nationwide impact of the NDPP.

Topic. Limited research has examined trauma and posttraumatic stress disorder (PTSD) among Asian Indians in the U.S. Thus, we (1) synthesize literature on trauma, PTSD, disparities in treatment for PTSD, the burden of untreated PTSD, and culturally-adapted (CA) PTSD interventions; and (2) discuss recommendations for clinicians/researchers working with this population. Method. We searched two databases using keywords related to Asian Indians, PTSD, and interventions. Of 238 identified articles, we used content from 26 articles to inform our review. Findings. Asian Indians report traumatic experiences before, during, or after immigration to the U.S. and consequential PTSD symptoms. Further, Asian Indians in the U.S. are disproportionately impacted by socio-cultural and economic determinants of poor mental health (e.g., shame/stigma associated with seeking mental health services, few culturally-responsive services), which may contribute to the under-reporting of PTSD and (interpersonal) traumas and less willingness to seek treatment. Additionally, CA PTSD interventions tailored to Asian Indians in the U.S. have not been developed. Socio-cultural considerations that can inform CA PTSD interventions for Asian Indians include: causal conditions (e.g., culturally-rooted beliefs about trauma/PTSD), intervening conditions/barriers (e.g., emotional inhibition), and mitigating/coping strategies (e.g., religious/spiritual practices, cultural idioms of distress). These considerations influence clinician/treatment preferences (e.g., solution-oriented and structured therapy, less emotional exposure). Lastly, we outline recommendations for clinicians/researchers: (1) need for national studies on trauma, PTSD, treatment utilization, and the burden of untreated PTSD; (2) consideration of immigration-related experiences influencing PTSD; (3) consideration of socio-cultural elements for CA PTSD interventions; and (4) need for culturally-valid PTSD assessments.

IMPORTANCE: Serotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs. OBJECTIVE: To assess whether patients with OCD who are taking SRIs and have attained wellness after EX/RP augmentation can discontinue their SRI with noninferior outcomes compared with those who continue their SRI therapy. DESIGN, SETTING, AND PARTICIPANTS: A 24-week, double-blind, randomized clinical trial was performed from May 3, 2013, to June 25, 2018. The trial took place at US academic medical centers. Participants included 137 adults with a principal diagnosis of OCD (≥1 year) who were taking an SRI (≥12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score ≥18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score ≤14 points; 103 patients [75.2%]) were study eligible. Data were analyzed from June 29, 2019, to October 2, 2021. INTERVENTION: Participants were randomly assigned either to receive taper to placebo (taper group) or to continue their SRI (continuation group) and monitored for 24 weeks. MAIN OUTCOME AND MEASURES: The Y-BOCS score (range, 0-40 points) was the primary outcome; the Hamilton Depression Rating Scale (HDRS; range, 0-52 points) and the Quality-of-Life Enjoyment and Satisfaction Questionnaire–Short Form (Q-LES-Q-SF; range, 0%-100%) scores were secondary outcomes. Outcomes were assessed at 8 time points by independent evaluators who were blinded to randomization. The taper regimen was hypothesized to be noninferior to continuation at 24 weeks using a 1-sided α value of .05. RESULTS: A total of 101 patients (mean [SD] age, 31.0 [11.2] years; 55 women [54.5%]) participated in the trial: 51 patients (50.5%) in the taper group and 50 patients (49.5%) in the continuation group. At 24 weeks, patients in the taper group had noninferior results compared with patients in the continuation group (mean [SD] Y-BOCS score: taper group, 11.47 [6.56] points; continuation group: 11.51 [5.97] points; difference, −0.04 points; 1-sided 95% CI, −∞ to 2.09 points [below the noninferiority margin of 3.0 points]; mean [SD] HDRS score: taper group, 5.69 [3.84] points; continuation group, 4.61 [3.46] points; difference, 1.08 points; 1-sided 95% CI, −∞ to 2.28 points [below the noninferiority margin of 2.5 points]; mean [SD] Q-LES-Q-SF score: taper group, 68.01% [15.28%]; continuation group, 70.01% [15.59%]; difference, 2.00%; 1-sided 95% CI, −∞ to 6.83 [below the noninferiority margin of 7.75]). However, the taper group had higher rates of clinical worsening (23 of 51 [45%] vs 12 of 50 [24%]; P = .04). CONCLUSIONS AND RELEVANCE: Results of this randomized clinical trial show that patients with OCD who achieve wellness after EX/RP therapy could, on average, discontinue their SRI with noninferior outcomes compared with those who continued their SRI. Those who tapered the SRI had higher clinical worsening rates. Future research should evaluate if SRI half-life alters these rates. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01686087

