Examining the Efficacy of a Brief Cognitive-Behavioral Therapy for Chronic Pain (Brief CBT-CP) Group Delivered via VA Video Connect (VVC) Among Older Adult Veterans.

OBJECTIVES: To evaluate the effectiveness of a Brief CBT-CP Group delivered via VA Video Connect (VVC) among different age groups of Veterans with chronic noncancer pain being seen in primary care. A secondary aim was to evaluate participant characteristics of patients who completed vs. did not complete the group. METHODS: Single-arm treatment study in which outcomes were evaluated by comparing self-reported symptom levels pre- and post-treatment. Dependent variables included generalized anxiety, quality of life, disability, physical health, and pain outcomes. RESULTS: Following a 2 × 3 mixed-model ANCOVA, a main effect of time was found for all outcome variables, demonstrating significant improvements in disability rating, physical health, quality of life, generalized anxiety, and pain outcomes from pre- to post-treatment. There were no significant main effects for age group for any outcome variable, suggesting that patients of all ages reported improvements. CONCLUSIONS: Accommodations and adaptations to telehealth treatment for older adults are proposed and discussed. CLINICAL IMPLICATIONS: The Brief CBT-CP Group via VVC is an effective and accessible treatment for older adults with chronic noncancer pain who are being managed in the primary care setting. Certain Veterans are less likely to complete the Brief CBT-CP Group via VVC.

Using the multiphase optimization strategy to adapt cognitive processing therapy (CPT MOST): study protocol for a randomized controlled factorial experiment.

BACKGROUND: Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format. METHODS: The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness. DISCUSSION: There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program. TRIAL REGISTRATION: ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022.

Monitoring long-term opioid therapy and chronic noncancer pain in primary care: Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP).

OBJECTIVE: To replicate and extend previous research by examining, among a larger sample, the effectiveness of a Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP) at increasing adherence to the Veteran Affairs/Department of Defense (VA/DoD) recommended guidelines for long-term opioid therapy among chronic noncancer patients seen in primary care-medications, hospitalization, monitoring/safety, assessment, and nonpharmacological pain treatment referrals. DESIGN/METHODS: Using data collected from medical records, a between-subjects comparison (PC-POP enrollees vs nonenrollees) was conducted to determine if there were differences between the groups 12 months post-enrollment in PC-POP (12 months post-index date for nonenrollees). Additionally, a within-subjects comparison of outcomes was also conducted with PC-POP enrollees, ie, 12 months pre-enrollment to 12 months post-enrollment. SUBJECTS: A convenience sample of adult Veterans with chronic noncancer pain receiving opioid therapy consecutively for ≥3 months in primary care. RESULTS: A total of 734 Veterans (423 PC-POP enrollees and 311 nonenrollees) were included in the analyses. Results showed increased concordance with VA/DoD guidelines among those enrolled in PC-POP, characterized by increased documentation of urine drug screens, Stratification Tool for Opioid Risk Mitigation reports, Narcan education/prescriptions, assessment measures for mental health/substance use/physical function, and referrals for nonpharmacological pain treatment. A decrease in morphine equivalent daily dose among patients enrolled in PC-POP across a 2-year timeframe was also found. CONCLUSIONS: PC-POP increases guideline concordant care for providers working in primary care.

Examining the relationship between pain interference, pain intensity, and mental health symptoms among veterans receiv-ing long-term opioid therapy for chronic noncancer pain in primary care.

OBJECTIVE: As part of the evaluation of the Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP), we examined the relationship between pain intensity, pain interference, and mental health symptoms among PC-POP enrollees. DESIGN/METHODS: Retrospective cohort study examining self-reported symptoms of pain intensity, pain interference, anxiety, depression, substance use, and quality of life. Data were retrieved through a combination of chart review and data extracted from the VA Informatics and Computing Infrastructure. SETTING: Veterans Health Administration Health Care System Primary Care -service. SUBJECTS: Adult veterans with chronic noncancer pain receiving opioid therapy >3 months being managed in primary care and enrolled in PC-POP between August 1, 2018 and April 1, 2019. RESULTS: A total of 439 participants were included in the final analysis. Results showed that anxiety has a unique relationship to pain intensity and that depression and quality of life have unique relationships to pain interference when relevant covariates, eg, gender, age, pain diagnosis, and predictors are examined among this unique sample of veterans enrolled in a pain and opioid education and monitoring program. CONCLUSIONS: Given that primary care is the dominant healthcare setting in which opioids are prescribed for chronic noncancer pain, further research is needed to examine factors that influence pain management in this setting. This study examined the role mental health factors have on pain intensity and pain interference among patients enrolled in an opioid monitoring program and found that anxiety and depression appear to uniquely predict how intensely and impactful these veterans experience their pain. This study extends the literature by examining such factors among a unique population that has yet to be studied and offers some recommendations for monitoring and practice.

