Women with PTSD have lower basal salivary cortisol levels later in the day than do men with PTSD: a preliminary study.

UNLABELLED: Acute stress responses of women are typically more reactive than that of men. Women, compared to men, may be more vulnerable to posttraumatic stress disorder (PTSD). Whether there are differences between women and men with PTSD in levels of the stress hormone, cortisol, was investigated in a pilot study. METHODS: women (n=6) and men (n=3) motor vehicle accident (MVA) survivors, with PTSD, had saliva collected at 1400 h, 1800 h, and 2200 h. Cortisol levels in saliva were measured by radioimmunoassay. An interaction between gender and time of sample collection was observed due to women's cortisol levels being lower and decreasing over time, whereas men's levels were higher and increased across time of day of collection. Results of this pilot study suggest a difference in the pattern of disruption of glucocorticoid secretion among women and men with PTSD. Women had greater suppression of their basal cortisol levels than did men; however, the diurnal pattern for cortisol levels to decline throughout the day was observed among the women but not the men.

Group cognitive behavior therapy for chronic posttraumatic stress disorder: an initial randomized pilot study.

Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment(GCBT) or a minimum contact comparison group (MCC).Compared to the MCC participants (n=16), individuals who completed GCBT (n=17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to31.3% of the MCC participants. Examination of anxiety,depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs.Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.

The role of stress in symptom exacerbation among IBS patients.

Over 200 treatment-seeking irritable bowel syndrome (IBS) patients completed 4 weeks of daily prospective measures of stress and gastrointestinal symptoms as well as retrospective measures of stress (life events over 12 months, hassles over 1 month). We also obtained the stress measures on 66 nonill controls. Irritable bowel syndrome patients report more frequent hassles than controls and a greater stress impact than controls. Using structural equation modeling, we found that the data were consistent with a model of robust autocorrelation effects of both week-to-week gastrointestinal (GI) symptom indices (r=.84) and stress indices (r=.73), as well as strong concurrent effects of stress on IBS symptoms (r=.90) and vice versa (r=.41). The data also were consistent with a model where there were effects of stress in Week t upon GI symptoms in Week t+1 and t+2, but they were mediated through the concurrent week effects and/or autocorrelation effects. There were no statistically significant independent pathways from stress in Week t to GI symptoms in Week t+1 or t+2. Thus, there is more support for a reciprocal relation between stress and symptoms than there is for a causal relation.

How does cognitive behavior therapy for irritable bowel syndrome work? A mediational analysis of a randomized clinical trial.

BACKGROUND AND AIMS: Although multiple clinical trials support the efficacy of psychological treatments for reducing irritable bowel syndrome (IBS) symptoms, the mechanisms responsible for symptomatic improvement are unknown. One hypothesis is that psychological treatments work by alleviating comorbid psychological distress implicated in the worsening of bowel symptoms and quality of life. An alternative hypothesis assumes that changes in distress are not strictly a cause but a consequence of IBS that will decrease with symptomatic improvement. METHODS: We evaluated these 2 hypotheses by applying structural equation modeling (SEM) to the data set of a large number (n = 147) of Rome II diagnosed participants randomized to CBT, psychoeducation, or wait list. Per Rome guidelines, the primary end point was global improvement of gastrointestinal (GI) symptoms measured 2 weeks after a 10-week regimen. Secondary end points were distress and quality of life (QOL). RESULTS: SEM analyses lend support to a model in which CBT is associated with improvements in IBS symptoms, but that therapeutic gains do not depend on changes in patients' overall level of psychological distress. Symptom severity, but not clinical status (pain catastrophizing, predominant bowel habits, symptom duration, abuse, diagnosable psychiatric disorder) or relevant sociodemographic variables (eg, gender, age), moderated treatment outcome. CONCLUSION: CBT has a direct effect on global IBS symptom improvement independent of its effects on distress. Improvement in IBS symptoms is associated with improvements in the QOL, which may lower distress. Symptom improvements are not moderated by variables reflecting the mental well-being of IBS patients.

Preliminary study of a self-administered treatment for irritable bowel syndrome: comparison to a wait list control group.

Despite the accumulation of efficacy data for cognitive-behavioral treatment of Irritable Bowel Syndrome (IBS), efforts to investigate methods for increasing access to psychological treatments are in their infancy. The current study examined the efficacy of self-administered treatment in comparison to a wait list control. Twenty-eight participants monitored gastrointestinal (GI) symptoms and completed measures of quality of life (QOL) and psychological distress prior to randomized assignment to self-help treatment or wait list. Wait listed participants later received treatment. A 3 month post-treatment follow-up was included. Seven participants completed immediate treatment; nine the wait list. The self-help treatment significantly decreased composite GI symptom scores in comparison to the wait list, but did not lead to significant improvements in QOL or distress. In the entire treated sample, including wait list crossovers, analyses showed significant improvement in abdominal pain, average GI symptoms, and perceived health and well-being. Interpretation of these results should be considered in the context of several limitations, including small sample size, brief baseline symptom monitoring, and high drop out rate. Despite these limitations, this study is an important first step in empirically validating low-cost, self-administered treatments as a first line psychological intervention for IBS.

