Compassion-Focused Therapy for the Treatment of ICD-11-Defined Complex Posttraumatic Stress Disorder.

The most effective treatments for ICD-11-defined complex posttraumatic stress disorder (CPTSD) remain unknown. Further research is needed to determine whether such treatments for CPTSD are the same as or different from-or require integration with-existing gold standard treatments for posttraumatic stress disorder (PTSD). Individuals with CPTSD experience the hallmark symptoms of PTSD (i.e., reexperiencing symptoms, avoidance symptoms, and the pervasive sense of perceived threat) and pervasive disturbances in self-organization, including affective dysregulation, negative self-concept, and difficulties with interpersonal relationships. Compassion-focused therapy (CFT) is a transdiagnostic approach that was originally developed to treat shame and self-criticism. CFT helps individuals learn how to regulate their emotions, shift their emotional response style from shaming and self-critical to wise and understanding, and engage in more compassionate and rewarding patterns of relating to self and others. This article describes CFT's possible application in the treatment of CPTSD and delineates areas for future research.

A Brief Self-Compassionate Letter-Writing Intervention for Individuals with High Shame.

Objectives: Over the last decade, the mental health of undergraduate students has been of increasing concern and the prevalence of psychological disorders among this population has reached an unprecedented high. Compassion-based interventions have been used to treat shame and self-criticism, both of which are common experiences among undergraduate students and transdiagnostic vulnerability factors for an array of psychological disorders. This randomized controlled study examined the utility of a brief online self-compassionate letter-writing intervention for undergraduate students with high shame. Method: Participants were 68 undergraduates who scored in the upper quartile on shame. Individuals were randomly assigned to a 16-day self-compassionate letter-writing intervention (n = 29) or a waitlist control group (n = 39). Participants completed baseline, post-assessment, and one-month follow-up measures. Results: Participants who practiced self-compassionate letter writing evidenced medium-to-large reductions in global shame, external shame, self-criticism, and general anxiety at post-assessment, and gains were sustained at follow-up. Additionally, there were trend-level effects for increases in self-compassion and decreases in depression for those who participated in the intervention. Conclusions: This study examined the efficacy of self-compassionate letter-writing as a stand-alone intervention for undergraduate students with high shame. This brief, easily accessible, and self-administered practice may be beneficial for a host of internalizing symptoms in this population and may support university counseling centers as they navigate high demand for mental health services.

Treatment outcomes and patient satisfaction of a virtual partial hospital program: A mixed-method study.

OBJECTIVE: Despite a proliferation of virtual partial hospital programs (PHP) during the COVID-19 pandemic, there is a dearth of research on such programs. In the current study, we compared treatment outcomes and patient satisfaction between an in-person and a virtual PHP. Further, we examined patients' qualitative feedback about the virtual PHP. METHOD: Participants included 282 patients attending a virtual PHP during the COVID-19 pandemic and 470 patients attending an in-person PHP one year prior. Patients completed daily measures of symptom severity, and post-treatment measures of patient satisfaction and treatment outcomes. Patients in the virtual PHP provided feedback about virtual care. Quantitative data were analyzed using multilevel modeling, and qualitative data were analyzed using the principles of inductive analysis. RESULTS: Patients experienced a reduction in depression (b = -.28, p < .001) and anxiety symptoms (b = -.25, p < .001) over time and reported high satisfaction in both the in-person and virtual PHPs. There were no significant differences across programs. Virtual PHP patients identified unique advantages and disadvantages of virtual care. CONCLUSION: Our results suggest that virtual PHPs should be explored as an ongoing model of care that may help to systematically reduce barriers to accessing mental health services.

Examining the relationship between shame and social anxiety disorder: A systematic review.

This paper is the first systematic review of the literature on the relationship between shame and social anxiety (SA). We reviewed a total of 60 peer-reviewed empirical articles that met criteria for inclusion. We begin by summarizing literature investigating the empirical association between shame and SA and review literature on whether this association is impacted by cultural or diagnostic differences. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of social anxiety disorder (SAD; Heimberg, Brozovich, & Rapee, 2014) and propose how shame may interact with five processes described therein: environmental experiences, observations/images of the self, perceived negative evaluation by others, post-event cognitive processes, and behavioral manifestations of SA. We review the current literature on shame and SA as it relates to each of these domains. Thereafter, we discuss existing research on the role of shame in the treatment of SAD and the implications of the research discussed in this review. Finally, we conclude with a discussion of some key limitations in the existing literature and areas for future research.

Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting.

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients' social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.

Barriers to mental health treatment among individuals with social anxiety disorder and generalized anxiety disorder.

Individuals with social anxiety disorder (SAD) or generalized anxiety disorder (GAD) are at risk for not utilizing mental health treatment. The purpose of this research was to examine barriers to treatment in a sample of adults with clinically significant SAD or GAD. Participants were 226 nontreatment-seeking adults with SAD or GAD who underwent semistructured diagnostic interview and received a clinician assessment of symptom severity as part of a clinical research study. Participants completed a self-report measure of barriers to treatment. Individual and combined associations of demographic and symptom severity variables with number of perceived barriers to treatment were examined. Individuals with GAD or SAD endorsed a similar number of overall barriers to treatment. Shame and stigma were the highest cited barriers followed by logistical and financial barriers. Both groups also endorsed not knowing where to seek treatment at high rates. Individuals with greater symptom severity reported more barriers to treatment. Racial and ethnic minorities reported more barriers to treatment even after controlling for symptom severity. Among individuals with GAD or SAD, increased education and culturally sensitive outreach initiatives are needed to reduce barriers to mental health treatment. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Do sudden gains predict treatment outcome in social anxiety disorder? Findings from two randomized controlled trials.

OBJECTIVE: Sudden gains (SGs) have been found to occur during randomized controlled trials (RCTs) for social anxiety disorder (SAD). Evidence is mixed whether SGs relate to treatment outcome in SAD. We examined SGs in two RCTs for SAD. METHOD: Study 1 (N = 68) examined SGs in individual cognitive-behavioral therapy (CBT), and Study 2 (N = 100) compared SGs in group CBT and Mindfulness-Based Stress Reduction (MBSR). Weekly ratings of social anxiety were used to calculate SGs. The Liebowitz Social Anxiety Scale-Self-Report and the Social Interaction Anxiety Scale were completed at pretreatment, posttreatment, and follow-up to assess outcome. RESULTS: In Study 1, 17.6% of participants experienced a SG. Participants with SGs started and ended treatment with lower social anxiety. SGs were not associated with greater decreases in social anxiety from pre-to posttreatment or 12-month follow-up. In Study 2, SGs occurred in 27% of participants and at comparable rates in MBSR and group CBT. SGs were not associated with changes in social anxiety during treatment in either condition. CONCLUSION: SGs occurred during treatment for SAD. In both RCTs, participants improved regardless of experiencing a SG, suggesting that SGs are not predictive of greater improvement during treatment for SAD.

Rural living environment predicts social anxiety in transgender and gender nonconforming individuals across Canada and the United States.

Transgender and gender nonconforming (TGNC) individuals frequently confront discrimination, rejection, and violence. Such experiences may put TGNC individuals at risk for minority stress and associated psychiatric symptoms. Protective factors like social support, pride in one's gender identity, or connectedness to similar others may make TGNC individuals less vulnerable to psychiatric symptoms, and the presence of risk and protective factors may vary depending on living environment. This study examined the relationship of living environment (urban vs. suburban vs. small-town/rural) to social anxiety (SA) in a sample of 902 TGNC individuals who participated in the Trans Health Survey. Analysis of variance revealed a significant difference in SA across living environments. Those living in small-town/rural environments reported significantly higher levels of SA compared to those living in urban environments. There was a trend-level difference in SA in suburban compared to urban environments. Linear regression analyses revealed that living environment significantly moderated the relationship between social support and SA. Higher social support was more protective against elevated SA in urban and suburban than in small-town/rural environments. This study is the first to demonstrate the experience of elevated SA among TGNC individuals living in rural environments. Implications and future directions for research are discussed.

Repeat-dose ketamine augmentation for treatment-resistant depression with chronic suicidal ideation: A randomized, double blind, placebo controlled trial.

