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Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship. The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis. Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior. These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets. ClinicalTrials.gov Identifier: NCT02161133

We describe a clinical trial which is seeking to determine the effectiveness and understand implementation outcomes for tele-collaborative specialty care for Veterans with Gulf War Illness (GWI).This study will be a hybrid type 1 randomized effectiveness-implementation trial comparing tele-collaborative specialty care to electronic consultation for Gulf War Veterans with GWI (N = 220). In tele-collaborative specialty care, the specialty provider team will deliver health coaching and problem-solving treatment to Veterans and recommend a plan for analgesic optimization. In electronic consultation, the specialty provider team will make a one-time recommendation to the primary care team for locally delivered health coaching, problem-solving treatment and analgesic optimization. The primary aim will be to determine the effectiveness of tele-collaborative specialty care as compared to electronic consultation to reduce disability related to GWI. Our secondary aim will be to understand implementation outcomes.There is a need to improve care for Veterans with GWI. A potentially useful model to improve care is tele-collaborative specialty care, where the specialists work with the primary care provider to synergistically treat the patients.This is the first clinical trial to prospectively compare different models of care for Veterans with GWI. This responds to multiple calls for research to improve treatment for Veterans with GWI, including from the National Academy of Medicine.

The opioid crisis has highlighted the importance of improving patients’ access to behavioral treatments for chronic pain and addiction. What is not known is if patients are interested in receiving these treatments. In this cross-sectional study, over 1000 participants with chronic pain were surveyed using an anonymous online questionnaire on Amazon Mechanical Turk (Mturk) to investigate participants’ use of and interest in pharmacological and behavioral treatments for chronic pain and addiction. Participants also indicated whether their doctor had recommended these treatments. The majority of participants reported using medication for their pain (83.19%) and that their doctor recommended medication (85.05%), whereas fewer participants reported using (67.45%) and being recommended to (62.82%) behavioral treatments. We found 63.67% of participants screened positive for possible opioid misuse; those who screened positive were more interested in receiving behavioral treatments than those who did not screen positive. Participants who received treatment recommendations were more likely to be interested in receiving those treatments as compared to participants who did not. The results suggest that recommendations for behavioral treatments and interest in those treatments are related. Results also suggest that patients endorsing behaviors consistent with opioid misuse are interested in behavioral treatments. Perspective: This study provides information around chronic pain patients’ treatment interests, treatment receipt, and recommendation receipt for behavioral pain management and addiction treatment. This study could help facilitate communication between patients and doctors regarding available treatments for chronic pain and pain treatment-related addiction problems.

Impaired cognition is a hallmark of schizophrenia spectrum disorders, including schizotypal personality disorder, and it is the best predictor of functional outcome. Cognitive remediation therapy has demonstrated efficacy for improving cognition, augmenting other rehabilitation efforts in schizophrenia, and effecting gains in real-world functioning. Pharmacological augmentation of cognitive remediation has been attempted, but the effects of augmentation on combined therapies, such as cognitive remediation and social skills training, have not been studied.Twenty-eight participants with schizotypal personality disorder enrolled in an 8-week, randomized, double-blind, placebo-controlled trial of guanfacine plus cognitive remediation and social skills training (15 guanfacine, 13 placebo). Cognition was assessed with the MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery (MCCB), social cognition with the Movie for the Assessment of Social Cognition (MASC), and functional capacity with the University of California San Diego Performance-Based Skills Assessment (UPSA).A statistically significant pre- versus posttreatment effect was observed for MCCB speed of processing, verbal learning, and visual learning and UPSA total score. A significant time-by-medication (guanfacine, placebo) interaction was observed for MCCB reasoning and problem solving and UPSA total score; the time-by-treatment interaction approached significance for MASC hypomentalizing errors.Both guanfacine and cognitive remediation plus social skills training were well tolerated, with no side effects or dropouts. Participants treated with cognitive remediation, social skills training, and guanfacine demonstrated statistically significant improvements in reasoning and problem solving, as well as in functional capacity and possibly social cognition, compared with those treated with cognitive remediation, social skills training, and placebo. Cognitive remediation plus social skills training may be an appropriate intervention for individuals with schizotypal personality disorder, and guanfacine appears to be a promising pharmaceutical augmentation to this psychosocial intervention.

Background Communication between patients and providers about persistent “medically unexplained” physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. Methods Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. Results The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. Conclusions Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Individuals with schizotypal personality disorder (SPD) often present with cognitive impairment similar, but of a lesser magnitude to, what is seen in schizophrenia. Cognitive dysfunction combined with social and perceptual disturbances, which are the hallmarks of this disorder, are directly related to substantially lower functioning. There is no FDA-approved medication for cognitive deficits in SPD; however, potential agents, including α2a and dopamine agonists, are under investigation. Cognitive remediation therapy (CRT) is a behavioral treatment that has been shown to improve cognitive and psychosocial functioning in individuals with schizophrenia. Application of CRT in this population is novel and more large-scale studies are needed, but this treatment holds promise for the cognitive and social deficits of SPD. There may be a synergy between cognitive remediation and cognitive enhancers such as the α2a agonist guanfacine; research in this area is nascent. Lifestyle modifications such as the use of memory aids, planners, and structured schedules, as well as exercise, may be beneficial for cognitive functioning in this population. Additionally, social skills training in a psychotherapeutic setting can be helpful. Patients frequently present with comorbid mood and anxiety symptoms, and standard SSRI treatment to ameliorate symptoms can have a positive secondary effect on cognitive functioning. For the patient with psychotic-like features, treatment with atypical antipsychotics may also improve overall functioning.

Background Prior work shows individuals with schizotypal personality disorder (SPD) evince temporal lobe volume abnormalities similar to schizophrenia but sparing of prefrontal cortex, which may mitigate psychosis and the severe neurocognitive impairments observed in schizophrenia. This study examined the extent to which frontal–temporal gray matter volume and neurocognitive performance predict: (1) SPD group membership in a demographically-balanced sample of 51 patients and 37 healthy controls; and (2) symptom severity in SPD. Methods Dimensional gray-matter volume (left frontal–temporal regions (Brodmann area (BA) 10, 21, 22)) and neurocognitive performance on key memory tasks (California Verbal Learning Test (CVLT), Dot Test, Paced Auditory Serial Addition Test (PASAT)), all salient to schizophrenia-spectrum disorders were examined in a multi-variable model. Results Middle temporal gyrus (BA21) volume and spatial–working memory (Dot Test) performance were significant predictors of SPD group membership likelihood, with poorer working-memory performance indicating increased probability of SPD membership. Combining across regional volumes or cognitive measures resulted in fair-to-good discrimination of group membership, but including neurocognitive and non-collinear regional volume measures together resulted in a receiver-operating-characteristic (ROC) curve with improved diagnostic discrimination. Larger BA10 volume in dorsolateral prefrontal cortex (DLPFC) significantly predicted less symptom severity in SPD. Conclusions These findings suggest that temporal lobe volume and spatial-working memory performance are promising biological/phenotype markers for likelihood of SPD classification, while greater DLPFC volume may serve as a protective factor.