Examining the Effect of a Whole Health Primary Care Pain Education and Opioid Monitoring Program on Implementation of VA/DoD-Recommended Guidelines for Long-term Opioid Therapy in a Primary Care Chronic Pain Population.

OBJECTIVE: To describe the core elements of a Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP) and examine its effectiveness at increasing adherence to six of the Veteran Affairs/Department of Defense (VA/DoD) recommended guidelines for long-term opioid therapy (LOT) among chronic noncancer patients seen in primary care (i.e., urine drug screens [UDS], prescription drug monitoring program [PDMP] queries, informed consent, naloxone education/prescriptions, morphine equivalent daily dose [MEDD], and referrals to nonpharmacological pain interventions). DESIGN/METHODS: A within-subjects comparison of outcomes was conducted between pre- and post-PC-POP enrollees (N = 25), as was a a between-subjects comparison to a comparison group (N = 25) utilizing a six-month range post-index date of 10/1/2018 (i.e., between-subjects comparison at Time 2). SUBJECTS: A convenience sample of adult veterans with chronic noncancer pain receiving opioid therapy consecutively for the past three months in primary care. RESULTS: Results showed increased concordance with VA/DoD guidelines among those enrolled in the PC-POP, characterized by increased documentation of urine drug screens, prescription drug monitoring program queries, informed consent, naloxone education/prescriptions, and a decrease in MEDD among patients enrolled in the PC-POP. CONCLUSIONS: The PC-POP shows promise for increasing guideline-concordant care for providers working in primary care.

Factors associated with participation and nonparticipation in a VA Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP).

OBJECTIVE: As part of the evaluation of the Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP), we compared demographic and health characteristics between participants and nonparticipants drawn from the same defined population. DESIGN/METHODS: Retrospective chart review comparing participants and nonparticipants in terms of two categories of variables: (1) demographic characteristics and (2) physical/mental health characteristics. SETTING: VA Primary Care. SUBJECTS: Adult veterans with chronic noncancer pain receiving opioid therapy >3 months being managed in primary care. RESULTS: A total of 749 veterans (424 participants in PC-POP and 325 nonparticipants) were included in the final analysis. Results showed that nonparticipation was associated with more widespread musculoskeletal pain, low back pain, anxiety, higher mortality, and rural areas. Participation was associated with more medical diagnoses overall, hypertension, sleep apnea, fibromyalgia, peripheral nerve pain, depression, and female gender. Other demographic and physical/mental health variables did not significantly differ between the groups. CONCLUSIONS: Given that primary care is the dominant healthcare setting in which opioids are prescribed for chronic noncancer pain, programs are needed to assist primary care providers to meet the rigorous requirements of guideline concordant care. The current study examined participation factors in such a program and found that certain veterans were less likely to participate than others. Identifying such veterans at the outset, in combination with intentional recruitment efforts and individualized interventions, may promote entry into PC-POP.

Outcomes of a 6-week Cognitive-Behavioral Therapy for Chronic Pain Group for veterans seen in primary care.

Primary Care Mental Health Integration (PC-MHI) visits are mandated to be brief, limited in number, and delivered in the primary care practice area. Current evidence-based protocols for Cognitive-Behavioral Therapy for Chronic Pain (CBT-CP) do not meet these PC-MHI requirements, however, and thus PC-MHI providers are often left with the daunting task of modifying these protocols for the primary care setting. The aims of the current study were to examine effectiveness for a brief CBT-CP Group (6, 50-min sessions) for patients seen in primary care with various chronic pain conditions and to assess whether opioid medication use was associated with treatment outcomes. The current study represents a single-arm treatment study in which outcomes were evaluated by comparing self-reported symptom levels at the beginning of treatment (Session 1) to the end of treatment (Session 6). Dependent variables included pain symptoms, physical function lower/upper body, family disability, emotional functioning, sleep problems, satisfactions with outcomes/care, pain-related anxiety, generalized anxiety, pain catastrophizing, and depressed mood. Seventy-seven participants were enrolled and completed the treatment group. They were 56.81 ± 13.11 years old, 61% male, 51.9% taking opioids, with 39% reporting multiple pain diagnoses. Results showed that participation in the Brief CBT-CP Group resulted in statistically significantly improvement across all dependent variables (except emotional functioning). Results also showed that there were no significant treatment-related differences between patients taking opioids compared with patients who were not on opioids. The current protocol for Brief CBT-CP is effective in a real-world setting and aligns with the PC-MHI model of care.

Differences in HPA axis reactivity to intimacy in women with and without histories of sexual trauma.

