Examining the Link Between Intolerance of Uncertainty and Positive and Negative Urgency in Veterans With Comorbid Posttraumatic Stress Disorder and Substance Use Disorders.

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are highly comorbid among the veteran population. Impulsivity, particularly negative and positive urgency, are prevalent within this dual-diagnosis population and associated with negative outcomes. One possible correlate of negative/positive urgency is intolerance of uncertainty (IU). IU is associated with exacerbated PTSD symptom severity and increased risk for substance use. However, few studies have examined the link between IU and negative/positive urgency in dual-diagnosis populations. This study aimed to examine whether there was a significant association between trait IU and baseline negative and positive urgency in veterans seeking treatment for both PTSD and SUD. In a sample of 114 veterans from a 6-week residential treatment program, IU was significantly associated with higher negative and positive urgency. Further research is warranted to extend these findings and examine whether IU plays an important role in negative/positive urgency for dual-diagnosis populations.

Increased Resilience is Associated with Positive Treatment Outcomes for Veterans with Comorbid PTSD and Substance Use Disorders.

OBJECTIVE: Resilience has been associated with less severe psychiatric symptomatology and better treatment outcomes among individuals with posttraumatic stress disorder (PTSD) and substance use disorders. However, it remains unknown whether resilience increases during psychotherapy within the comorbid PTSD and substance use disorder population with unique features of dual diagnosis, including trauma cue-related cravings. We tested whether veterans seeking psychotherapy for comorbid PTSD and substance use disorder reported increased resilience from pre- to posttreatment. We also tested whether increased resilience was associated with greater decreases in posttreatment PTSD and substance use disorder symptoms. METHODS: Participants were 29 male veterans (Mage = 49.07 years, SD = 11.24 years) receiving six-week residential day treatment including cognitive processing therapy for PTSD and cognitive behavioral therapy for substance use disorder. Resilience, PTSD symptoms, and trauma cue-related cravings were assessed at pre- and posttreatment. RESULTS: Veterans reported a large, significant increase in resilience posttreatment (Mdiff = 14.24, t = -4.22, p < .001, d = 0.74). Greater increases in resilience were significantly associated with fewer PTSD symptoms (ß = -0.37, p = .049, sr = -.36) and trauma-cued cravings (ß = -0.39, p = .006, sr = -.38) posttreatment when controlling for pretreatment scores and baseline depressive symptoms. CONCLUSIONS: Results suggest that evidence-based psychotherapy for comorbid PTSD and substance use disorder may facilitate strength-based psychological growth, which may further promote sustained recovery.

The Role of Impulsivity Dimensions in the Relation Between Probable Posttraumatic Stress Disorder and Aggressive Behavior Among Substance Users.

OBJECTIVE: Individuals with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder report heightened levels of numerous risky and health-compromising behaviors, including aggressive behaviors. Given evidence that aggressive behavior is associated with negative substance use disorder treatment outcomes, research is needed to identify the factors that may account for the association between PTSD and aggressive behavior among patients with substance use disorder. Thus, the goal of this study was to examine the role of impulsivity dimensions (i.e., negative urgency, lack of premeditation, lack of perseverance, and sensation seeking) in the relations between probable PTSD status and both verbal and physical aggression. METHODS: Participants were 92 patients in residential substance use disorder treatment (75% male; 59% African American; M age = 40.25) who completed self-report questionnaires. RESULTS: Patients with co-occurring PTSD-substance use disorder (vs. substance use disorder alone) reported significantly greater verbal and physical aggression as well as higher levels of negative urgency and lack of premeditation. Lack of premeditation and lack of perseverance were significantly positively associated with verbal aggression, whereas negative urgency, lack of premeditation, and lack of perseverance were significantly positively associated with physical aggression. The indirect relation of probable PTSD status to physical aggression through negative urgency was significant. CONCLUSIONS: Results highlight the potential utility of incorporating skills focused on controlling impulsive behaviors in the context of negative emotional arousal in interventions for physical aggression among patients with co-occurring PTSD-substance use disorder.

The relation of PTSD symptoms to migraine and headache-related disability among substance dependent inpatients.

