Massed written exposure therapy delivered to veterans with posttraumatic stress symptoms on an acute inpatient mental health unit.

Written exposure therapy (WET) is a brief, manualized trauma-focused treatment typically delivered in five individual weekly sessions. Given the brevity and effectiveness of WET, researchers have begun to focus on its delivery in a massed format. However, only one case study examining massed delivery has been published to date. As such, the objective of the current study was to examine the acceptability, feasibility, and preliminary effectiveness of massed WET among veterans with a trauma- and stressor-related disorder receiving care on an acute inpatient mental health unit. Veterans (N = 26) were assessed prior to, immediately after, and 1 month following massed WET. Most veterans found massed WET to be useful and acceptable. Recruitment and retention rates suggested that the treatment was feasible. Notably, the results revealed statistically significant reductions in overall posttraumatic stress symptoms, ηp 2 = .81, p < .001; depressive symptoms, ηp 2 = .71, p < .001; and functional impairment, ηp 2 = .42, p = .002. These findings add to a growing body of literature highlighting the preliminary effectiveness of WET across various settings, populations, and delivery formats. Limitations include the small sample size and uncontrolled design.

Obsessive-compulsive symptoms, perceived burdensomeness, and thwarted belongingness: Associations and implications among US veterans.

OBJECTIVE: Obsessive-compulsive disorder (OCD) is among the most debilitating psychiatric disorders worldwide, but has gone relatively unnoticed within the US veteran population. Simultaneously, suicide rates continue to remain high within this population despite the high volume of veterans who receive psychiatric care. With recent research demonstrating OCD's unique relationship with suicidality, it is imperative to explore this association and factors that may explain this association within veterans. METHODS: The present study investigated OCD symptoms and their relationship with two known risk factors of suicide, perceived burdensomeness (PB) and thwarted belongingness (TB), in two samples of veterans. RESULTS: In the first study (N = 100), OCD symptoms were found to be uniquely related to both PB and TB even after covarying for demographics, trauma exposure, and probable depression. In the second study (N = 99), these relationships were replicated longitudinally. OCD symptoms at baseline were found to be indirectly related to suicidal ideation severity at a 1-month follow-up via PB and TB at post-treatment. CONCLUSION: This study highlights the importance of assessing and addressing OCD symptoms within veterans due to the unique relationship these symptoms have with suicidal constructs. A deeper understanding of the impact of OCD within the veteran population will inform future prevention and intervention efforts.

Acceptability, feasibility, and utility of a safety aid reduction treatment in underserved veterans: a pilot investigation.

Access to mental health services, particularly for veterans residing in underserved communities, remain scarce. One approach to addressing availability barriers is through the use of group-based transdiagnostic or unified treatment protocols. One such protocol, Safety Aid Reduction Treatment (START), previously termed False Safety Behavior Elimination Treatment (FSET), has received increasing empirical support. However, prior research has only examined this treatment among civilians with a primary anxiety diagnosis. Thus, the purpose of the current study was to replicate and extend prior research by examining the acceptability, feasibility, and utility of START among veterans, particularly those living in underserved communities, and across a wider array of diagnoses. Veterans (n = 22) were assessed prior to, immediately after, and one month following the 8-week treatment. The majority of veterans found START useful and acceptable. Additionally, recruitment and retention rates suggest that the treatment was feasible. Notably, results revealed reductions in overall anxiety, depression, and safety aid usage, which were maintained throughout the brief follow-up period. These findings add to a growing body of literature highlighting the utility of transdiagnostic approaches in the amelioration of various anxiety and related disorders. Limitations include the small sample size and uncontrolled design.

Posttraumatic Stress, Alcohol Use, and Alcohol Use Motives among Non-Hispanic Black/African American College Students: The Role of Emotion Regulation.

OBJECTIVE: The associations between posttraumatic stress disorder (PTSD) symptom severity, alcohol use, and alcohol use motives are well-established. Emotion regulation difficulties have been implicated in the association between PTSD symptoms and alcohol use. A dearth of empirical work, however, has examined these associations among Black/African American college students, a population with high prevalence of exposure to potentially traumatic events, PTSD symptomatology, and alcohol-related consequences. METHODS: This study examined PTSD symptoms, emotion regulation difficulties, and alcohol use severity and motives among a sample of Black/African American trauma-exposed college students (N = 282; 77.4% identified as female; M age = 22.36, SD = 4.71). RESULTS: PTSD symptom severity was related to alcohol use and coping and conformity motives for alcohol use through heightened emotion regulation difficulties. Findings were significant above and beyond the effects of trauma load (i.e., number of potentially traumatic event types experienced). CONCLUSIONS: This study extends past work to an understudied population and contributes to groundwork for culturally informed interventions.

