Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:Anxiety disorders are characterized by biased perceptual judgment. An experimental model using simple verbal instruction to target specific decision parameters that influence perceptual judgment was developed to test if it could influence anger perception, and to examine differences between individuals with social anxiety disorder (SAD) relative to generalized anxiety disorder (GAD) or non-psychiatric controls. METHODS:Anger perception was decomposed into three decision parameters (perceptual similarity of angry vs. not-angry facial expressions, base rate of encountering angry vs. not-angry expressions, payoff for correct vs. incorrect categorization of face stimuli) using a signal detection framework. Participants with SAD (n = 97), GAD (n = 90), and controls (n = 98) were assigned an instruction condition emphasizing one of the three decision parameters. Anger perception pre-vs. post-instruction and its interaction with diagnosis were examined. RESULTS:For all participants, base rate instructions impacted response bias over and above practice effects, supporting the validity of this instructional task-based approach to altering response bias. We failed to find a similarity or payoff instruction effect, nor a diagnosis interaction. LIMITATIONS/CONCLUSIONS:Future instructional tasks may need to more closely target core cognitive and perceptual biases in anxiety disorders to identify specific deficits and how to optimally influence them. CONCLUSIONS:This study demonstrates that specific decision parameters underlying perceptual judgment can be experimentally manipulated. Although our study failed to show diagnosis specific effects, it suggests that individual parameter "estimation" deficits may be experimentally isolated and potentially targeted, with the ultimate goal of developing an objective approach to personalized intervention targeting biased perceptual judgments in anxiety disorders.

Objectives: Repeated, extended deployments in support of OEF/OIF/OND have important implications for not only veterans, but also their family members. While this topic is beginning to garner more attention, more research is needed on the relationship between symptoms of posttraumatic stress disorder (PTSD), parenting factors, and family functioning among OEF/OIF/OND veterans. The present study aimed to: (1) examine the relationship between specific PTSD symptom clusters and family functioning among a sample of N = 191 treatment-seeking veteran parents who served after September 11, 2001; and (2) examine the mediating role of parenting sense of competence in this relationship.Method: Participants completed the PTSD Check List (PCL), the Parenting Sense of Competence Scale (PSOC), and the Family Assessment Device (FAD) as part of their initial evaluation in an outpatient mental health clinic.Results: Numbing and avoidance symptoms of PTSD (Criterion C; PCL_c) were associated with more problematic family functioning (r = .164, p < .05). There was a strong negative relationship between parenting competence and problematic family functioning (r = -.514, p < .001). Examination of the indirect effect of PSOC on the association between PCL_c and FAD based on 4000 bootstrapped samples revealed a significant indirect effect (point estimate = 0.0092; BCa CI = 0.0035, 0.0170), suggesting that decreased parenting sense of competence might mediate the relationship between numbing/avoidance symptoms and problematic family functioning.Conclusions: Future studies confirming the central role of parenting in the relationship between PTSD symptoms and family functioning are warranted.

BACKGROUND:Telomeres cap and protect DNA but shorten with each somatic cell division. Aging and environmental and lifestyle factors contribute to the speed of telomere attrition. Current evidence suggests a link between relative telomere length (RTL) and depression but the directionality of the relationship remains unclear. We prospectively examined associations between RTL and subsequent depressive symptom trajectories. METHODS:Among 8,801 women of the Nurses' Health Study, depressive symptoms were measured every 4 years from 1992 to 2012; group-based trajectories of symptoms were identified using latent class growth-curve analysis. Multinomial logistic models were used to relate midlife RTLs to the probabilities of assignment to subsequent depressive symptom trajectory groups. RESULTS:We identified four depressive symptom trajectory groups: minimal depressive symptoms (62%), worsening depressive symptoms (14%), improving depressive symptoms (19%), and persistent-severe depressive symptoms (5%). Longer midlife RTLs were related to significantly lower odds of being in the worsening symptoms trajectory versus minimal trajectory but not to other trajectories. In comparison with being in the minimal symptoms group, the multivariable-adjusted odds ratio of being in the worsening depressive symptoms group was 0.78 (95% confidence interval, 0.62-0.97; p = 0.02), for every standard deviation increase in baseline RTL. CONCLUSIONS:In this large prospective study of generally healthy women, longer telomeres at midlife were associated with significantly lower risk of a subsequent trajectory of worsening mood symptoms over 20 years. The results raise the possibility of telomere shortening as a novel contributing factor to late-life depression.