Despite emerging evidence for the comorbidity of posttraumatic stress disorder (PTSD) and migraine, few studies have examined the relation of PTSD and migraine, particularly among clinical populations at-risk for both conditions (e.g., substance-dependent patients). This study examined the role of PTSD symptoms in migraine and headache-related disability within a sample of 153 substance-dependent inpatients (37.25% female, Mean age 36.46). PTSD symptoms predicted both migraine and headache-related disability above and beyond gender, depression and anxiety symptoms, the experience of a Criterion A traumatic event, and current alcohol use disorder. Findings highlight the strong association between migraine and PTSD symptoms in a unique population at risk for both conditions.

Postoperative Recurrent Cholesteatoma in Rural Versus Urban Populations.

OBJECTIVE: Chronic ear disease presents a unique challenge to otolaryngologists in both rural and urban settings. Cholesteatoma remains a difficult disease to treat in rural populations due to limited healthcare access and high risk of recurrence. The purpose of this study was to determine if there are differences in surgical outcomes among patients with acquired cholesteatoma residing in rural versus urban settings. STUDY DESIGN: Single-surgeon retrospective case series with chart review. SETTING: Tertiary care private otolaryngology practice. PATIENTS: One hundred twenty-two patients presenting to the Kentuckiana ENT otology and neurotology practice from January 2011 to May 2017. MAIN OUTCOME MEASURES: Surgical outcomes including recurrence, air-bone gap improvement, ossicular integrity, and complications were reviewed and compared between the rural and urban cohorts. RESULTS: Presence of postoperative residual cholesteatoma (OR = 8.667, 95% CI = 2.022-37.141, p = 0.008) and number of surgeries per patient (OR = 5.185, 95% CI = 1.086-24.763, p = 0.024) were significantly increased among patients in rural nonmetropolitan areas. No significant differences were found when comparing risk of recurrence, size of cholesteatoma, presence of complications, air-bone gap improvement, and ossicular chain integrity. There were significantly more second-look surgeries performed in privately insured patients (OR = 8.582, 95% CI = 1.937-38.017, p = 0.001). CONCLUSIONS: Patients in rural communities have an increased number of surgeries and postoperative risk for residual cholesteatoma compared to patients residing in urban settings. This study provides the basis for larger, multicenter, prospective examinations of outcomes among urban versus rural patients, which would enable a better understanding of difference in surgical outcomes between rural and urban cohorts.Level of Evidence: IV.

Pre- to Posttreatment Changes in Trauma-Cued Negative Emotion Mediate Improvement in Posttraumatic Stress Disorder, Depression, and Impulsivity.

Posttraumatic stress disorder (PTSD) is characterized by strong negative emotions, often in response to trauma cues or reminders. Subsequent emotion regulation strategies impact the maintenance of PTSD symptoms and other trauma-related outcomes (depression, substance use). This study aimed to examine a range of trauma-cued emotions to enhance our understanding of changes following treatment and their potential role in improving relevant outcomes. Participants included 67 veterans diagnosed with PTSD and a substance use disorder who completed a dual diagnosis residential program that used cognitive processing therapy. At pre- and posttreatment, we measured 8 negative emotions following a trauma recall and PTSD symptoms, depressive symptoms, and negative urgency (impulsivity following negative emotions) as treatment outcomes. We used t-tests to assess changes at posttreatment and a within-subjects mediational analysis to test whether changes in trauma-cued emotions mediated treatment outcomes. Participants reported moderate, significant decreases for 5 emotions at posttreatment: anger at self, disgust at self, fear, guilt, and sadness (d ≥ 0.50), whereas nonsignificant changes were found for anger at others, disgust at others, and shame. Mediation analyses indicated greater reductions in trauma-cued sadness had a significant indirect effect on improvement in PTSD symptoms, depressive symptoms, and negative urgency. Reductions in disgust at self and fear also demonstrated a significant indirect effect on depressive symptom improvement. In this dual diagnosis program, veterans reported a significant reduction in some, but not all, trauma-cued emotions, and improvements in only select emotions accounted for a significant portion of improvement in relevant treatment outcomes.

