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Purpose: Loving-kindness meditation has been used for centuries in the Buddhist tradition to develop love and transform anger into compassion. This pilot study tested an 8-week loving-kindness program for chronic low back pain patients. Method: Patients (N = 43) were randomly assigned to the intervention or standard care. Standardized measures assessed patients' pain, anger, and psychological distress. Findings: Post and follow-up analyses showed significant improvements in pain and psychological distress in the loving-kindness group, but no changes in the usual care group. Multilevel analyses of daily data showed that more loving-kindness practice on a given day was related to lower pain that day and lower anger the next day. Conclusions: Preliminary results suggest that the loving-kindness program can be beneficial in reducing pain, anger, and psychological distress in patients with persistent low back pain. Implications: Clinicians may find loving-kindness meditation helpful in the treatment of patients with persistent pain. [ABSTRACT FROM AUTHOR]

Objective: It is unclear whether PTSD treatments improve negative posttraumatic cognitions (NPCs) and if changes in NPCs mediate treatment outcomes in older veterans. The current study examined if prolonged exposure therapy (PE) and relaxation therapy (RT) reduce NPCs over time in older adult veterans with PTSD., Method: This study analyzed data from a randomized controlled trial of 86 older male veterans with PTSD randomized to PE or RT. The Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999), which includes a total score and three subscales, Negative Cognitions of the Self (Self), Negative Cognitions of the World (World), and Self-Blame (Blame), was used to assess NPCs at pretreatment, posttreatment, and 6-month follow-up., Results: Changes in NPCs differed by treatment condition. Veterans who received PE had significantly reduced overall NPCs and NPCs about the self at posttreatment, but these NPCs were no longer significantly different from baseline at the follow-up assessment. In contrast, NPCs about the world and self-blame did not significantly change following PE. NPCs did not change following RT. Effects of PE on decreased 6-month follow-up clinician-rated PTSD symptoms were conveyed through intervening effects of decreased posttreatment PTCI total scores, suggesting the utility of targeting posttraumatic cognitions as a mechanism of long-term PTSD symptom reduction., Conclusions: Given that reductions in overall negative cognitions are associated with lower clinician-administered PTSD scores 6 months after PE, clinicians could consider monitoring changes in these cognitions over the course of treatment. RT is not a recommended treatment approach to target NPCs in older adults with PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective/Background : The Insomnia Severity Index (ISI) is an insomnia self-report measure used to identify individuals at risk for insomnia disorder. Although the full ISI is only seven questions, a briefer version would allow more efficient and pragmatic administration in routine practice settings. Reliable and valid brief measures can support measurement-based care. The present study was a proof-of-concept study that developed a brief version of the ISI, the ISI-3, in a sample of older adult veterans with posttraumatic stress disorder (PTSD), a group which is at increased risk for insomnia. Patients/Methods : Participants included 86 older veterans with combat- or military-related PTSD. Veterans completed a clinician-administered PTSD diagnostic interview, self-report measures of insomnia and other psychosocial questionnaires, and two neuropsychological assessments. The factor structure of the ISI was examined to reduce the measure into a brief version. The reliability and validity of the ISI-3 were examined. Results : Principal axis factoring yielded a one-factor solution, which reproduced 59% of the item variance. Item reduction procedures resulted in three items, which best represented this factor ("Insomnia Impact;" ISI-3). For the ISI-3, internal consistency was good (α =.89). Convergent validity was demonstrated via moderate to high positive correlations between the ISI-3 and other measures of sleep disturbance. Divergent validity was demonstrated via non-significant correlations between the ISI-3 and unrelated measures and moderate correlations with self-reported depression. Conclusions : The ISI-3 is a psychometrically valid brief version of the ISI. Clinicians can administer the ISI-3 to screen for insomnia and monitor changes in insomnia during treatment.

Introduction: Veterans with post-traumatic stress disorder (PTSD) face significant barriers that make it less likely for them to pursue treatment. A randomized controlled non-inferiority trial was used to determine if providing psychotherapy for PTSD via videoconference (VC) is as effective as in-person (IP) psychotherapy., Methods: All eligible veterans ( n  = 207) received cognitive processing therapy (CPT) to treat PTSD symptoms in one of the two treatment modalities. Participant symptoms were collected at baseline, post-treatment, and six months after treatment completion. The primary outcome measure, the Clinician-Administered PTSD Scale (CAPS), was used to assess PTSD diagnosis and symptom severity. Secondary outcomes included two self-report measures of symptom severity, the Post-traumatic Stress Disorder Checklist - Specific (PCL-S) for PTSD and the Patient Health Questionnaire - 9 (PHQ-9) for depressive symptoms. A linear mixed-effects model was used to assess non-inferiority for participants who completed treatment (completers) and those who were randomized to treatment (intention-to-treat (ITT))., Results: Both completer and ITT analyses showed that improvement in CAPS scores in the VC condition was non-inferior to that in the IP condition at six-month follow-up, but VC was inferior to IP for improvement in CAPS at post-treatment. Non-inferiority was supported by completer analyses for PCL-S and PHQ-9 in both post-treatment change and six-month follow-up change, and the ITT analysis supported the significant non-inferiority for PCL at post-treatment change., Discussion: These findings generally suggest that CPT delivered via VC can be as effective as IP for reducing the severity of PTSD symptoms.