Despite considerable data from randomized controlled trials supporting use of behavioral therapies for anxiety disorders and anxiety-related disorders, there is a relative scarcity of data demonstrating that such findings are generalizable to patients in nonresearch settings, and a lack of standardized repeated outcome measurement in such settings. Using one of the largest examinations of naturalistic outcomes of behavioral therapies in treatment-seeking patients (N = 489), we examined the clinical characteristics and treatment outcomes of patients seeking treatment for anxiety and anxiety-related disorders in the past 3 years. Patients seeking treatment at a clinic specializing in cognitive-behavioral therapy (CBT) completed self-report questionnaires via an electronic data capture system and diagnostic interview at baseline, and were reassessed at mid- and posttreatment. Patients with anxiety and related disorders were assessed for changes in symptom severity and secondary outcomes (impairment/functioning, quality of life, and depression) over the course of therapy. Patients showed clinically significant and statistically reliable improvement in anxiety symptom severity scores over treatment (p < .001), after controlling for number of sessions received. Patients also showed significant improvement in depression, quality of life, and functioning (p values ≤ .001). We also found significant improvement in disorder-specific symptoms, including obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder (p values ≤ .001). Importance of, and ways to facilitate, integration of more routine assessment of a broader range of symptoms via online assessment systems and methods to better determine the effectiveness of CBT in naturalistic clinics are discussed.

Objective Numerous researchers have suggested that certain coping styles (e.g., maladaptive cognitive coping strategies) interfere with recovery from traumatic experiences and contribute to the onset/maintenance of posttraumatic stress disorder (PTSD). Further, given that individuals with PTSD have a high rate of smoking (e.g., Mahaffey et al., 2016) and that maladaptive coping strategies in general are associated with lower smoking quit rates, it is possible that use of maladaptive cognitive coping strategies are particularly problematic for the recovery of smokers with PTSD. The present study examined whether specific cognitive coping strategies are associated with poorer outcome among smokers with PTSD following an integrated treatment for both disorders. Method Patients with chronic PTSD and nicotine dependence (N = 142) received up to 12 sessions of smoking cessation counseling combined with varenicline or integrated prolonged exposure therapy and cessation counseling combined with varenicline. We hypothesized that greater maladaptive, and lower adaptive, cognitive coping strategies at baseline would moderate degree of improvement in smoking and PTSD outcomes through to follow-up. Results Multilevel modeling revealed that neither maladaptive nor adaptive cognitive coping strategies moderated smoking abstinence outcomes over the course of the study (ps ≥ .271). However, greater use of catastrophizing and lower use of positive reappraisal at baseline were associated with less improvement in the hyperarousal PTSD symptom cluster over the course of the study (ps ≤ .01). Conclusions These findings suggest that maladaptive cognitive coping strategies are not necessarily a contraindication for overall outcomes in integrated PTSD and smoking treatment, although they may influence improvement in hyperarousal symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Anxiety sensitivity (AS), a fear of arousal-related sensations, is prevalent in a number of disorders. We examined the relationship between internalizing symptoms and the anxiety sensitivity components of physical, social, and cognitive concerns in a sample of 165 patients seeking treatment in a clinic specializing in cognitive behavioral therapy for anxiety-related disorders. Social anxiety symptoms were associated with greater social concerns. Cognitive concerns were characteristic of both depression and generalized anxiety symptoms, suggesting these two classes of symptoms may share AS symptomatology. Physical concerns were specifically related to panic symptoms. Although obsessive–compulsive symptoms were related to cognitive concerns using univariate regression, these symptoms were not strongly related to any of the anxiety sensitivity components when the correlation between disorders was taken into account. Thus, within the internalizing symptoms studied here, the anxiety sensitivity domains were most relevant to panic, social anxiety, generalized anxiety, and depressive symptoms and less related to obsessive–compulsive symptoms.

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.