Co-Occurring Posttraumatic Stress Disorder Symptoms and Alcohol Use Behaviors: The Mediating Role of Drinking to Cope with PTSD Symptoms.

OBJECTIVE: Posttraumatic stress disorder (PTSD) symptoms and hazardous drinking often co-occur. One widely acknowledged explanation for this co-occurrence is the self-medication hypothesis. However, only one study to date has explicitly examined the extent to which drinking to cope with trauma-related symptoms, rather than drinking to cope with negative affect more broadly, accounts for this association. METHOD: Survey data were collected from a nationally representative sample of adults (n = 360; 48.9% female, Mage = 38.50 years, SD = 10.23). RESULTS: Results revealed a significant indirect effect of PTSD symptom severity on alcohol use frequency and alcohol use-related problems via drinking to cope with PTSD symptoms but not alcohol use quantity or binge drinking frequency. Drinking to cope with negative affect did not indirectly mediate the relations between PTSD symptom severity and any of the alcohol use-related outcomes. CONCLUSIONS: Findings will be discussed with regard to previous and future research.

Examination of a brief computerized Cognitive Anxiety Sensitivity intervention on obsessive-compulsive symptoms.

OBJECTIVES: Despite the existence of several first-line treatments for obsessive-compulsive disorder (OCD), many patients fail to experience symptom reduction and/or do not complete treatment. As a result, the field has increasingly moved towards identifying and treating malleable underlying risk factors that may in turn improve treatment efficacy. One salient underlying risk factor, anxiety sensitivity (AS) cognitive concerns, has been found to be uniquely associated with obsessive-compulsive (OC) symptom dimensions. However, no studies have yet examined whether reductions in AS cognitive concerns will lead to subsequent reductions in OC symptoms. METHODS: The current study attempted to fill this gap by recruiting individuals reporting elevations on both AS cognitive concerns and at least one OC symptom dimension. Participants were randomly assigned to receive either a one-session AS cognitive concerns intervention (n = 35) or a single health information control session (n = 37). AS cognitive concerns were assessed at post-intervention and one-month follow-up. RESULTS: The active intervention produced significantly greater reductions in AS cognitive concerns post-intervention than the control intervention. However, this effect was no longer significant at one-month follow-up. Further, while there was not an effect of treatment condition on OC symptoms at one-month follow-up, changes in AS cognitive concerns from baseline to post-intervention mediated changes in OC symptoms at one-month follow-up. CONCLUSIONS: Findings support previous research attesting to the malleable nature of AS. Extending this research, findings provide initial support for the efficacy of AS interventions among individuals with elevated OC symptoms. PRACTITIONER POINTS: Clinicians should consider assessing anxiety sensitivity (AS) among patients with obsessive-compulsive disorder. If elevated, clinicians should consider targeting AS as an adjunct to treatment as usual.

Anxiety, depression, and end-of-life care utilization in adults with metastatic cancer.

OBJECTIVE: End-of-life care for patients with cancer is often overly burdensome, and palliative and hospice care are underutilized. The objective of this study was to evaluate whether the mental health diagnoses of anxiety and depression were associated with variation in end-of-life care in metastatic cancer. METHODS: This study used electronic health data from 1,333 adults with metastatic cancer who received care at two academic health centers in Louisiana, USA, and died between 1/1/2011-12/31/2017. The study used descriptive statistics to characterize the sample and logistic regression to examine whether anxiety and depression diagnoses in the six months before death were associated with utilization outcomes (chemotherapy, intensive care unit [ICU] visits, emergency department visits, mechanical ventilation, inpatient hospitalization, palliative care encounters, and hospice utilization), while controlling for key demographic and health covariates. RESULTS: Patients (56.1% male; 65.6% White, 31.1% Black) commonly experienced depression (23.9%) and anxiety (27.2%) disorders within six months of death. Anxiety was associated with an increased likelihood of chemotherapy (odds ratio [OR] = 1.42, p = 0.016), ICU visits (OR = 1.40, p = 0.013), and inpatient hospitalizations (OR = 1.85, p < 0.001) in the 30 days before death. Anxiety (OR = 1.95, p < 0.001) and depression (OR = 1.34, p = 0.038) were associated with a greater likelihood of a palliative encounter. CONCLUSIONS: Patients with metastatic cancer who had an anxiety disorder were more likely to have burdensome end-of-life care, including chemotherapy, ICU visits, and inpatient hospitalizations in the 30 days before death. Depression and anxiety both increased the odds of palliative encounters. These results emphasize the importance of mental health considerations in end-of-life care.

