A Naturalistic Comparison of Group Transdiagnostic Behaviour Therapy (TBT) and Disorder-Specific Cognitive Behavioural Therapy Groups for the Affective Disorders.

BACKGROUND: Transdiagnostic psychotherapies are designed to apply the same underlying treatment principles across a set of psychiatric disorders, without significant tailoring to specific diagnoses. Several transdiagnostic psychotherapy protocols have been developed recently, each of which has its own strengths and weaknesses. One promising treatment is Transdiagnostic Behaviour Therapy (TBT), in that it is one of the few transdiagnostic treatments to date shown to be effective in patients with depressive and anxiety disorders. However, TBT has only been investigated via individual psychotherapy. AIMS: The present study investigated the effectiveness of a group protocol for TBT, compared with disorder-specific group psychotherapies, in a naturalistic setting. METHOD: 109 participants with various diagnoses of affective disorders completed either group TBT (n = 37) or a disorder-specific group psychotherapy (n = 72). Measures included assessments of psychiatric symptomatology and transdiagnostic impairment at baseline and post-treatment. RESULTS: Overall, participants in the TBT group demonstrated significant improvements across all measures. When compared with disorder-specific groups, no statistical differences were observed between groups across symptoms; however, participants in the TBT group demonstrated roughly twice the treatment effect sizes in transdiagnostic impairment compared with participants in the disorder-specific groups. In addition, when participants from the most well-represented diagnosis and disorder-specific treatment (social anxiety disorder) were investigated separately, participants in the TBT group demonstrated significantly larger improvements in comorbid depressive symptoms than participants in the disorder-specific treatment. CONCLUSIONS: Pending replication and additional comparison studies, group TBT may provide an effective group treatment option for patients with affective disorders.

Heterogeneity of treatment dropout: PTSD, depression, and alcohol use disorder reductions in PTSD and AUD/SUD treatment noncompleters.

Treatment dropout is often assumed to be due to worsening or lack of symptom improvement, despite minimal research examining symptom change among treatment dropouts. Thus, the present study examined symptom change in veterans who discontinued evidence-based treatment for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Participants were veterans who completed at least one session of a 12-session Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) for comorbid PTSD/AUD. The study analyses investigated the 43% of the sample (n = 22) that did not complete the full 12-session protocol and were therefore considered treatment dropouts. Symptom changes in PTSD, AUD, and depression were examined among dropouts using two methods: (a) clinically significant change criteria and (b) good end-state criteria. Results indicated that a significant proportion of treatment dropouts displayed clinically significant improvement and/or met good end-state criteria for PTSD (40-59%), AUD (66%), and depression (45-68%) prior to dropping out. The results revealed that participants who displayed symptom improvement attended more treatment sessions and completed more imaginal exposures than participants who did not experience significant improvement. Together, the findings add to a growing body of literature suggesting that a large proportion of treatment dropouts may actually improve. Although preliminary, the findings challenge the notion that treatment dropout is always associated with negative outcomes.

Predictors of Treatment Discontinuation During Prolonged Exposure for PTSD.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a 'sufficient dose' of psychotherapy, potentially limiting treatment gains. AIMS: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. METHOD: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. RESULTS: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. CONCLUSIONS: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.

The influence of traumatic brain injury on treatment outcomes of Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) in veterans.

BACKGROUND: The co-occurrence of posttraumatic stress disorder (PTSD), substance use disorders (SUD), and traumatic brain injury (TBI) in veterans of Operations Enduring/Iraqi Freedom and New Dawn has received much attention in the literature. Although hypotheses have been presented and disseminated that TBI history will negatively influence treatment response, little data exist to support these claims. The present study investigates the influence of TBI history on response to COPE (Concurrent Treatment of PTSD and SUD Using Prolonged Exposure), a 12-session, integrated psychotherapy designed to address co-occurring PTSD and SUD. METHOD: Participants were 51 veterans with current PTSD and SUD enrolled in a clinical trial examining COPE. Assessments of PTSD symptoms, substance use, and depression were collected at baseline and each treatment session. A TBI measure was used to dichotomize veterans into groups with and without a history of TBI (ns=30 and 21, respectively). RESULTS: Participants with and without TBI history demonstrated significant improvements in PTSD and depression symptoms during the course of treatment. However, participants with TBI history experienced less improvement relative to participants without TBI history. CONCLUSIONS: The present findings suggest that, although patients with a TBI history respond to treatment, their response to treatment was less so than that observed in patients without a TBI history. As such, identification, symptom monitoring, and treatment practices may require alteration and further special consideration in individuals with PTSD, SUD and TBI.

