Long-term follow-up of a randomised controlled trial of prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: a task-shifted intervention.

BACKGROUND: Empirical evidence on the longer-term effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed. The aim of the study was to evaluate the maintenance of treatment gains achieved in a comparative study of effectiveness of prolonged exposure therapy for adolescents (PE-A) and supportive counselling (SC) in adolescents with PTSD up to 24-months post-treatment. METHOD: Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment provided by trained and supervised non-specialist health workers (NSHWs). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale, at pretreatment, post-treatment, and at 3-, 6-, 12- and 24-months post-treatment follow-up (FU) evaluations. RESULTS: Participants in both the prolonged exposure and SC treatment groups attained a significant reduction in PTSD symptoms and maintained this reduction in PTSD symptoms at 12- and 24-month assessment. Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving SC at 12-months FU [difference in PE-A v. SC mean scores = 9.24, 95% CI (3.66-14.83), p < 0.001; g = 0.88] and at 24-months FU [difference in PE-A v. SC mean scores = 9.35, 95% CI (3.53-15.17), p = 0.002; g = 0.68]. CONCLUSIONS: Adolescents with PTSD continued to experience greater benefit from prolonged exposure treatment than SC provided by NSHWs in a community setting 12 and 24 months after completion of treatment.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Factor Structure and Psychometric Properties of the Peritraumatic and Posttraumatic Emotions Questionnaires Among Active Duty Military Personnel With Posttraumatic Stress Disorder.

The Peritraumatic Emotions Questionnaire (Peri-TEQ) and Posttraumatic Emotions Questionnaire (Post-TEQ) are self-report measures of emotions experienced during and after a traumatic event, respectively. The factor structure and psychometric properties of the Peri- and Post-TEQ were investigated among 474 military personnel with posttraumatic stress disorder (PTSD) following deployment. Exploratory factor analysis and confirmatory factor analysis were conducted to test the factor structure of the scales. Internal consistency, composite reliability, convergent validity, and discriminant validity were also assessed. Four factors were identified for the Peri-TEQ (Fear, Humiliation, Anger, and Sadness), and three factors were identified for the Post-TEQ (Fear, Anger-Hurt, and Humiliation). The full scales and all subscales demonstrated adequate-to-good internal consistency, Cronbach's αs = .722-.893. The subscales demonstrated adequate-to-good composite reliability, Cronbach's αs = .763-.861. The Peri- and Post-TEQ demonstrated good convergent validity with measures of PTSD symptoms, rs = .229-.601, ps < .001, and depressive symptoms, rs = .284-.470, ps < .001, and good discriminate validity with measures of resilience, ps = .116-.940, and unit cohesion, Peri-TEQ, p = .304 and Post-TEQ, r = -.123, p = .008. The Humiliation subscales demonstrated good convergent validity with guilt cognitions, rs = .315-.341, ps < .001, and the Anger subscales demonstrated good convergent validity with state anger, rs = .260-.347, ps < .001. The Peri- and Post-TEQ are reliable, valid self-report measures of emotions during and in response to remembering a trauma. The results support the use of these measures in research investigating trauma-related emotions.

Prolonged exposure therapy and supportive counselling for posttraumatic stress disorder in adolescents in a community-based sample, including experiences of stakeholders: study protocol for a comparative randomized controlled trial using task-shifting.

BACKGROUND: There is a dearth of empirical evidence on the effectiveness of pharmacological and non-pharmacological treatments for adolescents with posttraumatic stress disorder (PTSD) in developing countries. The primary aim of the study is to examine the effects of prolonged exposure therapy compared with supportive counseling for adolescents with PTSD delivered by nurses trained as counselors. METHODS/DESIGN: A single-blind randomized clinical trial comprising 90 adolescents with PTSD using a permuted block design will be utilized. Nurses previously naïve to prolonged exposure and supportive counselling will be trained to provide these treatments at the adolescents' high schools. Data collection will last from March 2014 to December 2017 and annually thereafter, dependent on the availability of funding. Participants will receive seven to fourteen 60 min sessions of prolonged exposure treatment (n = 45) or supportive counselling (n = 45). All assessments will be conducted before treatment, at mid-treatment, immediately after treatment completion, at 3-, 6-, and 12-month follow-up, and annually thereafter. It is hypothesized that PE-A will be superior to SC in reducing PTSD symptoms at post-treatment as measured by the CPSS-I administered by an independent evaluator. It is further hypothesized that PE-A treatment gains will be maintained at 3-, 6- and 12-month follow-ups and annually thereafter. DISCUSSION: While early indications are that PE-A is an effective treatment for PTSD in adolescents, this study will help determine the effectiveness of PE-A in a South African, community setting (school-based) when task-shifted to nurses, as compared to SC. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201511001345372 , retrospectively registered 11 November 2015.