Effect of Fatigue on Equine Metacarpophalangeal Joint Kinematics-A Single Horse Pilot Study.

The objective was to validate a scientific method for characterizing equine metacarpophalangeal joint (MCPJ) motion in the nonfatigued and fatigued states using a single horse at trot, slow canter, and fast canter. One healthy Thoroughbred gelding exercised on a treadmill to exhaustion (fatigued state) (heart rate >190 BPM and blood lactate >10 mmol/L) while bilateral MCPJ angular data were acquired using electrogoniometry. Blood lactate and heart rate reflected transition from nonfatigued to fatigued states with increasing exercise duration and treadmill speed. Electrogoniometry consistently demonstrated: increase in mean MCPJ maximum extension angle with onset of fatigue; altered extension and flexion angular velocities with onset of fatigue; and increasing stride duration and decreasing stride frequency with onset of fatigue. The method allowed a preliminary but comprehensive characterization of the dynamic relationship between MCPJ kinematics and fatigue, prompting the need for multisubject studies that may enhance our ability to moderate exercise-related distal limb injury in equine athletes.

Information processing in contamination fear: a covariation bias examination of fear and disgust.

The current study represents the first examination of covariation biases in contamination fear. Using an undergraduate sample we examined covariation bias for specific emotion outcomes (fear specific and disgust specific) associated with contamination stimuli in high contamination fear (HCF; n=32) and low contamination fear (LCF; n=30) individuals. Following random stimulus-outcome presentation participants provided estimations on the proportion of each presented stimulus-expression pairing. Analyses revealed a specific bias for the over-estimation of fear and disgust contingencies among the HCF group, but not the LCF group. The current study also revealed a specific covariation bias among HCF, not LCF, participants to over-estimate the contingency between contamination stimuli and fear outcomes, not disgust outcomes. Further, results indicate that HCF individuals significantly under-estimate the covariation among contamination stimuli and safety outcomes compared to LCF participants. These findings are discussed in terms of theoretical implications for information processing biases in anxiety disorders.

Behavioral avoidance and self-reported fainting symptoms in blood/injury fearful individuals: an experimental test of disgust domain specificity.

This study examined the specificity of disgust in predicting avoidance in blood/injury (BI) phobia. Participants high (n=38) and low (n=46) in BI fear completed measures of disgust across multiple domains and severity of BI-related fear. They then completed three randomly presented behavioral avoidance tasks (BATs) that consisted of exposure to a 15'' severed deer leg (BI task), a live spider (spider task), and a 'contaminated' cookie (cookie task). Fainting symptoms associated with each BAT were recorded as well. When controlling for gender and BI fear group membership, mutilation disgust contributed unique variance to avoidance on the BI task and animal disgust contributed unique variance to avoidance on the spider task. None of the disgust domains contributed unique variance to avoidance on the cookie task. For the high BI fear group, self-reported fainting symptoms were more pronounced during the BI and spider BAT than during the cookie BAT. Although mutilation disgust was significantly associated with self-reported fainting symptoms on the BI task among the high BI fear group, this relationship became nonsignificant when controlling for BI-related fear severity. Implications of the domain specificity of disgust and its relevance for understanding fainting responses in BI phobia are discussed.

A cognitive processing therapy-based treatment program for veterans diagnosed with co-occurring posttraumatic stress disorder and substance use disorder: The relationship between trauma-related cognitions and outcomes of a 6-week treatment program.

Dysfunctional trauma-related cognitions are important in the emergence and maintenance of posttraumatic stress disorder (PTSD) and the modification of such cognitions is a proposed mechanism of trauma treatment. However, the authors are not aware of any research examining trauma-related cognitions as a treatment mechanism in a sample of individuals with comorbid PTSD and substance use disorder (SUD). Accordingly, the present study sought to address this gap in the literature and examined the relationship between trauma-related cognitions and treatment outcomes within a sample of seventy-two veterans diagnosed with PTSD and SUD. Veterans completed a 6-week day CPT-based treatment program that included cognitive processing therapy as a central component. Measures of trauma-related cognitions, PTSD symptoms, depressive symptoms, and trauma-cued substance craving were completed at pre- and post-treatment. As expected, trauma-related cognitions were associated with several PTSD-related variables prior to treatment. Furthermore, results of a within-subjects mediational analysis indicated that maladaptive trauma-related cognitions decreased during the treatment program and accounted for a significant portion of the variance in the reduction of PTSD and depressive symptoms at post-treatment. This study provides support for the position that attempts to modify dysfunctional trauma-related cognitions among veterans with co-occurring PTSD and SUD can lead to desirable treatment outcomes.

