Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial.

Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.

Military Sexual Trauma and Chronic Pain in Veterans.

OBJECTIVE: Chronic pain rehabilitation warrants sensitivity to unique psychosocial factors, such as trauma history. In Veterans of the United States Armed Forces, military sexual trauma (MST) is a pervasive type of trauma associated with a host of physical and psychological sequelae. A growing literature suggests a relationship between history of MST and chronic pain. This study sought to clarify the relationship between MST and chronic pain among male and female Veterans and explore whether individual factors moderate this relationship. DESIGN: A baseline survey of 328 Veterans seeking care for chronic pain via behavioral pain treatments was conducted. RESULTS: MST was reported by 31.4% of the sample and uniquely predicted pain interference. A significant interaction was found between MST and age, such that younger Veterans with a history of MST reported greater pain interference than younger Veterans with no MST. CONCLUSION: Findings provide further evidence that the experience of MST may intensify the overall burden of chronic pain and suggest that younger Veterans with MST seem to be most vulnerable to impaired pain rehabilitation. Unique study contributions include a robust sample of women and men with elevated rates of MST and examination of MST-age relationships concurrent with chronic pain.

Social Anxiety Disorder and Perceived Criticism in Intimate Relationships: Comparisons With Normal and Clinical Control Groups.

Individuals with social anxiety disorder (SAD) have difficulties in their romantic relationships, including decreased satisfaction and intimacy, but the reasons for these difficulties are poorly understood. Because fear of negative evaluation is a cardinal feature of SAD, perceived criticism from a romantic partner may play a central role in socially anxious individuals' relationships. In the present study, we compared levels of perceived, expressed, and observed criticism and reactions to criticism among individuals with SAD and their partners (n = 21), individuals with other anxiety disorders and their partners (n = 35), and couples free of psychopathology (n = 30). Participants rated both global criticism and criticism during a 10-minute problem-solving task, which was also coded for criticism by observers. Individuals with anxiety disorders showed elevated levels of interaction-specific perceived criticism, expressed criticism, and upset and stress due to criticism relative to normal controls; they also reported that the interaction was more stressful. However, there were no group differences on global measures of criticism, and the two anxious groups did not differ on any measures. Findings suggest that the high levels of criticism anxious individuals perceive and their corresponding negative reactions to criticism, though not specific to SAD, may account for some of the relationship difficulties that have been identified in SAD. Results also indicate that anxious individuals may contribute to their relationship difficulties by being highly critical themselves. Overall, our findings point to the need for a clinical focus on decreasing perceived criticism among individuals with anxiety disorders.

Attributions and perceptions of criticism: An examination of patients with anxiety and normal control participants.

Perceived criticism from relatives predicts poor clinical outcomes for patients with a variety of psychological disorders. Research indicates the attributions individuals make about motives for relatives' criticism are linked to perceived criticism from this relative. Accordingly, attributions may be an important target of intervention to reduce perceived criticism and improve clinical outcomes, but this association requires testing in a clinical sample. We examined relationships among attributions of criticism, perceived criticism, and upset due to criticism among individuals with anxiety disorders (n = 53) and with no psychopathology (n = 52). Participants completed measures of global attributions, perceived criticism, and upset due to criticism regarding criticism from a romantic partner/spouse or parent. After a 10-min problem-solving interaction with their relative, they completed measures of attributions, perceived criticism, and upset with regard to this relative's critical behavior during the interaction, and observers reliably coded interactions for relatives' criticism. Results showed that negative attributions were related to greater perceived criticism and upset for both global and interaction-specific measures. In analyses of interaction-specific measures, negative attributions added to prediction of perceived criticism and upset over and above the contribution of observed criticism. Positive attributions were not significantly related to global or interaction-specific upset in any analyses. Relationships were consistent across patients and normal controls. Our findings suggest that negative attributions of relatives' motives for their criticism are important predictors of perceived criticism and upset. Thus, interventions targeting these attributions may be helpful in mitigating the negative effect of perceived criticism for individuals with psychopathology. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Ageing perceptions and non-adherence to aromatase inhibitors among breast cancer survivors.