BackgroundPost-traumatic stress disorder (PTSD) is a prevalent, debilitating, and costly psychiatric disorder. Evidenced-based psychotherapies, including Cognitive Processing Therapy (CPT), are effective in treating PTSD, although a fair proportion of individuals show limited benefit from such treatments. CPT requires cognitive demands such as encoding, recalling, and implementing new information, resulting in behavioral change that may improve PTSD symptoms. Individuals with PTSD show worse cognitive functioning than those without PTSD, particularly in acquisition of verbal memory. Therefore, memory dysfunction may limit treatment gains in CPT in some individuals with PTSD.Methods and AnalysisHere, we present a protocol describing the Cognition and PsychoTherapy in PTSD (CPTPTSD) study, a prospective, observational study examining how cognitive functioning affects treatment response in CPT for PTSD (NCT# 03641924). The study aims to recruit 105 outpatient veterans with PTSD between the ages of 18 and 70 years. Prior to beginning 12 sessions of CPT, Veteran participants will have standardized assessments of mood and functioning and complete a comprehensive neurocognitive battery assessing episodic learning, attention and speed of processing, language ability, executive control, and emotional functioning. This study aims to fill gaps in the current literature by: (1) examining the specificity of memory effects on treatment response; (2) exploring how baseline cognitive functioning impacts functional outcomes; and (3) examining potential mechanisms, such as memory for treatment content, that might explain the effects of baseline memory functioning on PTSD symptom trajectory.DiscussionIf successful, this research could identify clinically relevant neurocognitive mechanisms that may impact PTSD psychotherapy and guide the development of individualized treatments for PTSD.

Perfectionistic cognitions are thinking patterns that reflect excessive striving and are associated with emotional disorders in nonclinical samples. Despite literature connecting trait perfectionism with psychological disorders, much remains unknown about how perfectionistic cognitions relate to anxiety disorder symptoms in clinical populations. This is the first study to our knowledge that investigates how symptoms of anxiety and related symptoms are influenced by the frequency of perfectionistic cognitions when controlling for well documented correlates of anxiety. Perfectionistic cognitions, depressive symptoms, emotion regulation, anxiety sensitivity, and anxiety symptom severity were assessed prior to starting treatment in 356 treatment-seeking patients diagnosed with an anxiety or anxiety-related disorder at a specialty anxiety clinic. Perfectionistic cognitions were significantly correlated with all anxiety symptom measures as well as measures of depression, emotion regulation and anxiety sensitivity (range of rs =.22-.68). Hierarchical regression analyses revealed that when controlling for depressive symptoms, anxiety sensitivity, and emotion regulation, perfectionistic cognitions significantly and uniquely contribute to the variance of GAD (p .01) and PTSD (p .05) symptoms but not other anxiety-related symptoms (all ps.05). Regardless of specific diagnoses, treatment-seeking individuals reporting frequent perfectionistic thoughts are more likely to report more severe symptoms of PTSD and GAD.

Childhood is a developmental period associated with high risk of posttraumatic stress disorder (PTSD). Available validated pencil-and-paper diagnostic tools can be difficult for younger children to engage with given format and length. This study investigated psychometric properties of a briefer, more interactive game version of the Child PTSD Symptom Scale for DSM-5 (CPSS-5). Participants (n = 49) were children attending primary care appointments between 8 to 12 years of age who were exposed to a DSM-5 Criterion A trauma. Participants completed the 6-item screening version of the CPSS-5 delivered in mobile tablet game format (the CPSS-5 Screen Team Game) and a self-report version of the full CPSS-5 (CPSS-5-SR) before their medical appointments. The mobile game showed adequate internal consistency (α = 0.79), was significantly positively correlated to the total CPSS-5-SR (r = .74, p

OBJECTIVE/BACKGROUND: Few studies have examined the relationship between insomnia and anxiety treatment outcomes in naturalistic settings. Furthermore, prior studies typically examine insomnia within a single anxiety diagnosis without accounting for the high overlap between disorders. Here we investigate the association between insomnia and multiple anxiety disorders over a course of cognitive behavioral treatment (CBT) in a naturalistic treatment setting. PARTICIPANTS: Insomnia was assessed in 326 patients seeking treatment at a clinic specializing in CBT for anxiety. METHODS: Multilevel modeling was used to investigate whether insomnia moderated reductions in anxiety symptoms. A cross-lagged analysis tested for bidirectional effects between insomnia and anxiety. Multiple regression was used to investigate the relationship between insomnia and anxiety while controlling for the other anxiety disorders and depression. RESULTS: While there was a significant reduction in insomnia during treatment in all anxiety disorders, the majority of the most severe patients remained in the clinical range at post-treatment. Baseline insomnia did not significantly moderate anxiety outcomes, suggesting that patients with high or low levels of insomnia will do equally well in CBT for anxiety. The bidirectional effect between insomnia and anxiety did not reach significance. Additionally, posttraumatic stress disorder, generalized anxiety disorder, and panic disorder were associated with the greatest endorsement of insomnia, after controlling for the overlap between disorders. CONCLUSIONS: Sleep problems may persist after anxiety treatment, suggesting that CBT for insomnia may be warranted during or after a course of CBT for anxiety. Importantly, baseline insomnia does not impede anxiety reduction during CBT.