BACKGROUND: Several studies indicate that ketamine has rapid antidepressant effects in patients with treatment-resistant depression (TRD). The extent to which repeated doses of ketamine (versus placebo) reduce depression in the short and long term among outpatients with TRD and chronic, current suicidal ideation remains unknown. METHODS: Twenty-six medicated outpatients with severe major depressive disorder with current, chronic suicidal ideation were randomized in a double-blind fashion to six ketamine infusions (0.5 mg/kg over 45 minutes) or saline placebo over three weeks. Depression and suicidal ideation were assessed at baseline, 240 min post-infusion, and during a three-month follow-up phase. RESULTS: During the infusion phase, there was no differences in depression severity or suicidal ideation between placebo and ketamine (p = 0.47 and p = 0.32, respectively). At the end of the infusion phase, two patients in the ketamine group and one in the placebo group met criteria for remission of depression. At three-month follow-up, two patients in each group met criteria for remission from depression. LIMITATIONS: Limitations include the small sample size, uncontrolled outpatient medication regimens, and restriction to outpatients, which may have resulted in lower levels of suicidal ideation than would be seen in emergency or inpatient settings. CONCLUSIONS: Repeated, non-escalating doses of ketamine did not outperform placebo in this double-blind, placebo controlled study of patients with severe TRD and current, chronic suicidal ideation. This result may support our previously published open-label data that, in this severely and chronically ill outpatient population, the commonly used dose of 0.5 mg/kg is not sufficient.

Social anxiety among transgender and gender nonconforming individuals: The role of gender-affirming medical interventions.

Transgender and gender nonconforming (TGNC) individuals are at heightened risk for psychological distress, including social anxiety (SA). The current study aimed to examine whether gender-affirming medical interventions (GAMIs) are associated with lower SA among TGNC individuals. Two hundred ninety-one transfeminine and 424 transmasculine participants completed the Trans Health Survey, which assessed SA and interest in or utilization of GAMIs (genital surgery, chest surgery, hormone use, speech therapy, tracheal shave or Adam's apple removal, hair removal). Transfeminine individuals who had completed genital surgery, chest surgery, tracheal shave or Adam's apple removal, hair removal, hormone treatment, or speech therapy reported lower SA than those planning to undergo the intervention, and those who had completed genital or chest surgery reported lower SA than those considering it. Transmasculine individuals who had completed chest surgery, a hysterectomy, or used hormones reported lower SA than those who were planning to do so, and those who had completed genital surgery had lower SA than those considering it. Among those expressing interest, utilization of GAMIs is associated with less SA. GAMIs may result in greater conformity to societal expectations regarding binary gender norms, thus decreasing discrimination, rejection, victimization, and nonaffirmation. Increased alignment of physical characteristics and gender identity may increase self-esteem. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Worry and anxiety account for unique variance in the relationship between intolerance of uncertainty and depression.

The evidence supporting the relationship between intolerance of uncertainty (IU), a cognitive construct well established in the anxiety literature, and depression is mixed. Some research has demonstrated a direct association between IU and depression, whereas other studies suggest that IU is either unrelated or indirectly related to depression through other pathways, including anxiety. The present study aimed to further elucidate the relationship between IU and depression in an undergraduate sample (N = 221). We posited a model in which worry and anxiety account for unique variance in the association between IU and depression. Results supported this hypothesis. Worry and trait anxiety significantly accounted for unique variance in the relationship between IU and depression. Furthermore, the model that best fit the data included two additional direct paths, from IU to anxiety and from worry to depression, and excluded the direct path from IU to depression. Our findings support the notion that IU and depression are indirectly related through worry and anxiety. Limitations and future directions are discussed.

Ziprasidone augmentation for anxious depression.

Previously, we found an anxiolytic effect of ziprasidone augmentation to escitalopram (compared with placebo augmentation) in patients with depression in an 8-week, randomized, double-blind, parallel-group, placebo-controlled trial. Here, we carried out a post-hoc analysis, comparing changes in the Hamilton Depression and Anxiety Rating Scales between patients with anxious depression versus nonanxious depression, using a moderator analysis. Hamilton Depression Rating Scales total change scores from baseline and endpoint were not significantly different (interaction term P=0.91) in patients with anxious depression on ziprasidone augmentation (n=19; -9.1±4.9) or placebo (n=19; -6.1±8.9) versus patients without anxious depression on ziprasidone (n=52; -5.5±6.7) or placebo (n=49; -2.3±4.5). There was a trend toward statistical significance (interaction term P=0.1) in favor of patients without anxious depression for a difference in Hamilton Anxiety Rating Scale total change scores from baseline to endpoint [patients with anxious depression on ziprasidone augmentation (n=19; -2.7±5.3) or placebo (n=19; -3.3±5.8) versus patients without anxious depression on ziprasidone (n=51; -3.9±6.6) or placebo (n=44; -0.9±4.7)]. Ziprasidone augmentation was equally efficacious in treating depression in patients with versus without anxious depression. However, the observed anxiolytic effect for patients with higher anxiety was not clinically significant.