Adolescent and nurse perspectives of psychotherapeutic interventions for PTSD delivered through task-shifting in a low resource setting.

BACKGROUND: This investigation compared the perceived effectiveness of supportive counselling (SC) and prolonged exposure for adolescents (PE-A) by treatment users (adolescents with PTSD) and non-specialist treatment providers (supervised nurses). METHOD: Adolescent participants and nurse providers were purposively recruited to share their experiences of trial participation through face to face semi-structured in-depth interviews and treatment-specific focus groups (all recorded). Twelve adolescent participant transcripts (ten interviews and two focus groups) and three nurse provider transcripts were doubly transcribed. Thematic content analysis was applied using Atlas.ti software. Two emerging themes are presented in this paper: 1) Perceptions of the intervention and 2) Usefulness of the intervention. RESULTS: Regardless of treatment arm, adolescents experienced warm counselling relationships and described the process of extending trust to the counselor. Adolescents in the PE-A arm provided clear descriptions of session structure and treatment rationale compared with adolescents receiving SC. The most helpful tools were breathing retraining and imaginal exposure for PE-A and creation of distraction strategies during non-directive SC. Adolescents in both arms continued to use the techniques acquired during treatment and reported symptom improvement. Participants who received SC acknowledged ongoing reexperiencing. Nurses perceived SC to be an immediately transferable skill, but feedback on their preference for one intervention over the other was inconclusive. CONCLUSION: Both PTSD treatment strategies, implemented by non-specialists, were perceived as helpful. Overall, adolescents reported warm therapeutic relationships and a reduction in PTSD symptoms. Nurses stated that they would require institutional support to ensure delivery of these interventions in a scalable and sustainable manner.

Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: task-shifting randomised controlled trial.

BACKGROUND: Empirical evidence on the effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed.AimsTo evaluate the comparative effectiveness of prolonged exposure and supportive counselling in adolescents with PTSD. METHOD: Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment (trial registration in the Pan African Clinical Trials Registry: PACTR201511001345372). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale at pre-treatment, post-treatment, and at 3- and 6-month follow-up. RESULTS: Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving supportive counselling (between group differences at post-intervention, mean 12.49, 95% CI 6.82-18.17, P<0.001; d = 1.22). A similar effect size was maintained at 3-month (d = 0.85) and 6-month (d = 1.02) follow-up assessments. CONCLUSIONS: Adolescents with PTSD experienced greater benefit from prolonged exposure treatment when provided by non-specialist health workers (nurses) in a community setting.Declaration of interestNone.

Adolescents' Experience of Stigma When Accessing School-Based PTSD Interventions.

This qualitative investigation, nested within a randomized controlled trial (RCT), describes the experiences of adolescent participants accessing psychotherapy for posttraumatic stress disorder (PTSD) in a school-based setting. Supervised nurses provided the psychotherapeutic interventions. Twelve participants who took part in the RCT were invited, and 10 agreed to share their experiences through recorded face-to-face, semistructured, in-depth interviews and treatment-specific focus groups. Basic thematic analysis was applied using Atlas.ti software. Adolescents described a mixed range of perceived poor, ambivalent, and good support experiences when accessing treatment, and were particularly motivated when they had access to a caring adult. During the trial, adolescents used calculated disclosure strategies to reduce their vulnerability to marginalization and stigma. School-based therapy was well received but could be improved if sessions were offered after school hours. This study provides suggestions for improvement and scale-up of school-based PTSD interventions for adolescents.

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial.

Importance: Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. Objective: To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Design, Setting, and Participants: Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Interventions: Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Main Outcomes and Measures: Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided α = .05]); and efficacy of spaced therapy vs PCT at posttreatment. Results: Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, -2.48 to 2.27]; P = .93). Conclusions and Relevance: Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. Trial Registration: clinicaltrials.gov Identifier: NCT01049516.