A controlled evaluation of group cognitive therapy in the treatment of irritable bowel syndrome.

We randomized, at two sites, 210 patients with Rome II diagnosed irritable bowel syndrome (IBS), of at least moderate severity, to one of three conditions: group-based cognitive therapy (CT; n=120), psychoeducational support groups (n=46) as an active control, or intensive symptom and daily stress monitoring (n=44). One hundred eighty-eight participants completed the initial treatment. Those in symptom monitoring were then crossed over to CT. For an intent to treat analysis on a composite GI symptom measure derived from daily symptom diaries, both CT and the psychoeducational support groups were significantly more improved than those in the intensive symptom monitoring condition, but the CT and psychoeducational support group did not differ. Among treatment completers on the same composite measure of GI symptoms, again, both CT and psychoeducational support groups were statistically superior to symptom monitoring but did not differ on the symptom composite, or on any other measure. On individual IBS symptoms, both CT and psychoeducational support were statistically superior to symptom monitoring on reductions in abdominal pain and tenderness and for flatulence. Patient global ratings at the end of treatment showed the two active conditions statistically superior to symptom monitoring on change in Bowel Regularity, with CT superior to symptom monitoring on reduction in overall pain and in improvement in sense of well-being. Three-month follow-up data on 175 patients revealed maintenance of significant improvement or continued significant improvement on all IBS symptoms, including the McGill Pain Questionnaire. Group CT and psychoeducational support groups continued not to differ on any measure. We thus conclude that group CT is not superior to an attention placebo control condition.

Heart rate of motor vehicle accident survivors in the emergency department, peritraumatic psychological reactions, ASD, and PTSD severity: a 6-month prospective study.

This small-scale study investigates the relationships between the heart rate of motor vehicle accident survivors presenting in the emergency department (ED) and acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) symptom severity. It also examines the relationships between the survivor's heart rate in the ED and peritraumatic dissociation and peritraumatic distress reported 2 weeks posttrauma. Fifty motor vehicle accident (MVA) survivors were assessed 2 weeks, 1 (N = 42), 3 (N = 37), and 6 months (N = 37) post-MVA. The heart rate in the ED predicted self-reported ASD symptom severity and clinician-rated PTSD symptom severity at 6 months but not at 1 or 3 months. Survivors' heart rate in the ED was significantly correlated with peritraumatic dissociation but not peritraumatic distress. These findings support the role of elevated ED heart rate as a predictor of both ASD and chronic PTSD symptom severity and may help to clarify the discrepant findings of previous research.

Retaining pathological gamblers in cognitive behavior therapy through motivational enhancement: A pilot study.

Treatment for pathological gambling is in its infancy. Several cognitive and behavioral interventions have shown promise, but high attrition and relapse rates suggest that gamblers requesting treatment are not uniformly committed to change. This article describes an exploratory study with 9 severe pathological gamblers--in their majority horse race bettors--who were recruited from a community treatment center. The gamblers were treated with a hybrid intervention consisting of motivational enhancement and cognitive behavior therapy. All gamblers were retained in treatment and during a 12-month follow-up period. This retention rate was significantly higher than that of a control group of gamblers who received treatment as usual in the same community setting. Of the gamblers who received the experimental treatment, 6 maintained total abstinence during the 12-month follow-up period, 2 were significantly improved, and 1 remained unimproved. In addition to changing their gambling behavior, many clients made successful lifestyle changes. The possible benefits of combining a motivational intervention with cognitive behavior therapy are discussed.

What factors are associated with the maintenance of PTSD after a motor vehicle accident? The role of sex differences in a help-seeking population.

To investigate potential sex differences in factors that are associated with chronic PTSD, data from 223 participants were examined using logistic regression analyses. Each participant had been involved in a serious motor vehicle accident (MVA), which had occurred at least 6 months earlier (range 6mos-37 years). Although men and women did not differ in the rate of diagnosed PTSD, four variables were found to interact significantly with sex in the prediction of chronic PTSD: peritraumatic experiences of helplessness, danger, and the certainty that one would die during the MVA and lack of employment. Follow up analyses indicated that although the peritraumatic experience variables were statistically significant, no notable differences emerged in the odds ratios of men and of women. In contrast, men who were unemployed were 9.94 times more likely to be diagnosed with PTSD, relative to men who were employed, while unemployed women were 2.85 times more likely to be diagnosed with PTSD, relative to women who were employed. Results are discussed in light of the role of functional limitations and their impact on the maintenance of PTSD in men and women.

Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy.

Using a sample of over 125 patients with irritable bowel syndrome (IBS) who were treated with cognitive therapy administered in small groups, we sought to predict end of treatment and 3-month follow-up improvement in two changes indices of gastrointestinal (GI) symptoms (Pain/Discomfort Index which assessed change in abdominal pain, abdominal tenderness and bloating and Bowel Regularity Index which assessed change in diarrhea and constipation). We also sought to predict scores on IBS specific quality of life (QOL) and overall level of psychological distress using the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant, but modest, levels of prediction were found for prediction of improvement in GI symptoms (4-15% of variance). Stronger significant prediction was obtained for the QOL and global psychological distress measure with R(2)'s ranging from 0.36 to 0.50. A wide variety of demographic, GI symptom, psychological status and psychiatric status variables entered the final prediction equations.

Psychosocial aspects of chronic daily headache.

The objective was to investigate possible psychosocial factors in chronic daily headache (HA) by comparing those with chronic daily HA to matched patients with chronic episodic HA and to matched non-HA controls. Although there is some research on psychosocial factors in chronic daily HA, it is conflicting and none to date has compared such patients to both an episodic HA control and a non-HA control. Nineteen patients with chronic daily HA (less than 2% of 4-times-per-day HA ratings were zero) were compared to 19 HA patients matched on age, gender and nominal IHS diagnoses, and to 16 similarly matched non-HA controls on measures of psychological distress (MMPI, BDI, STAI), measures of life stress (major past events, hassles, prospective daily stress) and quality of life (SF-36). Those with chronic daily HA were significantly more distressed and had significantly poorer function on most measures relative to non-HA controls. Although there were many arithmetic trends for chronic daily HA to be more distressed and to function less well than those with episodic HA, only on the depression and social introversion scales of the MMPI and the overall vitality rating of the SF-36 were the differences significant. All three groups had comparable levels of life stress regardless of how it was measured. Those with chronic daily HA have greater levels of psychological distress and poorer quality of life than those with episodic HA or non-HA controls, despite comparable levels of life stress.

Psychiatric and behavioral problems in aggressive drivers.

Motor vehicle accidents (MVAs) are a leading cause of accidental death and injury, and aggressive driving has been identified as a risk factor for MVAs. Assessing psychiatric and behavioral disturbances in aggressive drivers is germane to the development of prevention and intervention programs for this population. The present study compared the prevalence of psychiatric diagnoses and behavioral problems in young adult drivers with self-reported high driving aggression to that of drivers with low driving aggression. Aggressive drivers evidenced a significantly higher current and lifetime prevalence of Oppositional Defiant Disorder, Alcohol and Substance Use Disorders, and Cluster B Personality Disorders, and a significantly greater lifetime prevalence of Conduct Disorder, Attention-Deficit/Hyperactivity Disorder, and Intermittent Explosive Disorder. Aggressive drivers also had a significantly greater prevalence of self-reported problems with anger, as well as a greater family history of anger problems and conflict. The findings suggest that prevention and intervention programs designed to reduce aggressive driving may need to address the presence of psychiatric and behavioral problems that could potentially complicate treatment or impede responses to treatment.

Psychophysiological assessment of youthful motor vehicle accident survivors.

Twenty-one children and adolescents (age range 8-17, mean 12.7 years) who had been in motor vehicle accidents (MVAs), and 14 non-MVA controls matched for age and gender, underwent a psychophysiological assessment in which heart rate, systolic and diastolic blood pressure, and skin conductance were measured during baseline and two stressor phases: mental arithmetic and listening to and imagining a MVA like their own. The eight youth who currently met criteria for PTSD or sub-syndromal PTSD significantly reported more subjective distress to the MVA audiotape than the 13 MVA non-PTSD youth or the 14 non-MVA controls. All groups responded physiologically to the mental arithmetic. However, in contrast to expectations, there were no differential physiological responses among the groups to the stimuli reminiscent of the trauma. Possible explanations are explored.

A behavioral group treatment program for menopausal hot flashes: results of a pilot study.

