Digital-Based Interventions for Complex Post-Traumatic Stress Disorder: A Systematic Literature Review.

Research has shown that complex post-traumatic stress disorder (cPTSD) differs from post-traumatic stress disorder (PTSD) on core symptoms relating to the individual's sense of self, and this has driven the need for treatment approaches to address these specific features of cPTSD. The COVID-19 pandemic has led to the increased use of digital-based interventions (DBIs) to treat mental illnesses, including trauma-related disorders. However, while evidence for the use of DBIs for PTSD has previously been synthesized, the current review is the first synthesis of research on the use of DBIs for cPTSD. A systematic search of Scopus, PsychINFO, and EBSCOhost was conducted, using search terms targeting "cPTSD" and "DBIs," to identify research on the use of DBIs to treat cPTSD symptoms. Ten papers were identified, which provided preliminary evidence for the efficacy of DBIs to reduce cPTSD symptoms. Further, DBIs were reported as acceptable by individuals with a history of complex trauma. The paper also provides insight into the therapeutic approaches adopted, digital modalities utilized, safety measures included, and whether/to what degree support was provided. While DBIs show promise for treating cPTSD, there is substantial room for advancement of the empirical evidence base for these approaches. Both clinical and research-based recommendations are provided separately.

I Am More than HIV: A Qualitative Exploration of Factors That Can Strengthen Resilience Among HIV-Positive Gay Men in Australia.

Introduction: HIV-positive gay men continue to experience stigma related to sexual orientation and HIV status. Although resilience toward such stressors can be achieved, limited Australian research exists that examines how resilience is strengthened toward these dual stigmas. Methods: A total of 20 men from Melbourne, Australia, participated in semi-structured interviews between March and October 2019 to explore ways in which they manage such stigmas. Results: Reflexive thematic analysis identified two primary themes: (1) "intrapersonal control," which relates to individual mind set and lifestyle changes that participants utilized to strengthen resilience; (2) "systemic change," which includes participants' needs for better public health messaging. Findings show resilience was enhanced when proactive approaches to sexual orientation, HIV health appraisal, lifestyle changes, and social support were made. Further, outdated HIV awareness campaigns and a lack of current messaging regarding HIV transmission in the wider community were identified as inhibiting resilience development and promoting stigma among gay men. Conclusion: The results from this study show ways that Australian gay men strengthen their resilience through both intrapersonal (e.g., self-awareness, reappraisal, and self-efficacy) and external resources (e.g., education and public awareness) and how health care providers and social policy makers could better support the men to achieve this. Social-Policy Implications: Findings suggest that targeted public health responses are required to compliment the advances made in biomedicine and viral suppression.

Loneliness and social anxiety in young adults: The moderating and mediating roles of emotion dysregulation, depression and social isolation risk.

OBJECTIVES: We aimed to investigate the mechanisms underlying loneliness, social anxiety, depression and emotion dysregulation, as well as how these relationships differ based on social isolation risk. DESIGN: We employed an online survey study to measure variables cross-sectionally. METHODS: A total of 1239 (77.2% Female, Mage = 21.52, SD = 2.32) participants completed measures of loneliness, social isolation risk, social anxiety, depression and emotion dysregulation. A moderated serial mediation model was conducted to determine whether emotion dysregulation and depression jointly mediate the relationship between loneliness and social anxiety and to determine whether these relationships are moderated by risk of social isolation. RESULTS: Loneliness was found to predict social anxiety and was mediated by emotion dysregulation and depression both independently and combined. Participants with a low risk of social isolation were found to be protected against poor mental health. CONCLUSIONS: Our studies replicate previous findings showing a relationship between loneliness and social anxiety. We also extend current knowledge to show the importance of social contact for protecting against elevated levels of social anxiety and depression. Overall, we provide empirical evidence for the role of social connection in managing mental health symptoms.

The Influence of the COVID-19 Pandemic on Social Anxiety: A Systematic Review.