Impediments and catalysts to task-shifting psychotherapeutic interventions for adolescents with PTSD: perspectives of multi-stakeholders.

BACKGROUND: This qualitative study was nested within a randomized controlled trial (RCT) where two psychotherapeutic interventions (supportive counselling and prolonged exposure for adolescents) were provided by supervised nurses (who served as 'nurse counsellors') to adolescents with PTSD in school settings. This paper describes the perspectives of nurse counsellors (NCs) and school liaisons (SLs). SLs were teachers or administrative personnel at the schools who coordinated the study visits of participants with the NCs. We focus on the impediments and catalysts to and recommendations for treatment implementation. METHODS: NCs (n = 3) and SLs (n = 3) who participated in the RCT during 2014 were purposively recruited by telephone and participated in face-to-face semi-structured in-depth interviews that were recorded and doubly transcribed. Thematic content analysis was applied using Atlas.ti software to identify emerging themes. This paper describes the impediments and catalysts to provide psychotherapy by task-shifting in a community setting across three sub-themes: personal, community, and collaborative care. RESULTS: Although nurses were initially resistant to supervision it was central to personally coping with complex interventions, managing traumatic content, and working apart from a multi-disciplinary team. Delivering the interventions in the community presented multiple logistical impediments (e.g. transport, communication, venue suitability) which required creative solutions. In light of resource shortages, networking is central to effective delivery and uptake of the interventions. Collaboration between government departments of health and education may have a major impact on providing school-based psychotherapy through task-shifting. CONCLUSIONS: Impediments to implementation are not insurmountable. This article provides recommendations to maximize the success of task-shifting interventions should they be rolled out.

A pilot and feasibility randomised controlled study of Prolonged Exposure Treatment and supportive counselling for post-traumatic stress disorder in adolescents: a third world, task-shifting, community-based sample.

BACKGROUND: There is a dearth of empirical evidence on the effectiveness of pharmacological and nonpharmacological treatments for adolescents with post-traumatic stress disorder (PTSD) in developing country settings. The primary aim of this study was to demonstrate that Prolonged Exposure Treatment for Adolescents (PE-A) and supportive counselling (SC) are implementable by nurses in a South African context. A secondary aim was to perform a preliminary analysis of the effectiveness of registered nurses delivering either PE-A or SC treatment to adolescents with PTSD. It is hypothesised that PE-A will be superior to SC in terms of improvements in PTSD symptoms and depression. METHOD: A pilot, single-blind, randomised clinical trial of 11 adolescents with PTSD. Nurses previously naïve to Prolonged Exposure (PE) Treatment and SC provided these treatments at the adolescents' high schools. Data collection lasted from March 2013 to October 2014. Participants received twelve 60-90-min sessions of PE (n = 6) or SC (n = 5). All outcomes were assessed before treatment, at mid-treatment, immediately after treatment completion and at 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed with the Child PTSD Symptom Scale-Interview (CPSS-I) (range, 0-51; higher scores indicate greater severity). The secondary outcome, depression severity, was assessed with the Beck Depression Inventory (BDI) (range, 0-41; higher scores indicate greater severity). RESULTS: Data were analysed as intention to treat. During treatment, participants in both the PE-A and SC treatment arms experienced significant improvement on the CPSS-I as well as on the BDI. There was a significant difference between the PE-A and SC groups in maintaining PTSD and depression at the 12-month post-treatment assessment, with the participants in the PE-A group maintaining their gains both on PTSD and depression measures. CONCLUSION: The treatment was adequately implemented by the nurses and well-tolerated by the participants. Preliminary results suggest that the delivery of either intervention led to a significant improvement in PTSD and depression symptoms immediately post treatment. The important difference was that improvement gains in PTSD and depression in the PE-A group were maintained at 12-month follow-up. The results of this pilot and feasibility study are discussed. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201511001345372 , registered on 11 November 2015.

Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client-Centered Therapy on Co-Occurring Emotional and Behavioral Problems.

The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.

Single unit activity in the lateral septum and central nucleus of the amygdala in the elevated plus-maze: a model of exposure therapy?

