Computer-Guided Problem-Solving Treatment for Depression, PTSD, and Insomnia Symptoms in Student Veterans: A Pilot Randomized Controlled Trial.

Depression is a highly prevalent psychological disorder experienced disproportionately by college student military veterans with many deleterious effects including risk for suicide. Treatment can help, but the debilitating nature of depression often makes seeking in-person treatment difficult and many are deterred by stigma, inconvenience, concerns about privacy, or a preference to manage problems themselves. The current study examines the efficacy of a computer-guided Problem-Solving Treatment (ePST®) for reducing symptoms of depression, posttraumatic stress disorder (PTSD), and insomnia in student military veterans. Twenty-four student veterans (Meanage = 32.7) with symptoms of depression were randomly assigned either to a treatment group receiving six weekly sessions of ePST or to a minimal contact control group (MCC). Participants completed the Patient Health Questionnaire-9 (PHQ-9) depression scale at baseline and then weekly through post-ePST or post-MCC. PTSD and insomnia questionnaires were also completed at baseline and posttreatment. A linear mixed model regression showed a statistically significant Group (ePST vs. MCC) × Time (pretreatment through posttreatment) interaction for depression, with the ePST showing substantial improvements in depressive symptoms over the 6-week period. Significant improvements were also seen in PTSD and insomnia symptoms. Results suggest that ePST can effectively treat depression, PTSD, and insomnia symptoms in student military veterans and may be a viable alternative for those who are not able to access live therapy. Future work should examine the durability of treatment effects and utility for more severe depression and suicide prevention.

A psychometric study of the Fear of Sleep Inventory-Short Form (FoSI-SF).

STUDY OBJECTIVES: Fear of sleep may play a significant role in sleep disturbances in individuals with posttraumatic stress disorder (PTSD). This report describes a psychometric study of the Fear of Sleep Inventory (FoSI), which was developed to measure this construct. METHODS: The psychometric properties of the FoSI were examined in a non-clinical sample of 292 college students (Study I) and in a clinical sample of 67 trauma-exposed adults experiencing chronic nightmares (Study II). Data on the 23 items of the FoSI were subjected to exploratory factor analyses (EFA) to identify items uniquely assessing fear of sleep. Next, reliability and validity of a 13-item version of the FoSI was examined in both samples. RESULTS: A 13-item Short-Form version (FoSI-SF) was identified as having a clear 2-factor structure with high internal consistency in both the non-clinical (α = 0.76-0.94) and clinical (α = 0.88-0.91) samples. Both studies demonstrated good convergent validity with measures of PTSD (0.48-0.61) and insomnia (0.39-0.48) and discriminant validity with a measure of sleep hygiene (0.19-0.27). The total score on the FoSI-SF was significantly higher in the clinical sample (mean = 17.90, SD = 12.56) than in the non-clinical sample (mean = 4.80, SD = 7.72); t(357) = 8.85 p < 0.001. CONCLUSIONS: Although all items are recommended for clinical purposes, the data support the use of the 13-item FoSI-SF for research purposes. Replication of the factor structure in clinical samples is needed. Results are discussed in terms of limitations of this study and directions for further research.

Exposure utilization and completion of cognitive behavioral therapy for PTSD in a "real world" clinical practice.

This study assessed rates of imaginal exposure therapy (ET) utilization and completion of cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD) in a clinical setting and examined variables associated with CBT completion. Using a clinical definition, the completion rate of CBT was markedly lower than rates reported in randomized trials. CBT completion was inversely related to severity of overall pretreatment measures of PTSD, avoidance, hyperarousal, depression, impaired social functioning, and borderline personality disorder. Regression yielded avoidance and depression as unique predictors of completion. Most dropouts occurred before starting imaginal ET, although initiating ET was associated with greater likelihood of completion. Results highlight methodological differences between research and practice notions of treatment completion and the need for further study of variables influencing CBT completion in practice settings.

Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization.

OBJECTIVE: This study estimates the prevalence of posttraumatic stress disorder (PTSD) and describes the relationships among PTSD status and health indices in a civilian primary care patient sample. METHODS: Participants (N = 232) completed a paper-and-pencil survey of life events, PTSD symptoms, physical symptoms and health functioning. Utilization was assessed from medical records. RESULTS: Nine percent of the participants met the criteria for full PTSD (based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) and another 25% were defined as partial PTSD. The full-PTSD group evidenced higher rates of medical utilization, more intense physical symptoms and poorer health functioning than the no-PTSD group. The partial-PTSD group more closely resembled the full-PTSD group. CONCLUSIONS: This study, although limited by sample size and diagnosis by questionnaire vs. diagnostic interview, suggests research directions for enhancing our understanding of PTSD among civilian primary care patients and for developing appropriate interventions that can be conducted in the primary care setting.

