Do acceptance and mindfulness moderate the relationship between maladaptive beliefs and posttraumatic distress?

OBJECTIVE: Maladaptive pre- and posttraumatic beliefs are reliable predictors of distress in the wake of trauma. Acceptance and mindfulness skills may be associated with less distress in the presence of these beliefs, but few studies have explored these relationships. This study examined whether individual differences in acceptance and mindfulness moderate the relationship between maladaptive thoughts and distress in postdeployment soldiers. METHOD: We explored the relationships between posttraumatic maladaptive beliefs, acceptance, mindfulness, and posttraumatic distress (posttraumatic stress disorder [PTSD] and general psychological symptoms) in a sample of recently postdeployed active duty U.S. Army Soldiers (N = 1,524). RESULTS: Maladaptive thoughts, acceptance, and mindfulness predicted posttraumatic distress, adjusted for combat exposure. In addition, mindfulness partially moderated the relationship between maladaptive thoughts and PTSD symptoms, and acceptance partially moderated the relationship between maladaptive thoughts and general psychological symptoms. Moderation effects were small. CONCLUSIONS: These findings suggest that individual differences in acceptance and mindfulness may weakly mitigate the relationship between maladaptive thinking and posttraumatic distress, but additional skills may be necessary to fully address maladaptive beliefs in Soldier postdeployment. (PsycINFO Database Record

Evaluating postdeployment training for coping with intrusive cognition: A comparison of training approaches.

OBJECTIVE: Although intrusive cognition (IC) is remarkably common in soldiers postdeployment and successful coping with ICs may predict better long-term psychological health, few elements of current programmatic postdeployment trainings have directly addressed adaptive strategies for managing intrusive deployment-related cognitions. The current study explored the efficacy of a brief acceptance-based skills training for coping with ICs relative to a change-based skills training, a psychoeducation-only training, or training as usual. METHOD: Participants were 1,524 (1,372 men) active-duty U.S. Army soldiers between 3 and 12 months' postdeployment. RESULTS: Soldiers who received acceptance-based training demonstrated larger reductions in distress and impairment related to ICs about deployment at 1 month follow-up and larger reductions in symptoms of PTSD and general psychopathology relative to other training conditions. In contrast, participants in the change-oriented skills training showed relatively fewer benefits than did those in the acceptance-based training. In addition, soldiers who received the psychoeducation-only training showed no benefits relative to training as usual. CONCLUSIONS: Results suggest that brief trainings focused on postdeployment ICs may have benefits for soldiers up to 1 month later and may be a useful addition to a broader postdeployment transition program. Findings also indicate that an acceptance-based training approach may be more beneficial than a change-oriented approach for helping soldiers manage ICs and that psychoeducation alone may be insufficient for helping soldiers manage these cognitions. (PsycINFO Database Record

Intrusive Cognitive Content and Postdeployment Distress.

Although intrusive cognitions (ICs) are common posttrauma, little is known about trauma-related IC content, or associations between IC content and posttraumatic adjustment. A mixed-method cross-sectional approach was used in a secondary analysis of IC content and postdeployment distress. Participants were 1,521 U.S. Army soldiers 3-12 months postdeployment reporting their most distressing postdeployment ICs (mean number of ICs reported was 1.20). ICs were transcribed and content was categorized by 13 emergent themes. The most commonly reported ICs were of injury or death (48.2%) and combat (43.5%), and soldiers with probable posttraumatic stress disorder (PTSD; n = 187) were more likely to report the presence of these ICs, χ(2) s(1) = 35.27, ps < .001, φs < .16 than those without probable PTSD (n = 1,331). Other domains also emerged frequently, including ICs about friends (31.0%), family (15.8%), and leadership concerns (13.8%). IC content was a small, but significant correlate of distress after adjusting for combat exposure (ΔR(2) ≥ .02, ps ≤ .001). The presence of ICs of injury or death, combat, military sexual trauma, health, leadership, and family (ßs > .06, ps < .02) were unique correlates of distress. Results suggested that ICs about a wide range of topics should be addressed in postdeployment interventions.