The central nucleus of the amygdala (CeA) is a major output region of the amygdala involved in organizing the expression of fear. There is also evidence that the lateral septum (LS) provides inhibitory control of neurons in CeA and is involved in the relief of fear. This study examined single unit activity in the lateral septum (LS) and the central nucleus of the amygdala (CeA) in the open and closed arms of the elevated plus-maze, a highly validated animal model of fear and anxiety. The general presumption is that animals normally avoid the open arms because the open arms are relatively more anxiety provoking than the closed arms which represent relative safety. It was expected that neurons in CeA would increase their activity in the open arms relative to the closed arms indicative of increased anxiety and that LS neurons would decrease their activity on the open arms. Contrary to expectations it was found that the preponderance of units in CeA decreased their firing rates on the open arms compared to the closed arms. An increase in firing rates in LS was seen in the open arms compared to the closed arms. The data suggest that when animals are placed on the open arms a compensatory process takes place to suppress fear so that the animal can engage in adaptive behavior. We liken this process to that which takes place in exposure therapy for phobias in humans which involves the inhibition of fear resulting from Pavlovian extinction.

Characteristics of individuals seeking treatment for obsessive-compulsive disorder.

Despite severe functional impairment, only 35% to 40% of individuals with obsessive-compulsive disorder (OCD) seek treatment, and fewer than 10% receive evidence-based treatment. The current study examined the characteristics of 525 individuals who contacted the clinic of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania to inquire about OCD treatment and completed a phone screen. Callers who were deemed appropriate for the clinic (n=396, 75%) were invited to participate in an in-person intake evaluation. Only 137 (35%) of the eligible individuals completed the intake evaluation ("treatment intake group") whereas the majority (n=259, 65%) did not ("phone screen-only group"). Compared to individuals in the phone screen-only group, those in the treatment intake group were younger, less likely to endorse depressed mood, and more likely to have received a diagnosis of OCD, to have previously sought psychological services, and to have taken psychotropic medication. The findings suggest that familiarity with their diagnosis and past contact with mental health professionals enhance openness to explore yet another treatment. In contrast, lack of awareness about the problem and depressed mood may reduce openness to seek treatment.

Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD.

Obsessive-compulsive disorder (OCD) is a highly debilitating disorder. Fortunately there are treatments that help the majority of OCD sufferers. The behavioral treatment with the most empirical support for its efficacy is exposure and response prevention (EX/RP). Over the years in our supervision meetings and in our clinical practice we have noted a number of relatively common therapist pitfalls that decrease the effectiveness of EX/RP. These pitfalls include not encouraging patients to approach the most distressing situations, doing imaginal exposure when in vivo is called for (and vice versa), encouraging distraction during exposure, providing reassurance, failing to address the core fear, ineffective handling of mental compulsions, and difficulty working with close others in the patient's life. In the current article we describe these common pitfalls and how to avoid them.

Electrophysiological analysis of the interaction between the lateral septum and the central nucleus of the amygdala.

Evidence suggests that the lateral septum (LS) and the central nucleus of the amygdala (CeA) play opposing roles in the modulation of fear and anxiety. The current study examined the interaction of the two structures in the albino rat by electrically stimulating each and recording single-unit activity in the other. In each case, electrical stimulation consisted of 50 trains of 5 pulses 800µA in amplitude, 0.1ms in duration with a .01s interval between pulses. Electrical stimulation of LS had a predominant inhibitory effect upon cells in CeA. Contrariwise, stimulation of CeA had a predominant excitatory effect on cells in LS. The results of the study suggest a possible regulatory, negative feedback model of the interaction between LS and CeA.

Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial.

OBJECTIVE: To examine the efficacy and maintenance of developmentally adapted prolonged exposure therapy for adolescents (PE-A) compared with active control time-limited dynamic therapy (TLDP-A) for decreasing posttraumatic and depressive symptoms in adolescent victims of single-event traumas. METHOD: Thirty-eight adolescents (12 to 18 years old) were randomly assigned to receive PE-A or TLDP-A. RESULTS: Both treatments resulted in decreased posttraumatic stress disorder and depression and increased functioning. PE-A exhibited a greater decrease of posttraumatic stress disorder and depression symptom severity and a greater increase in global functioning than did TDLP-A. After treatment, 68.4% of adolescents beginning treatment with PE-A and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for posttraumatic stress disorder. Treatment gains were maintained at 6- and 17-month follow-ups. CONCLUSIONS: Brief individual therapy is effective in decreasing posttraumatic distress and behavioral trauma-focused components enhance efficacy. CLINICAL TRIAL REGISTRY INFORMATION: Prolonged Exposure Therapy Versus Active Psychotherapy in Treating Post-Traumatic Stress Disorder in Adolescents, URL: http://clinicaltrials.gov, unique identifier: NCT00183690.

Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with significant health risk, illness, and functional impairment, e.g., Green and Kimerling [2004: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association] Kimerling et al. [2000: Trauma and Health: J Trauma Stress 13:115-128]. METHODS: These analyses examined whether negative health perceptions and general social functioning change with treatment of chronic PTSD among women from a randomized controlled study comparing prolonged exposure (PE; n=48) or PE combined with cognitive restructuring (PE/CR; n=40) to waitlist (n=19; Foa et al., 2005: J Consult Clin Psychol 73:953-964]. RESULTS: Self- reported physical health difficulties were significantly reduced in the PE and PE/CR conditions compared to the waitlist condition. These reductions did not demonstrate significant change during the 12 month follow-up period. Self-reported discomfort associated with physical health difficulties did not demonstrate significant change over treatment. No difference was detected between the active treatment and waitlist conditions. Both the PE and PE/CR groups reported improved social functioning at post treatment compared to the waitlist. Additional improvement in general social functioning was found between 3 and 12 month follow-up assessments. Changes in PTSD and depressive symptoms over treatment accounted for 29% of the variance in reduction of reported health problems and 30% of the variance in improvement of general social functioning. Importantly, only changes in PTSD symptoms significantly contribute to the model predicting change in physical health problems with depression associated only at a trend level. However, collinearity between PTSD and depression makes interpretation difficult. CONCLUSIONS: Negative health perceptions and general social function improve with PE. Changes in depression and PTSD with treatment are related to these changes.

The OCI-R: validation of the subscales in a clinical sample.

The psychometric properties of the Obsessive-Compulsive Inventory-Revised (OCI-R) subscales have not been validated in a clinical sample of individuals diagnosed with obsessive-compulsive disorder (OCD). Data were collected on 186 patients diagnosed with OCD and 17 patients diagnosed with generalized anxiety disorder (GAD) using the OCI-R and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Confirmatory factor analysis revealed an acceptable factor structure. Patients with a given primary symptom subtype were elevated on the corresponding subscale of the OCI-R compared to other OCD patients and patients with GAD. In addition, patients who acknowledged that symptom subtype as present but not primary on the Y-BOCS had elevated OCI-R scores on that scale compared to patients who did not endorse that symptom subtype and patients with GAD. Results indicate that the subscales of the OCI-R are valid measures of six symptom subtypes of OCD. The OCI-R is a psychometrically sound, brief instrument. The current data combined with previous efforts suggest that it is appropriate for clinical and non-clinical populations, and for clinical and research purposes. Further research should examine the sensitivity of the specific subscales to treatment effects, and the potential for adding more items to account for other symptom domains of OCD.

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics.

Female assault survivors (N=171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment.

Effects of chlordiazepoxide on single-unit activity in the septal region of the freely moving rat: aversive vs. non-aversive contexts.

Evidence suggests that stimuli that have the property of inhibiting fear in a Pavlovian fear conditioning paradigm increase cellular activity in the lateral septum, a result consistent with the idea that the lateral septum is actively involved in the inhibition of fear. The experiments reported here were designed to determine if an anxiolytic drug with fear-inhibiting properties would also increase neuronal activity in the lateral septum in a manner that might relate to its mechanism of action as an anxiolytic. An experiment was performed to compare the effects of the benzodiazepine anxiolytic chlordiazepoxide (CDP) upon single-unit activity in the septal region of the rat brain during Pavlovian aversive conditioning with the effects of CDP in a non-aversive context. During Pavlovian conditioning there was a decrease in unit activity in the more lateral regions of the septum, the dorsolateral and ventrolateral nuclei, when a stimulus signaling footshock (CS+) was presented. This conditioned suppression of unit activity was blocked by an intraperitoneal injection of CDP. Additionally, CDP increased baseline unit activity in these regions in the absence of conditioned stimuli. In the more medial regions of the septum, the intermediate lateral septum, we observed few consistent changes either to the conditioned stimuli or to the drug. In a non-aversive context CDP had either no effect at low to moderate doses, or a suppressant effect at a higher dose. The results support a fear-relief hypothesis of lateral septal functioning and suggest the lateral septum as a possible site for the anxiolytic action of benzodiazepines.