BACKGROUND: Sexual trauma can lead to longstanding effects on individuals' intimacy functioning. The current study aimed to assess hypothalamic pituitary adrenal (HPA) axis functioning (i.e., cortisol reactivity) prior to (-5min), during (+15, +30, +45min), and following (+60min) an experimental manipulation of emotional closeness in a sample of women survivors of sexual trauma with varying levels of posttraumatic stress disorder (PTSD) symptomatology versus controls. METHODS: Participants included 50 women, which were divided into 2 groups on the basis of a structured clinical interview: 26 women with a history of sexual trauma with and without PTSD (sexual trauma group), and 24 women without a history of sexual trauma or PTSD (controls). Participants came into the lab and participated in a 45min emotional closeness exercise with a male confederate and completed self-report questionnaires of closeness, state anxiety/depression, and cortisol assays at the aforementioned time points. RESULTS: Women with a history of sexual trauma exhibited a blunted cortisol response and greater anxious mood in reaction to the intimacy induction task compared to controls. Results also demonstrated that, unexpectedly, PTSD symptom severity scores among sexual trauma survivors were not associated with differential cortisol responding to the task compared to controls. CONCLUSIONS: Adaptive responses to stress are characterized by a relatively rapid cortisol increase followed by a steady decline. The results of this study demonstrated that women with a history of sexual trauma, in contrast, displayed a blunted cortisol response to an intimacy induction task. Both controls and women with a history of sexual trauma reported increased feelings of closeness to the male confederate in response to the intimacy induction task, suggesting that survivors were able to achieve similar adaptive feelings of intimacy when provided with the right conditions.

Prevalence of Sexual Trauma History Using Behaviorally Specific Methods of Assessment in First Year College Students.

There are several challenges associated with evaluating the prevalence of sexual trauma, including child sexual abuse and adult sexual assault. The aim of this study was to assess sexual trauma prevalence rates among first year college students (N = 954) using behaviorally specific questions and a more representative recruitment sample that did not rely on self-selection. Participants completed a list of sexual trauma questions, including general questions containing labels such as "rape" or "abuse" as well as behaviorally specific questions that describe specific behaviors that qualify as sexual trauma without labels. Results indicated that 6.7% of the sample reported at least one incident of child sexual abuse, with similar rates for men and women. Women were more likely to report a history of adult sexual assault, which was reported by 12.4% of the total sample. Participants were also more likely to endorse a history of sexual trauma when answering behaviorally specific rather than general "label" questions. Women survivors in particular were more likely than men to identify their experiences as abuse/assault (66.7% versus 21.1% for child sexual abuse), which may help explain prevalence differences between men and women in prior research. Men may be less likely than women to label their experiences as abuse and may be underidentified in sexual trauma research without the use of behaviorally specific questions. Overall, the results of this study suggest that the prevalence of sexual trauma is better assessed using behaviorally specific questions and that this is an important topic of study among both men and women.

Self-focused attention in response to laboratory stressors among women with premenstrual disorders.

The etiology of premenstrual disorders, including premenstrual syndrome (PMS) and premenstrual dysphoric disorders (PMDD), is not well understood. In the current study, the relationship between self-focused attention (SFA) and premenstrual disorders was examined to explore the hypothesis that women with premenstrual disorders tend to respond to symptoms in a maladaptive manner. Based on retrospective report, clinical interview, and 30-day prospective recording of premenstrual symptoms, women (N = 52) were categorized as meeting criteria for premenstrual disorders (PMD; n = 24) or not (controls; n = 28). Key findings indicated that women with premenstrual disorders reported greater use of SFA in response to negative affect elicited by laboratory tasks than controls, despite no significant differences in change in negative affect between the two groups. Women with premenstrual disorders also reported greater trait levels of SFA and maladaptive coping styles compared to controls. Women with premenstrual disorders may tend to respond to menstrual cycle changes using increased levels of SFA. The interaction between psychological and physiological menstrual cycle-related changes may lead to increased distress and impairment. Implications for psychological contributions to premenstrual distress and disorders are discussed.

Premenstrual disorders and rumination.

OBJECTIVES: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) involve emotional, behavioral, and physical symptoms; however, there is little understanding of psychological factors that contribute to these disorders. It was hypothesized that rumination, a form of depressive self-focused attention, is related to premenstrual distress. METHOD: Study 1 involved women (N = 735) meeting criteria for No/Mild PMS, Moderate/Severe PMS, and PMDD using retrospective self-report. Study 2 involved women (N = 85) meeting diagnostic criteria for PMS or PMDD (i.e., PMD group) and healthy controls (i.e., No PMD group) following 60-day symptom monitoring. Participants in both studies completed questionnaires of rumination, anxiety sensitivity, and coping styles. RESULTS: Rumination was strongly related to premenstrual disorders using both retrospective and prospective reports, as well as both categorical and continuous approaches to classification of premenstrual distress. CONCLUSIONS: Rumination, a transdiagnostic factor in psychopathology, may contribute to the onset and maintenance of premenstrual distress.

