The hidden burden of social anxiety disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study.

BACKGROUND: Social anxiety disorder (SAD) is a chronic and disabling psychiatric disorder associated with low levels of help-seeking. To date, however, scarce research has examined the epidemiology of SAD in veterans. This study examined the prevalence, comorbidities and incremental burden of SAD in relation to suicidality and functioning in a representative sample of U.S. military veterans. METHODS: A nationally representative sample of 3,157 U.S. veterans completed a web survey containing measures of SAD symptoms, trauma history, psychiatric history and functioning. Multivariable analyses were conducted to examine associations between SAD and psychiatric comorbidities, suicidality and functioning. RESULTS: A total 9.5% (n = 272) of the sample screened positive for lifetime SAD. Veterans with SAD were more likely than those without SAD to be younger, female, single, racial/ethnic minorities and to have experienced childhood abuse. They also had substantially elevated rates of comorbid psychiatric disorders, particularly lifetime major depression (odds ratio [OR]=5.8) and posttraumatic stress disorder (OR=3.1), as well as current suicidal ideation (OR=3.3). Veterans with SAD scored lower on measures of functioning, particularly social, emotional and mental health functioning (d's=0.21-0.34). LIMITATIONS: Data were collected cross-sectionally using self-report. CONCLUSIONS: SAD in U.S. veterans is prevalent and associated with psychiatric comorbidities, functional impairment and a more than 3-fold greater risk for suicidal ideation . Given that SAD is associated with low treatment seeking and engagement, it may be undetected and undertreated relative to other psychiatric morbidities. These results underscore the importance of screening, monitoring and treating SAD in this population along with other prevalent mental disorders.

Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study.

STUDY OBJECTIVES: Veterans experience high levels of trauma, psychiatric, and medical conditions that may increase their risk for insomnia. To date, however, no known study has examined the prevalence, risk correlates, and comorbidities of insomnia in a nationally representative sample of veterans. METHODS: A nationally representative sample of 4,069 US military veterans completed a survey assessing insomnia severity; military, trauma, medical, and psychiatric histories; and health and psychosocial functioning. Multivariable analyses examined the association between insomnia severity, psychiatric and medical comorbidities, suicidality, and functioning. RESULTS: A total of 11.4% of veterans screened positive for clinical insomnia and 26.0% for subthreshold insomnia. Greater age and retirement were associated with a lower likelihood of insomnia. Adverse childhood experiences, traumatic life events, lower education and income were associated with greater risk for insomnia. A "dose-response" association was observed for health comorbidities, with increasing levels of insomnia associated with elevated odds of psychiatric and medical conditions (clinical vs no insomnia odds ratio = 1.8-13.4) and greater reductions in health and psychosocial functioning (clinical vs no insomnia Cohen's d = 0.2-0.4). The prevalence of current suicidal ideation was 3-5 times higher in veterans with clinical and subthreshold insomnia relative to those without insomnia (23.9% and 13.6% vs 4.5%, respectively). CONCLUSIONS: Nearly 2 in 5 US veterans experience clinical or subthreshold insomnia, which is associated with substantial health burden and independent risk for suicidal ideation. Results underscore the importance of assessment, monitoring, and treatment of insomnia in veterans as they transition from the military.

Cue Exposure Therapy for Alcohol Use Disorders: What Can Be Learned from Exposure Therapy for Anxiety Disorders?

Background: Cue Exposure Therapy (CET) has shown efficacy for treating alcohol use disorders (AUDs). Exposure therapy is highly effective for treating anxiety. Both techniques involve repeated, controlled exposures to alcohol or fear-related stimuli. Objectives: We considered the mechanisms of CET for AUDs by comparing it to exposure therapy for anxiety. Method: We conducted a narrative review contrasting theoretical literature examining the mechanisms of CET versus exposure therapy for anxiety. We reviewed RCTs and acute laboratory paradigms examining CET for AUDs. We considered common areas of emerging research, including the use of d-Cycloserine (DCS) and virtual reality (VR). Results: We found evidence that exposure therapy and CET at least partially achieve their effects through extinction learning. We found evidence that CET for AUDs is effective, with comparable benefits to other effective psychosocial treatments. DCS and VR have shown some limited success for augmenting CET for AUDs, so further research is needed to determine their value. Conclusions: There are theoretical and practical similarities between exposure to fear cues and cues of addiction, especially regarding extinction learning. However, these processes are also unique, particularly regarding the differing motivational properties of fear versus reward-related stimuli. We propose that unlike exposure for anxiety, CET takes effect by increasing self-control with each unreinforced exposure. We consider reasons for CET's limited use for AUDs, including its lower acceptability to clients and clinicians. We also note the limited evidence for CET for other substance use disorders, highlighting the need for continued investigation into its mechanisms and efficacy.