Prevalence of eating disorders and comorbid psychopathology in a US sample of treatment-seeking veterans.

OBJECTIVE: Eating disorders (EDs) are a well-studied public health issue in the general population. Less is known, however, about the prevalence of such conditions and levels of comorbid psychopathology among military and veteran populations. The current study sought to describe the probable prevalence of EDs and levels of comorbid psychopathology using a racially diverse treatment-seeking sample of US veteran men and women. METHOD: Veterans (N =254) presenting for routine clinical care completed self-report questionnaires assessing EDs, posttraumatic stress disorder, depression, and shame. RESULTS: Thirty-one percent of the sample met probable criteria for either bulimia nervosa (BN), binge-eating disorder, or purging disorder. Although overall ED prevalence estimates were similar across men and women, estimates of BN were higher among Black veterans compared to White veterans or veterans who identified as a race other than Black or White. Further, mean levels of psychopathology were significantly higher in veterans with a probable ED compared to those without. DISCUSSION: This study extends previous research and highlights the importance of establishing dedicated ED screening programs within the Veterans Health Administration.

Anxiety sensitivity and posttraumatic stress symptoms: Associations among female Veterans with a history of military sexual trauma.

Anxiety sensitivity (AS), the degree to which individuals fear bodily sensations associated with anxious arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite this well-established link, AS has yet to be examined among women who experience military sexual trauma (MST). This is particularly important as research has shown that rates of AS and PTSD are higher among females compared to males. Thus, the purpose of the current investigation was to examine the association between AS and overall PTSD symptom and cluster severity using a sample of female Veterans with a history of MST. The sample included 50 women Veterans presenting for psychological services to a MST specialty clinic at a large southeastern Veterans Affairs hospital. Results revealed a significant positive association between AS and overall PTSD symptom severity, even after controlling for levels of depression, which appeared to be driven by the relationship between AS and negative alterations in cognitions and mood and arousal and reactivity clusters. These findings provide initial support for the association between AS and PTSD symptoms among female Veterans with a history of MST. Given the malleable nature of AS, future research should examine the extent to which targeting this cognitive-behavioral construct reduces PTSD symptoms among such samples.

Interactive effects of PTSD and substance use on suicidal ideation and behavior in military personnel: Increased risk from marijuana use.

BACKGROUND: The current study examines the unique and interactive effects of posttraumatic stress disorder (PTSD) symptoms and days using alcohol, opioids, and marijuana on PTSD symptoms, suicidal ideation, and suicidal behavior up to 1 year, later in a high-risk sample of military personnel not active in mental health treatment. METHODS: Current and former military personnel at risk for suicide (N = 545; M age = 31.91 years, standard deviation = 7.27; 88.2% male) completed self-report measures of PTSD symptoms, past 30 days heavy alcohol use, opioid use, marijuana use, and current suicidal ideation via telephone at baseline and 1, 3, 6, and 12 months later. PTSD symptoms and the substance use variables (and relevant covariates) were entered as predictors of changes in PTSD symptoms, the likelihood of suicidal ideation, suicidal ideation severity, and the likelihood of suicidal behavior during the 11-month follow-up period. RESULTS: PTSD symptoms predicted PTSD symptoms 1 month later. PTSD symptoms and marijuana use predicted the likelihood of suicidal ideation 1 month later and suicidal behavior during the 11-month follow-up period. The interaction between PTSD symptoms and marijuana use significantly predicted increased PTSD symptoms over time and suicidal behavior. At high, but not low levels of PTSD symptoms, more days using marijuana predicted increased PTSD symptoms over time and the likelihood of suicidal behavior. CONCLUSIONS: Results suggest marijuana, especially for military personnel experiencing elevated PTSD symptoms may negatively impact suicidal thoughts and behavior. These results are relevant to suggestions that medical marijuana could be used in treating or augmenting treatment for PTSD.

The relationship between DSM-5 PTSD symptom clusters and alcohol misuse among military veterans.