An Experimental Comparison of Techniques: Cognitive Defusion, Cognitive Restructuring, and in-vivo Exposure for Social Anxiety.

BACKGROUND: One of the primary differences between Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for anxiety is the approach to managing negative thoughts. CBT focuses on challenging the accuracy of dysfunctional thoughts through cognitive restructuring exercises, whereas ACT attempts to foster acceptance of such thoughts through cognitive defusion exercises. Previous research suggests that both techniques reduce the distress associated with negative thoughts, though questions remain regarding the benefit of these techniques above and beyond exposure to feared stimuli. AIMS: In the present study, we conducted a brief experimental intervention to examine the utility of cognitive defusion + in-vivo exposure, cognitive restructuring + in-vivo exposure, and in-vivo exposure alone in reducing the impact of negative thoughts in patients with social anxiety disorder. METHOD: All participants completed a brief public speaking exposure and those in the cognitive conditions received training in the assigned cognitive technique. Participants returned a week later to complete a second exposure task and self-report measures. RESULTS: All three conditions resulted in similar decreases in discomfort related to negative thoughts. ANOVA models failed to find an interaction between change in accuracy or importance and assignment to condition in predicting decreased distress of negative thoughts. CONCLUSIONS: These preliminary results suggest that changes in perceived importance and accuracy of negative thoughts may not be the mechanisms by which cognitive defusion and cognitive restructuring affect distress in the short-term.

Problems in sexual functioning among male OEF/OIF veterans seeking treatment for posttraumatic stress.

OBJECTIVE: Few studies have examined sexual dysfunction among Operations Enduring/Iraqi Freedom (OEF/OIF) veterans with posttraumatic stress disorder (PTSD). The present study investigated predictors of erectile dysfunction [ED] and self-reported sexual problems among 150 male combat veterans seeking outpatient treatment for PTSD within the Veterans Affairs healthcare system. METHOD: Participants completed clinical interviews and several questionnaires including measures of sexual arousal and sexual desire. A medical records review was also conducted to document evidence of an ED diagnosis or associated medication use. RESULTS: An ED diagnosis was present for 12% of the sample, and 10% were taking associated medications. Sexual arousal problems were reported by sixty-two percent of partnered veterans. Sexual desire problems were endorsed by 63% of the total sample, and by 72% of partnered veterans. Age was the only significant predictor of ED diagnosis or medication use. Age, race, PTSD diagnosis (versus subclinical symptoms), depression, and social support predicted self-reported sexual arousal problems; while race, combat exposure, social support, and avoidance/numbing symptoms of PTSD predicted self-reported sexual desire problems. CONCLUSIONS: Sexual problems are common among male OEF/OIF combat veterans seeking treatment for PTSD. Moreover, avoidance/numbing symptoms robustly predicted sexual desire problems. These findings highlight the importance of expanding assessment of sexual dysfunction and support the need for additional research in this area.

Effect of transdiagnostic cbt for anxiety disorders on comorbid diagnoses.

OBJECTIVE: The present study examines the effectiveness of a 12-week transdiagnostic cognitive-behavioral group in reducing comorbid diagnoses. METHOD: Data from 79 treatment completers (60.8% women; M age = 32.57 years) during three previous trials of transdiagnostic cognitive behavior therapy (CBT) were examined to compare treatment effects between those with and without comorbid diagnoses. Additionally, rates of remission of comorbid diagnoses were compared to published diagnosis-specific CBT trials. RESULTS: Results indicate that a majority of clients (64.6%) had at least one comorbid disorder and that those with comorbid diagnoses had higher primary diagnosis severity scores than did those without comorbid diagnoses. The presence of a comorbid diagnosis at pretreatment was not associated with differential improvement in primary diagnosis severity following treatment. Two-thirds of completers with comorbid diagnoses at pretreatment (66.7%) no longer met criteria for a clinically severe comorbid diagnosis at posttreatment, a rate higher than that associated with most trials of diagnosis-specific CBT for anxiety disorders used as benchmarks. CONCLUSIONS: These results suggest that transdiagnostic cognitive-behavioral group treatment for anxiety may be associated with greater decreases in comorbidity than traditional diagnosis-specific CBT.