Treatment of residual insomnia after CBT for PTSD: case studies.

Insomnia is one of the most common symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that insomnia may persist for many PTSD patients after other symptoms have responded to cognitive-behavioral therapy (CBT). The present article reports the effects of administering a five-session cognitive-behavioral insomnia treatment to 5 patients who responded to CBT for PTSD yet continued to report insomnia. Insomnia treatment was associated with improvements on subjective sleep measures (Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Beliefs and Attitudes about Sleep Scale) and self-monitored sleep efficiency and related measures in 4 of 5 cases. Results highlight issues specific to treating insomnia in trauma populations and future directions for examining treatment of insomnia associated with PTSD.

Comorbid PTSD and social phobia in a treatment-seeking population: an exploratory study.

The purpose of this study was to examine patterns of comorbidity of posttraumatic stress disorder (PTSD) and social phobia (SP) and explore factors associated with the etiology and effect of this comorbidity. The sample consisted of 443 patients seeking treatment of PTSD, SP, or both. Of 240 patients with principal PTSD, 43% had comorbid SP, whereas only 7% of 57 with principal SP had comorbid PTSD. Patients with principal PTSD and comorbid SP were more likely to meet criteria for major depression and other anxiety disorders, and reported worse depression, anxiety, and physical, mental, and social functioning, than those with only PTSD or SP, regardless of other anxiety comorbidity. PTSD patients with SP reported more trauma-related guilt and higher frequency of childhood abuse than those without SP. The results are discussed in terms of implications for treatment of the comorbid presentation and directions for future research.

Factors associated with insomnia among civilians seeking treatment for PTSD: an exploratory study.

This study explored relationships between insomnia (as measured by Item 13 of the Clinician-Administered PTSD [Posttraumatic Stress Disorder] Scale) and other PTSD symptoms, comorbidity, and measures of depression, worry, and panic in a mixed-trauma sample of 143 treatment-seeking civilians with PTSD (median age 39.4 years, 83% female, 96% White). Regression analyses showed that, adjusting for sleep medication use, severity of nightmares and diminished interest in pleasurable activities accounted for unique variance in insomnia severity level. Severity of nightmares and depression accounted for unique variance in the presence of severe insomnia. Findings support a role for conditioning related to nightmares in the etiology of PTSD-related insomnia.

Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment.

This exploratory study investigated the relationship between anxiety disorders, anxiety comorbidity, and eating disorder (ED) symptoms in clinical practice, and examined the naturalistic detection of ED when diagnoses were based on the Anxiety Disorders Interview Schedule (ADIS). Two hundred and fifty-seven female patients completed an ED questionnaire and were assessed with the ADIS. Although ED frequency did not differ among anxiety disorder diagnoses, regression analyses revealed that social phobia (SP) and posttraumatic stress disorder (PTSD) accounted for unique variance in eating pathology. Questionnaire results indicated that almost 12% of patients met criteria for a possible ED. Clinicians using the ADIS evidenced good specificity but were not sensitive to detecting ED, missing 80% of possible cases. Results support possible links between ED, social phobia and PTSD and highlight the importance of assessing anxiety comorbidity when examining the relationship between ED and anxiety disorders. Results also suggest that formal screening for ED among female anxiety patients may be warranted.

Residual insomnia following cognitive behavioral therapy for PTSD.

This study examined whether insomnia persisted after completion of cognitive behavioral therapy (CBT) for PTSD and whether persistence of insomnia was associated with continuing nightmares, vigilance, depression, childhood abuse history, or having been traumatized in a sleep-related context. A retrospective analysis of posttreatment Clinician-Administered PTSD Scale (CAPS) data from 27 patients who no longer met PTSD diagnosis following CBT for PTSD revealed that 48% reported residual insomnia. For the large majority, insomnia persisted in the absence of continuing nightmares and hypervigilance. Experiencing trauma in a sleep-related context was associated with greater risk for residual insomnia, whereas childhood abuse history and depression were not. These findings suggest that interventions to address factors maintaining insomnia residual to PTSD warrant study.