Early PTSD symptom sub-clusters predicting chronic posttraumatic stress following sexual assault.

Contemporary models of PTSD disaggregate this disorder into sub-clusters that differentially impact functioning. Severity of different types of PTSD symptoms in the acute posttrauma period may be predictive of the course of PTSD over time. Few research studies, however, have examined the predictive utility of PTSD sub-clusters. This study sought to determine the relative predictive validity of 4 sub-clusters, namely reexperiencing, strategic avoidance, emotional numbing, and hyperarousal, assessed within 1 month of a sexual assault. Women (N=120) who had been sexually assaulted completed self-report measures at 1 and 4 months postassault. Linear regression analyses revealed that early reexperiencing and emotional numbing sub-clusters uniquely contributed to the prediction of PTSD symptoms at month 4 (strategic avoidance and hyperarousal did not). To help explain and contextualize these findings, we explored the extent to which posttraumatic cognitions mediated the relationship between acute reexperiencing and emotional numbing and later PTSD symptoms. Simultaneous multiple mediation analyses revealed that general negative cognitions about the self significantly mediated the relationship between both reexperiencing and emotional numbing and month 4 PTSD symptoms. These findings have significant clinical implications, pointing to the importance of targeting posttraumatic cognitions in the acute posttrauma phase.

Effective Dissemination Requires Effective Talk: a Comparison of Behavior-Analytic Journals.

We explored language used in three behavior-analytic journals (the Journal of Applied Behavior Analysis (JABA), the Journal of the Experimental Analysis of Behavior (JEAB), and Behavior Analysis in Practice (BAP)) to evaluate differences in factors related to the ease of comprehension. Using a linguistic analysis tool, we compared the first three paragraphs of the introductions of research articles in ten issues of each of the journals. JEAB was found to use language that was less concrete, meaningful, and imageable than the two applied journals. Implications for the field are discussed.

What is the typical response to sexual assault? Reply to Bonanno (2013).

We respond to Bonanno's (2013) comment on our longitudinal evaluation of sexual assault survivors. Bonanno posits that minor disruption in functioning is the modal response to any stressor or trauma, yet most women we studied had marked initial symptoms in the immediate months following assault, which gradually improved over time. We argue that sexual violence is one example of intentional and malicious victimization, which differs from other experiences studied by Bonanno, such as spinal cord injury. Our study also differed from most previous studies in that it specifically examined the acute reactions period, which is the only period that can distinguish between resilience and recovery: Both trajectories ultimately involve good adaptation, but are distinguished by the degree of initial postevent disruption. We address Bonanno's contention that our results should be dismissed on methodological and statistical grounds. Our findings suggest that prior research about the frequency of resilience may in part be confounded by the degree and type of stress exposure.

Co-occurring posttraumatic stress and depression symptoms after sexual assault: a latent profile analysis.

BACKGROUND: Symptoms of posttraumatic stress disorder (PTSD) and depression frequently co-occur, but their distinctiveness following trauma remains unclear. We examined patterns of PTSD and depression symptoms after sexual assault to evaluate the extent to which assault survivors primarily reported symptoms of both disorders or whether there were meaningfully distinct subgroups with discordant PTSD and depression symptoms. METHODS: Latent profile analysis was used to examine self-reported PTSD and depression symptoms among 119 female sexual assault survivors at 1-, 2-, 3-, and 4-months post-assault. RESULTS: At all time points, a 4-class solution fit the data best, revealing four subgroups with low, low-moderate, high-moderate, and severe levels of both PTSD and depression symptoms. Within each subgroup, PTSD symptom severity co-occurred with comparable depression symptom severity. At no time point were there reliable subgroups with discordant PTSD and depression symptom severities. Emotional numbing, hyperarousal, and overall PTSD symptom severity reliably distinguished each class from the others. Class membership at 1-month post-assault predicted subsequent class membership and functional impairment. LIMITATIONS: Additional research is needed to evaluate predictors of class membership, temporal stability of classes, and generalizability to other trauma populations. CONCLUSIONS: Co-occurring and comparably severe PTSD and depression symptoms are pervasive among female sexual assault survivors. The absence of a distinct subset of individuals with only PTSD or depression symptoms suggests that PTSD and depression may be manifestations of a general posttraumatic stress response rather than distinct disorders after trauma. Integrated treatments targeting both PTSD and depression symptoms may therefore prove more efficient and effective.