Investigating Relations Between the Symptoms of Panic, Agoraphobia, and Suicidal Ideation: The Significance of Comorbid Depressive Symptoms in Veterans with Panic Disorder.

Although panic disorder has been frequently associated with increased suicidal ideation and behaviors, there are multiple explanations for this association in the literature. For example, some research has demonstrated panic disorder symptoms to mediate agoraphobia and suicidal ideation, while other researchers have hypothesized that comorbid depression symptoms contribute to suicidal ideation across anxiety disorders. Of note, none of these studies were completed in veterans, a population at higher risk for suicide relative to civilian samples. The present study investigated relations between the symptoms of panic, agoraphobia, depression, and suicidal ideation in 58 veterans diagnosed with panic disorder via correlations, hierarchical regression, and exploratory path analyses. Multiple models were investigated based on prior research. The final path model demonstrated that symptoms of panic disorder predicted agoraphobia symptoms, with agoraphobia predicting symptoms of depression. Symptoms of depression, then, predicted suicidal ideation. Discussion of the findings related to comorbid depressive symptoms highlight considerations for the assessment and treatment practices for panic disorder, with a particular focus on veterans receiving care within Veterans Affairs Healthcare System.

A real world dissemination and implementation of Transdiagnostic Behavior Therapy (TBT) for veterans with affective disorders.

Dissemination and implementation of evidence-based psychotherapies is challenging in real world clinical settings. Transdiagnostic Behavior Therapy (TBT) for affective disorders was developed with dissemination and implementation in clinical settings in mind. The present study investigated a voluntary local dissemination and implementation effort, involving 28 providers participating in a four-hour training on TBT. Providers completed immediate (n=22) and six-month follow-up (n=12) training assessments and were encouraged to collect data on their TBT patients (delivery fidelity was not investigated). Findings demonstrated that providers endorsed learning of and interest in using TBT after the training. At six-months, 50% of providers reported using TBT with their patients and their perceived effectiveness of TBT to be very good to excellent. Submitted patient outcome data evidenced medium to large effect sizes. Together, these findings provide preliminary support for the effectiveness of a real world dissemination and implementation of TBT.

High rates of PTSD treatment dropout: A possible red herring?

Few studies have examined symptom change among dropouts from posttraumatic stress disorder (PTSD) treatment. However, dropout is widely considered a negative event needing to be addressed. The present study investigated PTSD and depression symptom change in patients with PTSD who discontinued psychotherapy. Female civilians (n=321) diagnosed with PTSD participated in two randomized clinical trials examining PTSD treatment outcomes. Of those, 53 were identified as dropouts and included in this study. Symptom change was assessed by clinically significant change (CSC) criteria and symptom end-state criteria. Results demonstrated that considerable proportions of participants (35.85-55.56%) displayed significant improvement and/or met good end-state criteria for PTSD and depression. Results also revealed that participants who displayed symptom improvement were younger, attended more treatment sessions, were married or partnered, and had higher annual household income. Although preliminary, these findings contradict belief that treatment dropouts do not display symptom improvement.

Integrated, exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout.

High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.

Movement towards transdiagnostic psychotherapeutic practices for the affective disorders.