Negative cognitions about oneself, others, and the world are central to the development and maintenance of posttraumatic stress disorder (PTSD). We provide a comprehensive review of the literature examining the change in post-trauma negative cognitions in PTSD treatments. We explore the association between change in cognitions and change in PTSD symptoms and the mediational effect of negative cognitions on PTSD symptoms. A review of over 2000 manuscripts resulted in 65 PTSD treatment articles for review that included a measure of negative post-trauma cognitions and PTSD severity. Several studies found that PTSD treatments are associated with concurrent reductions in PTSD symptoms and negative post-trauma cognitions. Many studies suggest that the degree of reduction in negative post-trauma cognitions is both associated with the degree of reduction in PTSD symptoms and may mediate the change in PTSD symptoms in treatment. PTSD treatments are associated with significant improvements in negative post-trauma cognitions that often precede and predict reductions in PTSD symptoms.

Objective Prior studies of prolonged exposure therapy (PE) suggested that reduction of posttraumatic stress disorder (PTSD) precedes reduction in depression, yet no research has collapsed data across multiple studies to examine whether the directionality of reduction remains consistent in larger and diagnostically diverse samples. Thus, the objective of this study is to conduct an evaluation of bidirectional associations between PTSD and depression in PE. Method Participants (n = 216) from three randomized controlled trials of PE alone, PE + alcohol use disorder treatment, and PE + nicotine use disorder treatment completed weekly PTSD and depression severity measures. First, we analyzed the directional relationship between PTSD and depression over time in 2 single models to separately examine the effects of PTSD on depression and vice versa. Second, we analyzed a combined model to examine the simultaneous effects of reduction in PTSD on reduction in depression over and above the effects of reduction in depression on reduction in PTSD, and vice versa. Results Two single models suggested that reductions in PTSD lead to reductions in depression and vice versa. The combined models suggested that both directions of change are important and reciprocal. The strength of predictive power from PTSD to depression, and vice versa, is approximately equal. Most significant prediction of PTSD from depression and vice versa occurred early in treatment. Conclusion The relationship between reductions in PTSD and depression during PE is transactional. Regardless of whether PTSD or depression decreases first, reduction in the other symptom cluster is likely to follow. (PsycINFO Database Record

While cognitive reappraisal represents a promising emotion regulation strategy to assist refugees with posttraumatic stress disorder (PTSD) in managing responses to trauma reminders, there has been no experimental research investigating its efficacy in reducing intrusions and negative affect in this group. In this study, 76 refugees and asylum-seekers with varying levels of PTSD received instructions in cognitive reappraisal or emotional suppression before viewing emotional images depicting trauma-related scenes. Findings indicated that cognitive reappraisal led to fewer subsequent image-related intrusions in refugees high in PTSD symptoms. Trait suppression moderated the efficacy of cognitive reappraisal such that participants high in PTSD who had low levels of trait suppression reported significantly lower levels of negative affect when using cognitive reappraisal compared to emotional suppression. These findings highlight the potential utility of cognitive reappraisal when assisting individuals with PTSD to manage responses trauma reminders and for informing the treatment of the psychological effects of the refugee experience.

Our understanding of demographic specifications that put certain individuals at greater risk for trauma exposure and subsequent development of post-traumatic stress disorder (PTSD) has grown significantly over the past few decades. This brief review specifically examines the studies exploring the potential influence of ethnocultural and racial group status on trauma exposure and PTSD, with a focus on findings published recently in the past five years. We first provide a brief review of current epidemiological data examining associations among ethnicity/culture/race and trauma exposure/PTSD. We then explore a few related constructs (namely, stigma, acculturation/ethnic identity, and discrimination) in relation to trauma exposure and PTSD, with a focus on what is currently known about how these variables are empirically related to one another.