BACKGROUND AND OBJECTIVES: Prior research has revealed a strong relationship between Posttraumatic Stress Disorder (PTSD) and alcohol misuse. However, previous attempts to understand nuanced associations between PTSD symptom clusters and alcohol misuse within military veteran samples have produced mixed results. In an attempt to better understand the associations between PTSD and alcohol misuse, the current study examined the unique relationships between the newly classified Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) PTSD symptom clusters and alcohol misuse in an outpatient sample of military veterans seeking treatment for PTSD and Substance Use Disorders. METHODS: Veterans (N = 100) were administered a brief battery of self-report questionnaires prior to receiving psychological services to aid in diagnostic assessment and treatment planning. RESULTS: Hierarchical regression analyses revealed that PTSD intrusions (cluster B), negative alterations in cognition and mood (cluster D), and arousal/reactivity (cluster E) symptoms were associated with alcohol misuse. DISCUSSION AND CONCLUSIONS: The positive association between alcohol misuse and PTSD symptom severity is consistent with a broader body of literature demonstrating the co-occurrence of these disorders, particularly in military samples. SCIENTIFIC SIGNIFICANCE: Increased alcohol consumption may interfere with current front-line treatments for PTSD, which encourages patients to experience a full range of emotions. As such, future research should explore the impact of substance use on the effectiveness of trauma focused treatments in the alleviation of DSM-5 PTSD symptoms. (Am J Addict 2018;27:23-28).

Using a Clinician-Administered Interview to Examine the Overlap in Posttraumatic Stress Disorder Criteria D and E.

Although the diagnosis of posttraumatic stress disorder (PTSD) is often criticized for including symptoms that overlap with one another, only one study has explored the impact of symptom reporting. Using a clinician-rated interview for PTSD (N = 558), the current study examined overlap between PTSD criteria D1, D2, and D3 ("target D symptoms") and criterion E symptoms of similar content (i.e., E1 and E3). Furthermore, their impact on meeting criterion and disorder cutoffs was examined. Results revealed that target symptoms were endorsed in conjunction more than half the time. Criteria D and E also were often coded together. Removal of target D symptoms resulted in 24.7% of participants no longer meeting criterion D, but no reduction in the diagnosis of PTSD. This article is one of the first to report the functioning of the new criterion D symptoms, and the results have diagnostic implications for research and clinical work.

Anxiety sensitivity cognitive concerns drive the relation between anxiety sensitivity and symptoms of depression.

Depression is typically treated as a homogeneous construct despite evidence for distinct cognitive, affective, and somatic symptom dimensions. Anxiety sensitivity (AS; the fear of consequences of anxiety symptoms) is a cognitive risk factor implicated in the development of depressive symptoms. However, it is unclear how lower order AS dimensions (i.e. physical, cognitive, and social concerns) relate to depressive symptom factors. Confirmatory factor analysis, followed by structural equation modeling, were conducted to examine the factor structure of depression and to then examine the relations between these factors and the lower order factors of AS. This study was conducted in a sample of 374 adults (M age = 35.5, 54.3% female) with elevated levels of psychopathology (89.2% meeting criteria for at least one DSM-5 diagnosis, 25.6% primary depressive disorder). In this study a two-factor model of depression, composed of Cognitive and Affective/Somatic factors, was superior to one- and three-factor solutions. AS cognitive concerns were related to both cognitive and affective/somatic symptoms of depression. Neither of the other AS dimensions was related to depression symptom dimensions. These findings provide a better understanding of the relations between AS and depression symptoms.

Body Mass Index and functional impairment: the explanatory role of anxiety sensitivity among treatment-seeking smokers.

Obesity and smoking are highly prevalent public health concerns in the United States. Data indicate that elevated Body Mass Index (BMI) is related to functional impairment. However, there is limited understanding of mechanisms that may explain their comorbidity among smokers. The current study sought to test whether anxiety sensitivity explained the relation between BMI and functional impairment among 420 (46.9% females; Mage = 38 years, SD = 13.42) treatment-seeking, adult smokers. Results indicated that BMI yielded a significant indirect effect through anxiety sensitivity for functional impairment, b = 0.01, SE = .01, 95% CI = [.002, .021]. These findings remained significant after controlling for participant sex, negative affectivity, tobacco dependence, psychopathology, and medical conditions (i.e. hypertension, heart problems, respiratory disease, asthma). Such data provide novel empirical evidence that, among smokers, BMI may be a risk factor for functional impairment indirectly through anxiety sensitivity. Overall, such findings could potentially inform the development of personalized interventions among this particularly vulnerable segment of the smoking population.

An examination of the role of intolerance of distress and uncertainty in hoarding symptoms.

