Component analysis of a synchronous and asynchronous blended care CBT intervention for symptoms of depression and anxiety: Pragmatic retrospective study.

Background: Depression and anxiety are leading causes of disability worldwide. Though effective treatments exist, depression and anxiety remain undertreated. Blended care psychotherapy, combining the scalability of online interventions with the personalization and engagement of a live therapist, is a promising approach for increasing access to evidence-based care. Objectives: To evaluate the effectiveness and individual contribution of two components - i) digital tools and ii) video-based therapist-led sessions - in a blended care CBT-based intervention under real world conditions. Methods: A retrospective cohort design was used to analyze N = 1372 US-based individuals who enrolled in blended care psychotherapy. Of these, at baseline, 761 participants had depression symptoms in the clinical range (based on PHQ-9), and 1254 had anxiety symptoms in the clinical range (based on GAD-7). Participants had access to the program as a mental health benefit offered by their employer. The CBT-based blended care psychotherapy program consisted of regular video sessions with therapists, complemented by digital lessons and digital exercises assigned by the clinician and completed in between sessions. Depression and anxiety levels and clients' treatment engagement were tracked throughout treatment. A 3-level individual growth curve model incorporating time-varying covariates was utilized to examine symptom trajectories of PHQ-9 scores (for those with clinical range of depression at baseline) and GAD-7 scores (for those with clinical range of anxiety at baseline). Results: On average, individuals exhibited a significant decline in depression and anxiety symptoms during the initial weeks of treatment (P < .001), and a continued decline over subsequent weeks at a slower rate (P < .001). Engaging in a therapy session in a week was associated with lower GAD-7 (b = -0.81) and PHQ-9 (b = -1.01) scores in the same week, as well as lower GAD-7 (b = -0.58) and PHQ-9 (b = -0.58) scores the following week (all P < .01). Similarly, engaging with digital lessons was independently associated with lower GAD-7 (b = -0.19) and PHQ-9 (b = -0.18) scores during the same week, and lower GAD-7 (b = -0.25) and PHQ-9 (b = -0.27) the following week (all P < .01). Conclusions: Therapist-led video sessions and digital lessons had separate contributions to improvements in symptoms of depression and anxiety over the course of treatment. Future research should investigate whether clients' characteristics are related to differential effects of therapist-led and digital components of care.

Problematic driving in former service members: An evaluation of the Driving Behavior Survey in veterans with posttraumatic stress disorder.

Despite high levels of traffic-related mortality, injury, and impairment among former service members, measures validated to assess problematic driving in this population remain limited. The current study examined characteristics of the Driving Behavior Survey (DBS) in male veterans (76.3% White; age: M = 56.4, SD = 12.3) meeting criteria for PTSD. Confirmatory factor analyses indicated acceptable fit of a 3-factor model specifying dimensions of anxiety-based performance deficits, exaggerated safety/caution, and hostile/aggressive driving behavior. Concurrent associations with indices of anxiety, depression, trauma history, and clinician-rated PTSD were consistent with small (r = .10-.29) to medium (r = .30-.49) effects. Discriminative validity was noted through elevations in performance deficit (d = .26), safety/caution (d = .50), and hostile/aggressive (d = .39) scales relative to published data from student drivers. Scores comparable to civilian motorists with accident-related PTSD help to qualify the severity of problematic driving behavior in trauma-exposed veterans.

The Association Between Peritraumatic Dissociation and PTSD Symptoms: The Mediating Role of Negative Beliefs About the Self.

Peritraumatic dissociation, a term used to describe a complex array of reactions to trauma, including depersonalization, derealization, and emotional numbness, has been associated with posttraumatic stress disorder (PTSD) symptoms across a number of studies. Cognitive theory suggests that interpretations of traumatic events and reactions underlie the persistence of PTSD. The present study examined the associations among peritraumatic dissociation, posttraumatic cognitions, and PTSD symptoms in a group of trauma-exposed adults (N = 169). Results indicated that, after accounting for overall symptom severity and current dissociative tendencies, peritraumatic dissociation was significantly predictive of negative beliefs about the self (R2 = .06, p < .001). Other categories of maladaptive posttraumatic cognitions did not show a similar relationship (R2 = .01 to .02, nonsignificant). Negative thoughts about the self partially mediated the association between peritraumatic dissociation and PTSD severity (completely standardized indirect effect = .25). These findings lend support to cognitive theories of PTSD and point to an important area for clinical intervention.