Background Numerous randomized controlled trials (RCTs) have examined the efficacy of cognitive behavioral therapy (CBT) in reducing anxiety symptoms. However, relatively fewer studies have examined the effectiveness of CBT in naturalistic treatment settings. There is even less known about the mechanisms underlying successful outcomes in naturalistic samples receiving CBT. This study aimed to examine the absolute and relative mediation of emotion regulation (ER) difficulties and anxiety sensitivity (AS) on anxiety symptom reduction. Methods Participants were treatment-seeking patients (N = 247) at an outpatient anxiety clinic. Measures of difficulties in ER, AS, and disorder specific symptoms were administered at baseline, mid, and post-treatment. A composite anxiety score was calculated to measure anxiety disorder symptom severity across anxiety-related diagnoses. Results Individual mediation models revealed that both AS and ER significantly mediated the reduction in anxiety-related symptoms over the course of treatment. A multiple mediation model found that ER was the strongest mediator (indirect effect = −1.030, 95% CI = −2.172 to −0.153). Further analyses revealed that the ER subscale of impulse control difficulties (e.g., the tendency to avoid when confronted with a feared stimulus) was the strongest mediator (indirect effect = −0.849, 95% CI = −1.913 to −0.081). Limitations This study relied solely on self-report measures of ER, AS, and anxiety pathology, and did not have a control group. Conclusions These results suggest that improvement in the ability to control impulses may act as a mechanism of anxiety symptom reduction and may be important to target in CBT with naturalistic samples.

While clinical reports suggest that torture survivors may try to suppress their emotions during torture, little is known about the use of emotional suppression following torture. In this study, 82 refugees and asylum-seekers (including 33 torture survivors) completed self-report measures of trait suppression, PTSD symptoms and baseline negative affect before being exposed to images depicting scenes of interpersonal trauma. The use of suppression while viewing the images was indexed and negative affect was measured both immediately after viewing the images and following a five minute rest period. Findings indicated that torture survivors did not show higher rates of trait suppression or state emotional suppression during the experimental session compared to non-torture survivors. However, torture survivors who endorsed state suppression higher levels of distress, and this relationship was especially strong for those with more severe PTSD symptoms. In contrast, there was a negative relationship between state suppression and distress for non-torture survivors with high levels of PTSD symptoms. These findings suggest that, while torture exposure does not lead to greater use of suppression, it does influence the impact of suppression on emotional responses to stimuli.

Asian Indians represent a significant portion of the largest growing race of Asians in the past decade in the United States. This selective review examines major cultural themes related to first- and second-generation Asian Indians living in the United States as they impact psychological and psychiatric dysfunction in this population. Specifically, we review the impact of Asian Indian culture on mental health, discuss the impact of acculturation and ethnic identity development on the mental health of Indian-Americans, and focus on typical mental health problems of Asian Indian adolescents, women and elderly in America. Finally, we provide a brief overview of empirically-supported treatment approaches and cultural considerations for additional treatments relevant to this population. This review is intended to provide an important foundation for more systematic empirically-driven investigation into better understanding how Asian Indian cultural themes impact mental health for Indian-Americans, and how to develop effective treatments for these issues in this cultural group.

Trauma experienced in childhood and adolescence negatively affects the development of adaptive regulation of emotions and is associated with greater symptoms of anger. Prior research has suggested that high levels of anger may impede the outcome of treatment in adults with posttraumatic stress disorder (PTSD). The current study investigated whether high levels of anger resulted in poorer treatment outcomes in adolescent girls with PTSD. Participants included 61 female adolescent survivors of sexual abuse or assault who were randomized to either prolonged exposure for adolescents (PE-A) or client-centered therapy (CCT) for traumatized children for 8-14 weekly sessions. Participants were followed for 12 months posttreatment. High levels of state anger at baseline were associated with less improvement in PTSD symptoms in the CCT group than the PE-A group (d = 0.62). The moderating effects of state anger on improvement in PTSD symptoms was significant with emotion regulation difficulties, which may underlie anger symptoms (d = 0.58) in the model. The results of this study suggessted that high state anger was less of an impediment to treatment of PTSD for those receiving PE-A than those receiving less differentiated approaches such as CCT.

Although cognitive biases are involved in the maintenance of panic disorder (PD), cognitive bias modification (CBM) has not been tested in PD. The current study developed and piloted a combined CBM-attention/CBM-interpretation PD treatment to determine initial acceptability and efficacy. Ten individuals diagnosed with PD (nine with Agoraphobia) were asked to complete 8, 20-min sessions of a CBM-A (Dot Probe task with fearful faces) and CBM-I (Word-Sentence Association Paradigm) intervention. Cognitive bias, panic symptom severity, and anxiety during interoceptive exercises were assessed at pre- and post-assessments. At post-treatment, participants showed increased benign interpretations, reduced threat interpretations of ambiguous panic situations, and reported significantly less severe panic symptoms with six individuals meeting criteria for remission. Anticipatory anxiety for interoceptive exercises decreased following treatment, but duration of exercises and anxiety following the exercises did not. Results suggest that further testing of the treatment and putative mechanisms of action is warranted.

