Behavioral activation for PTSD: A meta-analysis.

OBJECTIVE: The efficacy of behavioral activation (BA) for depression has been firmly established, and training therapists in BA may be less time-intensive than for standard interventions. Because BA addresses problematic avoidance behaviors, BA holds promise as a treatment for posttraumatic stress disorder (PTSD). We conducted a meta-analysis of both randomized controlled trials and uncontrolled studies involving the use of BA for the treatment of PTSD. Outcomes of interest were PTSD symptoms, anxiety, depression, and grief. METHOD: Meta-analyses included published studies in which BA served as the primary form of treatment for PTSD symptoms, whether PTSD was a primary or secondary outcome. Analyses were performed using Comprehensive Meta Analysis software with a random-effects model. RESULTS: Eight studies (3 controlled, 5 uncontrolled) with a total sample size of 564 participants met final inclusion criteria. The primary analysis for controlled studies indicated a significant improvement in PTSD symptoms for BA compared with the case for wait-list control (Hedges's g = 1.484) and for uncontrolled (Hedges's g = 0.717) studies. Secondary analyses indicated improvement in anxiety, grief, and depression (Hedges's g ranging from 0.28 to 2.29). No significant difference in effectiveness was observed for BA versus 2 active treatment comparison conditions (cognitive processing therapy and Internet-guided exposure). Effect sizes were not moderated by treatment modality (in-person vs. remote delivery) or by use of completer versus intention-to-treat data. CONCLUSIONS: BA appears to be effective for PTSD symptoms, but additional randomized controlled trials are needed to increase confidence in these findings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Performance on the CVLT-2 during induced pain.

Objective: Chronic pain patients frequently report cognitive problems including learning and memory. However, recent research involving induced pain has demonstrated an absence of reliably detectable decrements on several standard cognitive measures, suggesting that factors other than pain likely explain perceived cognitive deficits in chronic pain patients. This study examined potential effects of induced pain on verbal learning and memory as measured by the California Verbal Learning Test (CVLT-2). Potential effects of self-reported pain intensity were also evaluated. Method: Participants (111 non-clinical undergraduate students in the Southwestern United States) completed one version (Standard or Alternate) of the CVLT-2 under normal conditions, and then were administered the other version (Alternate or Standard) either while experiencing cold pressor-induced pain (Pain condition) or non-painful warm water immersion (Control condition). Results: For the Pain condition decrements in performance across most CVLT-2 variables were observed, including a mean T-score decrease of 10.98 (SD = 10.99) for Trials 1-5, whereas the comparable decrease in the Control condition was an average of 1.5 words (SD = 8.27). Self-reported pain intensity was significantly correlated with the degree of Time 1 to Time 2 performance decrement for Short-Delay Free Recall (r = -.51, p < .050), but not for Trials 1-5 (r = -.37, p = .160). Conclusion: Induced pain produces detectable decrements in performance on a standard clinical measure of verbal learning and memory performance, suggesting that pain in clinical populations may contribute to learning and memory deficits apart from potential neurological conditions.

Beyond Efficacy and Effectiveness: Clinical Efficiency Is Necessary for Dissemination.

Nearly all patients interact with critical gatekeepers-insurance companies or centralized healthcare systems. For mental health dissemination efforts to be successful, these gatekeepers must refer patients to evidence-based care. To make these referral decisions, they require evidence about the amount of resources expended to achieve therapeutic gains. Without this information, a bottleneck to widespread dissemination of evidence-based care will remain. To address this need for information, we introduce a new perspective, clinical efficiency. This approach directly ties resource usage to clinical outcomes. We highlight how cost-effectiveness approaches and other strategies can address clinical efficiency, and we also introduce a related new metric, the incremental time efficiency ratio (ITER). The ITER is particularly useful for quantifying the benefits of low-intensity and concentrated interventions, as well as stepped-care approaches. Given that stakeholders are increasingly requiring information on resource utilization, the ITER is a metric that can be estimated for past and future clinical trials. As a result, the ITER can allow researchers to better communicate desirable aspects of treatment, and an increased focus on clinical efficiency can improve our ability to deliver high-quality treatment to more patients in need.

Effects of Cogmed working memory training on cognitive performance.

