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Motivation and pleasure deficits are common in schizophrenia, strongly linked with poorer functioning, and may reflect underlying alterations in brain functions governing reward processing and goal pursuit. While there is extensive research examining cognitive and reward mechanisms related to these deficits in schizophrenia, less attention has been paid to psychological characteristics that contribute to resilience against, or risk for, motivation and pleasure impairment. For example, psychological tendencies involving positive future expectancies (e.g., optimism) and effective affect management (e.g., reappraisal, mindfulness) are associated with aspects of reward anticipation and evaluation that optimally guide goal-directed behavior. Conversely, maladaptive thinking patterns (e.g., defeatist performance beliefs, asocial beliefs) and tendencies that amplify negative cognitions (e.g., rumination), may divert cognitive resources away from goal pursuit or reduce willingness to exert effort. Additionally, aspects of sociality, including the propensity to experience social connection as positive reinforcement may be particularly relevant for pursuing social goals. In the current review, we discuss the roles of several psychological characteristics with respect to motivation and pleasure in schizophrenia. We argue that individual variation in these psychological dimensions is relevant to the study of motivation and reward processing in schizophrenia, including interactions between these psychological dimensions and more well-characterized cognitive and reward processing contributors to motivation. We close by emphasizing the value of considering a broad set of modulating factors when studying motivation and pleasure functions in schizophrenia.

BackgroundThe Veterans Health Administration (VHA), 1 of 3 administrative branches in the US Department of Veterans Affairs (VA), is the largest integrated health care system in the United States. The VHA has 4 missions: providing health care to eligible veterans; supporting research to benefit veterans and the larger society; providing education for health care trainees; and supporting emergency response.ObservationsIn service of these goals, the VA has academic affiliations with training institutions throughout the country, offering unique and extensive training and research opportunities. These affiliations are a 2-way street where both the VA and the affiliate provide and gain from their partnership. For example, VA affiliations with University of California (UC) medical schools benefit veteran care and are a major contributor to the UC academic mission. This article explores the history of the VA, current veteran demographics and needs, academic affiliations, and the integrated care model of training in all VHA facilities. The VA and UC academic affiliation system is described further with regard to shared research and educational functions.ConclusionsWe identify risks to academic affiliations if a shift occurs from VHA care to VA-managed community-based care following the implementation of recent legislation. We also provide suggestions for VA academic affiliates to help assess and guide the potential impact of increased VA-managed community care.

Posttraumatic stress disorder (PTSD) is the most highly prevalent mental health disorder among U.S. military Veterans. Prolonged Exposure (PE) therapy is one of the most widely used evidence-based treatments for PTSD, but there is substantial room for improvement in outcomes and retention rates. Accumulating data suggest that oxytocin offers a promising pharmacological approach towards achieving this goal. Therefore, the primary objective of this two-site Phase II study is to examine the ability of oxytocin (vs. placebo) administration combined with PE therapy to (1) reduce PTSD symptom severity, (2) accelerate the rate of PTSD symptom improvement, and (3) improve PE adherence and retention rates. To accomplish these objectives, we will employ a randomized, double-blind, placebo-controlled trial and use standardized, repeated dependent measures of change at five time points (baseline, mid-treatment, end of treatment, and 3 and 6 month follow-up). Intranasal oxytocin (40 IU) will be administered directly prior to each PE therapy session. Findings from this study will provide critical new information regarding the efficacy of oxytocin to augment psychosocial treatment for PTSD, as well as information regarding the physiological mechanisms underlying PTSD and positive treatment response. ClinicalTrials.gov Identifier: NCT04228289.

Associations between subjective maternal bonding recalled from the first 16 years of life and current sleep indices were investigated in a clinical sample of 34 adults with major depressive disorder and 36 normal controls (n = 70) using the self-report parental bonding instrument and wrist actigraphy. Results of multiple linear regression analyses indicated that reports of maternal bonding indices were associated with several sleep indices in adulthood independent of depression status. Higher levels of maternal care were associated with greater time in bed and total sleep time. Higher levels of maternal overprotection were associated with fewer awakenings. Findings indicate that reported maternal bonding characteristics in childhood are related to objectively measured sleep characteristics in adulthood, independent of mood state.