Background There are a number of hypothesized underlying factors that, while present across a range of anxiety and fear-based disorders, are proposed to be specifically influential in the maintenance of social anxiety (SA) symptoms. Aims This study examined the influence of specific constructs (i.e., anxiety sensitivity, ruminative thinking, and depressive symptoms) on reduction of SA symptoms during a course of cognitive behavioral therapy (CBT). To better model potential causal relationships between observed moderators and social anxiety, time-lagged analyses between SA and significant moderators were also explored. Methods Participants (N = 107) were patients seeking treatment in a fee-for-service clinic specializing in CBT for anxiety disorders, OCD and PTSD. Participants were repeatedly assessed for a variety of symptoms and potential moderators throughout treatment. Results Even though anxiety sensitivity regarding social concerns, rumination, reflection, and depression showed significant within-and between-person relationships with SA symptoms, only rumination was found to uniquely moderate change in SA symptoms over the course of treatment. Specifically, those with higher average levels of ruminative thinking tended to improve greater on SA symptoms than those with lower levels throughout treatment. Further, this observed moderation effect was not found to significantly influence OCD, generalized anxiety, or PTSD symptoms. Finally, a bi-directional relationship was found between rumination and SA with rumination predicting subsequent changes in SA and vice versa. Conclusions High levels of ruminative thinking do not appear to be an impediment to improvement in SA symptoms in a naturalistic, treatment-seeking sample of individuals with anxiety disorders.

OBJECTIVES: To examine the relationship between improvements in adolescent ratings of therapeutic alliance and reductions in posttraumatic stress disorder (PTSD) severity over time among adolescent girls during prolonged exposure therapy for adolescents (PE-A) versus client-centered therapy (CCT), as well as to examine differences in changes in alliance between treatment groups. METHOD: A total of 61 adolescent girls (aged 13-18 years) with sexual assault-related PTSD received PE-A or CCT in a randomized controlled trial. Participants rated alliance at session 3, midtreatment, and posttreatment. RESULTS: The rate of improvement in adolescent-rated alliance was greater in PE-A than CCT over the course of treatment. In addition, improvement in adolescent-rated alliance significantly contributed to improvements in PTSD (regardless of treatment condition), but not vice versa. CONCLUSIONS: Contrary to beliefs that trauma-focused treatments fail to establish strong therapeutic alliance in sexually abused adolescents, improvement in adolescent ratings of alliance were greater in PE-A compared to CCT, and improvements in adolescent-rated alliance were significantly associated with better treatment outcome across both types of treatments.© 2016 Wiley Periodicals, Inc. Language: en

Given the high rates of comorbidity between posttraumatic stress disorder (PTSD) and substance use disorder (SUD), we investigated an integrated treatment for these disorders. Individuals with comorbid PTSD and alcohol dependence were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants also received BRENDA (supportive counseling). The naltrexone plus PE group showed a greater decline in alcohol craving symptoms than those in the placebo with no PE group. The PE plus placebo and the naltrexone without PE groups did not differ significantly from the placebo with no PE group in terms of alcohol craving. No treatment group differences were found for percentage of drinking days. Alcohol craving was moderated by PTSD severity, with those with higher PTSD symptoms showing faster decreases in alcohol craving. Both PTSD and alcohol use had a lagged effect on alcohol craving, with changes in PTSD symptoms and percentage of days drinking being associated with subsequent changes in craving. These results support the relationship between greater PTSD symptoms leading to greater alcohol craving and suggest that reducing PTSD symptoms may be beneficial to reducing craving in those with co-occurring PTSD/SUD.