Systematic Reviews of Mindfulness and Acceptance and Commitment Therapy for Alcohol Use Disorder: Should we be using Third Wave Therapies?

AIMS: Third wave therapies have shown efficacy for treating emotional disorders and potential for treating substance use disorders. There is developing interest in whether they can more specifically be used for treating alcohol use disorders (AUDs). We were interested in whether third wave therapies have value alongside current evidence-based psychosocial treatments for AUDs. METHOD: We conducted systematic reviews of third wave therapies for AUDs. We searched PsycINFO, Embase and Medline for peer reviewed journal articles where mindfulness or Acceptance and Commitment Therapy (ACT) were used to treat adults with AUDs or alcohol use that caused impairment. RESULTS: We identified 11 studies where mindfulness was used for treating AUDs and 6 where ACT was used for AUDs. The studies identified included RCTs, non-randomized controlled studies and uncontrolled studies. We found preliminary support that both third wave therapies are better than no treatment, treatments of minimal efficacy, as well as some evidence they are comparable to effective psychosocial treatments for AUDs. CONCLUSIONS: We conclude ACT and mindfulness provide an alternative to existing treatments, particularly for patients who have not responded to, or have disengaged from, standard treatments. We also found some evidence ACT and mindfulness are useful for comorbid mental health conditions. Yet while these results are promising, further research is needed to determine their utility, ideally employing randomized-controlled designs, larger clinical samples and longer follow-ups. Furthermore, few studies in this review directly compared third wave therapies to first line treatments, making it difficult to determine their relative efficacy.

Facial emotion recognition during pregnancy: Examining the effects of facial age and affect.

It is vital that new mothers quickly and accurately recognize their child's facial expressions. There is evidence that during pregnancy women develop enhanced processing of facial features associated with infancy and distress, as these cues signal vulnerability and are therefore biologically salient. In this study, 51 pregnant women at 17-36 weeks gestation watched neutral infant and adult faces gradually morph into either happy or sad expressions. We measured the speed and accuracy with which participants were able to recognize facial affect (happy vs. sad) across facial ages (infant vs. adult). Participants were faster and more accurate at recognizing happy versus sad faces and adult versus infant faces. We discuss how prior exposure to a certain face type may explain faster recognition. We also consider these results in the context of evidence indicating positive affect is recognized more quickly, but associated with slower attention and detection.

Latent typologies of DSM-5 PTSD symptoms in U.S. military veterans.

Posttraumatic stress disorder (PTSD) is a heterogeneous condition that can be characterized by unique typologies of symptoms. To date, no study has examined predominant PTSD typologies using DSM-5 criteria. We used latent class analysis (LCA) to identify typologies of DSM-5 PTSD symptoms in 158 U.S. veterans who screened positive for this condition. A three-class solution provided the best fit to the data, described as Dysphoric (36.2%), High Symptom (34.0%) and Threat (29.8%). The Threat class had higher probabilities of intrusions and avoidance compared to the Dysphoric class; the Dysphoric class had higher probabilities of negative affect, anhedonia and externalizing behavior relative to Threat; the High Symptom class had high probabilities of all symptoms. Compared to the Threat class, the Dysphoric class was more likely to have a lifetime history of major depressive, alcohol and drug use disorders; the High Symptom class was more likely to have a lifetime history of alcohol, drug, and nicotine use disorder, current generalized anxiety, or to have attempted or currently contemplated suicide. The High Symptom class reported greater mental, physical and cognitive impairment and lower quality of life. These findings underscore the importance of a personalized approach to the assessment and treatment of DSM-5 PTSD.

Executive Functioning Predicts Reflective Functioning in Mothers.

Parental reflective functioning (PRF) describes a parent's capacity for considering both their own and their child's thoughts, feelings, and behaviors, which can help parents to guide interactions with children. Given the cognitive demands of keeping infants in mind whilst caregiving, we examined the association between aspects of executive function (i.e., working memory and set-shifting) and PRF (employing the Parental Reflective Functioning Questionnaire) in recent mothers. In Study 1 (N=50), we found that better working memory was associated with higher levels of maternal interest and curiosity in their child's feelings. In Study 2 (N=68), we found that visual working memory and set-shifting capacity were also associated with higher levels of maternal interest and curiosity in their child's thoughts and feelings. Our results provide preliminary support for the association between executive processes and maternal reflective functioning. The implications of these findings and important future directions are discussed, including advancing our understanding of executive processes and PRF to support the broader family system.

Maternal Acceptance Moderates Fear Ratings and Avoidance Behavior in Children.