Posttraumatic stress disorder (PTSD) and depression are highly comorbid within the veteran population. Research studies have yielded divergent findings regarding the effect of depression on PTSD treatment outcomes. The present study investigated the influence of pretreatment depression severity on PTSD and depression symptom trajectories among 85 older (i.e., ≥ 60 years) male veterans with military-related PTSD who received either prolonged exposure or relaxation training as part of a randomized controlled trial. Participants were categorized as having no/mild depression (n = 23) or moderate/severe depression (n = 62). The PTSD Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) were completed at pretreatment, each of 12 therapy sessions, posttreatment, and 6-month follow-up, for a total of up to 15 data points per participant. Multilevel modeling (MLM) was used to evaluate the impact of pretreatment depression severity on piecewise symptom trajectories (i.e., active treatment and follow-up periods) over time and to determine whether treatment condition moderated the trajectories. The final MLM results showed significant main effects of depression severity on PCL-S scores, B = 10.84, p = .043 and PHQ-9 scores, B = 7.09, p = .001, over time. No significant interactions emerged for either the PCL-S or PHQ-9, indicating that although older veterans with more severe depression endorsed higher PTSD and depression scores across time, the symptom trajectories were not moderated by depression severity, treatment condition, or their interaction., (© 2020 International Society for Traumatic Stress Studies.)

Objective: This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP])., Method: A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout., Results: The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment., Conclusions: Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care., (Published 2019. This article is a U.S. Government work and is in the public domain in the USA.)

Introduction: Home-based delivery of psychotherapy may offer a viable alternative to traditional office-based treatment for post-traumatic stress disorder (PTSD) by overcoming several barriers to care. Little is known about patient perceptions of home-based mental health treatment modalities. This study assessed veterans' preferences for treatment delivery modalities and how demographic variables and trauma type impact these preferences., Materials and Methods: Veterans with PTSD (N = 180) participating in a randomized clinical trial completed a clinician-administered PTSD assessment and were asked to identify their modality preference for receiving prolonged exposure: home-based telehealth (HBT), office-based telehealth (OBT), or in-home-in-person (IHIP). Ultimately, modality assignment was randomized, and veterans were not guaranteed their preferred modality. Descriptive statistics were used to examine first choice preference. Chi-square tests determined whether there were significant differences among first choice preferences; additional tests examined if age, sex, and military sexual trauma (MST) history were associated with preferences., Results: The study includes 135 male veterans and 45 female veterans from all military branches; respondents were 46.30 years old, on average. Veterans were Caucasian (46%), African-American (28%), Asian-American (9%), American Indian or Alaskan Native (3%), Native Hawaiian or Pacific Islander (3%), and 11% identified as another race. Veterans experienced numerous trauma types (e.g., combat, sexual assault), and 29% had experienced MST. Overall, there was no clear preference for one modality: 42% of veterans preferred HBT, 32% preferred IHIP, and 26% preferred OBT. One-sample binomial tests assuming equal proportions were conducted to compare each pair of treatment options. HBT was significantly preferred over OBT (p = 0.01); there were no significant differences between the other pairs. A multinomial regression found that age group significantly predicted veterans' preferences for HBT compared to OBT (odds ratio [OR] = 10.02, 95% confidence interval [CI]: 1.63, 61.76). Older veterans were significantly more likely to request HBT compared to OBT. Veteran characteristics did not differentiate those who preferred IHIP to OBT. Because there were fewer women (n = 45), additional multinomial regressions were conducted on each sex separately. There was no age group effect among the male veterans. However, compared to female Veterans in the younger age group, older female Veterans were significantly more likely to request HBT over OBT (OR = 10.66, 95% CI: 1.68, 67.58, p = 0.012). MST history did not predict treatment preferences in any analysis., Conclusions: Fewer than 50% of the sample preferred one method, and each modality was preferred by at least a quarter of all participants, suggesting that one treatment modality does not fit all. Both home-based care options were desirable, highlighting the value of offering a range of options. The use of home-based care can expand access to care, particularly for rural veterans. The current study includes a diverse group of veterans and increases our understanding of how they would like to receive PTSD treatment. The study used a forced choice preference measure and did not examine the strength of preference, which limits conclusions. Future studies should examine the impact of modality preferences on treatment outcomes and engagement., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Objective: Although prolonged exposure (PE) has strong support for treating posttraumatic stress disorder (PTSD), there is little research on PE for older adults. Likewise, Relaxation Training (RT) has shown some benefit for PTSD, but has not been adequately tested in this population., Method: This study represents the first randomized controlled trial of two active psychotherapies for PTSD among older adults. Male combat veterans (N = 87; mean age = 65 years) were randomly assigned to 12 sessions of PE (n = 41) or RT (n = 46). Clinician-administered and self-report assessments were conducted at pre-treatment, post-treatment, and six-month follow-up; self-reported symptoms were also measured at each treatment session., Results: Multi-level modeling indicated that Clinician-Administered PTSD Scale scores significantly decreased from pre-treatment to follow-up, but the time by treatment condition interaction was not significant. Pre- to post-treatment change was large in PE and moderate in RT, but many gains were lost at follow-up. For self-reported PTSD symptoms, a significant time by treatment condition interaction emerged, suggesting that participants who received PE had both greater decreases in symptoms and a greater rebound in self-reported PTSD symptoms than those who received RT. Unlike PTSD symptoms, depression symptoms neither changed nor were moderated by treatment condition from pre-treatment to follow-up. For self-reported PTSD and depression symptoms assessed at each session, time significantly predicted symptom reductions across psychotherapy sessions., Conclusions: PE and RT are well-tolerated, feasible, and effective for older adults, though treatment gains were not maintained at follow-up., Trial Registration: clinicaltrials.gov Identifier: NCT00539279., (Published by Elsevier Ltd.)

Intimate partner violence (IPV) results in severe and chronic posttraumatic psychological symptoms, maladaptive trauma-related guilt (TRG) and functional impairment for many women. Cognitive Trauma Therapy (CTT) was developed to specifically address empirically identified contributors of distress and functioning difficulties specific to IPV and has been found to be efficacious in treating posttraumatic stress disorder (PTSD) and reducing TRG. The primary aim of this study was to investigate to what extent reductions in TRG contribute to improvements in PTSD and functioning, given evidence of the important role that TRG plays in posttraumatic distress in IPV survivors and the emphasis placed on TRG in CTT. Twenty women with IPV-related chronic and functionally impairing posttraumatic distress were recruited from the community and completed CTT as part of a larger neurobiological study of PTSD. Women experienced statistically and clinically significant improvements in functioning as well as expected reductions in PTSD and TRG with large effect sizes at post-treatment, and improvements were maintained at 3-month follow-up, with no participant meeting full PTSD criteria. Pre- to mid-treatment reductions in TRG predicted post-treatment PTSD and functioning outcomes. These findings support the efficacy of CTT and provide preliminary evidence for the importance of addressing TRG. Dismantling research is indicated to identify the active ingredient(s) of this multi-module treatment.

