Environmental Suppression Mediates the Relationship between Posttraumatic Stress and Cannabis Use Among Trauma-Exposed College Students.

OBJECTIVE: Trauma exposure and posttraumatic stress (PTS) are prominent risk factors for problematic substance use, but little research has evaluated the mechanisms that link PTS and substance use. Emerging research supports the utility of reward probability (i.e., access to and pleasure experienced in response to environmental reward) as a mediator of the relationship between trauma and alcohol use problems. However, no existing studies have examined whether reward probability mediates the link between posttraumatic stress (PTS) and cannabis use in trauma exposed individuals. METHOD: In a cross-sectional design, undergraduate students (N = 404) anonymously completed online measures, the Reward Probability Index (RPI; Carvalho et al., 2011), the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL5; Blevins et al., 2015), and the Cannabis Use Disorder Identification Test - Revised (CUDIT-R; Adamson et al., 2010), to satisfy course requirements. A parallel mediation path analysis model was used to test the hypothesis that RPI scales (Reward Probability, RP; Environmental Suppression, ES) would mediate the relationship between PTS and cannabis misuse. RESULTS: Findings revealed that RPI-ES fully mediated the relationship between PTS and cannabis misuse, whereas RPI-RP did not. CONCLUSIONS: Results support the utility of the RPI-ES scale as a transdiagnostic risk factor for both PTS and cannabis use and suggest further investigation into treatment approaches that optimize opportunities for (non-substance) rewarding experiences in the treatment of co-occurring PTS and substance misuse.

Trauma exposure among cannabis use disorder individuals was associated with a craving-correlated non-habituating amygdala response to aversive cues.

The relationship of cannabis-use disorder and trauma exposure at the level of the brain is not well-understood. Cue-reactivity paradigms have largely focused on characterizing aberrant subcortical function by averaging across the entire task. However, changes across the task, including a non-habituating amygdala response (NHAR), may be a useful biomarker for relapse vulnerability and other pathology. This secondary analysis utilized existing fMRI data from a CUD population with (TR-Y, n = 18) or without trauma (TR-N, n = 15). Amygdala reactivity to novel and repeated aversive cues was examined between TR-Y vs. TR-N groups, using a repeated measures ANOVA. Analysis revealed a significant interaction between TR-Y vs. TR-N and amygdala response to novel vs. repeated cues in the amygdala (right: F (1,31) = 5.31, p = 0.028; left: F (1,31) = 7.42, p = 0.011). In the TR-Y group, a NHAR was evident, while the TR-N group exhibited amygdala habituation, resulting in a significant difference between groups of amygdala reactivity to repeated cues (right: p = 0.002; left: p < 0.001). The NHAR in the TR-Y (but not TR-N) group was significantly correlated with higher cannabis craving scores, yielding a significant group difference (z = 2.1, p = 0.018). Results suggest trauma interacts with the brain's sensitivity to aversive cues, offering a neural explanation for the relationship between trauma and CUD vulnerability. These findings suggest the importance of considering the temporal dynamics of cue reactivity and trauma history in future studies and treatment planning, as this distinction may help decrease relapse vulnerability.

Intervention Design and Trial Protocol: Mindfulness-based Exposure for PAP-associated Claustrophobia.

Positive airway pressure (PAP) associated claustrophobia is common among obstructive sleep apnea patients and plays a prominent role in low adherence and treatment failure. As there are no evidence-based interventions for PAP-associated claustrophobia, the objective of the present research is to pilot test Mindfulness-based Exposure for PAP-associated Claustrophobia, in sleep apnea adults that present with treatment non-adherence and claustrophobia. This approach combines Mindfulness-based Stress Reduction with exposure-based treatment components to target this treatment-associated claustrophobia. The present article outlines the mindfulness exposure intervention design and methods and reports the pilot trial study protocol. Trial findings are intended to: (a) develop a preliminary effect size of the intervention on PAP-associated claustrophobia; (b) explore differences in treatment adherence by group (intervention vs control); and (c) establish feasibility for expanded protocol implementation, delivery, and participant acceptability of the intervention to support subsequent design of a fully powered randomized controlled trial.