The independent island nation of Saint Lucia and surrounding Caribbean countries have fairly well-documented high reported rates of trauma, but limited training infrastructure for trauma-related mental health support and treatment services. This study addresses this disparity between high trauma exposure and sparse trauma-related resources by studying how a one-day training workshop impacted self-rated knowledge about trauma and stigma towards trauma survivors. The training was provided by a licensed clinical psychologist in partnership with a local women&rsquo, s rights group. Participants (n = 41) included school counselors, nurses, psychiatric providers, health educators, and advocates on the island. Participants completed pre- and post-workshop measures examining the variables of interest. The one-day workshop provided training on trauma types, post-trauma reactions, options for treatment, and hands-on training for trauma crisis-management and short-term interventions. Following the workshop, participants reported increased knowledge of trauma, more accurate perceptions of its prevalence, better understanding of evidence-based treatments, and lower trauma survivor-related stigma. This is the first trauma-focused workshop tested in St. Lucia, where the need for such training is considerable given few treatment options for trauma survivors in this area. Work is underway to provide more expansive services for trauma across the Caribbean region, given these preliminary promising findings.

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

This study evaluated psychometric properties of interview, self-report, and screening versions of the Child PTSD Symptom Scale for DSM-5 (CPSS-5), a measure of posttraumatic stress disorder (PTSD) for traumatized youth based on DSM-5 criteria. Participants were 64 children and adolescents (51.6% female, 45.3% African American/Black) between 8 and 18 years of age (M = 14.1, SD = 2.5) who had experienced a DSM-5 Criterion A trauma. Participants completed test-retest procedures for the self-report and interviewer versions of the CPSS-5 in 2 visits that were up to 2 weeks apart. Analyses revealed excellent internal consistencies, good to excellent test-retest reliability, and good convergent validity and discriminant validity for interview and self-report versions of the scale. Receiver operating characteristic analysis yielded a cutoff score of 31 on the CPSS-5 self-report version for identifying probable PTSD diagnosis. Six most frequently endorsed items by those with a possible PTSD diagnosis on the CPSS-5 were identified to constitute a screen version of the CPSS-5, showing good internal consistency and test-retest reliability. The three versions of the CPSS-5 scales are valid and reliable measures of DSM-5 PTSD symptomatology in traumatized youth.

Researchers have suggested that posttraumatic stress disorder (PTSD) is associated with significant healthcare burden and utilization of medical services. The purpose of this study was to examine the impact of PTSD symptoms on health functioning among active-duty military personnel. Participants in the study were 366 treatment-seeking service members who had returned from deployment and were participating in a larger PTSD treatment study. Assessments included measures of PTSD symptom severity, combat experiences, life stress, health functioning, alcohol use, and depression. We hypothesized that at baseline, PTSD severity and its symptom clusters would be significantly associated with poorer physical and mental health functioning. We conducted separate hierarchical multiple regressions to examine the predictive contribution the hypothesized factors would have on the variance in physical and mental health scores. Consistent with previous literature, we found that PTSD severity was significantly associated with poorer mental health functioning, B = -0.25, SE = 0.08, β = -0.15, t(342) = -3.07, R2 = .37, p = .002; however, contrary to our hypotheses, PTSD severity was not associated with poorer physical health functioning. Further, the hyperarousal symptom cluster was significantly associated with poorer physical health functioning, B = -0.83, SE = 0.26, β = -0.18, t(340) = -3.16, R2 = .11, p = .002, but not mental health functioning. Limitations of our study included the use of self-report measures only and lack of objective measures. Future directions for study include examination of how health functioning perceptions change over a longer duration of PTSD symptoms and after treatment.

This randomized trial examines the dissemination and implementation of prolonged exposure (PE) therapy for posttraumatic stress symptoms in U.S. Army medical treatment facilities. The study compares two PE training models: Standard PE training, comprised of a 4-day workshop only, and Extended PE training, comprised of a 4-day workshop plus expert case consultation. Behavioral health providers (N=180) across three medium-to-large Army installations will be randomly assigned to either Standard PE training or Extended PE training. Changes in provider attitudes will be examined across groups. After completing PE training, the use of PE components with patients reporting posttraumatic stress symptoms and clinical outcomes of these participating patients (N=500) will be examined. This article describes the rationale and methods of the study. In addition, a number of methodological issues in conducting a multisite naturalistic study in the U.S. Army are discussed.