Structural differentiation of disgust from trait anxiety in the prediction of specific anxiety disorder symptoms.

Research has begun to implicate the role of disgust in the etiology of specific phobias and obsessive-compulsive disorder (OCD). However, it remains unclear if the association between disgust and specific anxiety disorder symptoms is an artifact of trait anxiety or a potential mechanism through which trait anxiety effects specific anxiety disorder symptoms. The present study employed structural equation modeling to differentiate disgust from trait anxiety in the prediction of four types of specific anxiety disorder symptoms in a non-clinical sample (N=352). Results indicate that disgust and trait anxiety latent factors were independently related to spider fears, blood-injection-injury (BII) fears, general OCD symptoms, and OCD washing concerns. However, when both variables were simultaneously modeled as predictors, latent disgust remained significantly associated with the anxiety disorder symptoms, whereas the association between latent trait anxiety and the anxiety disorder symptoms became non-significant or was substantially reduced. Statistical tests of intervening variable effects converged in support of disgust as a significant intervening variable between trait anxiety and spider fears, BII fears, and OCD symptoms (particularly washing concerns). The relevance of these findings for future research investigating the role of disgust in specific anxiety disorders is discussed.

Scrupulosity and obsessive-compulsive symptoms: confirmatory factor analysis and validity of the Penn Inventory of Scrupulosity.

The current study examined scrupulosity in 352 unselected college students as measured by the 19-item Penn Inventory of Scrupulosity (PIOS). Confirmatory factor analysis yielded support for a two-factor model of the 19-item PIOS. However, item-level analyses provided preliminary support for the validity of a 15-item PIOS (PIOS-R) secondary to the removal of items 2, 6, 15, and 10. The two domains of scrupulosity identified on the PIOS-R consisted of the Fear of Sin and the Fear of God. Both domains and total scrupulosity scores were strongly related to obsessive-compulsive symptoms. Scrupulosity also showed significant, but more modest correlations with a broad range of other measures of psychopathology symptoms (i.e., state anxiety, trait anxiety, negative affect, disgust sensitivity, specific fears). However, only obsessive-compulsive symptoms and trait anxiety contributed unique variance to the prediction of scrupulosity. Examination of specific obsessive-compulsive symptom dimensions revealed that only obsessions contributed unique positive variance to the prediction of Fear of God. However, OCD obsessions, washing, and hoarding symptoms contributed unique positive variance to the prediction of Fear of Sin. These findings are interpreted in the context of future research elucidating the relationship between scrupulosity and obsessive-compulsive symptom dimensions.

The impact of changes in distress tolerance on PTSD symptom severity post-treatment among veterans in residential trauma treatment.

Given that rates of PTSD, particularly among military populations, are increasing, it is critical to gain a better understanding of factors associated with treatment response. Low distress tolerance (DT), conceptualized as the perceived or actual inability to tolerate negative emotional states, may impacts veterans' responses to PTSD treatment. Low DT has been associated with more severe PTSD symptoms in clinical and non-clinical samples; however, its impact on PTSD symptomatology across treatment has yet to be assessed. We examined the impact of changes in DT, from intake to discharge, on post-treatment PTSD symptom severity within two samples of veterans recruited from Veterans Affairs residential PTSD treatment facilities in the northwestern and southern United States (Total N=86; 87% male; 46% White, 39% Black, 9% Latino, 6% Other). Veterans completed the Distress Tolerance Scale and PTSD Checklist (PCL) at intake and discharge from residential PTSD treatment. Regression analyses revealed that, within each veteran sample, those with the greatest improvements in DT had the lowest PCL total and subscale scores at discharge after controlling for respective intake PCL scores. This suggests increases in DT across treatment help explain the degree of benefits experienced by veterans following PTSD treatment.