The COVID-19 pandemic has resulted in negative mental health outcomes throughout the world, and its impact on social interactions and relationships is likely to be evident in problematic social anxiety. This systematic review qualitatively synthesized data from studies that have reported on the effects of the pandemic on social anxiety. A systematic search of Web of Science Core Collection, Embase, PsychINFO, Scopus, EBSCOhost, Cochrane Central Register of Controlled Trials, and Proquest Central-Dissertations and Theses was conducted, with thirty-three studies meeting the inclusion criteria. The results suggest that social anxiety has been heightened in the general population due to the pandemic, with women and low-income earners being especially vulnerable. Other contributing factors include impaired coping strategies, lower socio-emotional well-being, limited support networks, and contraction of the SARS-CoV-2 virus. Individuals with a Social Anxiety Disorder diagnosis may be at risk of a deterioration of mental health in general. Limitations of the literature reviewed include the predominance of cross-sectional study designs, which limit causal inferences are limited. Additionally, associations may be inflated as many studies have not accounted for mediating variables. Taken together, the research suggests that social anxiety, either pre-pandemic or arising due to the pandemic environment, has contributed to a variety of negative mental health outcomes related to social anxiety.

Long-term outcomes of cognitive behavioural therapy for social anxiety disorder: A meta-analysis of randomised controlled trials.

Cognitive Behavioural Therapy (CBT) is effective in treating Social Anxiety Disorder (SAD). However, less is known about whether gains achieved in disorder-specific and secondary outcomes (e.g., depression, general anxiety, quality of life, and self-esteem) are maintained 12 months or longer. A systematic literature search yielded 25 relevant studies that administered CBT to participants with SAD. Multivariate meta-analyses of post-treatment assessments, found that CBT was superior to control conditions in reducing social anxiety (g =.74), depression (g =.52), general anxiety (g =.69) and improving quality of life (g =.39). The within-groups effect sizes revealed that 12 months or more after CBT treatment, symptoms continued to improve for social anxiety (gav =.23) and quality of life (gav =.17), and gains were maintained for depressive (gav =.06) and general anxiety symptoms (gav =.03). However, meta-analyses of long-term outcomes lack comparison groups. Moderation was non-significant for the treatment model, format, number of sessions, treatment duration, or inclusion of booster sessions. Future research may investigate what drives improvement after treatment cessation and how CBT affects other co-occurring symptomatology. Taken together, CBT produces many benefits for SAD and individuals with co-occurring symptoms can benefit from extant SAD-focused treatments.

Self-compassion and social anxiety: The mediating effect of emotion regulation strategies and the influence of depressed mood.

OBJECTIVES: Self-compassion constitutes a positive way of relating towards the self that enables emotional regulation and reduces emotional distress. This research first explored differences among a sample of persons with social anxiety disorder (SAD) and groups of high socially anxious (HSA) and low socially anxious (LSA) students on self-compassion, emotion regulation, and social anxiety. We then investigated emotional regulation as a mediator of the prediction of social anxiety by self-compassion and the influence of depressed mood on those relationships. DESIGN: Study 1 compared a SAD group to matched groups of HSA and LSA students. Study 2 utilized the total sample (n = 330 students and n = 33 SAD) to test mediation. Self-compassion and emotion regulation were predictors of social anxiety and depression a covariate. RESULTS: In Study 1, the SAD group did not differ from the HSA group on most aspects of self-compassion and emotional regulation but was higher on depression. Both were lower on most measures and higher on depression than the LSA group. In Study 2, higher self-compassion predicted lower social interaction anxiety, and emotional regulation strategies mediated this effect, regardless of depression. However, for social performance anxiety, controlling for depression removed mediation. Refraining from uncompassionate responses was directly connected to social anxiety, whereas compassionate responses influenced social anxiety via emotional regulation. CONCLUSIONS: Results affirm the ameliorative role of self-compassion on social anxiety and emotion regulation strategies as mechanisms of that influence. However, self-compassion's influence was affected by depression and type of social anxiety. Also, refraining from uncompassionate self-responding appears to be of prime importance in predicting social anxiety, whereas compassionate self-responding influences social anxiety via emotion regulation.

The relative benefits of nonattachment to self and self-compassion for psychological distress and psychological well-being for those with and without symptoms of depression.