Punishment Learning in U.S. Veterans With Posttraumatic Stress Disorder.

Learning processes have been implicated in the development and course of posttraumatic stress disorder (PTSD); however, little is currently known about punishment-based learning in PTSD. The current study investigated impairments in punishment-based learning in U.S. veterans. We expected that veterans with PTSD would demonstrate greater punishment-based learning compared to a non-PTSD control group. We compared a PTSD group with and without co-occurring depression (n = 27) to a control group (with and without trauma exposure) without PTSD or depression (n = 29). Participants completed a computerized probabilistic punishment-based learning task. Compared to the non-PTSD control group, veterans with PTSD showed significantly greater punishment-based learning. Specifically, there was a significant Block × Group interaction, F(1, 54) = 4.12, p = .047, η(2) = .07. Veterans with PTSD demonstrated greater change in response bias for responding toward a less frequently punished stimulus across blocks. The observed hypersensitivity to punishment in individuals with PTSD may contribute to avoidant responses that are not specific to trauma cues.

Understanding heterogeneity in PTSD: fear, dysphoria, and distress.

Fear, dysphoria, and distress are prominent components in the conceptualization of posttraumatic stress disorder (PTSD). However, because our diagnostic categories are open concepts, relying on observed patterns of symptoms for classification, it is unclear whether these components represent core or auxiliary features of the disorder. Convergence across multiple indices is critical for this understanding. In this paper, we examine these components of PTSD across observed symptom patterns, broader theoretical conceptualizations, underlying information processing mechanisms of attention and memory, and underlying learning and neurobiological mechanisms. For each, evidence for similarity or distinctiveness of PTSD with other anxiety disorders and depression is examined. Throughout the review, key points of similarity to the anxiety disorders and divergence with depression argue for a distinction between core fear symptoms and auxiliary dysphoria and distress symptoms. Implications are discussed, noting that, as heterogeneity increases, core characteristics will become more diffused and ancillary constructs will gain an inflated degree of importance.

Sudden gains in prolonged exposure and sertraline for chronic PTSD.

BACKGROUND: Sudden gains are significant, rapid improvements in symptoms, larger than typical between-session symptom reduction.([8]) Sudden gains in a large sample of individuals with posttraumatic stress disorder (PTSD) have not been studied, and only one study has looked at it in pharmacotherapy, but not in PTSD. In the present study, we examined the occurrence of sudden gains in psychotherapy, specifically prolonged exposure (PE), and pharmacotherapy, specifically sertraline, for chronic PTSD. METHOD: Sudden gains in PTSD symptoms (PTSD symptom scale self-report([25]) ) were assessed in 200 individuals with PTSD during 10 weeks of PE or sertraline. RESULTS: Individuals in both PE (42.2%) and sertraline (31%) exhibited sudden gains. Individuals in PE made more gains toward the end of treatment (7.2%) than sertraline (2%, OR = 3.82). However, individuals in sertraline made larger gains during early treatment (M = 18.35, SD = 8.15) than PE (M = 12.53, SD = 5.16, d = .85). Notably, those on sertraline were more likely to exhibit a reversal of sudden gains than those in PE (OR = .23). Pointing to clinical significance, the presence of a sudden gain was associated with better reduction in symptoms from pre- to posttreatment (ß = -.49). CONCLUSIONS: Individuals in both PE and sertraline experienced gains, though sertraline was associated with earlier large but reversible gains, and PE was associated with later gains. This differential pattern of discontinuous change highlights potential differential mechanism for these therapies and marks important transition points for further detailed analyses of change mechanisms.

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications.

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.

Pharmacological treatment of anxiety disorders: current treatments and future directions.

Modern pharmacological treatments for anxiety disorders are safer and more tolerable than they were 30 years ago. Unfortunately, treatment efficacy and duration have not improved in most cases despite a greater understanding of the pathophysiology of anxiety. Moreover, innovative treatments have not reached the market despite billions of research dollars invested in drug development. In reviewing the literature on current treatments, we argue that evidence-based practice would benefit from better research on the causes of incomplete treatment response as well as the comparative efficacy of drug combinations and sequencing. We also survey two broad approaches to the development of innovative anxiety treatments:the continued development of drugs based on specific neuroreceptors and the pharmacological manipulation of fear-related memory. We highlight directions for future research, as neither of these approaches is ready for routine clinical use.