The many facets of mindfulness and the prediction of change following mindfulness-based stress reduction (MBSR).

OBJECTIVES: Mindfulness-based stress reduction (MBSR) promotes numerous psychological benefits, but few studies have identified for whom MBSR is most effective. The current study tested the hypothesis that lower baseline mindfulness invites more "room to grow" and, thus, predicts greater improvement during MBSR. METHOD: We examined three facets of mindfulness (awareness, acceptance, decentering) among 131 MBSR participants prior to enrollment, to test the hypothesis that lower baseline mindfulness predicts greater improvements in perceived stress, positive affect (PA), and negative affect (NA) following MBSR. RESULTS: Lower acceptance and decentering predicted greater decreases in perceived stress. Higher awareness, acceptance, and decentering predicted greater increases in PA. Higher awareness predicted greater reductions in NA. Lower decentering predicted greater reductions in NA. CONCLUSION: Findings partly supported the hypothesis that lower baseline mindfulness predicts greater improvement following MBSR and emphasize the importance of assessing multiple mindfulness facets given their unique, contrasting relations to outcomes.

Caregivers' Advice and Children's Bystander Behaviors During Bullying Incidents.

Many bullying prevention programs take a bystander approach, which encourages children to intervene when they are bystanders to bullying incidents. Little is known about how caregivers' advice to children might promote or undermine the positive bystander behaviors targeted by these programs. Accordingly, the aim of the current study was to investigate relations between caregivers' advice and children's bystander behavior during bullying situations. Participants were 106 racially/ethnically diverse 4th- and 5th-grade students (M age = 10.5 years, SD = .71 years), their classmates, and their caregivers. During classroom visits, peers reported on children's bystander behaviors. During home visits, caregivers and children completed a coded interaction task in which caregivers advised children about how to respond to bullying situations at school. Results suggested that (a) bystander intervention was positively predicted by caregivers' advice to help/comfort the victim, (b) bystander passivity was positively predicted by caregivers' advice to not intervene and negatively predicted by caregivers' advice to help/comfort the victim, and (c) bystander reinforcement/assistance of the bully was positively predicted by caregivers' advice not to intervene and not to tell adults. Results support a link between caregivers' advice at home and children's corresponding behavior when they are bystanders to bullying situations at school. These results emphasize the importance of collaboration between families and schools to reduce school bullying. Implications and directions for future research are discussed.

Unseen scars: Cocaine patients with prior trauma evidence heightened resting state functional connectivity (RSFC) between the amygdala and limbic-striatal regions.

BACKGROUND: Substance use disorder (SUD) patients with a history of trauma exhibit poorer treatment outcome, greater functional impairment and higher risk for relapse. Endorsement of prior trauma has, in several SUD populations, been linked to abnormal functional connectivity (FC) during task-based studies. We examined amygdala FC in the resting state (RS), testing for differences between cocaine patients with and without prior trauma. METHODS: Patients with cocaine use disorder (CUD; n=34) were stabilized in an inpatient setting prior to a BOLD fMRI scan. Responses to Addiction Severity Index and the Mini-International Neuropsychiatric Interview were used to characterize the No-Trauma (n=16) and Trauma (n=18) groups. Seed-based RSFC was conducted using the right and left amygdala as regions of interest. Examination of amygdala RSFC was restricted to an a priori anatomical mask that incorporated nodes of the limbic-striatal motivational network. RESULTS: RSFC was compared for the Trauma versus No-Trauma groups. The Trauma group evidenced greater connectivity between the amygdala and the a priori limbic-striatal mask. Peaks within the statistically significant limbic-striatal mask included the amygdala, putamen, pallidum, caudate, thalamus, insula, hippocampus/parahippocampus, and brain stem. CONCLUSIONS: Results suggest that cocaine patients with prior trauma (versus without) have heightened communication within nodes of the motivational network, even at rest. To our knowledge, this is the first fMRI study to examine amygdala RSFC among those with CUD and trauma history. Heightened RSFC intralimbic connectivity for the Trauma group may reflect a relapse-relevant brain vulnerability and a novel treatment target for this clinically-challenging population.

