Facilitated Extinction Training to Improve Pharmacotherapy for Smoking Cessation: A Pilot Feasibility Trial.

Introduction: Varenicline reduces smoking satisfaction during the pre-cessation run-in period, which may contribute to extinction of cravings and smoking behavior. Research indicates that efficacy is enhanced when the run-in period is increased from 1 to 4 weeks, providing a longer extinction opportunity. We hypothesized that efficacy could be further enhanced by harnessing basic and applied research on extinction. We developed a pre-cessation extinction-facilitating intervention and tested its feasibility in a pilot trial. Methods: The facilitated extinction (FE) intervention comprised brief counseling and workbook-recommending strategies to maximize extinction processes during the run-in, including instructions to smoke at a normal rate across contexts and cues, and use of an extinction cue to enhance generalization. Participants were randomly assigned to one of three varenicline interventions: standard (1-week run-in), extended (4-week run-in), and extended + FE. Interventions were delivered prior to the target quit date (TQD). Assessments were conducted in weeks 1 and 4 pre-TQD and 1 and 3 months post-TQD, with focus on feasibility indices. Results: Recruitment and retention goals were met (N = 58). Treatment satisfaction was high across groups. The majority of FE participants adhered to instructions and maintained their usual smoking rate during the run-in period. Greater decreases in craving and smoking satisfaction were observed among participants in both extended groups versus the standard group (p < .005). Conclusions: Feasibility was demonstrated. Participants adhered to the FE intervention, thereby optimizing the number and variety of extinction trials. Findings support testing the novel FE smoking cessation intervention in a fully powered trial. Implications: This study expands the research on the clinical benefits of extending the pre-cessation run-in period of varenicline. It introduces the hypothesis that further benefit might be achieved by translating basic behavioral research, as well as cue-exposure research and therapy for other disorders, to improve the extinction and generalization processes thought to underlie much of varenicline's effect. A FE intervention was developed and found acceptable to smokers and feasible to implement in a research setting. The study sets the stage for a subsequent randomized controlled trial.

Women's Behavioral Responses to the Threat of a Hypothetical Date Rape Stimulus: A Qualitative Analysis.

One in four college women experience sexual assault on campus; yet, campuses rarely provide the in-depth self-defense programs needed to reduce sexual assault risk. Further, little is known about the range of possible behaviors elicited by sexual assault threat stimuli besides assertion. To fill this gap, the aim of the current study was to explore qualitative themes in women's intended behavioral responses to a hypothetical sexual assault threat, date rape, by using a laboratory-controlled threat. College women (N = 139) were randomly assigned to one of four different levels of sexual assault threat presented via an audio-recorded vignette. Participants articulated how they would hypothetically respond to the experimentally assigned threat. Responses were blinded and analyzed using Consensual Qualitative Research methodology. Six major themes emerged: assertion, compliance/acceptance, conditional decision making, avoidance, expressions of discomfort, and allusion to future contact. Although almost all participants described assertion, a number of non-assertive responses were described that are not currently recognized in the literature. These non-assertive responses, including compliance/acceptance, conditional decision making, and avoidance, may represent unique behavioral response styles and likely reflect the complex psychological process of behavioral response to threat. The variety of themes found illustrates the great range of behavioral responses to threat. This broad range is not currently well represented or measured in the literature and better understanding of these responses can inform future interventions, advocacy efforts, and policies focused on sexual assault.

Epidemiological associations between posttraumatic stress disorder and incarceration in the National Survey of American Life.

BACKGROUND: In spite of an elevated prevalence of trauma histories among prisoners, there has been little research examining the relationship between incarceration and posttraumatic stress disorder (PTSD); this is especially true for Black Americans. AIMS: To examine relationships between PTSD and incarceration in a nationally representative sample of Black Americans. METHODS: We conducted analysis of data from the National Survey of American Life sample of 5008 Black American adults in the USA. Multivariate logistic regression analyses controlling for demographic factors including age, gender, home region and education were conducted to examine whether incarceration status was independently associated with PTSD. RESULTS: Incarceration was significantly associated with trauma exposure, PTSD in the 12 months prior to interview and lifetime PTSD, even while controlling for demographic covariates. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Incarceration, trauma exposure and PTSD share a significant number of risk factors and co-vary frequently in some populations, including the one of Black Americans investigated in this study. Interventions that can reduce shared risk factors for incarceration and PTSD and/or facilitate successful treatment of the established condition have the potential to make a large positive impact among incarcerated and formerly incarcerated people.