Prospective investigation of mental health following sexual assault.

BACKGROUND: Comorbidity in psychological disorders is common following exposure to a traumatic event. Relatively little is known about the manner in which changes in the symptoms of a given type of psychological disorder in the acute period following a trauma impact changes in symptoms of another disorder. This study investigated the relationship between changes in posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the first 12 weeks following sexual assault. METHODS: Participants were 126 women who had been sexually assaulted in the previous 4 weeks. RESULTS: Lower level mediation analyses revealed that changes in PTSD symptoms had a greater impact on changes in depression and anxiety than vice versa. CONCLUSIONS: The finding highlights the role of PTSD symptoms in influencing subsequent change in other psychological symptoms. These findings are discussed in the context of models detailing the trajectory of psychological disorders following trauma, and clinical implications are considered.

Trajectories of PTSD symptoms following sexual assault: is resilience the modal outcome?

Theoretical frameworks positing qualitatively distinct trajectories of posttrauma outcome have received initial empirical support, but have not been investigated in cases of severe interpersonal trauma. To address this limitation, we conducted latent class growth analysis with longitudinal data collected from 119 female sexual assault survivors at 1-, 2-, 3-, and 4-months postassault. Participants' mean age was 33 years; 63% were White. We hypothesized that given the severity of exposure associated with sexual assault, resilience would not be the modal course of adaptation. Four distinct PTSD growth trajectories, representing unique latent classes of participants, best fit the data: a high chronic trajectory, a moderate chronic trajectory, a moderate recovery trajectory, and a marked recovery trajectory. Contrary to previous studies and recent theoretical models, resilience and resistance trajectories were not observed, as high levels of distress were evident in nearly all participants at 1-month postassault. These results suggest that theoretical models of posttrauma response positing resilience as the modal outcome may not generalize to cases of sexual assault.

A randomized placebo-controlled trial of D-cycloserine and exposure therapy for posttraumatic stress disorder.

D-Cycloserine (DCS) is a partial NMDA receptor agonist that has been shown to enhance therapeutic response to exposure-based treatments for anxiety disorders, but has not been tested in the treatment of combat-related posttraumatic stress disorder (PTSD). The aim of this randomized, double-blind, placebo-controlled trial was to determine whether DCS augments exposure therapy for PTSD in veterans returning from Iraq and Afghanistan and to test whether a brief six-session course of exposure therapy could effectively reduce PTSD symptoms in returning veterans. In contrast to previous trials using DCS to enhance exposure therapy, results indicated that veterans in the exposure therapy plus DCS condition experienced significantly less symptom reduction than those in the exposure therapy plus placebo condition over the course of the treatment. Possible reasons for why DCS was associated with poorer outcome are discussed. Clinicaltrials.gov Registry #: NCT00371176; A Placebo-Controlled Trail of D-Cycloserine and Exposure Therapy for Combat-PTSD; www.clinicaltrials.gov/ct2/results?term=NCT00371176.

Acceptance-based behavioral therapy for GAD: effects on outcomes from three theoretical models.