Multi-site exploration of sex differences in brain reactivity to smoking cues: Consensus across sites and methodologies.

BACKGROUND: Biological sex influences cigarette smoking behavior. More men than women smoke, but women have a harder time quitting. Sex differences in smoking cue (SC) reactivity may underlie such behavioral differences. However, the influence of sex on brain reactivity to SCs has yielded inconsistent findings suggesting the need for continued study. Here, we investigated the effect of sex on SC reactivity across two sites using different imaging modalities and SC stimulus types. METHODS: Pseudo-continuous arterial spin-labeled (pCASL) perfusion functional magnetic resonance imaging (fMRI) was used to assess brain responses to SC versus non-SC videos in 40 smokers (23 females) at the University of Pennsylvania. BOLD fMRI was used to assess brain responses to SC versus non-SC still images in 32 smokers (18 females) at McLean Hospital. Brain reactivity to SCs was compared between men and women and was correlated with SC-induced craving. RESULTS: In both cohorts, males showed higher SC versus non-SC reactivity compared to females in reward-related brain regions (i.e., ventral striatum/ventral pallidum, ventral medial prefrontal cortex). Brain activation during SC versus non-SC exposure correlated positively with SC-induced subjective craving in males, but not females. CONCLUSIONS: The current work provides much needed replication and validation of sex differences in SC-reactivity. These findings also add to a body of literature showing that men have greater reward-related brain activation to drug cues across drug classes. Such sex differences confirm the need to consider sex not only when evaluating SC-reactivity but when examining nicotine dependence etiology and treatment.

A Randomized Controlled Trial of a Mindfulness and Acceptance Group Therapy for Residential Substance Use Patients.

BACKGROUND: Substance use disorders are understood as a chronically relapsing condition that is difficult to treat. However, in recent years there have been promising developments in the treatment of substance use disorders, specifically with interventions based on mindfulness and acceptance and commitment therapy. Little research has examined whether these types of interventions may positively impact residential substance use treatment outcomes. OBJECTIVES: Thus, in the current study we developed and examined, in a randomized controlled trial, a 4-week, eight-session, adjunctive mindfulness and acceptance group therapy for patients in residential substance use treatment. Our primary outcomes were substance use cravings, psychological flexibility, and dispositional mindfulness at treatment discharge. METHODS: Patients (N = 117) from a private residential substance use facility were randomized to receive the adjunctive mindfulness and acceptance group or treatment-as-usual. Patients were assessed at treatment intake and at discharge from a 28-30-day residential program. RESULTS: Although treatment groups did not statistically differ at discharge on any primary outcome, small effect sizes favored the mindfulness and acceptance group on cravings and psychological flexibility. Conclusions/Importance: Continued research is needed to determine whether the addition of mindfulness and acceptance-based interventions improve outcomes long term following residential substance use treatment.

Experiential avoidance, distress tolerance, and substance use cravings among adults in residential treatment for substance use disorders.

Substance use cravings are a known predictor of relapse to substance use following treatment for a substance use disorder. Thus, research on factors that may be correlated with cravings, and could then be targeted in substance use treatment, is needed. Both distress tolerance and experiential avoidance, similar but distinct constructs, are independently associated with substance use cravings. However, no known research has examined these constructs as simultaneous predictors of substance use cravings, which may have important implications for treatment. The current study examined this in a sample of men and women in residential substance use treatment (n = 117). The authors used pre-existing data from a larger study where men and women were recruited for participation from a residential substance use treatment facility. The majority of the sample was male (n = 87; 74.3%) and Caucasian (92.2%). The mean age was 41.27 (standard deviation = 10.68). Better distress tolerance and lower experiential avoidance were negatively and significantly associated with alcohol and drug cravings, but only experiential avoidance remained significantly and negatively associated with cravings when both predictors were examined simultaneously. The current findings provide preliminary support for the importance of decreasing experiential avoidance in substance use treatment, which may result in reduced substance use cravings.