Objective: Previous studies suggest that group "mantram" (sacred word) repetition therapy, a non-trauma-focused complementary therapy for posttraumatic stress disorder (PTSD), may be an effective treatment for veterans. The authors compared individually delivered mantram repetition therapy and another non-trauma-focused treatment for PTSD., Method: The study was a two-site, open-allocation, blinded-assessment randomized trial involving 173 veterans diagnosed with military-related PTSD from two Veterans Affairs outpatient clinics (January 2012 to March 2014). The mantram group (N=89) learned skills for silent mantram repetition, slowing thoughts, and one-pointed attention. The comparison group (N=84) received present-centered therapy, focusing on currently stressful events and problem-solving skills. Both treatments were delivered individually in eight weekly 1-hour sessions. The primary outcome measure was change in PTSD symptom severity, as measured by the Clinician-Administered PTSD Scale (CAPS) and by self-report. Secondary outcome measures included insomnia, depression, anger, spiritual well-being, mindfulness, and quality of life. Intent-to-treat analysis was conducted using linear mixed models., Results: The mantram group had significantly greater improvements in CAPS score than the present-centered therapy group, both at the posttreatment assessment (between-group difference across time, -9.98, 95% CI=-3.63, -16.00; d=0.49) and at the 2-month follow-up (between-group difference, -9.34, 95% CI=-1.50, -17.18; d=0.46). Self-reported PTSD symptom severity was also lower in the mantram group compared with the present-centered therapy group at the posttreatment assessment, but there was no difference at the 2-month follow-up. Significantly more participants in the mantram group (59%) than in the present-centered therapy group (40%) who completed the 2-month follow-up no longer met criteria for PTSD (p<0.04). However, the percentage of participants in the mantram group (75%) compared with participants in the present-centered therapy group (61%) who experienced clinically meaningful changes (≥10-point improvements) in CAPS score did not differ significantly between groups. Reductions in insomnia were significantly greater for participants in the mantram group at both posttreatment assessment and 2-month follow-up., Conclusions: In a sample of veterans with PTSD, individually delivered mantram repetition therapy was generally more effective than present-centered therapy for reducing PTSD symptom severity and insomnia.

Although lifetime exposure to potentially traumatic events among older adults is fairly high, rates of full-blown post-traumatic stress disorder (PTSD) are estimated at about 4.5%, a rate lower than that for middle-aged and young adults. Nevertheless, PTSD seems to be an under-recognized and under-treated condition in older adults. Assessment and treatment can be challenging in this population for various reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. This article provides highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health. The bulk of this piece is spent on reviewing the theory, description of, and efficacy for an evidence-based psychotherapy, Prolonged Exposure (PE), for PTSD. A detailed successful application of PE with an older veteran with severe, chronic PTSD in the Department of Veterans Affairs Health Care System is presented. Evidence-based psychotherapy for PTSD can be safely and effectively used with older individuals., (Published by Elsevier Inc.)

Posttraumatic stress disorder (PTSD) has been linked to deficits in response inhibition, and neuroimaging research suggests this may be due to differences in prefrontal cortex recruitment. The current study examined relationships between PTSD from intimate partner violence (IPV) and neural responses during inhibition. There were 10 women with PTSD from IPV and 12 female control subjects without trauma history who completed the stop signal task during functional magnetic resonance imaging. Linear mixed models were used to investigate group differences in activation (stop-nonstop and hard-easy trials). Those with PTSD exhibited greater differential activation to stop-nonstop trials in the right dorsolateral prefrontal cortex and the anterior insula and less differential activation in several default mode regions (d = 1.12-1.22). Subjects with PTSD exhibited less differential activation to hard-easy trials in the lateral frontal and the anterior insula regions (driven by less activation to hard trials) and several default mode regions (i.e., medial prefrontal cortex, posterior cingulate; driven by greater activation to easy trials; d = 1.23-1.76). PTSD was associated with difficulties disengaging default mode regions during cognitive tasks with relatively low cognitive demand, as well as difficulties modulating executive control and salience processing regions with increasing cognitive demand. Together, these results suggest that PTSD may relate to decreased neural flexibility during inhibition., (Copyright © 2016 International Society for Traumatic Stress Studies.)

Objective: Post-traumatic stress disorder (PTSD) has major public health significance. Evidence that PTSD may be associated with premature senescence (early or accelerated aging) would have major implications for quality of life and healthcare policy. We conducted a comprehensive review of published empirical studies relevant to early aging in PTSD., Method: Our search included the PubMed, PsycINFO, and PILOTS databases for empirical reports published since the year 2000 relevant to early senescence and PTSD, including: 1) biomarkers of senescence (leukocyte telomere length [LTL] and pro-inflammatory markers), 2) prevalence of senescence-associated medical conditions, and 3) mortality rates., Results: All six studies examining LTL indicated reduced LTL in PTSD (pooled Cohen's d = 0.76). We also found consistent evidence of increased pro-inflammatory markers in PTSD (mean Cohen's ds), including C-reactive protein = 0.18, Interleukin-1 beta = 0.44, Interleukin-6 = 0.78, and tumor necrosis factor alpha = 0.81. The majority of reviewed studies also indicated increased medical comorbidity among several targeted conditions known to be associated with normal aging, including cardiovascular disease, type 2 diabetes mellitus, gastrointestinal ulcer disease, and dementia. We also found seven of 10 studies indicated PTSD to be associated with earlier mortality (average hazard ratio: 1.29)., Conclusion: In short, evidence from multiple lines of investigation suggests that PTSD may be associated with a phenotype of accelerated senescence. Further research is critical to understand the nature of this association. There may be a need to re-conceptualize PTSD beyond the boundaries of mental illness, and instead as a full systemic disorder., (Published by Elsevier Inc.)