OBJECTIVES: Self-compassion represents a way of interacting with the self involving kindness and a balanced approach to negative self-related stimuli that has shown to contribute to reduced depression, anxiety and stress, and increased psychological well-being. Due to the potential barriers towards self-compassion for people with depressive symptoms, the objective of the present study what to investigate whether the emerging construct of 'nonattachment to self', which reflects a flexible and balanced approach to all self-related stimuli, may be more beneficial for positive psychological outcomes than self-compassion, for individuals with depressive symptoms. METHOD: A sample 388 participants (consisting of 71 men, 317 women) aged from 18 to 77 (M = 35.33, SD = 10.81) completed an online questionnaire measuring levels of self-compassion, nonattachment to self, depressive symptoms, and well-being. RESULTS: Higher levels of both nonattachment to self and self-compassion were related to reduced psychological distress and increased psychological well-being. However, for people with at least mild depressive symptoms, nonattachment to self was found to be a stronger predictor of reduced psychological distress and increased psychological well-being than self-compassion. CONCLUSION: In conclusion, the present study suggests both nonattachment to self and self-compassion are associated with better mental health in non-clinical populations. Further, for individuals experiencing at least mild symptoms of depression, self-compassion may be less beneficial than taking a more nonattached stance towards the self. The findings have implications for the way we conceptualize self-focused attention and suggest assisting individuals to let go of their fixated, self-focused attention may be especially beneficial for individuals with depressive symptoms. PRACTITIONER POINTS: The notion of letting of attachment to the separate static self lies at the core of Buddhist psychological teachings and recent research suggests it can have a positive impact on individuals psychological well-being and ill-being Given the barriers to self-compassion experienced by individuals with depressive symptoms, nonattachment to self may represent a healthy interaction with the self than is met with less resistance than self-compassion. Due to the balanced stance of nonattachment to self towards positive and negative self-related stimuli, it may be prove to be a valuable approach to treating individuals who feel conflict with taking any form of positive or kind stance towards the self.

Self-compassion and emotional regulation as predictors of social anxiety.

OBJECTIVES: Self-compassion and emotional regulation have been identified as constructive attitudes towards the self which can reduce emotional distress. This study is the first to examine the role of a self-compassionate attitude towards the self in reducing symptoms of social anxiety. The study also explored the role of emotional regulation strategies of cognitive reappraisal (CR) and expressive suppression (ES) as mechanisms that mediate the impact of self-compassion on social anxiety. DESIGN: Structural equation modelling (SEM) was conducted on cross-sectional correlational data with MPlus version 6. METHODS: A sample of 750 undergraduate students (378 men and 372 women) completed an online survey comprised of well validated self-report measures of social anxiety, emotional regulation and self-compassion. RESULTS: Structural equation modelling showed that self-compassion predicted lower social anxiety directly and indirectly through lower ES. Higher self-compassion also predicted higher CR. Contrary to expectation, CR did not predict lower social anxiety. Exploratory analyses of self-compassion divided into Compassionate Self-responding (CSR) and Refraining from Non-compassionate Responding (RUSR) identified RUSR as a predictor of lower social anxiety directly and indirectly via ES and CR. CSR had no direct effect on social anxiety but did so indirectly via CR. CONCLUSIONS: The findings provide preliminary evidence that self-compassion can play an important role in alleviating social anxiety and that emotion regulation through ES and CR are important mechanisms of that influence. PRACTITIONER POINTS: Adopting a more compassionate attitude towards the self can reduce the symptoms of social anxiety Emotional regulation through reducing emotional suppression may be a mechanism whereby higher levels of self-compassion reduce symptoms of social anxiety. Although higher levels of self-compassion predict greater use of emotional regulation through cognitive appraisal, cognitive appraisal does not predict levels of symptoms of social anxiety The capacity to refrain from non-compassionate self-responding may reduce symptoms of social anxiety directly and indirectly through lower levels of emotional suppression and greater cognitive reappraisal (CR). However, compassionate self-responding only influences symptoms of social anxiety through CR.

Letting Go of Self: The Creation of the Nonattachment to Self Scale.