OBJECTIVE:The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes. METHOD/METHODS:Data were derived from a NIMH-funded implementation-effectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n = 19) treated clients (n = 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications. RESULTS:Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelity-consistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms. CONCLUSIONS:The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Importance/UNASSIGNED:Meta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone. Objective/UNASSIGNED:To determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD. Design, Setting, and Participants/UNASSIGNED:The Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months' duration. Analyses were on an intent-to-treat basis. Intervention/UNASSIGNED:Participants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized. Main Outcomes and Measures/UNASSIGNED:The primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24. Results/UNASSIGNED:Of 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,-9.39; 95% CI, -11.62 to -7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, -9.39; sertraline plus enhanced medication management group, -10.37; and prolonged exposure therapy plus sertraline group, -9.99; P = .81). Conclusions and Relevance/UNASSIGNED:No difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline. Trial Registration/UNASSIGNED:ClinicalTrials.gov Identifier: NCT01524133.

BACKGROUND/OBJECTIVES/OBJECTIVE:Nonpharmacological interventions, such as biofeedback, cognitive behavioral therapy, and relaxation techniques are Level-A evidence-based treatments for headache. The impact of these interventions is often equivalent to or greater than pharmacological interventions, with fewer side effects. Despite such evidence, the rate of participation in nonpharmacological interventions for headache remains low. Once obstacles to optimizing use of behavioral interventions, such as local access to nonpharmacological treatment and primary headache providers are traversed, identification of barriers contributing to low adherence is imperative given the high levels of disability and cost associated with treating headache disorders. In this review of factors in adults associated with underuse of nonpharmacological interventions, we discuss psychological factors relevant to participation in nonpharmacological treatment, including attitudes and beliefs, motivation for change, awareness of triggers, locus of control, self-efficacy, acceptance, coping styles, personality traits, and psychiatric comorbidities associated with treatment adherence. Finally, future prospects and approaches to optimizing treatment matching and minimizing adherence issues are addressed. METHODS:An interdisciplinary team conducted this narrative review. Neuropsychologists conducted a literature search during the month of July 2017 using a combination of the keywords ("headache" or "migraine") and ("adherence" or "compliance") or "barriers to treatment" or various "psychological factors" discussed in this narrative review. Content experts, a psychiatrist, and a complementary and integrative health specialist provided additional commentary and input to this narrative review resulting in integration of additional noteworthy studies, book chapters and books. RESULTS:Various psychological factors, such as attitudes and beliefs, lack of motivation, poor awareness of triggers, external locus of control, poor self-efficacy, low levels of acceptance, and engagement in maladaptive coping styles can contribute to nonadherence. CONCLUSIONS:To maximize adherence, clinicians can assess and address an individual's level of treatment acceptance, beliefs that may present as barriers, readiness for change, locus of control, self-efficacy and psychiatric comorbidities. Identification of barriers to adherence as well as the application of relevant assessment and intervention techniques have the potential to facilitate adherence and ultimately improve treatment success.

Exposure therapy for social anxiety disorder (SAD) utilizes fear extinction, a memory process enhanced by sleep. We investigated whether naps following exposure sessions might improve symptoms and biomarkers in response to social stress in adults undergoing 5-week exposure-based group SAD therapy. Thirty-two participants aged 18-39 (18 females) with SAD were randomized. Before and after treatment, participants completed the Liebowitz Social Anxiety Scale (LSAS) and underwent a Trier Social Stress Test with psychophysiological monitoring (mpTSST) that included skin conductance (SCL), electromyographic (EMG) and electrocardiographic recording, and an auditory startle procedure while anticipating the social stressor. At sessions 3 and 4, exposure was followed by either a 120-min polysomnographically monitored sleep opportunity (Nap, N = 17) or wakefulness (Wake, N = 15). Primary hypotheses about SAD symptom change (LSAS) and EMG blink-startle response failed to differ with naps, despite significant symptom improvement (LSAS) with therapy. Some secondary biomarkers, however, provided preliminary support for enhanced extinction learning with naps, with trend-level Time (pre-, post-treatment) × Arm interactions and significant reduction from pre- to post treatment in the Nap arm alone for mpTSST SCL and salivary cortisol rise. Because of the small sample size and limited sleep duration, additional well-powered studies with more robust sleep interventions are indicated.