This study aimed to determine the unique impact of PTSD symptoms, beyond other frequently examined factors on physical and mental health functioning in a sample of returning veterans. Assessments of 168 returning OEF/OIF veterans conducted an average of six months following return from deployment included measures of emotional disorders and the Short Form (36) Health Survey. Hierarchical multiple regressions revealed significant, unique contribution of Clinician-Administered PTSD Scale (CAPS) score above all other predictors in the model (demographics, severity of trauma exposure, physical injury, substance abuse and depressive symptoms), for both the physical (8%) and mental (6%) health aggregate scores, along with significant prediction of physical health (4-10%) and mental health (3-7%) subscale scores. The only other significant predictors were age for physical health scores, and depressive symptoms for mental health scores. PTSD criterion B (re-experiencing) symptoms uniquely predicted reduced physical health functioning and higher experience of bodily pain, while criterion D (hyperarousal) symptoms uniquely predicted lower feelings of energy/vitality and poorer perceptions of emotional health.

Background and objectives There has been a recent proliferation of research evaluating the efficacy of mindfulness as a clinical intervention. However, there is still little known about trait mindfulness, or how trait mindfulness interacts with maladaptive emotion regulation strategies. The current study further explores the effect of trait mindfulness on emotion regulation, as well as whether specific factors of trait mindfulness are uniquely associated with subjective and autonomic reactivity to stress. Methods Forty-eight healthy male participants were trained in the use of the suppression strategy and then instructed to suppress their responses to the inhalation of a 15% CO2-enriched air mixture for 90 s while their subjective distress and heart rate were recorded. Results After controlling for anxiety-related variables, the ability to provide descriptions of observed experiences predicted less heart rate reactivity to CO2 inhalation, while skillfulness at restricting attention to the present moment was uniquely predictive of less subjective distress. The tendency to attend to bodily or sensory stimuli predicted greater distress during CO2 inhalation. Limitations The inclusion of only healthy males limits the generalizability of study findings. Also, the sample size was relatively small. Conclusions These findings suggest that factors associated with trait mindfulness predict less stress reactivity and distress while engaging in suppression above and beyond other variables that have been shown to predict anxious responding. The implications for emotion and clinical research are discussed.

Laska, Gurman, and Wampold (2014, pp. 467-481) raise a number of interesting arguments for clinical practice that involves the integration of the Common Factors and Empirically Supported Therapies perspectives. The merits, validity, and weaknesses in these arguments are discussed from a conceptual and empirical viewpoint. While we agree that the division in the field between the 2 approaches is excessive and interferes in the delivery of effective patient care, we highlight the important reasons to use unbiased, replicable assessments of treatment effects and interpretation when choosing a treatment approach. We emphasize the need to conduct empirical comparisons using study designs that allow us to vigorously test the influence of common factors over and beyond specific treatment ingredients, before we can more widely advocate for their necessary inclusion in existing treatments.

Gender differences in social anxiety disorder (SAD) have not received much empirical attention despite the large body of research on the disorder, and in contrast to significant literature about gender differences in other disorders such as depression or posttraumatic stress disorder. To address this gap, we comprehensively reviewed the literature regarding gender differences in eight domains of SAD: prevalence, clinical presentation, functioning and impairment, comorbidity, course, treatment seeking, physiological arousal, and the oxytocin system. Findings from the present review indicate that women are more likely to have SAD and report greater clinical severity. Notwithstanding, men with the disorder may seek treatment to a greater extent. According to the present review, the course of SAD seems to be similar for men and women, and findings regarding gender differences in functional impairment and comorbidity are inconclusive. We highlight areas requiring future research and discuss the findings in the context of a number of theoretical perspectives. We believe that further research and integration of scientific findings with existing theories is essential in order to increase our understanding and awareness of gender differences in SAD, thus facilitating gender-sensitive and specifically-tailored interventions for both men and women with the disorder.

Item does not contain fulltext Cognitive bias modification has recently been discussed as a possible intervention for mental disorders. A specific form of this novel treatment approach is approach-avoidance modification. In order to examine the efficacy of approach-avoidance modification for positive stimuli associated with social anxiety, we recruited 43 individuals with social anxiety disorder and randomly assigned them to a training (implicit training to approach smiling faces) or a control (equal approach and avoidance of smiling faces) condition in three sessions over the course of a 1-week period. Dependent measures included clinician ratings, self-report measures of social anxiety, and overt behavior during behavioral approach tasks. No group differences in any of the outcome measures were observed after training. In addition, while individuals in the training group showed increased approach tendency in one of the sessions, this effect was inconsistent across the three sessions and did not result in long-term changes in implicit approach tendencies between the groups over the course of the entire study. These results suggest that approach-avoidance modification might result in short-lasting effects on implicit approach tendencies towards feared positive stimuli, but this modification may not result in meaningful behavioral change or symptom reduction in individuals with social anxiety disorder. 13 p.