Research on the cognitive benefits of working memory training programs has produced inconsistent results. Such research has frequently used laboratory-specific training tasks, or dual-task n-back training. The current study used the commercial Cogmed Working Memory (WM) Training program, involving several different training tasks involving visual and auditory input. Healthy college undergraduates were assigned to either the full Cogmed training program of 25, 40-min training sessions; an abbreviated Cogmed program of 25, 20-min training sessions; or a no-contact control group. Pretest and posttest measures included multiple measures of attention, working memory, fluid intelligence, and executive functions. Although improvement was observed for the full training group for a digit span task, no training-related improvement was observed for any of the other measures. Results of the study suggest that WM training does not improve performance on unrelated tasks or enhance other cognitive abilities.

Bayesian analysis of multimethod ego-depletion studies favours the null hypothesis.

Ego-depletion refers to the purported decrease in performance on a task requiring self-control after engaging in a previous task involving self-control, with self-control proposed to be a limited resource. Despite many published studies consistent with this hypothesis, recurrent null findings within our laboratory and indications of publication bias have called into question the validity of the depletion effect. This project used three depletion protocols involved three different depleting initial tasks followed by three different self-control tasks as dependent measures (total n = 840). For each method, effect sizes were not significantly different from zero When data were aggregated across the three different methods and examined meta-analytically, the pooled effect size was not significantly different from zero (for all priors evaluated, Hedges' g = 0.10 with 95% credibility interval of [-0.05, 0.24]) and Bayes factors reflected strong support for the null hypothesis (Bayes factor > 25 for all priors evaluated).

Performance on selected visual and auditory subtests of the Wechsler Memory Scale-Fourth Edition during laboratory-induced pain.

Although chronic pain patients commonly report problems with concentration and memory, recent research indicates that induced pain alone causes little or no impairment on several Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) subtests, suggesting that cognitive complaints in chronic pain may be attributable to factors other than pain. The current studies examined potential effects of induced pain on Wechsler Memory Scale-Fourth Edition (WMS-IV) visual working memory index (VWM) subtests (Experiment 1, n = 32) and on the immediate portions of WMS-IV auditory memory (IAM) subtests (Experiment 2, n = 55). In both studies, participants were administered one of two subtests (Symbol Span or Spatial Addition for Experiment 1; Logical Memory or Verbal Paired Associates for Experiment 2) normally and were then administered the alternate subtest while experiencing either cold pressor pain induction or a nonpainful control condition. Results indicate that induced pain in nonclinical volunteers did not impair performance on either VWM or IAM performance, suggesting that pain alone does not account for complaints or deficits in these domains in chronic pain patients. Nonpainful variables such as sleep deprivation or emotional disturbance may be responsible for reported cognitive complaints in chronic pain patients.

Accuracy of the Modified Somatic Perception Questionnaire and Pain Disability Index in the detection of malingered pain-related disability in chronic pain.

The Modified Somatic Perception Questionnaire (MSPQ) and the Pain Disability Index (PDI) are both popular clinical screening instruments in general orthopedic, rheumatologic, and neurosurgical clinics and are useful for identifying pain patients whose physical symptom presentations and disability may be non-organic. Previous studies found both to accurately detect malingered pain presentations; however, the generalizability of these results is not clear. This study used a criterion groups validation design (retrospective cohort of patients with chronic pain, n = 328) with a simulator group (college students, n = 98) to determine the accuracy of the MSPQ and PDI in detecting Malingered Pain Related Disability. Patients were grouped based on independent psychometric evidence of MPRD. Results showed that MSPQ and PDI scores were not associated with objective medical pathology. However, they accurately differentiated Not-MPRD from MPRD cases. Diagnostic statistics associated with a range of scores are presented for application to individual cases. Data from this study can inform the clinical management of chronic pain patients by screening for psychological overlay and malingering, thus alerting clinicians to the possible presence of psychosocial obstacles to effective treatment and triggering further psychological assessment and/or treatment.

Do administration instructions alter optimal neuropsychological test performance? Data from healthy volunteers.

The degree to which patients should be prompted to give their best effort has not been adequately addressed in the literature, nor has the issue of the extent to which they should be informed that measures of effort will be included in the assessment battery. Three groups of undergraduates were given three different instructional sets prior to completing a neuropsychological evaluation. The instructions provided different levels of motivation to perform optimally as well as possible warning regarding the detection of poor effort. The three groups did not differ in performance on any of the cognitive measures, although outlier performance resulted in lower mean performance on the Finger Tapping Test by the most clearly warned group. The results are discussed in terms of the potential of different instructional sets to affect motivation for optimal test performance.