A pilot program that delivers telemental health care for posttraumatic stress disorder provides best practices for facilities looking to expand in-home and remote care to veterans., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Clinical video teleconferencing (CVT) is a treatment delivery modality that can be used to provide services to clinical populations that experience barriers to accessing mental health care. Recently, home-based CVT (HBCVT) has been developed in order to deliver treatment via CVT to patients in their homes. A number of clinical considerations, including the appropriate clinical population and individual patient factors, need to be taken into account when delivering CVT. Particular challenges can exist when setting up the home environment for HBCVT. Concerns about maintaining patient privacy while living in shared spaces, ensuring adequate CVT technology in the patient's home, and conducting risk management remotely are important to consider when delivering treatment via CVT. Since treatments delivered via CVT are often conducted across state lines, novel ethical and legal issues such as privacy laws, licensing of providers, prescribing practices, and insurance reimbursements need to be addressed when conducting services via these modalities. Future research on HBCVT will provide researchers and clinicians with information regarding which patients are most appropriate for treatment delivered via this modality and help further develop evidence for the cost-effectiveness of CVT and HBCVT clinical practice guidelines.

Mobile health (mHealth) refers to the use of mobile technology (e.g., smartphones) and software (i.e., applications) to facilitate or enhance health care. Several mHealth programs act as either stand-alone aids for Veterans with post-traumatic stress disorder (PTSD) or adjuncts to conventional psychotherapy approaches. Veterans enrolled in a Veterans Affairs outpatient treatment program for PTSD (N = 188) completed anonymous questionnaires that assessed Veterans' access to mHealth-capable devices and their utilization of and interest in mHealth programs for PTSD. The majority of respondents (n = 142, 76%) reported having access to a cell phone or tablet capable of running applications, but only a small group (n = 18) reported use of existing mHealth programs for PTSD. Age significantly predicted ownership of mHealth devices, but not utilization or interest in mHealth applications among device owners. Around 56% to 76% of respondents with access indicated that they were interested in trying mHealth programs for such issues as anger management, sleep hygiene, and management of anxiety symptoms. Findings from this sample suggest that Veterans have adequate access to, and interest in, using mHealth applications to warrant continued development and evaluation of mobile applications for the treatment of PTSD and other mental health conditions., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

The purpose of this review was to compare and contrast Prolonged Exposure (PE) and Narrative Exposure Therapy (NET). We examined the treatment manuals to describe the theoretical foundation, treatment components, and procedures, including the type, manner, and focus of exposure techniques and recording methods used. We examined extant clinical trials to investigate the range of treatment formats reported, populations studied, and clinical outcome data. Our search resulted in 32 studies on PE and 15 studies on NET. Consistent with prior reviews of PTSD treatment, it is evident that PE has a solid evidence base and its current status as a first line treatment for the populations studied to this date is warranted. We argue that NET may have advantages in treating complex traumatization seen in asylum seekers and refugees, and for this population NET should be considered a recommended treatment. NET and PE have several commonalities, and it is recommended that studies of these treatments include a broader range of populations and trauma types to expand the current knowledge on the treatment of PTSD., (Published by Elsevier Ltd.)

Therapy for combat and accident-related posttraumatic stress disorder (PTSD) has been reported to influence amygdala and anterior cingulate cortex (ACC) response during emotional processing. It is not yet understood how therapy influences different phases of emotional processing, and whether previous findings generalize to other PTSD populations. We hypothesized that cognitive trauma therapy for battered women (CTT-BW) would alter insula, amygdala, and cingulate responses during anticipation and presentation of emotional images. Fourteen female patients with PTSD related to domestic violence completed the Clinician Administered PTSD Scale (CAPS) and functional magnetic resonance imaging (fMRI) before and after CTT-BW. The fMRI task involved cued anticipation followed by presentation of positive versus negative affective images. CTT-BW was associated with decreases in CAPS score, enhanced ACC and decreased anterior insula activation during anticipation, and decreased dorsolateral prefrontal cortex and amygdala response during image presentation (negative-positive). Pre-treatment ACC activation during anticipation and image presentation exhibited positive and negative relationships to treatment response, respectively. Results suggest that CTT-BW enhanced efficiency of neural responses during preparation for upcoming emotional events in a way that reduced the need to recruit prefrontal-amygdala responses during the occurrence of the event. Results also suggest that enhancing ACC function during anticipation may be beneficial for PTSD treatment., (© 2013 Elsevier Ireland Ltd. All rights reserved.)

A meta-analysis was conducted to summarize and integrate the literature on the cognitive functioning of older adults with posttraumatic stress disorder (PTSD). We hypothesized that those with PTSD would exhibit worse performance in each of the cognitive domains studied when compared to older adults without PTSD. Major databases were queried and eleven articles met criteria for review. As predicted, there was evidence of worse performance across cognitive measures in older adult samples with PTSD relative to older samples without PTSD. The strongest effect across samples was found for lower test scores in the broad domain of memory among older adults with PTSD, and there was evidence that trauma exposure is uniquely associated with worse performance on tests specific to learning. We outline factors thought to contribute to the interactions among PTSD, cognitive deficits, and the aging process. These findings highlight the need for thorough evaluation of cognitive functioning in older adults with PTSD, particularly in the areas of processing speed, learning, memory, and executive functioning., (Published by Elsevier Ltd.)