Evidence-based cognitive behavioural therapy (CBT) practices were first developed in the 1960s. Over the decades, refinements and alternative symptom foci resulted in the development of several CBT protocols/manuals for each of the many disorders, especially in the affective disorders. Although shown to be effective in highly trained providers, the proliferation of CBT protocols also has shown to demonstrate challenges in dissemination and implementation efforts due to the sheer number of CBT protocols and their related training requirements (eg, 6 months per protocol) and their related cost (eg, over US$2000 each; lost days/hours at work). To address these concerns, newer transdiagnostic CBT protocols have been developed to reduce the number of disorder-specific CBT protocols needed to treat patients with affective disorders. Transdiagnostic treatments are based on the notion that various disorder-specific CBT protocols contain important but overlapping treatment components that can be distilled into a single treatment and therefore address the symptoms and comorbidities across all of the disorders at once. 3 examples of transdiagnostic treatments include group CBT of anxiety, unified protocol for transdiagnostic treatment for emotional disorders and transdiagnostic behaviour therapy. Each transdiagnostic protocol is designed for a different set of disorders, contains a varied amount of CBT treatment components and is tested in different types of samples. However, together, these 3 transdiagnostic psychotherapies represent the future of CBT practice.

Sexual Problems Predict PTSD and Depression Symptom Change Among Male OEF/OIF Veterans Completing Exposure Therapy.

OBJECTIVE: A growing literature documents frequent sexual problems among Operations Enduring/Iraqi Freedom (OEF/OIF) veterans with post-traumatic stress disorder (PTSD). However, there has been no examination of how (1) sexual problems may be affected by evidenced-based psychotherapy for PTSD or (2) how the presence of sexual problems might impact effectiveness of evidenced-based psychotherapy for PTSD. As such, the present study investigated associations among symptoms of PTSD, depression, and problems with sexual desire and arousal among 45 male OEF/OIF veterans receiving behavioral activation and therapeutic exposure (BA-TE), an evidence-based behavior therapy targeting co-occurring symptoms of PTSD and depression. METHOD: Participants completed clinical interviews and several questionnaires including measures of sexual arousal, sexual desire, PTSD symptoms, and depression symptoms at baseline and after completion of 8 sessions of BA-TE treatment. A records review was also conducted to assess for relevant medication use. RESULTS: Overall, sexual desire and sexual arousal problems did not improve during the course of treatment. Moreover, veterans with co-occurring sexual problems at baseline evidenced significantly less improvement in symptoms of PTSD and depression across treatment as compared to veterans without sexual problems. CONCLUSIONS: These findings suggest that veterans with co-occurring symptoms of PTSD and sexual problems may require additional assessment and treatment considerations in order to improve their treatment outcomes for both primary psychiatric symptoms as well as sexual problems. Future research on combination treatments of medication for sexual problems and psychotherapy for PTSD is needed.

Investigation of abbreviated 4 and 8 item versions of the PTSD Checklist 5.

Posttraumatic stress disorder (PTSD) is a significant public health concern associated with marked impairment across the lifespan. Exposure to traumatic events alone, however, is insufficient to determine if an individual has PTSD. PTSD is a heterogeneous diagnosis such that assessment of all 20 symptoms is problematic in time-limited treatment settings. Brief assessment tools that identify those at risk for PTSD and measure symptom severity are needed to improve access to care and assess treatment response. The present study evaluated abbreviated measures of PTSD symptoms derived from the PTSD Checklist for DSM-5 (PCL-5) - a 20-item validated measure of PTSD symptoms - across two studies. In the first, using a community sample of adults exposed to a traumatic event, 4-and 8-item versions of the PCL-5 were identified that were highly correlated with the full PCL-5. In the second, using a sample of combat veterans, the 4-and 8-item measures had comparable diagnostic utility to the total-scale PCL-5. These results provide support for an abbreviated measure of the PCL-5 as an alternative to the 20-item total scale.

Validity of posttraumatic stress disorder service connection status in Veterans Affairs electronic records of Iraq and Afghanistan Veterans.

