Treatment for Moral Injury: Impact of Killing in War.

Purpose of Review: Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior. Recent Findings: In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition. Summary: IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury.

Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans.

STUDY OBJECTIVES: Trauma-related nightmares are highly prevalent among veterans and are associated with higher-severity insomnia and posttraumatic stress disorder. Cognitive behavioral therapy for insomnia (typically 6-8 sessions) has been shown to reduce trauma-related nightmares. Brief behavioral treatment for insomnia (BBTI, 4 sessions) has been found to be comparable to CBT-I in decreasing insomnia severity; however, the effects of BBTI on nightmares have not been investigated. The current study tested the effects of BBTI on both trauma-related nightmares and nontrauma-related bad dreams using an active control group treated using progressive muscle relaxation therapy. In addition, we tested whether baseline trauma-related nightmare frequency and baseline nontrauma-related bad dream frequency moderated changes in insomnia severity. METHODS: Participants were 91 military veterans with insomnia disorder randomized to BBTI or progressive muscle relaxation therapy. Participants reported insomnia severity on the Insomnia Severity Index and reported trauma-related nightmare frequency and nontrauma-related bad dream frequency on the Pittsburgh Sleep Quality Index-PTSD Addendum. RESULTS: We found that BBTI significantly reduced trauma-related nightmares from baseline to posttreatment, whereas progressive muscle relaxation therapy did not. However, reductions in trauma-related nightmares were not maintained at the 6-month follow up. Neither BBTI nor progressive muscle relaxation therapy reduced nontrauma-related bad dreams from baseline to posttreatment. We also found that neither baseline trauma-related nightmare frequency nor baseline nontrauma-related bad dream frequency moderated changes in insomnia symptom severity. CONCLUSIONS: Findings from the current study suggest that BBTI may help reduce trauma-related nightmares. Further research is needed to better understand the potential mechanisms underlying how improved sleep may reduce trauma-related nightmares. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Brief Behavioral Insomnia Treatment Study (BBTI); URL: https://clinicaltrials.gov/ct2/show/NCT02571452; Identifier: NCT02571452. CITATION: Ranney RM, Gloria R, Metzler TJ, Huggins J, Neylan TC, Maguen S. Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans. J Clin Sleep Med. 2022:18(7):1831-1839.

Central stress response among deprived and continuing marijuana users and nonusers.

OBJECTIVE: We examined central nervous system [CNS] stress responses among deprived and continuing heavy marijuana users and nonusers. METHOD: Participants (N = 210; 46.7% female; Mage = 21.99; 91.4% White, 94.3% Non-Hispanic) were heavy marijuana users (N = 134) and nonusers (N = 76). Heavy users were randomly assigned to a 3-day marijuana deprivation condition (N = 68) or to continue using regularly (N = 66). Participants completed two threat-of-shock stressor tasks that manipulated stressor predictability by varying shock probability or timing. We measured central stress responses via startle potentiation (stressor conditions minus matched no-stressor condition). We examined two group contrasts (heavy use: all heavy users vs. nonusers; deprivation: deprived vs. continuing heavy users) on startle potentiation overall and moderated by stressor predictability (unpredictable vs. predictable). RESULTS: Deprivation did not affect startle potentiation overall (timing task: p = .184; probability task: p = .328) or differently by stressor predictability (timing task: p = .147; probability task: p = .678). Heavy use did not affect startle potentiation overall (timing task: p = .213; probability task: p = .843) or differently by stressor predictability (timing task: p = .655; probability task: p = .273). Posthoc analyses showed mixed evidence of general startle reactivity × deprivation interaction on startle potentiation overall (timing task: p = .019; probability task: p = .056) and differently by stressor predictability (probability task: p = .024; timing task: p = .364). CONCLUSIONS: A history of marijuana use or acute deprivation did not alter central stress responses despite prominent theoretical expectations. This study adds to growing research on central stress responses in individuals with a history of drug use and begins to parse moderating roles of individual differences and stressor characteristics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Reducing Barriers to Behavioral Treatments for Insomnia: A Qualitative Examination of Veterans' Perspectives of BBTI.

Objective: Although behavioral treatments are recommended for treating insomnia disorder, these treatments are not the most commonly provided treatments due to numerous barriers (e.g., treatment length, time limitations). Brief Behavioral Treatment for Insomnia (BBTI) was developed, in part, to help overcome these barriers. The purpose of the current study was to qualitatively examine the treatment experiences of veterans with insomnia disorder participating in BBTI.Methods: All veterans (n=46) who were randomized to receive BBTI as part of a randomized clinical trial participated in 10-20 minute semi-structured interviews one week after completing treatment. Rapid analysis procedures were used for qualitative analysis.Results: Thirteen qualitative themes were identified: BBTI provided veterans with the skills they believed they needed to continue improving independently post-treatment; beginning BBTI with in-person sessions was valued; phone sessions helped participation; veterans did not perceive that they could cover the same content during phone and in-person sessionsl; materials could be more portable; BBTI created accountability; BBTI required discipline and willingness; BBTI facilitated buy-in; BBTI was aligned with military culture; loved ones could provide important support; BBTI could be improved with more personalization; BBTI challenged expectations of mental health; and BBTI improved awareness of health behaviors beyond sleep.Conclusions: BBTI was successful in overcoming barriers to behavioral insomnia treatment and interviews identified critical treatment aspects that should be maintained to preserve acceptability (e.g., in-person session first). Areas in which BBTI did not fully meet the needs of veterans and targets for improvement (e.g., ameliorating understanding and expectations of phone sessions) were also identified.

Brief behavioral treatment for insomnia improves psychosocial functioning in veterans: results from a randomized controlled trial.