Background: Some data suggest that older adults with anxiety disorders do not respond as well to treatment as do younger adults., Aims: We examined age differences in outcomes from the Coordinated Anxiety Learning and Management (CALM) study, an effectiveness trial comparing usual care to a computer-assisted collaborative care intervention for primary care patients with panic disorder, generalised anxiety disorder, post-traumatic stress disorder (PTSD), and/or social anxiety disorder. This is the first study to examine the efficacy of a collaborative care intervention in a sample that included both younger and older adults with anxiety disorders. We hypothesised that older adults would show a poorer response to the intervention than younger adults., Method: We examined findings for the overall sample, as well as within each diagnostic category (clinicaltrials.gov identifier: NCT00347269)., Results: The CALM intervention was more effective than usual care among younger adults overall and for those with generalised anxiety disorder, panic disorder and social anxiety disorder. Among older adults, the intervention was effective overall and for those with social anxiety disorder and PTSD but not for those with panic disorder or generalised anxiety disorder. The effects of the intervention also appeared to erode by the 18-month follow-up, and there were no significant effects on remission among the older adults., Conclusions: These results are consistent with the findings of other investigators suggesting that medications and psychotherapy for anxiety disorders may not be as effective for older individuals as they are for younger people.

Many women have unidentified anxiety or trauma histories that can impact their health and medical treatment-seeking behavior. This study examined the sensitivity, specificity, efficiency, and sensitivity to change of the Overall Anxiety Severity and Impairment Scale (OASIS) for identifying an anxiety disorder in a female sample with and without trauma history related to intimate partner violence (IPV). Forty-three women with full or partial PTSD from IPV and 41 women without PTSD completed the OASIS. All participants with trauma history completed the Clinician Administered PTSD Scale. This report is a secondary analysis of a study on the neurobiology of psychological trauma in survivors of IPV recruited from the community. A cut-score of 5 best discriminated those with PTSD from those without, successfully classifying 91% of the sample with 93% sensitivity and 90% specificity. The measure showed strong sensitivity to change in a subsample of 20 participants who completed PTSD treatment and strong convergent and divergent validity in the full sample. This study suggests that the OASIS can identify the presence of an anxiety disorder among a female sample of IPV survivors when PTSD is present.

Background: A portable practice of repeating a mantram-a sacred word or phrase-has been shown to reduce the severity of posttraumatic stress disorder (PTSD) symptoms in veterans with military trauma. It is thought that the intervention re-directs attention and initiates relaxation to decrease symptom severity, but there may be other mechanisms that may contribute to this improvement., Purpose: We tested the hypothesis that increases in existential spiritual wellbeing (ESWB) would mediate reductions in self-reported PTSD symptoms following a group mantram intervention., Method: Veterans diagnosed with PTSD from war-related trauma completed 6 weeks of case management plus a group mantram intervention (n = 66) as part of a randomized trial. Measures included PTSD Checklist (PCL) and Functional Assessment of Chronic Illness Therapy-Spiritual Wellbeing. Path analysis was conducted on those who completed treatment to assess ESWB as a possible mediator of change in PCL from baseline to post-treatment., Results: A significant indirect effect, -2.24, 95% CI (-4.17, -1.05) of the mantram intervention on PCL change was found. The path from the mantram intervention to ESWB change was significant and positive (B = 4.89, p < 0.0001), and the path from ESWB change to PCL change was significant and negative (B = -0.46, p = 0.001), thus supporting the hypothesis., Conclusions: Findings suggest that one contributing mechanism that partially explains how the mantram intervention reduces PTSD symptom severity in veterans may be by increasing levels of ESWB.

Background: Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late-life anxiety disorders., Methods: This paper reviews the unique features of anxiety in later life and synthesizes the work of the Advisory Committee., Results: Suggestions are offered for refining our understanding of the effects of aging on anxiety and other disorders (e.g., mood disorders) and changes to the DSM5 criteria and text that could facilitate more accurate recognition and diagnosis of anxiety disorders in older adults. Several of the recommendations are not limited to the study of anxiety but rather are applicable across the broader field of geriatric mental health., Conclusions: DSM5 should provide guidelines for the thorough assessment of avoidance, excessiveness, and comorbid conditions (e.g., depression, medical illness, cognitive impairment) in anxious older adults., (Copyright © 2011 John Wiley & Sons, Ltd.)

Individuals with mental health problems may face barriers to accessing effective psychotherapies. Videoconferencing technology, which allows audio and video information to be shared concurrently across geographical distances, offers an alternative that may improve access. We conducted a systematic literature review of the use of videoconferencing psychotherapy (VCP), designed to address 10 specific questions, including therapeutic types/formats that have been implemented, the populations with which VCP is being used, the number and types of publications related to VCP, and available satisfaction, feasibility, and outcome data related to VCP. After electronic searches and reviews of reference lists, 821 potential articles were identified, and 65 were selected for inclusion. The results indicate that VCP is feasible, has been used in a variety of therapeutic formats and with diverse populations, is generally associated with good user satisfaction, and is found to have similar clinical outcomes to traditional face-to-face psychotherapy. Although the number of articles being published on VCP has increased in recent years, there remains a need for additional large-scale clinical trials to further assess the efficacy and effectiveness of VCP.

This article summarizes two ongoing randomized controlled trials that compare individual in-person psychotherapy with psychotherapy provided using video teleconferencing for military veterans with posttraumatic stress disorder. We describe training methods, populations, technology, challenges, successes, and lessons learned so far during the trials.

Objectives: : The purpose of this pilot study was to assess the feasibility and preliminary efficacy of prolonged exposure psychotherapy in older Veterans with posttraumatic stress disorder (PTSD). Exposure therapy has broad empirical support for PTSD, but it has not been studied systematically in older adults, partly due to published concerns that older adults would not tolerate the treatment., Methods: : The trial followed a prospective pre-post design of 11 men recruited from a Veterans Affairs (VA) PTSD Clinical Team program. After baseline assessment, eight participants completed prolonged exposure therapy. Results were compared with a nonrandomized treatment-as-usual comparison group. The traumatic events identified by the Veterans in our samples had occurred, on average, 40 years prior to their study participation., Results: : Results revealed that conducting 6 weeks of exposure therapy with older Veterans with PTSD was feasible and efficacious, with evidence of some superiority to treatment-as-usual therapy., Conclusions: : As hypothesized, Veterans showed a significant decrease in symptoms of PTSD (clinician-rated and self-reported) following exposure therapy.