Residential treatment outcomes for adolescents with obsessive-compulsive disorder.

OBJECTIVE: We examined outcomes from a residential treatment program emphasizing exposure and response prevention (ERP) to determine if the typically robust response to this treatment in outpatient settings extends to patients treated in this unique context. METHOD: One hundred and seventy-two adolescents with primary Obsessive-compulsive disorder (OCD) completed measures at admission and discharge. Almost all (92.4%) participants had at least two diagnoses and nearly half (44.2%) had three or more. Treatment consisted of intensive ERP (i.e., approximately 26.5 hr per week), additional cognitive behavioral therapy interventions, and medication management within a residential setting. In contrast to the samples reported on in the vast majority of other pediatric OCD trials, participants in the current study were living apart from their families and were immersed within the treatment setting, with staff members available at all times. RESULTS: Paired sample t-tests revealed significant decreases in OCD and depression severity. CONCLUSIONS: Results suggest that residential treatment for adolescents with OCD using a multimodal approach emphasizing ERP can be effective for complex cases with significant comorbidity. Results were comparable with several randomized controlled trials.

Primum non nocere (first do no harm): symptom worsening and improvement in female assault victims after prolonged exposure for PTSD.

BACKGROUND: Prolonged Exposure (PE) therapy is an efficacious treatment for PTSD; despite this, many clinicians do not utilize it due to concerns it could cause patient decompensation. METHOD: Data were pooled from four published well-controlled studies of female assault survivors with chronic PTSD (n = 361) who were randomly assigned to PE, waitlist (WL), or another psychotherapy, including cognitive processing therapy (CPT), Eye Movement and Desensitization Reprocessing (EMDR), or the combination of PE plus stress inoculation training (SIT) or PE plus cognitive restructuring. PTSD and depression severity scores were converted to categorical outcomes to evaluate the proportion of participants who showed reliable symptom change (both reliable worsening and reliable improvement). RESULTS: The majority of participants completing one of the active treatments showed reliable improvement on both PTSD and depression compared to WL. Among treatment participants in general, as well as those who received PE, reliable PTSD worsening was nonexistent and the rate of reliable worsening of depression was low. There were no differences on any outcome measures among treatments. By comparison, participants in WL had higher rates of reliable symptom worsening for both PTSD and depression. Potential alternative explanations were also evaluated. CONCLUSIONS: PE and a number of other empirically supported therapies are efficacious and safe treatments for PTSD, reducing the frequency of which symptom worsening occurs in the absence of treatment.

Use of the response-latency paradigm for eliciting and evaluating women's responses to the threat of date rape.

This study evaluates the novel use of the response-latency paradigm to elicit women's hypothetical behavioral responses to the threat of acquaintance rape. There were 146 college women recruited and randomly assigned to 4 study conditions. In 3 of the conditions, the threat to which participants responded was experimentally controlled; in the fourth control condition, participants selected the level of threat themselves, following standard procedure of the response-latency paradigm. Results indicated that participant's responses became more intense as threat levels increased; this relationship was not moderated by whether the threat was controlled by the experimenter or the participant. These results indicate the response-latency paradigm is useful for eliciting and evaluating women's hypothetical responses to the threat of acquaintance rape to learn more about this process.

Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders.

PURPOSE: Eating disorders and obsessive-compulsive disorder (OCD) commonly co-occur, but there is little data for how to treat these complex cases. To address this gap, we examined the naturalistic outcome of 56 patients with both disorders, who received a multimodal treatment program designed to address both problems simultaneously. METHODS: A residential treatment program developed a cognitive-behavioral approach for patients with both OCD and an eating disorder by integrating exposure and response prevention (ERP) treatment for OCD with ERP strategies targeting eating pathology. Patients also received a supervised eating plan, medication management, and social support. At admission and discharge, patients completed validated measures of OCD severity (the Yale-Brown Obsessive-Compulsive Scale--Self Report [Y-BOCS-SR]), eating disorder severity (the Eating Disorders Examination-Questionnaire), and depressive severity (the Beck Depression Inventory II [BDI-II]). Body mass index (BMI) was also measured. Paired-sample t-tests examined change on these measures. MAIN RESULTS: Between 2006 and 2011, 56 individuals completed all study measures at admission and discharge. Mean length of stay was 57 days (SD = 27). Most (89%) were on psychiatric medications. Significant decreases were observed in OCD severity, eating disorder severity, and depression. Those with bulimia nervosa showed more improvement than those with anorexia nervosa. BMI significantly increased, primarily among those underweight at admission. CONCLUSION: Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases.

Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial.

Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.

Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder.

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.

Evidence for poorer outcome in patients with severe negative trauma-related cognitions receiving prolonged exposure plus cognitive restructuring: implications for treatment matching in posttraumatic stress disorder.

In the current article, we address the existing assumption in the literature on cognitive behavioral treatment of PTSD that patients with severe negative trauma-related cognitions would benefit more from a treatment package that includes exposure and cognitive techniques compared with a treatment that includes exposure only. To test this assumption, 54 PTSD patients were randomized to prolonged exposure therapy or prolonged exposure therapy plus cognitive restructuring. Contrary to expectations, findings revealed that patients characterized by more severe pretreatment trauma-related cognitions (and more severe pretreatment PTSD symptoms) fared slightly worse in treatment combining exposure and cognitive restructuring. However, there was no relationship between pre- and post-treatment measures of negative cognitions and PTSD symptoms in the exposure alone group. The implications of these findings for examining Person X Treatment interactions and the efficacy of combining treatments for PTSD are discussed.

Extending the ACEs Framework: Examining the Relations Between Childhood Abuse and Later Victimization and Perpetration With College Men.

Research has revealed that forms of violence are interconnected, but less work focuses on the interconnection of victimization and perpetration, particularly with men. Subsequently, our understanding of the complexities of violence exposure in men's lives and related policies and treatments remains limited. The present study utilizes a sample of at-risk for violence involvement, college men, to examine the relationships between childhood victimization, adulthood victimization, and adulthood perpetration. Participants are 423 college men receiving course credit who completed a battery of standardized questionnaires via an anonymous web survey. Logistic regression is used. Results indicate that 27% of the men report polyperpetration (two or more types of perpetration), 43.5% report polyvictimization (two or more types of victimization), and 60% report experiencing both forms of victimization and perpetration in the past year. Childhood physical abuse has predictive power for perpetration (psychological aggression and polyperpetration) and victimization (sexual violence, psychological aggression, and polyvictimization) for the men in the past year. Childhood sexual abuse has strong predictive power for perpetration (physical violence, sexual violence, and polyperpetration) and victimization (physical violence and sexual violence) with the men in the past year. Finally, emotional abuse has predictive power for victimization (physical violence and psychological aggression), but not perpetration, for the men in the past year. Developmental psychopathology and the adverse childhood experiences frameworks are used to posit potential pathways explaining the relation between childhood abuse and the overlap between victimization and perpetration in adulthood for men. Implications of this study include the use of trauma-informed models of care with men and expanding the scope of study to examine experiences of both victimization and perpetration, and various types of violence, among men.

Predictors of Assertive and Nonassertive Styles of Self-Defense Behavior During a Lab-Based Sexual Assault Scenario.

The current study examined how psychological factors influence hypothetical behavioral responses to threat (BRTT). College women (n = 113) with a history of sexual victimization completed a standardized lab-based self-defense scenario. Interpersonal skills, coping style, and assertive and nonassertive BRTT during a prior assault predicted assertive BRTT during the task. The use of nonassertive BRTT during past assaults no longer predicted assertive BRTT during the task when accounting for rape acknowledgment. Findings regarding rape acknowledgment demonstrate the complexity of recovery from sexual assault. Our results highlight interpersonal skills as an intervention target for innovative sexual assault risk reduction interventions.

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

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

Acceptance-enhanced behavior therapy for trichotillomania: Randomized controlled trial rationale, method, and strategies for recruiting minority participants.

Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.

Anger and posttraumatic stress disorder symptoms in crime victims: a longitudinal analysis.

Among trauma-exposed individuals, severity of posttraumatic stress disorder (PTSD) symptoms is strongly correlated with anger. The authors used 2 longitudinal data sets with 282 and 218 crime victims, respectively, to investigate the temporal sequence of anger and PTSD symptoms following the assault. Cross-lagged regression analyses indicated that PTSD symptoms predicted subsequent level of anger, but that anger did not predict subsequent PTSD symptoms. Testing alternative models (common factor model, unmeasured 3rd variable model) that might account for spuriousness of the relation strengthened confidence in the results of the cross-lagged analyses. Further analyses suggested that rumination mediates the effect of PTSD symptoms on anger.

Primum Non Nocere (First Do No Harm): Symptom Worsening and Improvement in Female Assault Victims After Prolonged Exposure for PTSD.