In the present study, we tested the effectiveness of a cognitive-behavioral group treatment (CBGT) for hot flashes in menopausal women. Treatment was administered over 8, 90 min weekly sessions and consisted of education, relaxation training and cognitive restructuring. Nineteen women meeting STRAW staging criteria for the menopause transition (stages -1 to +1) were randomly assigned to immediate or delayed treatment (wait list) and were asked to monitor their hot flashes and night sweats prospectively. They also completed questionnaires, including the Women's Health Questionnaire and the Menopause Specific Quality of Life Questionnaire to determine psychosocial benefits of treatment. Results suggested that the CBGT was moderately successful in reducing the frequency of total vasomotor symptoms [F (1, 17) = 6.16, p < .01], as measured by daily symptom diaries. While there were arithmetic improvements in psychosocial functioning in this sample, these results were not significant. Despite the limitations of small sample size and possible placebo effect, this pilot study supports the notion that cognitive-behavioral interventions aimed at reducing vasomotor symptoms may be of value for menopausal hot flashes when administered in a small-group format.

The effect of the definition of menstrually-related headache on the response to biofeedback treatment.

Twelve women with either pure migraine headache (HA) or a combination of migraine and tension-type HA monitored HA activity over two menstrual cycles while noting onset of menstruation and onset of ovulation. They then received 12 sessions of thermal biofeedback (TBF) with adjunctive autogenic training. Six women with only tension-type HA participated in similar monitoring before receiving 9 sessions of progressive relaxation training. Results for those with vascular HA showed a significant reduction in HA activity and a reduction in medication taken for HAs. Those with tension-type HA did not respond significantly to the relaxation training. Depending upon how one defined menstrually-related HAs among those with vascular HA, there either was, or was not, a differential effect of TBF on menstrual-cycle-related HA.

Hot flash, hot topic: conceptualizing menopausal symptoms from a cognitive-behavioral perspective.

While most healthy women report that the menopausal transition is nondistressing, a subset of women does report that symptoms significantly interfere in their lives. The most common reason that women seek treatment during this time is for vasomotor symptoms, namely, hot flashes and night sweats. Research has suggested that reports of distress during flashing are only weakly related to more objective measures of the flash, including duration and frequency and that differences in treatment-seeking during the menopausal transition may be better accounted for by differences in symptom awareness mediated by a variety of personality and stress factors. This paper discusses hot flashes and night sweats from a cognitive-behavioral perspective, taking into account individual difference variables that may also affect the experience of menopausal symptoms.

Testing the sequential model of pain processing in irritable bowel syndrome: a structural equation modeling analysis.

Pain, the cardinal feature of irritable bowel syndrome (IBS), is a multidimensional phenomenon with sensory and affective dimensions. Price's pain processing model was used to delineate four a priori sequentially related stages (pain sensation intensity, immediate pain unpleasantness, long-term suffering, and pain-related behavior). Although prior research with both healthy individuals and somatic pain patients supports the model in general, its applicability to IBS is unclear. Our goal was to extend the scope of the sequential model and test its fundamental tenets using structural equation modeling (SEM) with data obtained from 168 Rome II diagnosed IBS patients (19% male, 81% female). A secondary goal was to assess the relationship between a set of contextual factors associated with IBS (age, gender, trait anxiety) and the four pain stages. Results were consistent with a successive order of pain processing such that the pain sensation directly impacts pain unpleasantness, which, in turn, leads to suffering and illness behaviors. However, contrary to a model with strictly successive stages, pain sensation had independent effects on illness behaviors over and above pain affect. The effect of anxiety on illness behavior was mediated by suffering, while psychopathology directly influenced pain sensation and pain unpleasantness but not later stages. Age was related to pain sensation and illness behaviors but not pain affect. Gender tended to be more strongly associated with more distal pain stages (e.g., pain affect) vis-a-vis its effects on pain sensation. These data are generally supportive of a four-stage pain processing model.

A randomized controlled trial of an internet-based treatment for chronic headache.

Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.

Posttraumatic stress and depressive symptoms in a college population one year after the September 11 attacks: the effect of proximity.

As a follow-up to our earlier report [Behav. Res. Ther., in press] on the level of posttraumatic stress symptoms (PTSS), depressive symptoms, and frequency of diagnoses of probable posttraumatic stress disorder (PTSD) among college students at three public universities (Albany, NY, Augusta, GA, and Fargo, ND) resulting from the September 11, 2001. Terrorist attacks, we surveyed comparable groups of students (total, n = 1313) from these three institutions in the weeks following the first anniversary (2002) of the attacks. We found proximity effects (Albany higher than Augusta which was higher than Fargo) for PTSS and depressive symptoms but not for frequency of diagnoses of probable PTSD. Within the Albany site data, proximity of county of residence to New York City (NYC) also showed a proximity effect on PTSS. Although depressive symptoms were significantly different in 2002 versus 2001, the arithmetic differences in PTSS or in frequency of diagnoses of probable PTSD were not significant. The September 11 attacks continued to exert a psychic toll on college students even a year later.