Perceptions of health and somatic sensations in women reporting premenstrual syndrome and premenstrual dysphoric disorder.

Focus on bodily sensations may be involved in the etiology of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). This study investigated the relationship between two types of somatic self-focus (i.e., health anxiety and anxiety sensitivity) and health-related quality of life (QOL) in women with provision diagnoses of PMS and PMDD. On the basis of responses to a screening measure, 731 college women were divided into three groups: PMDD, Moderate/Severe PMS, and Mild/No PMS. Measures included health-related QOL, health anxiety, anxiety sensitivity, and trait anxiety. Women with provisional diagnoses of PMDD and moderate/severe PMS reported higher levels of health anxiety and anxiety sensitivity. These relationships were not accounted for by trait anxiety. Furthermore, women in the PMDD and Moderate/Severe PMS groups reported lower health-related QOL. There is a significant health-related QOL burden for college women with PMDD and PMS. Health anxiety and anxiety sensitivity may contribute to the etiology of premenstrual disorders.

Processing of intimacy-related stimuli in survivors of sexual trauma: the role of PTSD.

To fully understand the negative impact of sexual trauma and posttraumatic stress disorder (PTSD) upon adult intimacy-related functioning, cognitive models designed to investigate implicit processing of stimuli with emotional content are warranted. Using an emotional Stroop paradigm, the present study examined the impact of sexual trauma history (childhood sexual abuse and/or adult sexual assault) and a PTSD diagnosis on the implicit processing of 3 types of word stimuli: intimacy, sexual trauma, and neutral. Based on the results of a structured clinical interview and a behavioral-specific sexual trauma questionnaire, participants (n = 101; 74 females, 27 males) were placed in 3 groups: sexual trauma only (n = 33), sexual trauma and PTSD (n = 33), and controls (n = 35). Results indicated that men and women with a history of sexual trauma and a current PTSD diagnosis had increased latency for intimacy-related words and trauma words compared to controls, whereas individuals with only a history of sexual trauma did not differ from controls. Thus, it appears that the presence of symptoms associated with a diagnosis of PTSD is important for implicit processing of intimacy stimuli, rather than having a history of sexual trauma alone. Avoidance, a key feature of PTSD, may strengthen this relationship. More research is needed to determine the mechanisms by which individuals with a history of sexual trauma and PTSD experience intimacy difficulties.

Panorama del manejo cognitivo conductual de la disfunción de la memoria asociada a la quimioterapia / An overview of cognitive-behavioral management of memory dysfunction associated with chemotherapy

Objective: This article summarizes current empirical support for Memory and Attention Adaptation Training (MAAT), a cognitive-behavioral treatment program that uses a compensatory strategy approach for management of late cognitive effects of chemotherapy among cancer survivors. A description of MAAT, in addition to other treatment approaches, is presented. Results: Current methods of assessing treatment gains among cancer survivors with cognitive problems who have completed programs such as MAAT need to be expanded. As such, a table of patient reported outcome (PRO) measures that may be better suited for future outcome research is proposed. Conclusions: Identifying outcome measures that accurately assess the clinical targets of MAAT and other behavioral treatments is of prime importance, as certain variables (e.g., quality of life, role strain) are not detected by neuropsychological testing in isolation. The PRO table presented in this article is intended to aid future researchers in identifying measures that can reflect quality of life improvement in response to treatments such as MAAT (AU)

Objetivo: El presente artículo resume el apoyo empírico actual para el Entrenamiento de la Adaptación de la Memoria y la Atención (MAAT), un programa de tratamiento cognitivo-conductual que utiliza un enfoque de estrategia compensatoria para el manejo de los efectos cognitivos tardíos de la quimioterapia en los supervivientes del cáncer. Se presenta una descripción del MAAT, además de otros enfoques de tratamiento. Resultados: Es necesario ampliar los métodos actuales de evaluación de las mejorías del tratamiento en los supervivientes de cáncer con problemas cognitivos que han completado programas como el MAAT. En este sentido, se propone una tabla de medidas de resultado informadas (PRO) por el paciente que puede ser más adecuada para la investigación de resultados futuros. Conclusiones: Identificar medidas de de resultado que evalúen con precisión los objetivos clínicos del MAAT y otros tratamientos conductuales es de vital importancia, ya que algunas variables (ej., calidad de vida, estrés de rol), no son detectados por pruebas neuropsicológicas de modo aislado. La tabla de PRO presentada en este artículo tiene el propósito de ayudar a los futuros investigadores a identificar las medidas que pueden reflejar la mejoría en calidad de vida en respuesta a tratamientos como el MAAT (AU)