PURPOSE: Aromatase inhibitors (AIs) are a potentially life-saving treatment for breast cancer survivors, yet poor adherence to treatment is a prevalent problem. A common adverse effect of AI treatment is arthralgia, which is identified by survivors as a major reason for treatment discontinuation. Women who experience arthralgia on AIs often report feeling they have aged rapidly while on the treatment. In the present study, we examined whether arthralgia-associated ageing perceptions predicted non-adherence. PATIENTS AND METHODS: We conducted a prospective cohort study among women with stage I-III breast cancer, who were on an AI and completed the Penn Arthralgia Aging Scale within 2 years of AI initiation. Adherence data were abstracted from medical charts by trained raters. Cox proportional hazard analysis was used to determine the relationship between ageing perceptions and time to non-adherence. All analyses included adjustments for joint pain severity. RESULTS: Among 509 participants, 144 (28.3%) were non-adherent. As hypothesised, women with high levels of ageing perceptions were at greater risk of non-adherence than women with low levels of ageing perceptions (adjusted hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.10-2.67; p = .02). High levels of depressive symptoms were also uniquely associated with increased risk of non-adherence (adjusted HR, 1.63; 95% CI, 1.03-2.59; p = .04). CONCLUSION: Perceptions of ageing related to arthralgia and depressive symptoms predicted non-adherence to AIs. These findings suggest that interventions that address negative beliefs about ageing due to AI-related arthralgia and depressive mood can potentially improve rates of adherence to AIs.

Quality of Relationships With Caregivers, Depression, and Life Satisfaction After Dysvascular Lower Extremity Amputation.

OBJECTIVE: To describe the relationship between caregiver-specific support and conflict, and psychosocial outcomes among individuals experiencing their first dysvascular lower extremity amputation (LEA). DESIGN: Cross-sectional cohort study using self-report surveys. SETTING: Department of Veterans Affairs, academic medical center, and level I trauma center. PARTICIPANTS: Individuals undergoing their first major LEA because of complications of peripheral arterial disease (PAD) or diabetes who have a caregiver and completed measures of caregiver support and conflict (N=137; 94.9% men). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Patient Health Questionnaire-9 to assess depression and the Satisfaction With Life Scale to assess life satisfaction. RESULTS: In multiple regression analyses, controlling for global levels of perceived support, self-rated health, age, and mobility, caregiver-specific support was found to be associated with higher levels of life satisfaction and caregiver-specific conflict was found to be associated with lower levels of life satisfaction and higher levels of depressive symptoms. CONCLUSIONS: The specific relationship between individuals with limb loss and their caregivers may be an important determinant of well-being. Conflict with caregivers, which has received little attention thus far in the limb loss literature, appears to play a particularly important role. Individuals with limb loss may benefit from interventions with their caregivers that both enhance support and reduce conflict.

Perceived barriers to treatment predict adherence to aromatase inhibitors among breast cancer survivors.

BACKGROUND: Although poor adherence to hormonal therapies such as aromatase inhibitors (AIs) is widely documented, to the authors' knowledge less is known regarding whether health beliefs predict treatment nonadherence. The objective of the current study was to evaluate the relationship between health beliefs (perceived susceptibility to breast cancer, perceived benefits of AI treatment, and perceived barriers to AI treatment) and adherence to AIs. METHODS: Postmenopausal women with early-stage, estrogen receptor-positive breast cancer who were currently receiving treatment with an AI completed the 3-factor Health Beliefs and Medication Adherence in Breast Cancer scale and questionnaires concerning their demographics and symptoms. Adherence data (treatment gaps and premature discontinuation) were abstracted from participants' medical charts. Logistic regression analyses were conducted to evaluate the relationship between health beliefs and adherence. RESULTS: Among 437 participants, 93 (21.3%) were nonadherent. Those who perceived greater barriers to their AI treatment were more likely to demonstrate AI nonadherence behaviors by the end of their treatment period compared with those who reported fewer barriers to AI therapy (adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.86 [P = .04]). In contrast, perceived susceptibility to cancer recurrence and perceived benefits of AIs did not appear to predict AI adherence. Minority individuals were found to have lower perceived susceptibility to breast cancer recurrence and higher perceived barriers to AI treatment (P<.05 for both). CONCLUSIONS: Greater perceived barriers appeared to predict nonadherence to AIs. Interventions addressing women's negative beliefs regarding the challenges of AI treatment are needed to help optimize adherence in survivors of breast cancer. Cancer 2017;169-176. © 2016 American Cancer Society.

Association between self-report adherence measures and oestrogen suppression among breast cancer survivors on aromatase inhibitors.