Emotional, physical and sexual abuse are associated with a heightened limbic response to cocaine cues.

Drug-reward cues trigger motivational circuitry, a response linked to drug-seeking in animals and in humans. Adverse life events have been reported to increase sensitivity to drug rewards and to bolster drug reward signaling. Therefore, we hypothesized that cocaine-dependent individuals with prior emotional, physical and sexual abuse might have a heightened mesolimbic brain response to cues for drug reward in a new brief-cue probe. Cocaine-dependent human individuals (N = 68) were stabilized in an inpatient setting and then completed an event-related blood-oxygen-level dependent functional magnetic resonance imaging task featuring 500-ms evocative (cocaine, sexual, aversive) and comparator (neutral) cues. Responses to three questions about emotional, physical and sexual abuse from the Addiction Severity Index were used to divide the patients into subgroups (history of Abuse [n = 40] versus No Abuse [n = 28]). When subjects were grouped by the historical presence or absence of emotional, physical or sexual abuse, the Abuse group showed a heightened midbrain, thalamic, caudate, and caudal orbitofrontal cortex response to cocaine cues; a similar result was found in other evocative cues, as well. These findings are the first reported for a 500-ms cocaine-cue probe, and they highlight the ability of very brief evocative cues to activate the brain's motivational circuitry. Although all participants had severe cocaine use disorders, individuals reporting prior abuse had a heightened mesolimbic response to evocative cues. To our knowledge, this is the first study in humans linking a history of abuse to a brain vulnerability (heightened mesolimbic response to drug cues) previously shown to contribute to drug-seeking.

The relationship between mindfulness and compulsive sexual behavior in a sample of men in treatment for substance use disorders.

Substance use disorders (SUDs) are a serious worldwide problem. Despite years of research on the treatment of SUDs, relapse remains high. One factor that may complicate SUDs treatment for some patients is compulsive sexual behavior. Factors that are related to both SUDs and compulsive sexual behavior could be targeted in SUDs treatment. In the current study, we examined dispositional mindfulness, a protective factor for a range of mental health problems, and its relationship to compulsive sexual behavior in a SUDs treatment sample. This is the first study to examine this relationship in a SUDs sample. Medical records from men in residential SUDs treatment were reviewed for the current study (N = 271). Upon admission to treatment, men completed self-report measures on alcohol and drug use, dispositional mindfulness, and compulsive sexual behavior. Bivariate correlations demonstrated dispositional mindfulness to be negatively associated with a variety of indicators of compulsive sexual behavior. After controlling for alcohol and drug use and problems in hierarchical regression analyses, which were both associated with compulsive sexual behaviors, dispositional mindfulness remained negatively associated with all of the compulsive sexual behavior indicators. Our results provide the first empirical association between dispositional mindfulness and compulsive sexual behavior in a SUDs sample. Although continued research is needed in this area, our findings suggest that it may be beneficial for SUDs treatment to incorporate mindfulness-based interventions for individuals with comorbid compulsive sexual behavior.

The relationship between dispositional mindfulness, borderline personality features, and suicidal ideation in a sample of women in residential substance use treatment.

Borderline personality disorder (BPD), which is characterized by unstable moods, behavior, and relationships, is also associated with heightened suicidal ideation. Prior research has demonstrated that BPD and suicidal ideation are prevalent among women in substance use treatment. Efforts to treat substance use in this population are made difficult due to the severity of BPD, and it is possible that mindfulness-based interventions specific to substance use could be an effective approach for this population. However, basic research is needed on the relationship between dispositional mindfulness, BPD, and suicidal ideation among women in treatment for substance use to support their associations, which was the purpose of the present study. Pre-existing medical records were reviewed from a residential substance use treatment center. A total of 81 female patients were included in the current study. Patients completed self-report measures of mindfulness, BPD, suicidal ideation, substance use, and impression management at treatment intake. Findings demonstrated dispositional mindfulness to be negatively associated with BPD features and suicidal ideation. With the exception of self-harm, this negative relationship was found even after controlling for age, substance use, and impression management. Future research should examine whether mindfulness-based interventions are an effective treatment for comorbid substance use and BPD.