Anger expression and essential hypertension: behavioral response to confrontation.

OBJECTIVE: The purpose of this study was to examine the range of anger-expressive behaviors and social competencies among essential hypertensive patients. METHODS: Behavioral reactions to both neutral and anger-evoking role-play interactions were measured in 26 hypertensive and 15 normotensive patients. Social behaviors were assessed using self-report measures of anger expression, assertiveness, self- and other-ratings of social competence and behavioral measures of anger expression observed during role-play interactions. RESULTS: Hypertensive patients showed less eye contact, used fewer positive assertive statements and were rated as being less assertive during confrontational role-play scenarios than normotensive controls. Hypertensive patients also exhibited higher pulse pressure reactions to confrontation than normotensives, particularly hypertensive patients who expressed anger overtly. CONCLUSION: Essential hypertension is associated with specific social skill deficits that are only apparent during the assertive expression of anger.

A survey of psychologists' attitudes towards and utilization of exposure therapy for PTSD.

Although research supports the efficacy of exposure therapy for PTSD, some evidence suggests that exposure is under-utilized in general clinical practice. The purpose of this study was to assess licensed psychologists' use of imaginal exposure for PTSD and to investigate perceived barriers to its implementation. A total of 852 psychologists from three states were randomly selected and surveyed. An additional 50 members of a trauma special interest group of a national behavior therapy organization were also surveyed. The main survey results indicate that a large majority of licensed doctoral level psychologists do not report use of exposure therapy to treat patients with PTSD. Although approximately half of the main study sample reported that they were at least somewhat familiar with exposure for PTSD, only a small minority used it to treat PTSD in their clinical practice. Even among psychologists with strong interest and training in behavioral treatment for PTSD, exposure therapy is not completely accepted or widely used. Clinicians also appear to perceive a significant number of barriers to implementing exposure.

Comorbid anxiety disorders in civilians seeking treatment for posttraumatic stress disorder.

Research indicates that posttraumatic stress disorder (PTSD) is associated with high rates of comorbid psychiatric diagnoses. Yet, it remains unknown whether PTSD is associated with greater comorbidity relative to patients with other anxiety disorders. This study examined prevalence of comorbid anxiety disorders with PTSD relative to other disorders among a treatment-seeking population. Patients with PTSD (n = 83) evidenced greater overall comorbidity as compared to patients with other anxiety (n = 151) or Axis I (n = 73) disorders. Compared to patients with panic disorder, patients with PTSD were more likely to be diagnosed with depression and social phobia, but not other anxiety disorders. Extent of anxiety disorder comorbidity was not related to PTSD severity. These findings are discussed in terms of their relevance for treatment of PTSD.

Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression.

Although anxiety disorders have been associated with impairments in self-reported health functioning, the relative effect of various anxiety disorders has not been studied. We compared health functioning of patients with a principal diagnosis of posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), and major depressive disorder (MDD). Patients with PTSD and MDD were equally impaired on overall mental health functioning, and both were significantly worse than patients with PD and GAD. PTSD was associated with significantly worse physical health functioning relative to PD, GAD, and MDD. Hierarchical regression showed that the association of PTSD with physical health functioning was unique and was not caused by the effects of age, depression, or comorbid anxiety disorders. Both PTSD and comorbid anxiety accounted for unique variance in mental functioning. These results highlight the association of PTSD with impaired physical and mental functioning and suggest that effective treatment of PTSD may affect overall health.

The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain.

Fear of pain has been implicated in the development and maintenance of chronic pain behavior. Consistent with conceptualizations of anxiety as occurring within three response modes, this paper introduces an instrument to measure fear of pain across cognitive, overt behavioral, and physiological domains. The Pain Anxiety Symptoms Scale (PASS) was administered to 104 consecutive referrals to a multidisciplinary pain clinic. The alpha coefficients were 0.94 for the total scale and ranged from 0.81 to 0.89 for the subscales. Validity was supported by significant correlations with measures of anxiety and disability. Regression analyses controlling for measures of emotional distress and pain showed that the PASS made a significant and unique contribution to the prediction of disability and interference due to pain. Evidence presented here supports the potential utility of the PASS in the continued study of fear of pain and its contribution to the development and maintenance of pain behaviors. Factor analysis and behavioral validation studies are in progress.