The Buddhist notion of nonattachment relates to an engagement with experience with flexibility and without fixation on achieving specified outcomes. The present study sought to define, create and validate a new measure of nonattachment as it applies to notions of the self. A new construct of "nonattachment to self" (NTS) was developed, defined the absence of fixation on self-related concepts, thoughts and feelings, and a capacity to flexibly interact with these concepts, thoughts and feelings without trying to control them. Two studies were conducted in the development of the new scale. With expert consultation, study 1 (n = 445) established a single factor, internally consistent 7-item scale via exploratory factor analysis. Study 2 (n = 388, n = 338) confirmed the factor structure of the new 7-item scale using confirmatory factor analyses. Study 2 also found the new scale to be internally consistent, with evidence supporting its test-retest reliability, criterion, and construct validity. Nonattachment to self-emerged as a unique way of relating to the self, distinct from general nonattachment, that aligned with higher levels of well-being and adaptive functioning.

Differences Across Illness Perceptions in Inflammatory Bowel Disease and Their Relationships to Psychological Distress and Quality of Life.

Patients with greater inflammatory bowel disease activity readily identify poorer psychosocial outcomes; however, the role of gender, disease type, and individual illness perceptions facets are less well known. This study aimed to characterize the role of illness perceptions, gender, and disease type on anxiety, depression, and quality of life. Eighty-one patients diagnosed with inflammatory bowel disease (39 men, mean age 35 years) attending a tertiary hospital outpatient clinic were studied. Questionnaires used included the Manitoba Index, the Brief Illness Perceptions Questionnaire, Hospital Anxiety and Depression Scale, and the World Health Organization Brief Quality of Life Scale. Female patients with active disease tended to report increased anxiety, depression, and reduced quality of life. Regarding illness perceptions, patients with Crohn disease reported significantly more concerns about its chronicity, while female patients reported being significantly more concerned about the impact of their illness on identity, chronicity, overall concern, and having a greater emotional impact. Hierarchical regression indicated that 36% of depression, 42% of anxiety, and 57% of quality of life could be accounted for by disease activity and type, gender, and illness perceptions. The findings suggest that in addition to a patient's perceived disease status, gastroenterology nurses should also be aware that patient gender and their perceptions of illness play a significant impact not only on anxiety and depression but also on quality of life. Increased disease activity is associated with more severe anxiety and depression and reduced quality of life. Female patients are also at a greater risk of reporting negative illness perceptions and increased levels of anxiety, depression, and lower quality of life.

Prevalence of mental health disorders in inflammatory bowel disease: an Australian outpatient cohort.

BACKGROUND: This study aimed to characterize prevalence of anxiety and depressive conditions and uptake of mental health services in an Australian inflammatory bowel disease (IBD) outpatient setting. METHODS: Eighty-one IBD patients (39 males, mean age 35 years) attending a tertiary hospital IBD outpatient clinic participated in this study. Disease severity was evaluated according to the Manitoba Index. Diagnosis of an anxiety or depressive condition was based upon the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale. RESULTS: Based on Hospital Anxiety and Depression Scale subscale scores >8 and meeting Mini-International Neuropsychiatric Interview criteria, 16 (19.8%) participants had at least one anxiety condition, while nine (11.1%) had a depressive disorder present. Active IBD status was associated with higher prevalence rates across all anxiety and depressive conditions. Generalized anxiety was the most common (12 participants, 14.8%) anxiety condition, and major depressive disorder (recurrent) was the most common depressive condition reported (five participants, 6.2%). Seventeen participants (21%) reported currently seeking help for mental health issues while 12.4% were identified has having at least one psychological condition but not seeking treatment. CONCLUSION: We conclude that rates of anxiety and depression are high in this cohort, and that IBD-focused psychological services should be a key component of any holistic IBD service, especially for those identified as having active IBD.

Understanding the trauma of first-episode psychosis.