PURPOSE: Poor adherence to oral adjuvant hormonal therapy for breast cancer is a common problem, but little is known about the relationship between self-report adherence measures and hormonal suppression. We evaluated the relationship of three self-report measures of medication adherence and oestrogen among patients on aromatase inhibitors (AIs). MATERIALS AND METHODS: We recruited 235 women with breast cancer who were prescribed AI therapy. Participants self-reported AI adherence by completing the following: (1) a single item asking whether they took an AI in the last month, (2) a modified Morisky Medication Adherence Scale-8 (MMAS-8) and (3) the Visual Analog Scale (VAS). Serum estrone and estradiol were analysed using organic solvent extraction and Celite column partition chromatography, followed by radioimmunoassay. RESULTS: Ten percent of participants reported they had not taken an AI in the last month and among this group, median estrone (33.2 pg/ml [interquartile range (IQR)=22.3]) and estradiol levels (7.2 pg/mL [IQR=3.3]) were significantly higher than those in participants who reported AI use (median estrone=11.5 pg/mL [IQR=4.9]; median estradiol=3.4 pg/mL [IQR=2.1]; p<0.001). This relationship held when controlling for race and AI drug type. CONCLUSIONS: A single-item monthly-recall adherence measure for AIs was associated with oestrogen serum levels. This suggests that patient-reported monthly adherence may be a useful measure to identify early non-adherence behaviour and guide interventions to improve patient adherence to hormonal treatment.

Development and validation of the Penn Arthralgia Aging Scale among breast cancer survivors.

BACKGROUND: Breast cancer survivors on aromatase inhibitors often experience joint pain as a side effect of their treatment; qualitative investigations suggest that this arthralgia may cause women to feel that they are aging faster than they should be. To facilitate further study of this experience, the Penn Arthralgia Aging Scale (PAAS) was developed. This report describes the development and validation of the PAAS in a racially diverse sample of breast cancer survivors suffering from joint pain. METHODS: The items of the scale were developed from a content analysis of interviews with patients. The scale was pilot-tested, and modifications were made on the basis of patient feedback. Subsequently, 596 breast cancer survivors who endorsed joint pain completed the 8-item PAAS. The factor structure (with exploratory factor analysis), the internal consistency, and the convergent, divergent, and incremental validity were examined. RESULTS: The resulting scale had a 1-factor structure with strong internal consistency (Cronbach's α = .94) and demonstrated both convergent and divergent validity: the PAAS was significantly correlated with joint pain severity (rs = 0.55, P < .01) and had a small and nonsignificant correlation with actual age (rs = -0.07, P = .10). The PAAS was also found to explain incremental variance in anxiety, depression, and pain interference outcomes. CONCLUSIONS: These findings suggest that the PAAS produces reliable and valid scores that capture perceptions of aging due to arthralgia among breast cancer survivors. With further research, the PAAS may advance our understanding of how perceptions of aging may affect breast cancer survivors' emotional, behavioral, and clinical outcomes.

Psychosocial, health-promotion, and neurocognitive interventions for survivors of childhood cancer: a systematic review.

OBJECTIVE: Survivors of childhood cancer must contend with a number of medical and psychosocial vulnerabilities after their cancer treatment ends. Interventions have been developed to alleviate or prevent adverse outcomes among this population. This systematic review summarizes the efficacy of psychosocial, health behavior, and neurocognitive interventions for survivors of pediatric cancer. METHOD: Multiple databases were searched for studies published between January 1970 and June 2013. Studies were coded by 2 raters for methodological quality using the Effective Public Health Practice Project quality assessment tool. RESULTS: Twenty-four interventions were identified (7 psychosocial, 10 health behavior, and 7 neurocognitive). Eleven were controlled trials, of which 7 achieved medium to large effect sizes. Survivor interest, as demonstrated by consent rates, was high for interventions that did not require travel. CONCLUSIONS: Interventions using delivery methods varying from traditional counseling to computers achieved moderate to strong efficacy and merit replication. Survivor needs related to transition to adult-oriented health care and school reentry were not addressed by existing interventions. This review also revealed the absence of health behavior interventions for survivors in middle childhood and late adolescence. Intervention formats that are cost-effective and reduce participant burden should be prioritized for further testing. To broaden the reach and appeal of interventions, alternative delivery methods, such as mobile phone software applications, should be evaluated.

Screening for psychosocial risk in pediatric cancer.