The impact of intolerance of emotional distress and uncertainty on veterans with co-occurring PTSD and substance use disorders.

The risk of developing a substance use disorder (SUD) is significantly higher among veterans with posttraumatic stress disorder (PTSD). Veterans with this co-occurrence have poorer outcomes than singly diagnosed veterans, which may be related to two risk factors: intolerance uncertainty (IU) and low tolerance of emotional distress (TED). We hypothesized low TED and high IU would independently and interactively relate to heightened PTSD symptomatology and trauma-cue elicited SUD cravings. A sample of 70 veterans (M age=50; 95% men; 65% Black) with co-occurring PTSD-SUD was recruited. The Posttraumatic Stress Disorder Checklist (PCL), Craving Questionnaire, Distress Tolerance Scale, and Intolerance of Uncertainty Scale were administered. In general, low TED and high IU were significantly correlated with the PCL total and subscale scores. When examined within regression models, low TED was associated with elevated PCL scores and trauma-cue elicited SUD cravings; IU was not. However, there was a significant interaction between IU and TED; veterans with elevated IU and low TED had higher PCL Total, Hyperarousal, and Intrusions scores. This highlights the importance of assessing TED and IU among veterans with co-occurring PTSD-SUD, as these risk factors may not only be prognostic indicators of outcomes, but also treatment targets.

Diagnostic Concordance between DSM-5 and ICD-10 Cannabis Use Disorders.

OBJECTIVES: With the recent federal mandate that all U.S. health care settings transition to ICD-10 billing codes, empirical evidence is necessary to determine if the DSM-5 designations map to their respective ICD-10 diagnostic categories/billing codes. The present study examined the concordance between DSM-5 and ICD-10 cannabis use disorder diagnoses. METHOD: Data were derived from routine clinical assessments of 6871 male and 801 female inmates recently admitted to a state prison system from 2000 to 2003. DSM-5 and ICD-10 diagnostic determinations were made from algorithms corresponding to the respective diagnostic formulations. RESULTS: Past 12-month prevalence rates of cannabis use disorders were comparable across classification systems. The vast majority of inmates with no DSM-5 diagnosis continued to have no diagnosis per the ICD-10, and a similar proportion with a DSM-5 severe diagnosis received an ICD-10 dependence diagnosis. Most of the variation in diagnostic classifications was accounted for by those with a DSM-5 moderate diagnosis in that approximately half of these cases received an ICD-10 dependence diagnosis while the remaining cases received a harmful use diagnosis. CONCLUSIONS: Although there appears to be a generally high level of agreement between diagnostic classification systems for those with no diagnosis or those evincing symptoms of a more severe condition, concordance between DSM-5 moderate and ICD-10 dependence diagnoses was poor. Additional research is warranted to determine the appropriateness and implications of the current DSM-5 coding guidelines regarding the assignment of an ICD-10 dependence code for those with a DSM-5 moderate diagnosis.

Regulation of directionality in bacteriophage lambda site-specific recombination: structure of the Xis protein.

Upon induction of a bacteriophage lambda lysogen, a site-specific recombination reaction excises the phage genome from the chromosome of its bacterial host. A critical regulator of this process is the phage-encoded excisionase (Xis) protein, which functions both as a DNA architectural factor and by cooperatively recruiting integrase to an adjacent binding site specifically required for excision. Here we present the three-dimensional structure of Xis and the results of a structure-based mutagenesis study to define the molecular basis of its function. Xis adopts an unusual "winged"-helix motif that is modeled to interact with the major- and minor-grooves of its binding site through a single alpha-helix and loop structure ("wing"), respectively. The C-terminal tail of Xis, which is required for cooperative binding with integrase, is unstructured in the absence of DNA. We propose that asymmetric bending of DNA by Xis positions its unstructured C-terminal tail for direct contacts with the N-terminal DNA-binding domain of integrase and that an ensuing disordered to ordered transition of the tail may act to stabilize the formation of the tripartite integrase-Xis-DNA complex required for phage excision.