Clinical psychology training for research-oriented scientist-practitioners tends to have a gap in research training during the predoctoral internship year. In 1982, the Clinical Psychology Training Program (CPTP) at the University of California, San Francisco (UCSF) began a 2-year clinical and clinical research training program combining an American Psychology Association (APA)-accredited internship and a postdoctoral fellowship. The goal of the program is to prepare graduates for leadership roles as principal investigators who are licensed clinicians able to function as independent practitioners. This article conveys the philosophy behind the program, its structure, and the results of the program over the last 31 years. The CPTP accepted 142 trainees, of whom 46 (32%) were minorities and 78 (55%) were women. CPTP fellows have published over 250 articles, chapters, and books with their mentors and have contributed to submitting research grants with them. The vast majority continued research and academic activities after graduation. The most recent self-study for APA accreditation reported that of 43 trainees admitted in the 10 years between 1999 and 2008, 41 (95%) went on to academic positions, research, or clinical positions in academic settings or research positions in other settings; 1 obtained a clinical position; and 1 provided no information. The program serves as a model for clinical psychology nationally, allowing for uninterrupted clinical research training during the internship and postdoctoral years, nurturing clinical psychologists committed to clinical research careers, and contributing substantially to the clinical research productivity of the host department.

ObjectiveIdentifying treatments to improve functioning and reduce negative symptoms in consumers with schizophrenia is of high public health significance.MethodIn this randomized clinical trial, participants with schizophrenia or schizoaffective disorder (N = 149) were randomly assigned to cognitive behavioral social skills training (CBSST) or an active goal-focused supportive contact (GFSC) control condition. CBSST combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning and negative symptoms. GFSC was weekly supportive group therapy focused on setting and achieving functioning goals. Blind raters assessed functioning (primary outcome: Independent Living Skills Survey [ILSS]), CBSST skill knowledge, positive and negative symptoms, depression, and defeatist performance attitudes.ResultsIn mixed-effects regression models in intent-to-treat analyses, CBSST skill knowledge, functioning, amotivation/asociality negative symptoms, and defeatist performance attitudes improved significantly more in CBSST relative to GFSC. In both treatment groups, comparable improvements were also found for positive symptoms and a performance-based measure of social competence.ConclusionsThe results suggest CBSST is an effective treatment to improve functioning and experiential negative symptoms in consumers with schizophrenia, and both CBSST and supportive group therapy actively focused on setting and achieving functioning goals can improve social competence and reduce positive symptoms.

ObjectivesTo determine whether Cognitive Behavioral Social Skills Training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST.DesignAn 18-month, single-blind, randomized controlled trial.SettingOutpatient clinic at a university-affiliated Veterans Affairs hospital.ParticipantsVeteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N = 79) age 45-78.InterventionsCBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals.MeasurementsBlind raters assessed functioning (primary outcome: Independent Living Skills Survey), CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction.ResultsFunctioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem, and life satisfaction.ConclusionsCBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self-esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning.Trial registryClinicalTrials.Gov #NCT00237796 (http://clinicaltrials. gov/show/NCT00237796).

Among substance-dependent individuals, comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of posttreatment substance use outcomes within this population. Using latent growth curve models, the authors tested relationships between individual rates of change in 12-step involvement and substance use, utilizing posttreatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT) for veterans with substance dependence and MDD. Although TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared with ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.

PurposeEstimates of insomnia in breast cancer patients are high, with reports of poor sleep lasting years after completion of cancer treatment. This randomized controlled crossover pilot study looked at the effects of individual cognitive behavioral therapy for insomnia (IND-CBT-I) on sleep in breast cancer survivors.Patients and methodsTwenty-one participants were randomly assigned to either a treatment group (six weekly IND-CBT-I sessions followed by six weeks of follow up) or a delayed treatment control group (no treatment for six weeks followed by six weekly IND-CBT-I sessions). Of these, 14 participants completed the pilot study (six in the treatment group and eight in the delayed treatment control group).ResultsSelf-rated insomnia was significantly improved in the treatment group compared to the waiting period in the delayed treatment control group. The pooled pre-post-IND-CBT-I analyses revealed improvements in self-rated insomnia, sleep quality, and objective measures of sleep.ConclusionsThese preliminary results suggest that IND-CBT-I is appropriate for improving sleep in breast cancer survivors. Individual therapy in a clinic or private practice may be a more practical option for this population as it is more easily accessed and readily available in an outpatient setting.