AIM: This study examined the distress of first-episode psychosis (FEP) beyond the acute episode. It focused on how people understand the experience of FEP and its negative impact and how this relates to the traumagenic phenomena. METHODS: This research was a longitudinal qualitative study including interpretative phenomenological analysis of interview data. Ten people who had experienced FEP were interviewed 3-6 months following their psychotic episode (time one) and again 3 months after their initial interview (time two). Clinicians and significant others were interviewed at time two. RESULTS: Interpretative phenomenological analysis of the interview data supported a conceptualization of recovery from FEP within a broad trauma framework. The traumatic nature of FEP was found to be extended beyond the acute episode and was not linked to symptoms of post-traumatic stress disorder (PTSD) but included impact on identity, relationships and worldview. CONCLUSIONS: The diagnosis of PTSD does not appear to capture all aspects of the distress of FEP. Traumagenic distress appears explained by incorporating a range of negative emotions, viewing the impact of FEP as ongoing rather than contained to the acute episode, and recognizes disruption of the individual's views of the self, others and the world.

Evaluation of the dimensions of anger reactions-5 (DAR-5) scale in combat veterans with posttraumatic stress disorder.

After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α=.86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g., HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31, 166-173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.

Utility of the Dimensions of Anger Reactions-5 (DAR-5) scale as a brief anger measure.

BACKGROUND: Anger is a common emotional sequel in the aftermath of traumatic experience. As it is associated with significant distress and influences recovery, anger requires routine screening and assessment. Most validated measures of anger are too lengthy for inclusion in self-report batteries or as screening tools. This study examines the psychometric properties of a shortened 5-item version of the Dimensions of Anger Reactions (DAR), an existing screening tool. METHODS: Responses to the DAR-5 were analysed from a sample of 486 college students with and without a history of trauma exposure. RESULTS: The DAR-5 demonstrated strong internal reliability and concurrent validity with the State Trait Anger Expression Inventory-2 (STAXI-2). Confirmatory factor analysis supported a single factor model of the DAR-5 for the trauma-exposed and nontrauma subsamples. A screening cut-off point of 12 on the DAR-5 successfully differentiated high and low scorers on STAXI-2 Trait Anger and PCL posttraumatic stress scores. Further discriminant validity was found with depression symptom scores. CONCLUSIONS: The results support use of the DAR-5 for screening for anger when a short scale is required.

Anger in PTSD: is there a need for a concept of PTSD-related posttraumatic anger?

Despite extensive research on posttraumatic stress disorder (PTSD), anger in PTSD has received little attention. This is surprising, given anger is a key predictor of treatment outcome in PTSD. This paper seeks to build an argument for investigating anger in PTSD as a discrete entity. A key argument is that the capacity to image visual mental phenomena is crucial to the aetiology and maintenance of anger in PTSD. Evidence is reviewed for the influence of visual imagery in anger in PTSD from the perspectives of neuropsychology, psychopathology, anger and PTSD. An argument is advanced for including visual imagery in an integrated (visual-linguistic) cognitive model of anger in PTSD. Directions for research on visual imagery in anger in PTSD and its treatment implications are discussed.

The self-regulation of gambling.

Despite the prevalence of gambling world-wide, relatively few individuals become problem gamblers. Additionally many problem gamblers recover without professional assistance. The current study aim was to examine how individuals self-manage their gambling through (a) assessing frequency of use of a range of self-regulation strategies (b) examining how these strategies cluster and (c) exploring relationships between strategies, gambling frequency, amount spent and problem gambling severity. A sample of 303 gamblers was recruited, over-sampling for problem gamblers as assessed by the Problem Gambling Severity Index (PGSI) of the Canadian Problem Gambling Index (mean age 26.4 years, SD = 10.1 years; 119 males, 184 females; 238 social gamblers, 63 problem gamblers, 2 unclassified). They rated extent of usage of 27 gambling self-management techniques and completed the PGSI and other gambling measures. Factor analysis of items produced five factors, named Cognitive Approaches, Direct Action, Social Experience, Avoidance and Limit Setting. The relationships between these factors and key gambling variables were consistent with hypotheses that problem gamblers trying to reduce their gambling would be more likely to use the strategies than other gambler groups. The potential for developing the factors into a Gambling Self-regulation Measure was explored.

The tasks of self-managing hepatitis C: the significance of disclosure.