The Anxiety Sensitivity Profile revisited: factor structure and psychometric properties in two nonclinical samples.

Anxiety sensitivity (AS) refers to the fear of anxiety-related symptoms based upon the belief that the sensations have harmful consequences. Although the most popular existing measure is the Anxiety Sensitivity Index (ASI), the Anxiety Sensitivity Profile (ASP) was developed as an alternative and theoretically improved assessment of the multifaceted nature of the AS construct. Nevertheless, there has been a paucity of research on this measure. We evaluated the psychometric properties and factor structure of the ASP in two large, geographically diverse undergraduate samples who completed the ASP and measures of anxiety and depression. Exploratory factor analysis revealed four lower order ASP factors in both samples: (1) fear of arousal-related symptoms, (2) fear of cognitive dyscontrol and dissociation, (3) fear of gastrointestinal symptoms, and (4) fear of cardiac symptoms. The fear of cardiac symptoms factor was relatively unstable in both studies. Correlations between the ASP factors and related variables were consistent with AS theory. The strengths and limitations of the ASP are offered as well as the implications of our findings for the nature and assessment of AS.

A Preliminary Examination of Negative Affect, Emotion Dysregulation, and Risky Behaviors among Military Veterans in Residential Substance Abuse Treatment.

Substance use disorder (SUD) is highly prevalent among military populations and associated with a wide range of negative outcomes. The goal of the present study was to explicate the relations among negative affect, emotion dysregulation, and urges to engage in risky behaviors among military veterans in residential SUD treatment. Emotion dysregulation (overall and three dimensions: access to emotion regulation strategies, impulse control, and emotional awareness) mediated the relation between negative affect and urges to engage in risky behaviors. Findings highlight the potential utility of treatments targeting emotion dysregulation in reducing risky behaviors among military veterans with SUD.

Localization and mutagenesis of the sorting signal binding site on sortase A from Staphylococcus aureus.

Surface proteins in Gram-positive bacteria are anchored to the cell wall by the action of sortase enzymes. The Staphylococcus aureus sortase A (SrtA) protein anchors proteins by recognizing a cell wall sorting signal containing the amino acid sequence LPXTG. To understand how SrtA binds this sequence, we carried out NMR studies of new peptidyl-cyanoalkene and peptidyl-sulfhydryl inhibitors that contain the sorting signal sequence LPAT. These studies combined with amino acid mutagenesis identified a catalytically important and conserved binding surface formed by residues A118, T180, and I182. Compatible with its recently proposed role as a general base, R197 is also shown to be required for catalysis.

Feeding practices of dog breeders in the United States and Canada.

OBJECTIVE: To determine the proportion of dog breeders who fed diets meeting the Association of American Feed Control Officials regulations for nutritional adequacy for reproduction and growth and to investigate factors that influenced feeding practices of breeders. DESIGN: Web-based cross-sectional survey. SAMPLE: 2,067 dog breeders from the United States and Canada. PROCEDURES: A self-administered, anonymous, Web-based questionnaire was used to collect information on breeder demographics and feeding practices during 3 life stages of dogs: adult maintenance for nonpregnant dogs, gestation-lactation, and puppy growth. Appropriateness of commercial diets for each life stage was determined by respondent-reported nutritional adequacy statements on product labels. Data were also collected regarding breeder criteria for diet selection and sources of nutrition information. RESULTS: A substantial number of breeders reported feeding commercial diets not intended for that life stage during gestation-lactation (126/746 [16.9%]) and puppy growth (57/652 [8.7%]). Additionally, approximately one-seventh of breeders reported feeding home-prepared diets for ≥ 1 life stage. Unsubstantiated health and marketing information influenced diet selection of many breeders. Veterinarians, although generally viewed as a trusted source of nutrition information, were consulted by only 823 of 1,669 (49.3%) breeders and were viewed less favorably by breeders feeding home-prepared diets, compared with the opinion of breeders feeding commercial diets. CONCLUSIONS AND CLINICAL RELEVANCE: Veterinarians should consider taking a more proactive role in directing dog breeders and other pet owners toward scientifically substantiated sources of diet information and in explaining the importance of current nutritional standards for reproduction and early development of dogs.