The number of older patients with chronic schizophrenia is increasing. There is a need for empirically validated psychotherapy interventions for these older patients. A randomized controlled trial compared treatment as usual (TAU) with TAU plus cognitive-behavioral social skills training (TAU+CBSST) in 76 middle-aged and older patients with chronic schizophrenia. CBSST teaches cognitive-behavioral coping techniques, social functioning skills, problem solving and compensatory aids for neurocognitive impairments over 24 weekly group therapy sessions. Blind raters obtained assessments of social functioning, psychotic and depressive symptoms, and cognitive insight and CBSST skill mastery. After treatment, patients in TAU + CBSST performed social functioning activities significantly more frequently than patients in TAU, although general skill at performing social functioning activities did not differ significantly between the two groups. Significant treatment group effects were also found for cognitive insight and skill mastery, indicating patients in CBSST became more objective in reappraising psychotic symptoms and learned CBSST skills. The overall treatment group effect was not significant for symptoms, but greater increase in cognitive insight in CBSST was significantly correlated with greater reduction in positive symptoms, suggesting patients who showed increased cognitive insight in CBSST were more likely to show psychotic symptom reduction. With CBSST, therefore, middle-aged and older outpatients with chronic schizophrenia were able to learn cognitive-behavioral coping skills, changed the way they evaluate anomalous experiences (cognitive insight), and improved their social functioning. Future research is needed to determine whether cognitive insight mediates psychotic symptom change in cognitive-behavioral therapy for psychosis.

Goal-Oriented Attentional Self-Regulation (GOALS) is a cognitive rehabilitation training program that combines mindfulness-based attention regulation with individualized goal management strategies to improve functioning in daily life after traumatic brain injury (TBI). While not a specific target of GOALS training, previous research has indicated improvements in emotional functioning following GOALS training, specifically symptoms related to depression and posttraumatic stress disorder (PTSD). The current study is based on the hypothesis that improvements in cognitive control processes related to executive functioning and attention after GOALS training generalize to improvements in emotional functioning, thereby resulting in reductions in emotional distress. The current study analyzed archival data from 33 Veteran participants with a confirmed diagnosis of PTSD and a history of mild TBI who received either GOALS training or a psychoeducational intervention matched for time, therapist attention, and participation format. Regression analysis was used to assess the strength of the relationship between improvements in Overall Attention/Executive Functioning and decreases in hyperarousal symptoms associated with PTSD. Results from the regression analysis revealed that improvements in Overall Attention/Executive Functioning after GOALS was significantly associated with reductions in hyperarousal symptoms associated with PTSD (R2 = 0.26, F(1,15) = 5.01, β = −.51, p <.05). The current findings suggest that cognitive improvements after GOALS training may lead to changes in emotional functioning, resulting in decreased emotional distress. This is important, particularly in VA settings, because the results potentially highlight additional areas of research and focus on the treatment of comorbid mild TBI and PTSD among Veterans. [ABSTRACT FROM AUTHOR]

Purpose: This study had two aims: (1) to determine the prevalence of five categories of retrospectively reported childhood maltreatment in an adult community sample and (2) to examine relationships between three theoretically and practically chosen demographic variables and childhood maltreatment. Method: Participants were a representative sample of 967 adult men and women in the metropolitan Memphis, Tennessee area. They completed a telephone survey that included a reliable, valid questionnaire assessing five types of childhood maltreatment (i.e., emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse) and demographic questions. Simultaneous logistic regression analyses were used to identify demographic correlates of specific trauma types. Results: Prevalence of childhood maltreatment ranged from approximately 30% for women to over 40% for men. Approximately 13% of participants reported multiple forms of maltreatment. The most common forms of trauma for both men and women were physical abuse, physical neglect, and emotional abuse, all of which were highly likely to co-occur. Race, sex, and current educational level were each associated with an increased likelihood of childhood maltreatment; differential relationships with particular maltreatment types were also observed. Implications: These findings highlight the importance of research on the prevalence of and risks for multiple types of childhood maltreatment, particularly in the somewhat neglected area of emotional abuse and neglect. These findings can be used to highlight the need for preventive interventions aimed at the negative sequelae of childhood maltreatment and to tailor preventive interventions to the needs and expectations of those at high risk.