Dimensions of distress tolerance and the moderating effects on mindfulness-based stress reduction.

BACKGROUND AND OBJECTIVES: This study examined the relationship between distress tolerance and psychosocial changes among individuals participating in Mindfulness-Based Stress Reduction (MBSR). The objective of the analysis was to discern whether individuals with lower distress tolerance measured before MBSR showed larger reductions in perceived stress following MBSR. DESIGN AND METHODS: Data were collected from a sample of convenience (n = 372) using a quasi-experimental design. Participants completed self-report measures immediately prior to course enrollment and following course completion. RESULTS: Perceived stress, distress tolerance, and mood states showed favorable changes from pre- to post-MBSR in the current study. Baseline distress tolerance significantly moderated reductions on perceived stress, supporting the primary hypothesis that individuals with lower baseline distress tolerance evidenced a greater decline in perceived stress following MBSR. For a one-unit increase on the self-reported baseline Distress Tolerance Scale, reported perceived stress scores decreased by 2.5 units (p < .0001). CONCLUSIONS: The finding that individuals with lower baseline distress tolerance evidenced a greater decline in perceived stress may offer hints about who is most likely to benefit from MBSR and other mindfulness-based treatments. Identifying moderators of treatment outcomes may yield important benefits in matching individuals to treatments that are most likely to work for them.

Dispositional mindfulness, spirituality, and substance use in predicting depressive symptoms in a treatment-seeking sample.

OBJECTIVE: It is imperative that research identifies factors related to depression among individuals in substance use treatment, as depression is associated with substance use relapse. Dispositional mindfulness and spirituality may bear an important role in the relationship between depression and substance use. METHOD: Using preexisting patient medical records (N = 105), the current study investigated dispositional mindfulness and spirituality in relation to depressive symptom clusters (affective, cognitive, and physiological) among men in residential substance use treatment. The mean age of the sample was 41.03 (standard deviation = 10.75). RESULTS: Findings demonstrated that dispositional mindfulness and spirituality were negatively associated with depressive symptoms. After controlling for age, alcohol use, and drug use, dispositional mindfulness remained negatively associated with all of the depression clusters. Spirituality only remained associated with the cognitive depression cluster. CONCLUSION: Mindfulness-based interventions may hold promise as an effective intervention for reducing substance use and concurrent depressive symptoms.

Functional neuroimaging of personally-relevant stimuli in a paediatric case of impaired awareness.

BACKGROUND: Functional neuroimaging studies have observed preserved neural activation to personally relevant stimuli in patients within the disorders of consciousness (DOC) spectrum. As the majority of studies have focused on adult DOC patients, little is known about preserved activation in the developing brain of children with impaired consciousness. CASE STUDY: The aim of this study is to use fMRI to measure preserved neural activation to personally relevant stimuli (subject's own name and familiar voice) in a paediatric patient who sustained a traumatic brain injury and anoxic-ischaemia following a motor vehicle accident at 18 months of age rendering her probable for minimally conscious state. Contrasts revealed activation in the right middle frontal gyrus when hearing the subject's own name and the anterior supramarginal gyrus when hearing a familiar voice. CONCLUSION: This study provides preliminary support for fMRI as a method to measure preserved cognitive functioning in paediatric DOC patients.

Pragmatic psychodynamic psychotherapy for a patient with depression and breast cancer: functional MRI evaluation of treatment effects.

Time-limited psychodynamic psychotherapy is garnering empirical support as an intervention for clinical depression. However, research is needed to examine the efficacy of psychodynamic approaches among patients presenting with diverse psychiatric and medical problems. This case study examined the efficacy of eight sessions of pragmatic psychodynamic psychotherapy (PPP) in treating a woman with major depression and breast cancer. Pre- to posttreatment assessment indicated significant reductions in depression and weekly assessment indicated increased environmental reward was associated with reduced depression. Secondary aims involved piloting a functional magnetic resonance imaging (fMRI) task as a neurobiological indicator of depression attenuation as a function of PPP. This assessment was conducted to explore alternative means of evaluating treatment responsiveness and addressing the problem of arbitrary metrics in measuring change. Clinical and assessment implications are discussed, with a focus on innovative approaches to evaluate treatment outcome and behavioral and neurobiological mechanisms of change associated with PPP.