Rapid and Sustained Reductions in Current Suicidal Ideation Following Repeated Doses of Intravenous Ketamine: Secondary Analysis of an Open-Label Study.

BACKGROUND: Ketamine rapidly reduces thoughts of suicide in patients with treatment-resistant depression who are at low risk for suicide. However, the extent to which ketamine reduces thoughts of suicide in depressed patients with current suicidal ideation remains unknown. METHODS: Between April 2012 and October 2013, 14 outpatients with DSM-IV-diagnosed major depressive disorder were recruited for the presence of current, stable (≥ 3 months) suicidal thoughts. They received open-label ketamine infusions over 3 weeks (0.5 mg/kg over 45 minutes for the first 3 infusions; 0.75 mg/kg over 45 minutes for the last 3). In this secondary analysis, the primary outcome measures of suicidal ideation (Columbia-Suicide Severity Rating Scale [C-SSRS] and the Suicide Item of the 28-item Hamilton Depression Rating Scale [HDRS28-SI]) were assessed at 240 minutes postinfusion and for 3 months thereafter in a naturalistic follow-up. RESULTS: Over the course of the infusions (acute treatment phase), 7 of 14 patients (50%) showed remission of suicidal ideation on the C-SSRS Ideation scale (even among patients whose depression did not remit). There was a significant linear decrease in this score over time (P < .001), which approached significance even after controlling for severity of 6-item Hamilton Depression Rating Scale (HDRS6) core depression items (P = .05). Similarly, there were significant decreases in the C-SSRS Intensity (P < .01) and HDRS28-SI (P < .001) scores during the acute treatment phase. Two of the 7 patients who achieved remission during the acute treatment phase (29%) maintained their remission throughout a 3-month naturalistic follow-up. CONCLUSIONS: In this preliminary study, repeated doses of open-label ketamine rapidly and robustly decreased suicidal ideation in pharmacologically treated outpatients with treatment-resistant depression with stable suicidal thoughts; this decrease was maintained for at least 3 months following the final ketamine infusion in 2 patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01582945.

Ziprasidone Augmentation of Escitalopram for Major Depressive Disorder: Efficacy Results From a Randomized, Double-Blind, Placebo-Controlled Study.

OBJECTIVE: The authors sought to test the efficacy of adjunctive ziprasidone in adults with nonpsychotic unipolar major depression experiencing persistent symptoms after 8 weeks of open-label treatment with escitalopram. METHOD: This was an 8-week, randomized, double-blind, parallel-group, placebo-controlled trial conducted at three academic medical centers. Participants were 139 outpatients with persistent symptoms of major depression after an 8-week open-label trial of escitalopram (phase 1), randomly assigned in a 1:1 ratio to receive adjunctive ziprasidone (escitalopram plus ziprasidone, N=71) or adjunctive placebo (escitalopram plus placebo, N=68), with 8 weekly follow-up assessments. The primary outcome measure was clinical response, defined as a reduction of at least 50% in score on the 17-item Hamilton Depression Rating Scale (HAM-D). The Hamilton Anxiety Rating scale (HAM-A) and Visual Analog Scale for Pain were defined a priori as key secondary outcome measures. RESULTS: Rates of clinical response (35.2% compared with 20.5%) and mean improvement in HAM-D total scores (-6.4 [SD=6.4] compared with -3.3 [SD=6.2]) were significantly greater for the escitalopram plus ziprasidone group. Several secondary measures of antidepressant efficacy also favored adjunctive ziprasidone. The escitalopram plus ziprasidone group also showed significantly greater improvement on HAM-A score but not on Visual Analog Scale for Pain score. Ten (14%) patients in the escitalopram plus ziprasidone group discontinued treatment because of intolerance, compared with none in the escitalopram plus placebo group. CONCLUSIONS: Ziprasidone as an adjunct to escitalopram demonstrated antidepressant efficacy in adult patients with major depressive disorder experiencing persistent symptoms after 8 weeks of open-label treatment with escitalopram.