Avoidance is a hallmark feature of anxiety disorders, and avoidance-related impairment is often key to meeting diagnostic criteria. In children and adolescents with anxiety disorders, levels of avoidance vary considerably. Using a novel motion-tracking measure of avoidance behavior, we examined whether maternal acceptance, characterized by warm and accepting responses to child feelings and behaviors, moderates the association between fear of spiders and behavioral avoidance of spider stimuli in 103 clinically anxious children. As hypothesized, maternal acceptance significantly moderated children's avoidance behavior. Child's fear of spiders was significantly associated with behavioral avoidance when mothers were low in acceptance, as rated by either mothers or children. When mothers were high in acceptance, as rated by either mothers or children, child self-rated fear of spiders was not significantly associated with child avoidance. These are the first results to empirically demonstrate the moderating role of maternal acceptance in anxious children's avoidance behavior.

Correlates of Nonimprovement to Pharmacotherapy for Chronic, Antidepressant-Resistant, Military Service-Related Posttraumatic Stress Disorder: Insights From the Veterans Affairs Cooperative Study No. 504.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a chronic and often difficult-to-treat condition that is prevalent among military veterans. First-line pharmacotherapy for this population typically involves antidepressants; however, veterans who do not improve are sometimes prescribed antipsychotics such as risperidone. A 2011 randomized controlled trial of adjunctive risperidone versus placebo for veterans with chronic, antidepressant-resistant, military service-related PTSD revealed no difference between groups. Hence, there is a need to examine predictors of nonimprovement for chronic, treatment-resistant PTSD. METHODS: We examined correlates of nonimprovement and delayed improvement (ie, ≥12 weeks) using data from 267 veterans with chronic, antidepressant-resistant PTSD who were prescribed adjunctive risperidone or a placebo. Veterans received 1 to 4 mg adjunctive risperidone (n = 133; mean dose, 2.74 mg) or a placebo daily (n = 134) in addition to their original treatment regimen over the 24-week trial. RESULTS: Greater severity of PTSD symptoms at baseline, specifically reexperiencing (ie, nightmares) and emotional numbing (ie, sense of foreshortened future), was independently associated with nonimprovement. Of the 194 veterans (72.7%) who did improve, 95 (49.0%) showed delayed improvement, taking 12 weeks or longer to demonstrate a 10-point reduction in Clinician-Administered PTSD Scale scores. Emotional difficulties affecting role functioning, as assessed using the Veterans RAND 36-item Health Survey, independently predicted nonimprovement. CONCLUSIONS: While results are indicative of nonspecific pharmacotherapeutic effects, they suggest that specific PTSD symptom clusters and impairment are associated with variable improvement in veterans with antidepressant-resistant PTSD. They underscore the importance of developing more effective and targeted pharmacotherapies for specific symptom clusters in this population.

Anxiety and neural responses to infant and adult faces during pregnancy.

Women are vulnerable to anxiety during pregnancy and postpartum. However, little is known about antenatal anxiety and neural processing of infant-relevant information. In this experiment, the N170, P300, and LPP (late positive potential) event-related potentials were measured from 43 pregnant women as they viewed infant and adult faces, which were either neutral or distressed in expression. Mother's self-reported anxiety levels were also assessed. The N170 was comparable across face conditions and was not associated with anxiety. However, our central finding was that greater levels of antenatal anxiety were associated with a larger LPP, but only for neutral infant faces. Results suggest that antenatal anxiety may result in deeper processing of neutral, emotionally ambiguous, infant faces during pregnancy. These findings are discussed in light of other work indicating an interpretive bias toward threat in response to neutral stimuli in anxiety.

D-cycloserine enhances generalization of fear extinction in children.

BACKGROUND: For exposure therapy to be successful, it is essential that fear extinction learning extends beyond the treatment setting. D-cycloserine (DCS) may facilitate treatment gains by increasing generalization of extinction learning, however, its effects have not been tested in children. We examined whether DCS enhanced generalization of fear extinction learning across different stimuli and contexts among children with specific phobias. METHODS: The study was a double-blind placebo-controlled randomized controlled trial among dog or spider phobic children aged 6-14. Participants ingested either 50 mg of DCS (n = 18) or placebo (n = 17) before receiving a single prolonged exposure session to their feared stimulus. Return of fear was examined 1 week later to a different stimulus (a different dog or spider), presented in both the original treatment context and an alternate context. Avoidance and fear were measured with Behavior Approach Tests (BATs), where the child was asked to increase proximity to the stimulus while reporting their fear level. RESULTS: There were no differences in BAT performance between groups during the exposure session or when a new stimulus was later presented in the treatment context. However, when the new stimulus was presented in a different context, relative to placebo, the DCS group showed less avoidance (P = .03) and less increase in fear (P = .04) with moderate effect sizes. CONCLUSIONS: DCS enabled children to better retain their fear extinction learning. This new learning generalized to different stimuli and contexts.