Assessment of medical student burnout: toward an implicit measure to address current issues.

The feasibility of implicitly assessing medical student burnout was explored, using the Implicit Relational Assessment Procedure (IRAP), to measure longitudinal student burnout over the first two years of medical school and directly comparing it with an existing explicit measure of burnout (Maslach Burnout Inventory; MBI). Three successive cohorts of medical students completed both implicit and explicit measures of burnout at several time points during their first two years of medical school. Both assessments were conducted via the internet within a one-week period during the first week of medical school, the end of the first year of medical school, and the end of the second year, though not all cohorts were able to complete the assessments at all time points. Mixed linear models were used to compare the two measures directly, as well as to evaluate changes over time in each measure separately. Minimal correspondence was observed between the implicit and explicit measures of burnout on a within-subject basis. However, when analyzed separately, all subscales of both measures detected significant change over time in the direction of greater levels of burnout, particularly during the first year of medical school. These results provide preliminary evidence the IRAP is able to assess implicit attitudes related to burnout among medical students, though additional research is needed. The IRAP detected consistent improvements in positive implicit attitudes toward medical training during students' second year of medical school, which was not detected by the MBI. Possible implications of these findings are discussed.

Serial Mediation Analysis of Psychological Inflexibility and Daytime Insomnia Rumination in the Relationship Between Dysfunctional Beliefs About Sleep and Insomnia in College Students.

Emerging research suggests that psychological inflexibility may be a factor contributing to the development and maintenance of insomnia. However, less is known about the potential cognitive pathways that may explain this relationship. In this study, we investigated the serial mediating effects of psychological inflexibility and daytime insomnia-related rumination on the association between dysfunctional beliefs and attitudes about sleep (DBAS) and insomnia symptoms. The sample included 490 college students who underwent assessments at two time points over a 1-month period. The results of our mediational tests yielded significant indirect effects, supporting the prediction that psychological inflexibility and daytime insomnia rumination serially mediate the relationship between DBAS and insomnia. The study provides insights into potential mechanisms for insomnia, emphasizing the role of psychological inflexibility in perpetuating maladaptive cognitive processes associated with insomnia. Future researchers should explore other maladaptive responses to insomnia-related concerns and distress, such as worry and safety behaviors, and replicate findings in clinically elevated insomnia samples.

Relapse of anxiety-related fear and avoidance: Conceptual analysis of treatment with acceptance and commitment therapy.

Excessive fear and avoidance in relatively safe situations can lead to a narrowing of one's behavioral repertoire and less engagement with valued aspects of living. Ultimately, these processes can reach clinical levels, as seen in anxiety, trauma, and obsessive-compulsive disorders. Research on the basic behavioral processes underlying successful treatment with exposure therapy is growing, yet little is known about the mechanisms contributing to clinical relapse. Until recently, these mechanisms have largely been conceptualized in terms of Pavlovian return of fear, with relatively little research into operant processes. In the current paper, we briefly review translational research in anxiety disorders and the connections between fear and avoidance, focusing on recent work in the acquisition, extinction, and relapse of avoidance behavior and the generalization of this learning through arbitrary symbolic relations. We then introduce one possible treatment approach to mitigating clinical relapse, acceptance and commitment therapy (ACT), and provide a conceptual analysis for why ACT may be especially well-situated to address this issue. Finally, we end with potential directions for future research on treatment and relapse of anxiety disorders.

Psychological inflexibility and intolerance of uncertainty moderate the relationship between social isolation and mental health outcomes during COVID-19.

The COVID-19 pandemic has had an enormous impact on human activity worldwide, in part due to many governments issuing stay-at-home orders and limiting the types of social interactions in which citizens can engage. Previous research has shown that social isolation can contribute to psychological distress. The impact of increased social isolation on mental health functioning during the COVID-19 crisis, as well as potential mechanisms to buffer this impact, have yet to be investigated. The current study explored the moderating role of psychological flexibility and related constructs on the relationships between social isolation and mental health outcomes during the COVID-19 pandemic. Cross-sectional data from 278 participants, the majority residing in the United States, were collected during a 3-week period from mid-April to early May 2020 via online survey. A series of hierarchical linear regression analyses indicated statistically significant relationships between social isolation and psychological distress (depression, anxiety, and stress), well-being, and valued living. Psychological inflexibility, intolerance of uncertainty, and emotional suppression significantly moderated these relationships in a number of instances. Greater psychological flexibility and acceptance of difficult experiences appeared to act as a buffer against the negative effects of increased social isolation, while amplifying the benefits of social connectedness. Implications for promoting mental health and buffering against the harmful effects of social isolation during the COVID-19 pandemic and beyond are discussed.

Effects of Acceptance and Commitment Therapy on Impulsive Decision-Making.