OBJECTIVE: This study examined the extent to which veterans' posttraumatic stress disorder (PTSD) service connection (SC) status corresponded to their PTSD diagnostic status, as determined by a semistructured diagnostic interview. METHOD: Participants were 834 veterans in the Veterans After-Discharge Longitudinal Registry (Project VALOR), an observational registry of veterans with and without PTSD who are enrolled in the Veterans Affairs (VA) health care system. PTSD diagnostic status was confirmed using the Structured Clinical Interview for DSM-IV (SCID). RESULTS: Concordance between PTSD SC status and current and lifetime PTSD diagnosis was 70.2% and 77.2%, respectively. Individuals with PTSD SC were twice as likely as those without PTSD SC to have a current SCID PTSD diagnosis (OR = 2.11 [95% CI, 1.47-3.04]; P < .001) and almost 3 times as likely to have a lifetime SCID PTSD diagnosis (OR = 2.72 [95% CI, 1.67-4.41]; P < .001). For current PTSD, results showed a slightly higher proportion of false positives-individuals who did not meet SCID criteria but who did have SC for PTSD-than false negatives-individuals who met SCID criteria but did not have SC for PTSD. For lifetime PTSD, the proportion of false negatives was approximately twice the proportion of false positives. CONCLUSIONS: PTSD diagnostic and SC status are discordant for a significant minority of veterans. Findings revealed that both the number of veterans who are service connected without meeting criteria for PTSD and the number of veterans who meet PTSD criteria but have not been granted SC status are concerning.

Relations Between Pain, PTSD Symptoms, and Substance Use in Veterans.

OBJECTIVE: The frequent co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain has received much attention in the literature. However, the extant literature is limited in that these investigations generally exclude patients with co-occurring substance use disorders (SUD). Thus, the present study investigated symptoms of PTSD and SUD in veterans with high and low pain symptoms. METHOD: Veterans (N = 136) seeking treatment for comorbid symptoms of PTSD and SUD were recruited as part of a larger study. All participants completed a baseline assessment, which included a series of diagnostic interviews and self-report questionnaires measuring symptoms of pain, PTSD and SUD. RESULTS: Higher levels of self-reported pain were found to be associated with both self-reported and clinician-rated PTSD symptoms above and beyond the influence of the demographic variables. However, no reliable relations were demonstrated between substance use and pain. CONCLUSIONS: Although preliminary, the findings highlight the common occurrence of chronic pain among veterans with comorbid PTSD/SUD, and the potential impact of pain on clinical presentation. The findings may help inform special considerations for assessment and treatment practices for this high-risk population.

Predictors of length of stay among OEF/OIF/OND veteran inpatient PTSD treatment noncompleters.

High rates of attrition occur in outpatient and inpatient evidence-based treatments (EBTs) targeting newly returning veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with posttraumatic stress disorder (PTSD). Traditionally, research has examined attrition as a dichotomous variable (i.e., noncompleters vs. completers) and focused almost exclusively on outpatient EBTs for PTSD. These studies have provided little information to inpatient psychiatric providers about timing-related predictors of treatment discontinuation. The present study attempted to mend these gaps by examining attrition as a continuous variable and investigated predictors of length of stay (LOS) among 282 OEF/OIF/OND male veterans, 69 of which did not complete the full 25-day intensive, multimodal inpatient PTSD EBT program. At admission, participants completed a series of clinician-rated, biological, and self-report assessments. Linear regression analyses were used to identify predictors of shorter LOS. The results demonstrated that less improvement in symptom reduction, overall functioning, and greater number of drugs used at admission were significant and unique predictors of shorter LOS. Overall, these findings reveal clinically relevant, timing-related predictors of attrition and provide generalizable clinical information to inpatient psychiatric providers.

Test anxiety inventory: 30 years later.

Research suggests that test anxiety is associated with a number of maladaptive factors. The majority of test anxiety research includes the Test Anxiety Inventory (TAI) as a primary outcome variable. However, the TAI was normed on college undergraduates in 1980. The academic landscape has altered in a variety of ways in the past 30 years, which may result in out-of-date norms. This study examined changes in TAI scores in college undergraduates (n =437) as well as convergent validity with measures of trait anxiety and academic performance. Results indicated increases in TAI scores for females while holding constant for males. Additionally, females and males displayed positive correlations between the TAI and state-trait anxiety inventory, while only females displayed a significant negative correlation between the TAI and grade point average. Data provide evidence of changes in TAI scores. As a result, researchers should be careful when drawing conclusions based on original TAI norms, especially in the case of female undergraduates.