Faculty Bibliography

Background: Depression among those who have experienced childhood abuse is associated with earlier onset, more persistent and severe symptoms, more frequent relapse, and poorer treatment outcomes across a variety of psychiatric disorders. In addition, individuals with a history of childhood abuse are more likely to develop post-traumatic stress disorder (PTSD) co-occurring with depression. Objective: This study evaluated whether severity of depression moderated the outcome in a PTSD treatment for childhood abuse survivors. Specifically, we assessed whether individuals with significant depression obtained better outcomes when provided with a two-module treatment which included a skills training component with behavioral activation interventions, Skills Training in Affective and Interpersonal Regulation (STAIR) followed by a trauma-focused component, Narrative Therapy, as compared to two control conditions where one component (STAIR or Narrative Therapy) was replaced with Supportive Counseling. Method: Participants were 104 women with PTSD related to childhood abuse. Participants were randomized into three conditions: (1) STAIR plus Narrative Therapy (SNT), (2) STAIR plus Supportive Counseling (SSC), and (3) Supportive Counseling plus Narrative Therapy (SCNT). Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) PTSD symptom severity was assessed at pre-treatment, post-treatment, and 3 and 6 month follow-up. Results: Participants with severe depression showed superior PTSD symptom reduction following SNT, while those in the other two conditions experienced a loss of improvement after treatment ended. A similar finding was obtained among those with moderate depression, while among those with low levels of depression, outcomes did not differ across the three treatment conditions. Conclusions: Childhood abuse survivors with severe depression obtained superior outcomes in a treatment that combined skills training with trauma-focused work. Skills packages which contain behavioral activation interventions in combination with trauma-focused work may be particularly beneficial for patients with childhood abuse and severe depression.

STUDY OBJECTIVES/OBJECTIVE:This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176). METHODS:VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released. RESULTS:Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes. CONCLUSIONS:Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.

BACKGROUND: Post-traumatic stress disorder (PTSD) psychotherapy research has failed to identify patient characteristics that consistently predict differential outcome. AIMS: To identify patient characteristics associated with differential outcome via a statistically generated composite moderator among women with childhood abuse-related PTSD in a randomised controlled trial comparing exposure therapy, skills training and their combination. METHOD: Six baseline patient characteristics were combined in a composite moderator of treatment effects for PTSD symptoms across the three treatment conditions through a 6-month follow-up. RESULTS: The optimal moderator was the combined burden of all symptoms and emotion regulation strength. Those with high moderator scores, reflecting high symptom load relative to emotion regulation, did least well in exposure, moderately well in skills and best in the combination. CONCLUSIONS: A clinically meaningful moderator, which combines patient symptom burden and strengths, was identified. Assessment at follow-up may provide a more accurate indicator of variability in outcome than that obtained immediately post-treatment

Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given these threats, sexual minorities may engage in sexual orientation concealment in order to avoid danger. This social stigma and minority stress places sexual minorities at risk for anxiety and related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24, the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual young adults matched on age and gender completed self-report measures of the aforementioned disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual minority young adults reported greater symptoms relative to heterosexuals across all outcome measures. There were no interactions between sexual minority status and gender, however, women had higher symptoms across all disorders. Sexual minority young women appeared to be at the most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual orientation significantly predicted symptoms of social phobia. Implications are offered for the cognitive and behavioral treatment of anxiety and related disorders in this population.

This pilot project implemented a mental health program, STAIR, targeting basic skills in mood management training and social functioning for women veterans with military-related trauma who live in rural areas. We report on outreach and implementation procedures, the women veterans' reactions to the program, and lessons learned.

This study examined posttraumatic stress disorder (PTSD) and related symptoms among sexual minority (SM) and heterosexual women and the influence of social support on the relationship between SM status and symptoms. We hypothesized that SM women would endorse higher symptoms of PTSD and related difficulties and that social support would moderate the relationship between SM status and symptoms. The sample, women seeking treatment for PTSD related to interpersonal violence (n = 477; mean age = 36.07 years; 22.9% SM) completed clinician-administered measures of PTSD and self-report measures of trauma-related difficulties and social support. The rate of PTSD diagnosis was higher for SM women. Social support and SM status were significantly associated with suicidality, self-perceptions, depression, somatic complaints, and functional impairment. The interaction between social support and SM status was significant for both functional impairment (beta = -.26) and somatic complaints (beta = -.39). High social support had an equal, positive effect among SM and nonminority women, whereas low social support had a greater negative impact among SM women. Results suggested the particular salience of social support on functioning and symptom severity among SM women and the potential importance of including interventions addressing social support into PTSD treatments for SM women.