BACKGROUND: Although cognitive-behavioral therapy (CBT) is efficacious in the treatment of generalized anxiety disorder (GAD), many individuals remain symptomatic following treatment, indicating a need for further treatment development. As a result, many researchers have developed unique cognitive-behavioral therapies that highlight specific targets for intervention. METHODS: The current study examined the effect of an acceptance-based behavioral therapy for GAD on the proposed targets for intervention highlighted in several theoretical models: emotion regulation difficulties, intolerance of uncertainty, and low perceptions of control. Clients were randomly assigned to immediate (n=15) or delayed (n=16) treatment. RESULTS: Individuals treated with the acceptance-based behavioral therapy reported significantly fewer difficulties in emotion regulation and fear of emotional responses, as well as greater tolerance of uncertainty and perceived control over anxiety than individuals in the waitlist control condition. In addition, these effects were maintained at 3- and 9-month follow-up assessments. CONCLUSIONS: The present study provides promising evidence that an acceptance-based behavioral therapy for GAD has significant effects on the unique targets of intervention highlighted in several prominent theoretical models of GAD.

Examining the role of emotional avoidance in the relationship between posttraumatic stress disorder symptom severity and worry.

A growing body of literature suggests that worry is a cognitive activity functioning to avoid unpleasant internal experiences such as negative thoughts, emotions, and somatic responses. Given the highly aversive internal events associated with posttraumatic stress disorder (PTSD), individuals experiencing PTSD symptoms following exposure to a traumatic event may be particularly motivated to engage in avoidant regulation strategies such as worry. Surprisingly, however, few studies to date have examined the relationship between PTSD and worry as well as potential factors that might explain this association. Therefore, the goal of this study was to examine the association between PTSD symptom severity and worry and the extent to which emotional avoidance explains this relationship. To this end, 207 college students with a history of traumatic exposure (meeting Criterion A for a PTSD diagnosis) completed a series of questionnaires assessing history of exposure to potentially traumatic events, PTSD symptom severity, emotional avoidance tendencies, and worry. Results demonstrated that PTSD symptom severity was positively associated with worry and emotional avoidance. Further, emotional avoidance was found to fully account for this relationship, providing support for the proposed emotionally avoidant function of worry. The implications of these findings for future research and the treatment of worry among individuals with a history of traumatic exposure are discussed.

Mindfulness and emotion regulation difficulties in generalized anxiety disorder: preliminary evidence for independent and overlapping contributions.

Diminished levels of mindfulness (awareness and acceptance/nonjudgment) and difficulties in emotion regulation have both been proposed to play a role in symptoms of generalized anxiety disorder (GAD); the current studies investigated these relationships in nonclinical and clinical samples. In the first study, among a sample of 395 individuals at an urban commuter campus, self-reports of both emotion regulation difficulties and aspects of mindfulness accounted for unique variance in GAD symptom severity, above and beyond variance shared with depressive and anxious symptoms, as well as variance shared with one another. In the second study, individuals with GAD (n=16) reported significantly lower levels of mindfulness and significantly higher levels of difficulties in emotion regulation than individuals in a nonanxious control group (n=16). Results are discussed in terms of directions for future research and potential implications for treatment development.

The Experience of Intrusions Scale: a preliminary examination.

Intrusive thoughts (i.e., unwelcome, distressing, involuntary thoughts) are prevalent in a variety of clinical conditions and are increasingly a focus of translational research. The goal of this study was to develop and preliminarily examine a brief self-report measure designed to assess clinically relevant aspects of the experience of intrusive thoughts related to a particular target. The Experience of Intrusions Scale (EIS) is a five-item measure that assesses the frequency, unpredictability, and unwantedness of intrusive thoughts, as well as the interference and distress caused by the intrusions, each on a five-point Likert-type scale. Five times over a four-] period, female undergraduates (N=160) completed the EIS in response to intrusive thoughts regarding a film clip depicting a sexual assault. On the first and last days, participants completed the EIS five minutes after watching the clip. In between film clip viewings, participants completed the EIS once per day. The EIS demonstrated good internal consistency, good to excellent test-retest reliability using both immediate post-stimulus and 24-hour time intervals, and convergent validity with two existing measures of intrusive phenomena: the White Bear Suppression Inventory (Wegner & Zanakos, 1994) and the Post-traumatic Stress Disorder Checklist-Civilian Version (Weathers, Litz, Herman, Huska, & Keane, 1993).