STUDY OBJECTIVES: Our goal was to compare brief behavioral treatment for insomnia (BBTI) to a progressive muscle relaxation training (PMRT) control condition among veterans with insomnia, examining psychosocial functioning as a primary outcome and sleep-related outcomes, mood, cognition, and pain as secondary outcomes. METHODS: Veterans were randomly assigned to either BBTI or PMRT (N = 91; 24-74 years; M = 49 years). BBTI consisted of two in-person (60-min and 30-min sessions) and two telephone sessions (20-min each), and the PMRT control condition was matched to BBTI for session duration and type. Veterans were assessed through clinical interview at baseline and self-report measures at pre-, mid-, and posttreatment, as well as 6-month follow-up for the BBTI condition to assess sustained response. Measures also included continuous sleep monitoring with sleep diary. RESULTS: Intent-to-treat analyses demonstrated that individuals who completed BBTI versus PMRT reported greater improvements in work, home, social and cognitive functioning, insomnia symptom severity, mood, and energy. Improvements in psychosocial functioning, insomnia symptoms, and mood were maintained 6-months following BBTI treatment completion. CONCLUSIONS: Veterans who received BBTI improved and maintained gains in psychosocial functioning, insomnia, and mood. BBTI is a treatment that can be implemented in primary care, mental health, or integrated care settings and provide symptom relief and improved functioning among those with insomnia, one of the most commonly reported mental health problems among veterans. CLINICAL TRIAL REGISTRATION: NCT02571452.

Cognitive conflict following appetitive versus negative cues and smoking cessation failure.

RATIONALE: Attentional biases and executive control deficits may play a role in smoking cessation failure. OBJECTIVES: The object of this study was to determine whether smokers' pre-quit reaction times on a computerized modified Simon task (which assesses attentional biases and executive control deficits) predict abstinence following a quit attempt. METHODS: Participants (N = 365) in a larger smoking cessation clinical trial completed the modified Simon task twice (while 10-h nicotine-deprived vs. not deprived). In the task, two photographs (i.e., two digital slides) were displayed­one always neutral, the other positive, negative, smoking-relevant, or neutral. A probe (<<< or >>>) then appeared to the left or right of center, and participants indicated the arrow's direction (left or right) which was either congruent or incongruent with the arrow's location on the screen. The incongruency effect, a measure of executive control, was calculated by subtracting the reaction time to congruent probes from the reaction time to incongruent probes. RESULTS: Greater impairment in executive control (i.e., greater probe incongruency effects) after viewing positive and smoking slides relative to negative slides predicted an inability to establish initial cessation and to maintain abstinence up to 8 weeks post-quit. CONCLUSIONS: These effects may be because smokers who avoid/escape from processing negative affect are more likely to fail in a cessation attempt. Differences in relatively automatic responses to affective cues distinguish smokers who are successful and unsuccessful in their smoking cessation attempts, but effects were modest in size.

An fMRI investigation of the impact of withdrawal on regional brain activity during nicotine anticipation.

Previous research indicates that drug motivational systems are instantiated in structures that process information related to incentive, motivational drive, memorial, motor/habit, craving, and cognitive control processing. The present research tests the hypothesis that activity in such systems will be powerfully affected by the combination of drug anticipation and drug withdrawal. Event-related fMRI was used to examine activation in response to a preinfusion warning cue in two experimental sessions that manipulated withdrawal status. Significant cue-induced effects were seen in the caudate, ventral anterior nucleus of the thalamus, the insula, subcallosal gyrus, nucleus accumbens, and anterior cingulate. These results suggest that withdrawal and nicotine anticipation produce (1) different motor preparatory and inhibitory response processing and (2) different craving related processing.

Attention bias in nicotine withdrawal and under stress.

Drug motivation models postulate that attention biasing toward smoking-related cues is a cognitive mechanism supporting continued or renewed drug use, and they predict that drug use history, deprivation, and distress should modulate the extent of this bias. The present study used the modified Stroop paradigm to extend past research regarding attention biasing toward smoking and unpleasant, pleasant, and neutral words among adult nonsmokers and daily smokers. Both nonsmokers and smokers showed differential attention toward unpleasant and pleasant cues, particularly pleasant cues, but did not show a unique bias toward smoking-related stimuli. Results suggested that, among smokers, nicotine deprivation and exogenous stress (threat of electric shock) have a nonadditive effect on attention toward pleasant cues but no effect on attention to smoking cues specifically. Similarly, instructing smokers that they would have an opportunity to smoke did not significantly increase the bias of nicotine-deprived smokers' attention toward smoking-related cues, relative to arousing unpleasant and pleasant cues. Overall, results suggest that smokers' attention may be biased toward both smoking-related and other salient cues when deprived of nicotine and anticipating an opportunity to smoke. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Cognitive effects of a Ginkgo biloba/vinpocetine compound in normal adults: systematic assessment of perception, attention and memory.

A computerized test battery was used in a double-blind design to assess the cognitive effects of a nutrient compound containing Ginkgo biloba in 24 normal adults. Ten tasks (perceptual, attention and short-term memory) were presented in a standardized manner designed to maximize performance, with substantial pre-test practice employed to minimize response variability. Subjects were given either placebo or Ginkgo biloba extract capsules to consume for 14 days, after which they performed all tasks twice. They then received the other condition, and after 14 days completed the final test session. Response time and error rate stabilized after pre-test practice. A 'working memory capacity' paradigm demonstrated a reliable 50 ms response time decrease between the placebo and Ginkgo biloba testing, suggesting that Ginkgo biloba speeds short-term working memory processing in normal adults. Copyright 2001 John Wiley & Sons, Ltd.