This study examined the transdiagnostic effect of acceptance and commitment therapy (ACT) on impulsive decision-making in a community sample. A total of 40 adults were randomized to eight individual sessions of ACT or an inactive control. Participants completed pre-, mid-, and post-assessments for psychological symptoms; overall behavior change; valued living; delay discounting; psychological flexibility; and distress tolerance. Data were analyzed with multilevel modeling of growth curves. Significant interaction effects of time and condition were observed for psychological flexibility, distress tolerance, psychological symptoms, and the obstruction subscale of valued living. No significant interaction effect was found for two delay discounting tasks nor the progress subscale of valued living. The ACT condition had a significantly larger reduction of problem behavior at post-assessment. The results support use of ACT as a transdiagnostic treatment for impulsive behaviors. The lack of change in delay discounting contrasts previous research.

The Influence of a Personal Values Intervention on Cold Pressor-Induced Distress Tolerance.

Research has demonstrated that values and acceptance interventions can increase distress tolerance, but the individual contribution of each remains unclear. The current study examined the isolated effect of a values intervention on immersion time in a cold pressor. Participants randomized to Values (n = 18) and Control (n = 14) conditions completed two cold pressor tasks, separated by a 30-min values or control intervention. Immersion time increased 51.06 s for participants in the Values condition and decreased by 10.79 s for those in the Control condition. Increases in self-reported pain and distress predicted decreases in immersion time for Control, but not Values, participants. The best-fitting model accounted for 39% of the variance in immersion time change. Results suggest that a brief isolated values exercise can be used to improve distress tolerance despite increased perceptions of pain and distress, such that values alone may be sufficient to facilitate openness to difficult experiences.

Persistence and relapse of reinforced behavioral variability.

The present study examined persistence and relapse of reinforced behavioral variability in pigeons. Pigeons emitted four-response sequences across two keys. Sequences produced food according to a lag schedule, in which a response sequence was followed by food if it differed from a certain number of previous sequences. In Experiment 1, food was delivered for sequences that satisfied a lag schedule in both components of a multiple schedule. When reinforcement was removed for one component (i.e., extinction), levels of behavioral variability decreased for only that component. In Experiment 2, food was delivered for sequences satisfying a lag schedule in one component of a multiple schedule. In the other component, food was delivered at the same rate, but without the lag variability requirement (i.e., yoked). Following extinction, levels of behavioral variability returned to baseline for both components after response-independent food delivery (i.e., reinstatement). In Experiment 3, one group of pigeons responded on a lag variability schedule, and the other group responded on a lag repetition schedule. For both groups, levels of behavioral variability increased when alternative reinforcement was suspended (i.e., resurgence). In each experiment, we observed some evidence for extinction-induced response variability and for variability as an operant dimension of behavior.

Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial.

The objective of this study was to test whether treatment acceptability, exposure engagement, and completion rates could be increased by integrating acceptance and commitment therapy (ACT) with traditional exposure and response prevention (ERP). 58 adults (68% female) diagnosed with obsessive-compulsive disorder (OCD; M age = 27, 80% white) engaged in a multisite randomized controlled trial of 16 individual twice-weekly sessions of either ERP or ACT + ERP. Assessors unaware of treatment condition administered assessments of OCD, depression, psychological flexibility, and obsessional beliefs at pretreatment, posttreatment, and six-month follow-up. Treatment acceptability, credibility/expectancy, and exposure engagement were also assessed. Exposure engagement was high in both conditions and there were no significant differences in exposure engagement, treatment acceptability, or dropout rates between ACT + ERP and ERP. OCD symptoms, depression, psychological inflexibility, and obsessional beliefs decreased significantly at posttreatment and were maintained at follow-up in both conditions. No between-group differences in outcome were observed using intent to treat and predicted data from multilevel modeling. ACT + ERP and ERP were both highly effective treatments for OCD, and no differences were found in outcomes, processes of change, acceptability, or exposure engagement.

Effects of differential rates of alternative reinforcement on resurgence of human behavior.

Despite the success of exposure-based psychotherapies in anxiety treatment, relapse remains problematic. Resurgence, the return of previously eliminated behavior following the elimination of an alternative source of reinforcement, is a promising model of operant relapse. Nonhuman resurgence research has shown that higher rates of alternative reinforcement result in faster, more comprehensive suppression of target behavior, but also in greater resurgence when alternative reinforcement is eliminated. This study investigated rich and lean rates of alternative reinforcement on response suppression and resurgence in typically developing humans. In Phase 1, three groups (Rich, n = 18; Lean, n = 18; Control, n = 10) acquired the target response. In Phase 2, target responding was extinguished and alternative reinforcement delivered on RI 1 s, RI 3 s, and extinction schedules, respectively. Resurgence was assessed during Phase 3 under extinction conditions for all groups. Target responding was suppressed most thoroughly in Rich and partially in Lean. Target responding resurged in the Rich and Lean groups, but not in the Control group. Between groups, resurgence was more pronounced in the Rich group than the Lean and Control groups. Clinical implications of these findings, including care on the part of clinicians when identifying alternative sources of reinforcement, are discussed.