Interventions for alcohol- and substance-dependent adults with comorbid depressive disorders are needed, but few have been empirically tested. In a randomized clinical trial of two psychotherapy interventions for these disorders, we examined whether initial focus of treatment was related to retention, substance use, and depression outcomes. Both interventions, integrated cognitive-behavioral therapy (ICBT; n = 105) and twelve-step facilitation (n = 92), were delivered in group formats with entry points every 4 weeks at the beginning of three content-distinct modules. Entry module (i.e., initial treatment focus) was not related to percentage days abstinent, proportion of the sample abstinent, or depression symptoms for either intervention. This was true at both 12 and 24 weeks postbaseline. Furthermore, attendance was similar for both treatments, regardless of initial treatment focus, with a single exception in the ICBT condition. Our findings support the use of modular formats with multiple or rotating entry points for psychotherapy group interventions. Keywords: Addiction treatment; Depression; Retention; Treatment components; Alcohol and substance dependence

Objective: In a population of veterans with co-occurring substance use disorders and concomitant major depressive disorder, the current study compared mechanisms of change and therapeutic effects relevant to both disorders between integrated, dual disorder-specific cognitive behavioral therapy (ICBT) and twelve-step facilitation (TSF). Method: Veterans (N = 148) were given standard pharmacotherapy for depression and were randomly assigned to receive 24 weeks of either TSF or ICBT. Process measures were selected to quantify (1) changes in self-efficacy in ICBT, (2) changes in ability to terminate negative affect in ICBT, (3) twelve-step affiliation (TSA) in TSF, and (4) changes in social support in both conditions. Measures of depression and substance use were administered to all participants before treatment, during treatment, and at the end of treatment. Results: Self-efficacy increased among both TSF and ICBT participants during treatment, whereas self-reported ability to regulate negative affect did not change. Consistent with predictions, TSF participants increased community TSA during treatment, whereas those receiving ICBT reduced TSA. Changes in self-efficacy and TSA were associated with improvement in substance use outcomes at the end of treatment. Hypothesized changes in social support were not supported. Conclusions: Both ICBT and TSF produce improvements in self-efficacy, and these changes are related to substance use outcomes for depressed substance abusers. In TSF, intervention-specific changes in TSA occur during the course of treatment and are related to substance use outcomes., PROCESS-ORIENTED INTERVENTION STUDIES have been advocated for many years in efforts to understand how particular psychosocial interventions exert their effects on outcomes (e.g., Greenberg and Pinsof, 1986). Such studies have [...]

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are associated with an increased risk for health problems. We examined whether trauma history and PTSD were related to physical health in patients with an SUD. We compared health stressors, health service utilization, and self-rated health status in three groups of male veterans receiving SUD treatment: (1) no trauma exposure (SUD-only group), n = 55; (2) with PTSD (SUD-PTSD group), n = 32; and (3) trauma exposure without PTSD (SUD-trauma group), n = 34. The veterans were assessed quarterly for 1 year. Groups differed in their likelihood of experiencing chronic health stressors at all time points. The SUD-only group consistently had the lowest rates of chronic health stressors, the SUD-PTSD group had the highest rates, and the SUD-trauma group fell in between. In contrast, groups did not differ in rates of acute health problems. Chronic health stressors appear to be associated with trauma exposure and psychologic response to the trauma. Substance use disorder interventions may benefit from incorporation of primary care services. Keywords: Alcohol dependence; Substance dependence; Posttraumatic stress disorder; Physical health; Trauma