BACKGROUND: Hoarding disorder (HD) is a common and debilitating disorder characterized by an accumulation of and failure to discard one's possessions. The identification and examination of underlying factors that may contribute to hoarding symptoms are needed to elucidate the nature of the disorder and refine existing treatments. Two transdiagnostic vulnerability factors that have been associated with hoarding symptoms are distress intolerance (DI) and intolerance of uncertainty (IU). OBJECTIVES: This study examined the relationships between DI, IU, and symptoms of hoarding in two samples consisting of outpatients and individuals recruited from Amazon's Mechanical Turk. We hypothesized that DI and IU would show unique and interactive associations with hoarding symptoms. RESULTS: Across both samples, DI and IU were significantly associated with hoarding symptoms. However, DI and IU did not interact in their prediction of symptoms, and only IU remained a significant predictor, when accounting for relevant covariates. CONCLUSIONS: Results suggest that IU is a robust predictor of hoarding symptoms and may be a promising and novel treatment target for HD.

Sometimes Less is More: Establishing the Core Symptoms of PTSD.

Historically, the symptoms of posttraumatic stress disorder (PTSD) have garnered attention and controversy due to symptom overlap with other disorders. To improve diagnostic specificity, researchers have proposed to reformulate PTSD symptoms into a parsimonious set of core criteria. The core symptoms consisted of recurrent distressing dreams or flashbacks; internal or external avoidance; and hypervigilance or exaggerated startle. The purpose of this study was to examine a previously proposed set of "core" PTSD criteria in identifying cases of PTSD within a veteran sample. Veterans (N = 383) presenting to a Veterans Affairs (VA) Medical Center PTSD clinic for psychological services were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). A logistic regression analysis revealed that the core criteria accurately identified 79% of veterans with PTSD (OR = 11.57). Findings support a parsimonious set of core criteria in the assessment and diagnosis of PTSD. Future studies should replicate these findings in diverse, nonveteran samples.

Hoarding Behaviors and Alcohol Use: The Mediating Role of Emotion Dysregulation.

BACKGROUND: Despite recent research establishing high rates of comorbidity between hoarding disorder and alcohol use disorders (AUD), no studies have systemically examined the associations between symptoms of hoarding and alcohol use. Moreover, no studies have explored potential mechanisms that may help to explain these relations. OBJECTIVES: Thus, the current study was designed to examine the associations between hoarding and AUD symptoms, as well as the mediating role of emotion dysregulation. METHODS: Self-report measures of hoarding, depression, anxiety, alcohol use, and emotion regulation were collected in a sample of 574 adults (M age = 35.43, SD = 12.57; 62% female). RESULTS: Even when controlling for depression and anxiety, AUD symptoms were associated with overall hoarding severity (ß =.23, p <.001) as well as acquiring symptoms (ß =.16, p =.03). Further, the relation between hoarding symptoms and AUD symptoms was mediated by difficulties regulating emotions (B =.04, 95% CI [.02,.06]). Conclusions/Importance: Results of the current study suggest that increased alcohol use may be one way in which individuals with hoarding symptoms attempt to regulate their emotions.

Associations between lower order anxiety sensitivity dimensions and DSM-5 posttraumatic stress disorder symptoms.

Anxiety sensitivity (AS), a well-established individual difference variable reflecting a tendency to fear bodily sensations associated with arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite these associations, little research has examined the relations between AS subfactors (eg physical, cognitive, and social) and PTSD symptoms and none have examined these associations in the context of DSM-5 (Diagnostic Statistical Manual of Mental Disorders, Fifth Edition) PTSD clusters (ie intrusion, avoidance, negative alterations in cognitions/mood, and arousal). Participants included 50 veterans presenting to an outpatient Veteran Affairs Clinic for psychological services. Upon intake, veterans completed a brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. Results revealed unique associations between lower order AS dimensions, in particular the cognitive concerns dimension, and all four DSM-5 PTSD symptom clusters. Given the malleable nature of AS cognitive concerns, as well as the growing number of veterans in need of care, future research should determine the extent to which targeting this cognitive risk factor reduces PTSD symptom severity among veterans.

Hoarding and eating pathology: the mediating role of emotion regulation.

Hoarding disorder is characterized by persistent difficulty discarding possessions resulting in clutter that precludes one from using living areas for their intended purposes. The limited empirical work available has suggested a strong link between hoarding and various non-psychiatric conditions, including obesity. Despite these associations, no research has examined the link between hoarding and other forms of eating pathology including symptoms associated with binge eating. Moreover, little is known about mechanisms that may account for this relationship. The current study examined the associations between hoarding severity, obesity, and symptoms associated with binge eating in a sample (N=97) of individuals with elevated hoarding symptoms. Results revealed that hoarding severity was associated with increased body mass index (BMI) and symptoms of binge eating. In addition, difficulties regulating emotions mediated the association between hoarding and eating concerns. Considering the lack of information on hoarding behaviors, as well as its classification as a new diagnosis within DSM-5, these findings add considerably to a growing body of literature on hoarding disorder.