Objective: : The objective of this study was to examine the influence of military veteran status within a data set of older patients with schizophrenia or schizoaffective disorder., Methods: : The data set was examined to determine whether veteran status influenced psychopathology, quality of life, cognitive performance, and everyday functioning among 746 male participants., Results: : There were no significant differences between the groups on measures of premorbid functioning or psychopathology. Veterans in the sample were older, had a higher likelihood of being married (or previously married), had a lower likelihood of living in a board-and-care facility, and had a later age of onset of schizophrenia compared with nonveterans. Though veterans reported worse physical health, they also had better everyday functioning and better performance on some cognitive tasks than nonveterans. Fewer veterans endorsed current use of substances than nonveterans., Conclusions: : There were several differences based on veteran status, including everyday functioning, health-related quality of life, cognitive performance, and current substance use.

Traumatic events are common, but the psychological distress that may follow usually subsides naturally. For some individuals, distress develops into posttraumatic stress disorder (PTSD). PTSD lends itself to the application of prevention strategies for at-risk individuals. The identification of a causal event may make prevention efforts for PTSD more feasible and effective than for other psychological disorders. For PTSD, these efforts target those traumatized persons who are beginning to exhibit symptoms of PTSD. These interventions could also target individuals meeting criteria for acute stress disorder with the goal of preventing chronic PTSD., (Published by Elsevier Inc.)

Some evidence suggests that acceptance-based approaches such as Acceptance and Commitment Therapy (ACT) may be well-suited to geriatric generalized anxiety disorder (GAD). The primary goal of this project was to determine whether ACT was feasible for this population. Seven older primary-care patients with GAD received 12 individual sessions of ACT; another 9 were treated with cognitive-behavioral therapy. No patients dropped out of ACT, and worry and depression improved. Findings suggest that ACT may warrant a large-scale investigation with anxious older adults., (Copyright © 2010. Published by Elsevier Ltd.)

Background: Intimate-partner violence (IPV) is one of the most common causes of posttraumatic stress disorder (PTSD) among women. PTSD neuroimaging studies have identified functional differences in the amygdala and anterior cingulate cortex (ACC)/medial prefrontal cortex during emotion processing. Recent investigations of the limbic sensory system and its associated neural substrate, the insular cortex, have demonstrated its importance for emotional awareness. This study examined the hypothesis that women with IPV-PTSD show a dysregulation of this limbic sensory system while processing threat-related emotional faces., Methods: 12 women with IPV-PTSD and 12 nontraumatized comparison women underwent blood oxygenation level-dependent functional magnetic resonance imaging while completing an emotional face-matching task., Results: IPV-PTSD subjects relative to comparison subjects displayed increased activation of the anterior insula and amygdala and decreased connectivity among the anterior insula, amygdala, and ACC while matching to fearful versus happy target faces. A similar pattern of activation differences was also observed for angry versus happy target faces. IPV-PTSD subjects relative to comparison subjects also displayed increased dorsal ACC/medial prefrontal cortex activation and decreased ventral ACC activation when matching to a male versus a female target, and the extent of increased dorsal ACC activation correlated positively with hyperarousal symptoms., Conclusions: Women with IPV-PTSD display hyperactivity and disconnection among affective and limbic sensory systems while processing threat-related emotion. Furthermore, hyperactivity of cognitive-appraisal networks in IPV-PTSD may promote hypervigilant states of awareness through an exaggerated sensitivity to contextual cues, i.e., male gender, which relate to past trauma., (Copyright 2010 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Imagery Rehearsal Therapy (IRT) has been shown to be efficacious in reducing nightmares, but the treatment has not been well-studied in veterans. The effectiveness of IRT was assessed from a chart review of veterans seeking outpatient treatment for chronic, trauma-related nightmares. Of those offered IRT, veterans who completed a full course of treatment for PTSD in the past year were more likely to initiate treatment. However, completion of IRT was not related to previous treatment, demographic variables, or nightmare severity reported at the first treatment session. Treatment completers reported significant reductions in nightmare frequency and intensity, severity of insomnia, and subjective daytime PTSD symptoms. Insomnia and PTSD symptoms, on average, were below clinical cutoffs following treatment, and 23% of patients showed a complete treatment response (< or =1 nightmare/week). Findings suggest IRT may be an effective short-term treatment for nighttime and daytime PTSD symptoms among veterans who complete a full course of treatment., (2009. Published by Elsevier Ltd.)

Posttraumatic stress disorder (PTSD) has been associated with neuropsychological impairments across multiple domains, but consensus regarding the cognitive profile of PTSD has not been reached. In this study of women with PTSD related to intimate partner violence (n = 55) and healthy, demographically similar comparison participants (NCs; n = 20), we attempted to control for many potential confounds in PTSD samples. All participants were assessed with a comprehensive neuropsychological battery emphasizing executive functioning, including inhibition, switching, and abstraction. NCs outperformed PTSD participants on most neuropsychological measures, but the differences were significant only on speeded tasks (with and without executive functioning components). The PTSD group's mean performance was within the average range on all neuropsychological tests. Within the PTSD group, more severe PTSD symptoms were associated with slower processing speed, and more severe dissociative symptoms were associated with poorer reasoning performance. These results suggest that women with PTSD related to intimate partner violence demonstrate slower than normal processing speed, which is associated with the severity of psychiatric symptoms. We speculate that the cognitive slowing seen in PTSD may be attributable to reduced attention due to a need to allocate resources to cope with psychological distress or unpleasant internal experiences.