Objective: Women with histories of childhood maltreatment (CM) have higher rates of physical health problems and greater medical utilization compared to women without abuse histories. This study examined whether current post-traumatic stress disorder (PTSD) symptoms mediate the relationship between CM and indicators of physical health and medical utilization in female veterans. Method: Respondents were 221 female veterans (56% of the potential sample), who received medical care from the San Diego VA Healthcare System during a 12-month period. Respondents provided self-report information about CM, PTSD symptoms, use of pain medication, and physical symptoms and functioning. Additional information about medical utilization was extracted from respondents' medical charts. Regression-based models were conducted to test whether PTSD symptoms mediate the relationships between CM and physical symptoms and between CM and medical utilization. Results: Emotional abuse was associated with poorer role-physical functioning, increased bodily pain and greater odds of using pain medication in the past 6 months. Physical abuse was associated with poorer general health. Contrary to prediction, emotional neglect was associated with better role-physical functioning, and CM was not associated with increased healthcare utilization. PTSD was shown to mediate the relationship between emotional and physical abuse and health outcomes. Conclusions: PTSD, or psychopathology more generally, appears to be an important factor in the negative health impact of CM. Given that several empirically supported interventions are available for PTSD, there may be physical health benefits in early identification and treatment of psychopathology related to CM. Keywords: Post-traumatic stress disorder; Childhood abuse; Self-reported health; Medical utilization

Most research and treatment focussing on the relationship between life stress and substance use have considered stress as a unitary construct despite the fact that stressors vary in terms of temporal characteristics (short-term vs. long-term) and domains (work, health). In contrast to most stressor domains, increasing evidence suggests that health stressors may reduce the risk of initiating substance use after treatment. We separately evaluated the effect of short-term stress events (discrete date of occurrence), long-term stressors (ongoing stressors lasting 2 weeks or longer), and health stressors on posttreatment alcohol and drug use. Veterans (N = 195) were assessed while receiving addiction treatment and quarterly for 1 year. The odds of initiating posttreatment substance use were 2.5 times greater for participants experiencing severe (nonhealth) long-term stressors. In contrast, participants experiencing short-term health events or severe (nonhealth) short-term events were less likely to initiate posttreatment substance use (odds ratio = .28 and .44, respectively). Keywords: Alcohol dependence; Addiction treatment; Life stress; Health

Current age and age of onset of alcohol dependence and whether they are linked to the type of stress experienced preceding treatment, was examined in male veterans receiving inpatient treatment for alcohol dependence. The likelihood of life events related to achievement, relationship and legal problems fell with age, although the likelihood of health difficulties rose.

Clinical depression is frequently unrecognized, even in health care settings. This study (a) reports high levels of major depressive episodes (MDEs) and depressive symptoms in a public sector women's clinic, (b) compares computerized voice recognition with live interviews, and (c) compares Spanish and English versions of the depression-screening instruments. Patients (N = 104) completed face-to-face interviews and/or computerized voice recognition interviews in counterbalanced order; 38% scored positive for current MDE, and 67% scored positive for lifetime MDE. The mean score on the Center for Epidemiological Studies Depression scale (CES-D) was 22.1 (SD = 12.1), with 68% scoring 16 or above. No differences were found on either measure between English and Spanish speakers. Overall agreement between computer and live interviews was as follows: [Kappa] = .82 for both current and lifetime MDE and r = .89 for CES-D scores. Kappas between the MDE Screener developed for this study and the Primary Care Evaluation of Mental Disorders were .75 for live interviews and .81 for the computerized version. Depression screening with computerized voice recognition methods yielded results comparable with those of live interviews in both English and Spanish.

To evaluate relationships between stressful life events, chronic stress and alcoholic drinking relapse, 129 male inpatients aged 22 to 70 years (with an average age of 45.8 years) who had just completed an alcohol treatment program were studied. The men were predominantly Caucasian (85 percent) and single (66 percent). At the beginning of the program, they were each given a thorough diagnostic interview. Interviews of either a family member or close friend were also conducted to corroborate patient information. Three months after discharge from the program, patients were interviewed again. They were questioned about the occurrence of 133 life events related to factors such as work, health, family, deaths, relationships, crime, school and finances, which had occurred within the year preceding treatment and during the three months following their discharge. Of the 111 patients who completed the entire assessment, 76 remained sober. Thirty-five had resumed drinking during the three-month follow-up period. A comparison of stressful life-events between those who relapsed and those who didn't demonstrated that the relapsed group had experienced significantly more severe and acute stress prior to relapse. About 40 percent of the relapsed group also demonstrated significantly higher ratings of chronic, severe stressors during the year prior to treatment. While moderate stressors did not seem to affect relapse, results suggest that both acute and ongoing severe stressors are implicated in alcoholic relapse. (Consumer Summary produced by Reliance Medical Information, Inc.)