Major professional organizations have called for psychosocial risk screening to identify specific psychosocial needs of children with cancer and their families and facilitate the delivery of appropriate evidence-based care to address these concerns. However, systematic screening of risk factors at diagnosis is rare in pediatric oncology practice. Subsequent to a brief summary of psychosocial risks in pediatric cancer and the rationale for screening, this review identified three screening models and two screening approaches [Distress Thermometer (DT), Psychosocial Assessment Tool (PAT)], among many more articles calling for screening. Implications of broadly implemented screening for all patients across treatment settings are discussed.

Challenges in providing family-centered support to families in palliative care.

BACKGROUND: Supporting the family-as-a-whole presents challenges in palliative care, although family meetings are increasingly used in routine practice. The Family Focused Grief Therapy (FFGT) Model guides clinicians in using a range of intervention strategies. AIM: To examine the therapists' techniques used in assessing 'at risk' families in palliative care to better illuminate what helps and what remains challenging. METHOD: Recorded sessions 1 and 2 were coded using the FFGT fidelity coding measure, with its glossary of definitions. Inter-rater reliability between three coders was satisfactory at 88%. Frequencies of strategy utilization were computed, with extraction of examples of both successful and problematic approaches. SETTING/PARTICIPANTS: From within a larger study of family therapy during palliative care at a comprehensive cancer center, the first two sessions (n = 144) delivered to 74 families (299 individuals) by 32 therapists were coded and analyzed. RESULTS: Therapists readily explored the story of illness and families' ways of coping (97%) and assessed communication and cohesiveness in the majority. Exploration of relational patterns occurred in 89% of sessions, use of a genogram in 80%, understanding members' roles in 65% and family values and beliefs in 62%. Less use was made of summaries (39%), family mottos (34%), exploration of family conflict (35%) and the formalization of a comprehensive family treatment plan (20%). CONCLUSIONS: Challenges exist in therapy with difficult families. Therapy in the home brings special issues. Therapists can apply most of the interventions prescribed by the FFGT model.

Profiles of Health Competence Beliefs Among Young Adult Survivors of Childhood Cancer.

Purpose: The goal of this study was to identify profiles of young adult (YA)-aged cancer survivors' beliefs about their health and well-being. Survivors' beliefs and their associated psychosocial and demographic characteristics may be clinically useful in survivorship care. Patients and methods: YA survivors of pediatric leukemias (n=51), lymphomas (n=24), and solid tumors (n=44), aged 18-29 years old (N=119), were categorized using cluster analysis based on their responses to the Health Competence Beliefs Inventory, a measure assessing beliefs about their health, satisfaction with healthcare, autonomy, and cognitive competence. Profiles of beliefs generated by cluster analysis were examined using self-report measures of health problems, distress, demographics, and provider-reported health problems and cancer treatment intensity. Results: Three distinct clusters were identified: Adaptive (n=54), Low Autonomy (n=25), and Vulnerable (n=40). Adaptive survivors had positive beliefs, low distress, and minimal health problems. The Low Autonomy survivors were similar to those in the Adaptive cluster except they had low autonomy beliefs and the majority reported living with their parents. The Vulnerable cluster had more negative beliefs, the most medical problems, and the highest levels of distress. Conclusion: Health competence belief profiles identified unique subsets of YA survivors of pediatric cancer that have potentially distinct risk factors. Categorizing survivors by health belief patterns may help healthcare providers treat and educate their patients in ways that are tailored to individual survivors' needs and risks.

The risk of return: intimate partner violence in northern Uganda's armed conflict.

The physical and psychological consequences of armed conflict and intimate partner violence are well documented. Less research focuses on their intersection and the linkages between domestic violence, gender-based discrimination, and the structural violence of poverty in armed conflict. This paper describes emerging themes from qualitative interviews with young women who have returned from abduction into the Lord's Resistance Army in northern Uganda, many of whom were forcibly given as "wives" to commanders. Their interviews reveal multiple levels of violence that some women experience in war, including physical and sexual violence in an armed group, verbal and physical abuse from extended family members, and intimate partner violence. Striking is the violence they describe after escaping from the rebels, when they are back with their families. The interviews point to how abduction into the armed group may exacerbate problems but highlight the structural factors that permit and sustain intimate partner violence, including gender inequalities, corruption in the police system, and devastating poverty. Findings suggest that decreasing household violence will depend on the strength of interventions to address all levels, including increasing educational and economic opportunities, increasing accountability of the criminal justice system, minimizing substance abuse, and improving the coping mechanisms of families and individuals exposed to extreme violence.