Objective: To develop and test a modular psychotherapy protocol in older primary care patients with anxiety disorders., Design: Randomized, controlled pilot study., Setting: University-based geriatric medicine clinics., Participants: Thirty-one elderly primary care patients with generalized anxiety disorder or anxiety disorder not otherwise specified., Intervention: Modular form of psychotherapy compared with enhanced community treatment., Measurements: Self-reported, interviewer-rated, and qualitative assessments of anxiety, worry, depression, and mental health-related quality of life., Results: Both groups showed substantial improvements in anxiety symptoms, worry, depressive symptoms, and mental health-related quality of life. Most individuals in the enhanced community treatment condition reported receiving medications or some other form of professional treatment for anxiety. Across both conditions, individuals who reported major life events or stressors and those who used involvement in activities as a coping strategy made smaller gains than those who did not., Conclusions: Results suggest that modular psychotherapy and other treatments can be effective for anxiety in older primary care patients. Results further suggest that life events and coping through increased activity may play a role in the maintenance of anxiety in older adults.

Objective: To evaluate the efficacy of different types of behavioral treatments for geriatric anxiety (cognitive behavior therapy [CBT] alone, CBT with relaxation training [RT], and RT alone)., Method: The authors compared effect sizes from 19 trials. Analyses were based on uncontrolled outcomes (comparing posttreatment and pretreatment scores) and effects relative to control conditions on both anxiety and depressive symptoms., Results: Treatments for older adults with anxiety symptoms were, on average, more effective than active control conditions. Effect sizes were comparable to those reported elsewhere for CBT for anxiety in the general population or for pharmacotherapy in anxious older adults. CBT (alone or augmented with RT) does not seem to add anything beyond RT alone, although a direct comparison is challenging given differences in control conditions. Effects on depressive symptoms were smaller, with no differences among treatment types., Conclusion: Results suggest that behavioral treatments are effective for older adults with anxiety disorders and symptoms. Results must be interpreted with caution given the limitations of the literature, including differing sample characteristics and control conditions across studies.

Background: Intimate partner violence (IPV) is one of the most common causes of posttraumatic stress disorder (PTSD) in women. Victims of IPV are often preoccupied by the anticipation of impending harm. This investigation tested the hypothesis that IPV-related PTSD individuals show exaggerated insula reactivity to the anticipation of aversive stimuli., Methods: Fifteen women with a history of IPV and consequent PTSD (IPV-PTSD) and 15 non-traumatized control (NTC) women performed a task involving cued anticipation to images of positive and negative events during functional magnetic resonance imaging., Results: Both groups showed increased activation of bilateral anterior insula during anticipation of negative images minus anticipation of positive images. Activation in right anterior/middle insula was significantly greater in the IPV-PTSD relative to the NTC group. Functional connectivity analysis revealed that changes in activation in right middle insula and bilateral anterior insula were more strongly associated with amygdala activation changes in NTC than in IPV-PTSD subjects., Conclusions: This study revealed increased activation in the anterior/middle insula during negative anticipation in women with IPV-related PTSD. These findings in women with IPV could be a consequence of the IPV exposure, reflect pre-existing differences in insular function, or be due to the development of PTSD. Thus, future longitudinal studies need to examine these possibilities.

The contribution of personality traits and social support to mental health is well established, but to our knowledge there have been no longitudinal investigations of the relation between personality and social support in depressed older adults. In the current study, we examined a repeated measures multi-level mixed model of change in perceived social support to determine whether personality traits and depressive symptoms were associated with changes in perceived social support over the 3 year study interval in a sample of depressed older adults. Results suggest that Conscientiousness and Extraversion were personality traits that were significantly predictive of changes in perceived social support over this time interval. Based on these results it appears that, among depressed older adults, those with conscientious or extraverted personality traits are more likely to resist impulses to withdraw from relationships. In addition, these traits may lead to more satisfying interactions and greater perceived social support over time. The implications of these results are discussed.

Background: Anxiety disorders are among the most common forms of psychiatric disorder, yet few investigations have examined the prevalence or service use of clients with anxiety disorders in the public mental health sector., Methods: We examined demographics, clinical information, and service use in clients with anxiety disorders enrolled in San Diego County Adult and Older Adult Mental Health Services in fiscal 2002-2003., Results: Almost 15% of the sample had a diagnosis of an anxiety disorder based on administrative billing data. Most anxiety disorder clients had additional psychiatric diagnoses, most commonly depression. Clients with both anxiety disorders and depression were more likely than those with anxiety or depression alone to use emergency psychiatric services and outpatient services than those with depression alone. Those with anxiety disorders alone used more outpatient services than those with depression alone., Limitation: Data were taken from an administrative database., Conclusions: Data indicate that anxiety disorders are not uncommon in public mental health settings and are associated with higher utilization of outpatient mental health services.

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults., (((c) 2007 APA, all rights reserved).)

Background and Significance: The treatment of personality disorders in older adults, particularly those co-morbid with other Axis I disorders (e.g., Major Depressive Disorder), is an understudied clinical phenomenon. It has also been demonstrated that personality disorders in older adults complicate treatment of other psychopathology, as well as result in heightened interpersonal disturbance and emotional distress., Methods: Two studies utilizing standard Dialectical Behavior Therapy (DBT) to treat depression and personality disorders in older adults are reviewed. Study 1 examined 34 chronically depressed individuals aged 60 and older who were randomly assigned to receive 28 weeks of antidepressant medication plus clinical management, either alone (MED) or with the addition of DBT skills-training and scheduled telephone coaching sessions (MED + DBT). Study 2 had two phases of treatment: Phase I: 8-week open-trial of antidepressant medication (n = 65); Phase II: 24-week randomized trial of DBT + MED versus MED alone for those who prospectively failed to respond to the Phase I medication trial (n = 37)., Results: Study 1 demonstrated that 71% of MED + DBT patients were in remission at post-treatment, in contrast to 47% of MED patients. This became a significant difference at the 6-month follow-up; where 75% of MED + DBT-D patients were in remission compared with only 31% of MED patients. Study 2 showed that after 8 weeks of treatment with antidepressant medication alone (Phase 1) only 14% of the sample had at least a 50% reduction in HAM-D scores. Phase II results showed on average, the DBT + MED group reached depression remission by the post-group assessment and maintained these gains while the MED group did not reach remission, until the follow-up assessment. Results demonstrated superiority of DBT + MED compared to MED alone on Interpersonal Sensitivity and Interpersonal Aggression at post-treatment and 6-month follow-up., Conclusion: Results from these two treatment development studies indicate that applying standard DBT for the treatment of co-morbid MDD or MDD + PD in older adults is feasible, acceptable, and has clinical promise. Modifications to standard DBT and an overview of a new treatment manual for this population are summarized.