Outcomes of Prolonged Exposure therapy for veterans with posttraumatic stress disorder.

Prolonged Exposure (PE) is an evidenced-based psychotherapy for posttraumatic stress disorder (PTSD) that is being disseminated nationally within the U.S. Department of Veterans Affairs (VA) with promising initial results. Empirical evidence, however, regarding the effectiveness of PE for treatment of PTSD in military veterans is limited. Building on previous treatment outcome research, the current study investigated the effectiveness of PE in a diverse veteran sample. One-hundred fifteen veterans were enrolled in PE at an urban VA medical center and its surrounding outpatient clinics. PTSD and depression symptoms as well as quality of life were measured before and after treatment. Several baseline patient characteristics were examined as predictors of treatment response. Eighty-four participants completed treatment. Participants experienced a 42% reduction in PTSD symptoms, a 31% reduction in depression symptoms, and an increase in quality of life following PE. Veterans not prescribed psychotropic medication reported greater PTSD symptom reduction than veterans prescribed such medication. The implications of these results for treatment programs targeting PTSD in veterans are discussed.

Neural Changes following Behavioral Activation for a Depressed Breast Cancer Patient: A Functional MRI Case Study.

Functional neuroimaging is an innovative but at this stage underutilized method to assess the efficacy of psychotherapy for depression. Functional magnetic resonance imaging (fMRI) was used in this case study to examine changes in brain activity in a depressed breast cancer patient receiving an 8-session Behavioral Activation Treatment for Depression (BATD), based on the work of Hopko and Lejuez (2007). A music listening paradigm was used during fMRI brain scans to assess reward responsiveness at pre- and posttreatment. Following treatment, the patient exhibited attenuated depression and changes in blood oxygenation level dependence (BOLD) response in regions of the prefrontal cortex and the subgenual cingulate cortex. These preliminary findings outline a novel means to assess psychotherapy efficacy and suggest that BATD elicits functional brain changes in areas implicated in the pathophysiology of depression. Further research is necessary to explore neurobiological mechanisms of change in BATD, particularly the potential mediating effects of reward responsiveness and associated brain functioning.

Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial.

OBJECTIVE: Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression. METHOD: In a primarily Caucasian, well-educated sample of women (age = 55.4 years, SD = 11.9) diagnosed with breast cancer and major depression (n = 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes. RESULTS: Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre-post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group. CONCLUSIONS: BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed.

The reward probability index: design and validation of a scale measuring access to environmental reward.

Behavioral models of depression implicate decreased response-contingent positive reinforcement (RCPR) as critical toward the development and maintenance of depression (Lewinsohn, 1974). Given the absence of a psychometrically sound self-report measure of RCPR, the Reward Probability Index (RPI) was developed to measure access to environmental reward and to approximate actual RCPR. In Study 1 (n=269), exploratory factor analysis supported a 20-item two-factor model (Reward Probability, Environmental Suppressors) with strong internal consistency (α=.90). In Study 2 (n=281), confirmatory factor analysis supported this two-factor structure and convergent validity was established through strong correlations between the RPI and measures of activity, avoidance, reinforcement, and depression (r=.65 to .81). Discriminant validity was supported via smaller correlations between the RPI and measures of social support and somatic anxiety (r=-.29 to -.40). Two-week test-retest reliability was strong (r=.69). In Study 3 (n=33), controlling for depression symptoms, hierarchical regression supported the incremental validity of the RPI in predicting daily diary reports of environmental reward. The RPI represents a parsimonious, reliable, and valid measure that may facilitate understanding of the etiology of depression and its relationship to overt behaviors.