The Reliable Digit Span test in chronic pain: classification accuracy in detecting malingered pain-related disability.

This study used criterion groups validation (known-groups design) to examine the classification accuracy of the Reliable Digit Span test (RDS) in a large group of chronic pain patients referred for psychological evaluation. The sample consisted of 612 patients classified into one of six groups based on evidence of malingered pain-related disability (MPRD): No-Incentive, Not MPRD; Incentive-Only, Not MPRD; Indeterminate; Possible MPRD; Probable MPRD; Definite MPRD. A total of 30 college student simulators were also included. Lower average RDS scores and higher rates of RDS failure were seen in patients classified as MPRD and in simulators. Consistent with previous literature in a variety of populations, RDS < = 6 provided the most accurate differentiation between MPRD and non-MPRD pain patients. Clinical implications are discussed.

Detecting malingered pain-related disability: classification accuracy of the test of memory malingering.

This study used criterion groups validation to determine the accuracy of the Test of Memory Malingering (TOMM) in detecting malingered pain-related disability (MPRD) across a range of cutoffs in chronic pain patients undergoing psychological evaluation (n = 604). Data from patients with traumatic brain injury (n = 45) and dementia (n = 59) are presented for comparison. TOMM scores decreased and failure rates increased as a function of greater external evidence of intentional under-performance. The TOMM detected from 37.5% to 60.2% of MPRD patients, depending on the cutoff. False positive (FP) error rates ranged from 0% to 5.1%. Accuracy data for Trial 1 are also reported. In chronic pain the original cutoffs produced no FP errors but were associated with high false negative error rates. Higher cutoffs increased sensitivity without adversely affecting specificity. The relevance of these findings to research and clinical practice is discussed.

Detecting malingered pain-related disability: classification accuracy of the Portland Digit Recognition Test.

This study used criterion groups validation to determine the classification accuracy of the Portland Digit Recognition Test (PDRT) at a range of cutting scores in chronic pain patients undergoing psychological evaluation (n = 318), college student simulators (n = 29), and patients with brain damage (n = 120). PDRT scores decreased and failure rates increased as a function of greater independent evidence of intentional underperformance. There were no differences between patients classified as malingering and college student simulators. The PDRT detected from 33% to nearly 60% of malingering chronic pain patients, depending on the cutoff used. False positive error rates ranged from 3% to 6%. Scores higher than the original cutoffs may be interpreted as indicating negative response bias in patients with pain, increasing the usefulness and facilitating the clinical application of the PDRT in the detection of malingering in pain.

Classification accuracy of MMPI-2 validity scales in the detection of pain-related malingering: a known-groups study.

The purpose of this study was to determine the accuracy of Minnesota Multiphasic Personality Inventory 2nd edition (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity indicators in the detection of malingering in clinical patients with chronic pain using a hybrid clinical-known groups/simulator design. The sample consisted of patients without financial incentive (n = 23), nonmalingering patients with financial incentive (n = 34), patients definitively determined to be malingering based on published criteria ( n = 32), and college students asked to simulate pain-related disability (n = 26). The MMPI-2 validity scales differentiated malingerers from nonmalingerers with a high degree of accuracy. Hypochondriasis and Hysteria were also effective. For all variables except Scale L, more extreme scores were associated with higher specificity. This study demonstrates that the MMPI-2 is capable of differentiating intentional exaggeration from the effects on symptom report of chronic pain, genuine psychological disturbance, and concurrent stress associated with pursuing a claim in a medico-legal context.

Pain, malingering, and performance on the WAIS-III Processing Speed Index.

Pain patients often report cognitive symptoms and many will include them in their claims of disability. The Processing Speed Index (PSI) of the WAIS-III was investigated as one aspect of cognitive functioning in six groups. Slight impairment was found for PSI and Digit Symbol subtest performance, but not for Symbol Search, in a Laboratory-induced Pain group and a Clinical Pain group. The lowest scores were found in a Simulator group instructed to fake cognitive impairment and a Clinical Pain group diagnosed as Malingering. Results suggest that PSI scores are only slightly reduced by laboratory-induced pain or chronic pain, and that unexpectedly low scores in the absence of significant/documented brain dysfunction suggest poor effort or deliberate misrepresentation.