The authors review the literature on psychological treatment for anxiety in older adults, focusing on randomized, controlled trials. Evidence exists for the efficacy of relaxation training for subjective anxiety symptoms and cognitive-behavioral therapy for generalized anxiety disorder and miscellaneous anxiety syndromes, including panic disorder. The authors also present the rationale for the CALM Study (Controlling Anxiety in Later-life Medical Patients), an ongoing randomized trial in which a modular psychotherapeutic intervention for anxiety in older primary care patients is compared with treatment as usual. Data are presented from 2 pilot patients in the CALM Study, and preliminary lessons are discussed.

Unlabelled: Clinical observations suggest that many patients with chronic pain have difficulty forgiving persons they perceive as having unjustly offended them in some way. By using a sample of 61 patients with chronic low back pain, this study sought to determine the reliability and variability of forgiveness assessments in patients and to examine the relationship of forgiveness to pain, anger, and psychological distress. Standardized measures were used to assess patients' current levels of forgiveness, forgiveness self-efficacy, pain, anger, and psychological distress. Results showed that forgiveness-related constructs can be reliably assessed in patients with persistent pain, and that patients vary considerably along dimensions of forgiveness. Furthermore, correlational analyses showed that patients who had higher scores on forgiveness-related variables reported lower levels of pain, anger, and psychological distress. Additional analyses indicated that state anger largely mediated the association between forgiveness and psychological distress, as well as some of the associations between forgiveness and pain. These findings indicate that forgiveness can be reliably assessed in patients with persistent pain, and that a relationship appears to exist between forgiveness and important aspects of living with persistent pain., Perspective: This preliminary study suggests there is a relationship between forgiveness and pain, anger, and psychological distress in patients with chronic low back pain. Patients who report an inability to forgive others might be experiencing higher pain and psychological distress that are mediated by relatively higher levels of state anger.

This study examined severity of depression, age of onset, and thought suppression as predictors of treatment outcome. Measures were taken pre-treatment, post-treatment, and at six-month follow-up in 34 depressed older adults receiving the treatment protocol described in Lynch, Morse, Mendelson & Robins (Dialectical behavior therapy for depressed older adults, American Journal of Geriatric Psychiatry, 11, 33-45, 2003). Severity and chronicity of depression and higher levels of thought suppression were associated with higher depressive symptoms six months after treatment. Findings are consistent with research suggesting that severity and chronicity of depression predict poor clinical outcome. In addition, these results provide preliminary evidence that the tendency to cope with unwanted thoughts by deliberate attempts to not experience such thoughts may be an important pre-treatment predictor of outcome among depressed older adults. Larger studies are needed to explore whether thought suppression mediates long-term recovery from depression.

Objective: To examine the impact of late-life generalized anxiety disorder (GAD) on health-related quality of life., Method: We compared quality of life in 75 treatment-seeking older adults with GAD, 39 of whom had psychiatric comorbidity, with 32 older adults without psychiatric illness. We examined predictors of quality of life in these samples. We also compared data from the GAD patients to published norms from a large national sample of older adults with chronic medical conditions or major depression., Results: Older GAD patients reported worse health-related quality of life across most domains than asymptomatic older individuals. There were no differences in quality of life between GAD patients with and without psychiatric comorbidity, and comorbidity did not predict quality of life in multivariate regression analyses. Presence of GAD or symptoms of anxiety or depression were significantly related to impairment in every domain of quality of life. Comparisons with national norms suggest that older GAD patients report overall worse quality of life than individuals with recent acute myocardial infarction or type II diabetes, and are comparable in quality of life to individuals with major depression., Conclusion: Results suggest that late-life GAD is associated with substantial impairment in quality of life, and these findings cannot be explained by psychiatric comorbidity.

Objective: This study examined whether anxiety symptoms make an independent contribution to poorer quality of life among middle-aged and older outpatients with schizophrenia or schizoaffective disorder., Method: We evaluated data from an ongoing study of 163 older patients with DSM-III-R or DSM-IV schizophrenia or schizoaffective disorder who were enrolled in research at the University of California, San Diego, Advanced Center for Interventions and Services Research from October 1992 to April 1998. Measures used were the anxiety, somatization, obsessive-compulsive, and phobic anxiety subscales of the Brief Symptom Inventory. We performed hierarchical multiple regressions with forced entry of variables to determine whether anxiety symptoms significantly predicted poorer health-related quality of life (measured by 2 scales) after controlling for demographic variables, akathisia, cognitive impairment, depressive symptoms, and overall psychopathology., Results: Anxiety symptoms were associated with poorer outcomes on overall quality of well-being and subscales representing vitality, social functioning, and role functioning limitations due to physical problems. In most cases, the proportion of variance in quality of life accounted for by anxiety symptoms was greater than that accounted for by depressive symptoms., Conclusions: Results suggest that anxiety symptoms have a significant negative impact on the quality of life of middle-aged and older patients with schizophrenia and schizoaffective disorder.