STUDY OBJECTIVES/OBJECTIVE:Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning. DESIGN/METHODS:RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control. SETTING/METHODS:Department of Veterans Affairs (VA) Medical Center. PARTICIPANTS/METHODS:Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females). INTERVENTIONS/METHODS:Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist. MEASUREMENTS AND RESULTS/RESULTS:Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares. CONCLUSIONS:Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine. CLINICAL TRIAL INFORMATION/BACKGROUND:TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647. REGISTRATION NUMBER/BACKGROUND:NCT00881647.

BACKGROUND: There has been debate regarding whether Complex Posttraumatic Stress Disorder (Complex PTSD) is distinct from Borderline Personality Disorder (BPD) when the latter is comorbid with PTSD. OBJECTIVE: To determine whether the patterns of symptoms endorsed by women seeking treatment for childhood abuse form classes that are consistent with diagnostic criteria for PTSD, Complex PTSD, and BPD. METHOD: A latent class analysis (LCA) was conducted on an archival dataset of 280 women with histories of childhood abuse assessed for enrollment in a clinical trial for PTSD. RESULTS: THE LCA REVEALED FOUR DISTINCT CLASSES OF INDIVIDUALS: a Low Symptom class characterized by low endorsements on all symptoms; a PTSD class characterized by elevated symptoms of PTSD but low endorsement of symptoms that define the Complex PTSD and BPD diagnoses; a Complex PTSD class characterized by elevated symptoms of PTSD and self-organization symptoms that defined the Complex PTSD diagnosis but low on the symptoms of BPD; and a BPD class characterized by symptoms of BPD. Four BPD symptoms were found to greatly increase the odds of being in the BPD compared to the Complex PTSD class: frantic efforts to avoid abandonment, unstable sense of self, unstable and intense interpersonal relationships, and impulsiveness. CONCLUSIONS: Findings supported the construct validity of Complex PTSD as distinguishable from BPD. Key symptoms that distinguished between the disorders were identified, which may aid in differential diagnosis and treatment planning.

A number of self-report measures of social anxiety contain language that appears to assume heterosexuality. It is unclear how such items should be answered by individuals who are not exclusively heterosexual, which may lead to inaccurate measurement of symptoms, perpetuation of stigma, and alienation of respondents. More specific wording could improve measurement accuracy for sexual minorities as well as heterosexual respondents. Gender-neutral wording was developed for items containing the phrase "opposite sex" in commonly used self-report measures of social anxiety (Interaction Anxiousness Scale [Leary, 1983], Social Avoidance and Distress Scale [Watson & Friend, 1969], Social Interaction Anxiety Scale [Mattick & Clarke, 1998], and Social Phobia and Anxiety Inventory [Turner, Beidel, Dancu, & Stanley, 1989]). Undergraduate college students (N=405; mean age=19.88, SD=2.05) completed measures containing original and revised items. Overall, results indicated that the alternate-worded items demonstrated equivalent or slightly stronger psychometric properties compared to original items. Select alternate-worded items are recommended for clinical and research use, and directions for future research are recommended.

The Pittsburgh Sleep Quality Index (PSQI) is a widely used, comprehensive self-report measure of sleep quality and impairment, which has demonstrated good psychometric properties within various populations, including older adults. However, the psychometric properties of the PSQI and its component scores have not been evaluated for older adults with generalized anxiety disorder (GAD). Additionally, changes in PSQI global or component scores have not been reported following cognitive-behavioral treatment (CBT) of late-life GAD. This study examined (1) the psychometric properties of the PSQI within a sample of 216 elderly primary care patients age 60 or older with GAD who were referred for treatment of worry and/or anxiety; as well as (2) response to CBT, relative to usual care, for 134 patients with principal or coprincipal GAD. The PSQI demonstrated good internal consistency reliability and adequate evidence of construct validity. Those receiving CBT experienced greater reductions in PSQI global scores at post-treatment, relative to those receiving usual care. Further, PSQI global and component scores pertaining to sleep quality and difficulties falling asleep (i.e., sleep latency and sleep disturbances) demonstrated response to treatment over a 12-month follow-up period. Overall, results highlight the usefulness of the PSQI global and component scores for use in older adults with GAD.