An examination of recent non-clinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties in the prediction of generalized anxiety disorder in an analogue sample.

Both non-clinical panic attacks and panic disorder (PD) have been found to be associated with generalized anxiety disorder (GAD). This study examined a proxy risk factor model of the relationship between non-clinical panic attacks, PD, and GAD. Specifically, it was proposed that non-clinical panic attacks and PD predict GAD only due to their shared association with anxiety sensitivity (AS) and difficulties in emotion regulation. Results demonstrated that emotion regulation difficulties reliably predicted GAD above and beyond the experience of non-clinical panic attacks and PD. However, although PD lost strength as a predictor, it remained significantly associated with GAD in the full model, providing only partial support for the proposed proxy risk factor model. Findings speak to the underlying role of emotion regulation difficulties in GAD, and suggest that it may be the shared relationship of these difficulties with both PD and GAD that partially explain the association of these disorders.

Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial.

Generalized anxiety disorder (GAD) is a chronic anxiety disorder, associated with comorbidity and impairment in quality of life, for which improved psychosocial treatments are needed. GAD is also associated with reactivity to and avoidance of internal experiences. The current study examined the efficacy of an acceptance-based behavioral therapy aimed at increasing acceptance of internal experiences and encouraging action in valued domains for GAD. Clients were randomly assigned to immediate (n = 15) or delayed (n = 16) treatment. Acceptance-based behavior therapy led to statistically significant reductions in clinician-rated and self-reported GAD symptoms that were maintained at 3- and 9-month follow-up assessments; significant reductions in depressive symptoms were also observed. At posttreatment assessment 78% of treated participants no longer met criteria for GAD and 77% achieved high end-state functioning; these proportions stayed constant or increased over time. As predicted, treatment was associated with decreases in experiential avoidance and increases in mindfulness.

An experimental investigation of the effect of worry on responses to a discrimination learning task.

The current study examined the impact of both the tendency to worry (trait worry) and the process of worry (state worry) on subsequent behavioral responding in a schedule discrimination learning task. High and low trait worriers were randomly assigned to a state worry or relaxation incubation condition and completed a test of executive functioning and a dual contingency learning task that utilized neutral discriminative cues over the course of 2 contingency phases. Although state and trait worry did not impact executive functioning, the state worry condition was associated with diminished sensitivity to learning task contingencies over the course of the first contingency learning trials in comparison to the relaxation condition. This relationship was unique to the state worry condition above and beyond shared variance with subjective anxiety level. Results suggest that state worry may lead to a decrement in selective behavioral responding to neutral discriminative cues in the environment. The findings suggest that the process of worry may lead to less adaptive responding to neutral cues and interfere with adaptive behaviors, which may thereby contribute to and maintain anxiety.

The role of fear of emotion in distress, arousal, and cognitive interference following an emotional stimulus.

Diverse theories of psychopathology suggest that reactions to internal experiences, such as emotion, are important in the development and maintenance of psychological distress and symptomatology. This study examines the relationships between one type of reaction to emotion, fear of emotion, and reactivity to, recovery from, and interference of emotional material. As predicted, fear of emotion was related to greater increases in distress, negative affect, and skin conductance in reaction to an emotional film clip, and to greater interference of film-related material in a modified emotional Stroop task. These relationships remained when variance contributed by general negative affect was removed. Findings provide preliminary evidence that fear of emotion may be related to emotional distress and physiological arousal, and that this relationship may exist beyond shared variance due to self-report response style and general negative affectivity.