The narratives of those with hepatitis C were viewed through the lens of Corbin and Strauss' [Corbin, J., & Strauss, A. (1988). Unending work and care: Managing chronic illness at home. The Jossey-Bass health series and The Jossey-Bass social and behavioral science series. San Francisco, CA: Jossey-Bass.] self-management model for chronic illness, using qualitative methodology. Fifteen Australian hepatitis C positive interviewees described the challenges and turning points in adjusting to their diagnosis. The data were analysed using open- and closed-coding methods. Support was found for a self-management model encompassing medical, emotional and life role facets for those adjusting to life with hepatitis C. Unique challenges emerged beyond those described by Corbin and Strauss (1988), namely that disclosure impacted both positively and negatively on the tasks of self-management. It was concluded that self-management may be compromised by disclosure, particularly distress derived from hepatitis C-related stigma. The self-management tasks described contribute to broadening clinicians' understanding of the challenges faced by those living with hepatitis C.

Comparing the psychometric properties of two measures of wisdom: predicting forgiveness and psychological well-being with the Self-Assessed Wisdom Scale (SAWS) and the Three-Dimensional Wisdom Scale (3D-WS).

Two recently developed scales of wisdom were compared on their abilities to have their dimensional structure replicated and to predict relevant personality (i.e., forgiveness) and life satisfaction (i.e., psychological well-being) variables. One hundred and seventy-six primarily (71%) Australian participants ranging in age from 18 to 68 years (M = 36.60, SD = 12.07) completed an online survey of the Self-Assessed Wisdom Scale (SAWS; Webster, 2003, Journal of Adult Development, 10, 13-22; 2007, International Journal of Aging and Human Development, 65, 163-183), the Three-Dimensional Wisdom Scale (3D-WS; Ardelt, 2003, Journal of Gerontology: Psychological Sciences, 52B, 15-27), the Heartland Forgiveness Scale (Thompson et al., 2005, Journal of Personality, 73, 313-360), Ryff's (1989, Journal of Personality and Social Psychology, 57, 1069-1081) measure of psychological well-being (PWB), and a measure of social desirability (BIDR; Paulhus, 1984, Journal of Personality and Social Psychology, 46, 598-609). Results indicated that the dimensional structure of the SAWS, but not the 3D-WS, replicated, and the 3D-WS, but not the SAWS, was contaminated by a social desirability response bias. Both scales predicted equally well PWB and forgiveness in predicted directions. Implications for future use of both scales are discussed.

Gambling accessibility: a scale to measure gambler preferences.

Geographic closeness of gambling venues is not the only aspect of accessibility likely to affect gambling frequency. Perceived accessibility of gambling venues may include other features such as convenience (e.g., opening hours) or "atmosphere". The aim of the current study was to develop a multidimensional measure of gamblers' perceptions of accessibility, and present evidence for its reliability and validity. We surveyed 303 gamblers with 43 items developed to measure different dimensions of accessibility. Factor analysis of the items produced a two factor solution. The first, Social Accessibility related to the level at which gambling venues were enjoyed because they were social places, provided varying entertainment options and had a pleasant atmosphere. The second factor, Accessible Retreat related to the degree to which venues were enjoyed because they were geographically and temporally available and provided a familiar and anonymous retreat with few interruptions or distractions. Both factors, developed as reliable subscales of the new Gambling Access Scale, demonstrated construct validity through their correlations with other gambling-related measures. Social Accessibility was moderately related to gambling frequency and amount spent, but not to problem gambling, while, as hypothesised, Accessible Retreat was associated with stronger urges to gamble and gambling problems.

Internal consistency, test-retest reliability and sex differences on the Posttraumatic Growth Inventory in an Australian sample with trauma.

The Posttraumatic Growth Inventory is designed to measure positive changes that can emerge after traumatic experiences. This study established that the high internal consistency and sound test-retest reliability of the inventory can be generalised from U.S. college students to an Australian sample drawn from the general community who had experienced major traumatic events. Interestingly, the 75 women endorsed more positive change overall than the 54 men, confirming earlier findings. However, there was no sex difference on items reflecting the perception of new possibilities in life.