Pain, malingering and the WAIS-III Working Memory Index.

BACKGROUND CONTEXT: Pain patients often report cognitive symptoms, and many will include them in their claims of disability. There is empirical evidence that patients with pain do experience problems on attention-demanding cognitive tasks, but the results are mixed and the potential impact of exaggeration in the context of pain-related litigation has not been addressed. PURPOSE: 1) Examine the impact of pain and malingering on attention; 2) determine if the Working Memory Index (WMI) of the Wechsler Adult Intelligence Scale-3 (WAIS-III) can reliably detect malingering. STUDY DESIGN/SETTING: Study 1: simulator design; Study 2: clinical known-groups design. PATIENT SAMPLE: Study 1 used healthy college students; Study 2 used chronic pain patients and neurological patients. OUTCOME MEASURES: The WMI and its constituent subtests. METHODS: Study 1: College students were administered the WMI under three conditions: standard administration, with cold-pressor induced pain, or with instructions to simulate impairment due to pain. Study 2: Known-groups design in which the WMI was examined in non-malingering and definite malingering chronic pain patients, non-malingering moderate-severe traumatic brain injury, and memory disorder patients seen for routine psychological evaluation. Malingering was operationalized using published criteria. RESULTS: There were no group differences in WMI or its subtests among non-malingering groups, but some individual clinical patients with pain did score at a level suggestive of attentional impairment. The lowest scores were found in the simulated malingering college students and definite malingering clinical pain groups, in which about half scored worse than 95% of the non-malingering clinical patients. CONCLUSIONS: This study demonstrated that even when controlling for exaggeration some pain patients do exhibit problems with attentional function. However, significant impairment in WMI performance (eg, index score

Sensitivity and specificity of reliable digit span in malingered pain-related disability.

The reliable digit span (RDS) performance of chronic pain patients with unambiguous spinal injuries and no evidence of exaggeration or response bias (n = 53) was compared to that of chronic pain patients meeting criteria for definite malingered neurocognitive dysfunction (n = 35), and a group of nonmalingering moderate-severe traumatic brain injury (TBI) patients (n = 69). The results demonstrated that scores of 7 or lower were associated with high specificity (> .90) and sensitivity (up to .60) even when moderate to severe TBI are included. Multiple studies have demonstrated that RDS scores of 7 or lower rarely occur in TBI and pain patients who are not intentionally performing poorly on cognitive testing. This study supports the use of the RDS in detecting response bias in neuropsychological patients complaining of pain as well as in the assessment of pain-related cognitive impairment in patients whose primary complaint is pain.

Test of Memory Malingering Performance is unaffected by laboratory-induced pain: implications for clinical use.

The Test of Memory Malingering (TOMM) is a well-validated and widely used forced-choice symptom validity test. However, little is known about how TOMM performance is affected by pain. The present study evaluated the sensitivity of the TOMM to pain induced in healthy participants via the cold-presser test. Participants (n=20 per group) were administered the TOMM under one of three conditions: (1) standard instructions; (2) instructions to simulate pain-related memory deficit in pursuit of personal injury litigation; (3) while experiencing cold-induced pain. Results indicate that TOMM performance was unaffected by laboratory-induced moderate to severe pain and support the TOMM's use in evaluating clinical patients with pain.

Reliable digit span is unaffected by laboratory-induced pain: implications for clinical use.

Reliable Digit Span (RDS) is an indicator used to assess the validity of cognitive test performance. Scores of 7 or lower suggest poor effort or negative response bias. The possibility that RDS scores are also affected by pain has not been addressed thus potentially threatening RDS specificity. The current study used cold pressor-induced pain to investigate the effect of pain on RDS scores. Sixty undergraduate volunteers randomly assigned to one of three conditions (control, simulator, pain) completed the Digit Span subtest from the Wechsler Adult Intelligence Scale-III from which the RDS is derived. No differences in RDS scores were found between the control and pain groups, and neither group scored below 8. Sixty-five percent of the simulator group scored 7 or below. These results suggest that RDS is not affected by pain, and scores of 7 or less in persons with pain can be more confidently attributed to negative response bias.