(Reprinted with permission from Depression and Anxiety 2014; 31:412-419).

Social, psychological, and psychiatric interventions following terrorist attacks: recommendations for practice and research.

The terrorist attacks of September 11, 2001, and the constant threat of imminent terrorist activity have brought into the forefront the urgent need to prepare for the consequences of such attacks. Such preparation entails utilization of existing knowledge, identification of crucial gaps in our scientific knowledge, and taking steps to acquire this knowledge. At present, there is little empirical knowledge about interventions following terrorism and absolutely no available empirical knowledge about interventions following bioterrorism. Therefore, this paper reviews knowledge about (1) reactions following the September 11 terrorist attacks in New York City and other places, (2) the practical experiences accumulated in recent years in countries (eg, Israel) that have had to cope with the threat of bioterrorism and the reality of terrorism, and (3) interventions for acute and chronic stress reactions following other types of traumatic events (eg, rape, war, accidents). Our review found several treatments efficacious in treating individuals for acute and chronic post-traumatic stress disorder (PTSD) related to other traumatic events that will likely be efficacious in treating PTSD related to terrorist attacks. However, there were significant gaps in our knowledge about how to prepare populations and individuals for the possibility of a terrorist attack and what interventions to apply in the immediate aftermath of such an attack. Accordingly, we conclude the paper with several questions designed to guide future research.

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

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

Six-month outcomes from a randomized trial augmenting serotonin reuptake inhibitors with exposure and response prevention or risperidone in adults with obsessive-compulsive disorder.

OBJECTIVE: To compare outcomes after 6-month maintenance treatment of adults diagnosed with obsessive-compulsive disorder (OCD) based on DSM-IV criteria who responded to acute treatment with serotonin reuptake inhibitors (SRIs) augmented by exposure and response prevention (EX/RP) or risperidone. METHOD: A randomized trial was conducted at 2 academic sites from January 2007 through December 2012. In the acute phase, 100 patients on therapeutic SRI dose with at least moderate OCD severity were randomized to 8 weeks of EX/RP, risperidone, or pill placebo. Responders entered the 6-month maintenance phase, continuing the augmentation strategy they received acutely (n = 30 EX/RP, n = 8 risperidone). Independent evaluations were conducted every month. The main outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). RESULTS: Intent-to-treat analyses indicated that, after 6-month maintenance treatment, EX/RP yielded OCD outcomes that were superior to risperidone (Y-BOCS = 10.95 vs 18.70; t40 = 2.76, P = .009); more patients randomized to EX/RP met response criteria (Y-BOCS decrease ≥ 25%: 70% vs 20%; P < .001) and achieved minimal symptoms (Y-BOCS ≤ 12: 50% vs 5%; P < .001). During maintenance, OCD severity decreased slightly in both conditions (Y-BOCS decrease = 2.2 points, P = .020). Lower Y-BOCS at entry to maintenance was associated with more improvement in both conditions (r38 = 0.57, P < .001). CONCLUSIONS: OCD patients taking SRIs who responded to acute EX/RP or risperidone maintained their gains over 6-month maintenance. Because EX/RP patients improved more during acute treatment than risperidone-treated patients, and both maintained their gains during maintenance, EX/RP yielded superior outcomes 6 months later. The findings that 50% of patients randomized to EX/RP had minimal symptoms at 6-month maintenance, a rate double that of prior studies, suggests that EX/RP maintenance helps maximize long-term outcome. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00389493.

Sequential treatment for child abuse-related posttraumatic stress disorder: methodological comment on Cloitre, Koenen, Cohen, and Han (2002).

M. Cloitre, K. Koenen, L. R. Cohen, and H. Han (2002; see record 2002-18226-001) presented results of a randomized trial that clearly demonstrate the safety and efficacy of a treatment program delivering skills training in affective and interpersonal regulation (STAIR) prior to conducting imaginal exposure (IE) to trauma memories for adults with posttraumatic stress disorder (PTSD) related to childhood abuse. In this comment the authors review the results presented by Cloitre et al and specifically compare the impact of the STAIR and IE phases of the treatment on affect regulation and psychopathology measures. Evidence for adverse events associated with exposure therapy is reviewed. The authors emphasize that the present study should not be interpreted as evidence that pretreatment with STAIR is additively helpful or necessary prior to IE for PTSD associated with child abuse and that a between-groups comparison is necessary before such conclusions can be drawn.