Targeting hyperarousal: Mantram Repetition Program for PTSD in US veterans.

Background: Hyperarousal appears to play an important role in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms, but current evidence-based treatments appear to address this symptom type less effectively than the other symptom clusters. The Mantram Repetition Program (MRP) is a meditation-based intervention that has previously been shown to improve symptoms of posttraumatic stress disorder (PTSD) and may be especially helpful for hyperarousal. If MRP is an effective tool for decreasing this often treatment-resistant symptom cluster, it may become an important clinical tool. Objective: The goal of this secondary analysis was to examine the effect of the MRP on hyperarousal and other PTSD symptom clusters and to examine hyperarousal as a mediator of treatment response. Method: Secondary analyses were conducted on data from a randomized controlled trial in which Veterans with PTSD (n = 173) were assigned to the MRP or a non-specific psychotherapy control and assessed pre-treatment, post-treatment and 8 weeks after treatment completion. The impact of the interventions on PTSD symptom clusters was examined, and time-lagged hierarchical linear modelling was applied to examine alternative mediation models. Results: All PTSD symptom clusters improved in both treatments. MRP led to greater reductions in hyperarousal at post-treatment (Hedge's g = 0.57) and follow-up (Hedge's g = 0.52), and in numbing at post-treatment (Hedge's g = 0.47). Hyperarousal mediated reductions in the composite of the other PTSD symptom clusters. Although the reverse model was significant as well, the effect was weaker in this direction. Conclusion: Interventions focused on the management of hyperarousal may play an important role in recovery from PTSD. The MRP appears efficacious in reducing hyperarousal, and thereby impacting other PTSD symptom clusters, as one pathway to facilitating recovery.

Antecedentes: La hipervigilancia parece desempeñar un papel importante tanto en el desarrollo como en la mantención de los síntomas del trastorno de estrés postraumático (TEPT), pero los tratamientos basados en la evidencia actuales parecen abordar esta sintomatología de una manera menos efectiva que otras constelaciones de síntomas. El Programa de Repetición de Mantras (MRP por sus siglas en inglés) es una intervención basada en la meditación que previamente ha demostrado que puede mejorar los síntomas del TEPT y que pudiese ser beneficiosa específicamente en la hipervigilancia Si el MRP fuese una técnica efectiva para disminuir este síntoma que frecuentemente es resistente al tratamiento, se podría convertir en una herramienta clínica importante.Objetivo: El objetivo de este análisis secundario fue el evaluar el efecto del MRP sobre la hipervigilancia y otras constelaciones sintomáticas del TEPT, y el de evaluar cómo la hipervigilancia media la respuesta al tratamiento.Método: Se realizaron análisis secundarios sobre la base de datos de un ensayo clínico controlado aleatorizado en el cual un grupo de veteranos con TEPT (n = 173) fueron asignados al programa MRP o a un grupo control de psicoterapia inespecífica. Se evaluaron antes del tratamiento, inmediatamente luego del tratamiento, y a las ocho semanas posteriores de concluir el tratamiento. Se evaluó el impacto de las intervenciones sobre las constelaciones de síntomas del TEPT, y se aplicó un modelo linear jerárquico de temporalidad retrasada para evaluar modelos alternativos de mediación.Resultados: Todas las constelaciones sintomáticas del TEPT mejoraron con ambos tratamientos. El MRP condujo a mayores reducciones en la hipervigilancia inmediatamente luego del tratamiento (g de Hedge = 0,57) y en el seguimiento (g de Hedge = 0,52), así como en la insensibilidad inmediatamente luego del tratamiento (g de Hedge = 0,47). La hipervigilancia medió las reducciones en la integración de otras constelaciones sintomáticas del TEPT. A pesar de que el modelo de regresión también fue significativo, el efecto fue más débil en esta dirección.Conclusión: Las intervenciones enfocadas en el manejo de la hipervigilancia podrían desempeñar un papel importante en la recuperación del TEPT. El MRP impresiona ser eficaz en reducir la hipervigilancia, generando de esta manera un impacto sobre otras constelaciones sintomáticas del TEPT, constituyéndose en un camino para facilitar la recuperación.

Examining Changes in Sexual Functioning after Cognitive Processing Therapy in a Sample of Women Trauma Survivors.

BACKGROUND: Posttraumatic stress disorder (PTSD) and sexual dysfunction commonly co-occur. Although sexual dysfunction is more prevalent among women and the negative impact of sexual dysfunction on quality of life is stronger in women compared with men, few studies examine the impact of evidence-based PTSD treatments on sexual functioning outcomes in women with PTSD. The current study examined the relationship between PTSD and sexual functioning among women trauma survivors to examine if sexual functioning improves after cognitive processing therapy (CPT). PROCEDURES: A total of 126 civilian and veteran women were randomly assigned to receive CPT delivered via either office-based videoconferencing or traditional office-based care. PTSD outcomes were examined from before treatment to after treatment and sexual functioning outcomes were examined from before treatment to the 3-month follow-up. Multigroup structural equation modeling was used to compare changes in sexual functioning and PTSD scores over time. We also compared how sexual functioning changed after treatment among women who identified a sexual trauma as their index trauma compared with those with nonsexual index traumas. FINDINGS: Greater baseline PTSD symptoms predicted poorer sexual satisfaction at baseline. Sexual satisfaction, arousal, and desire improved after CPT; veteran status and index trauma type (i.e., sexual vs. nonsexual) did not attenuate this relationship. Women who had greater decreases in PTSD symptoms experienced greater improvements in sexual satisfaction, arousal, and desire. CONCLUSIONS: The current study provides preliminary support that CPT treatment may improve sexual functioning in women trauma survivors. Clinicians should assess sexual functioning to promote disclosure and develop a treatment plan.

Negative affect and intolerance of uncertainty as potential mediators of change in comorbid depression in transdiagnostic CBT for anxiety.

BACKGROUND: Transdiagnostic group cognitive behavioral therapy for anxiety (TGCBT) has demonstrated effectiveness in improving comorbid conditions, including depression. Mediators of change in reductions in comorbid depression have yet to be established following this anxiety-focused treatment. Negative affect (NA) and intolerance of uncertainty (IU) have demonstrated contributions to anxiety reduction in TGCBT, as has positive affect (PA) on depression reductions in other cognitive behavioral treatments. IU is also associated with depression and anxiety as a transdiagnostic vulnerability. This study evaluated the mediational effect of NA, IU, and PA on reduction in comorbid depressive symptoms in TGCBT. We hypothesized the indirect effect of the treatment through IU would be significant even when controlling for indirect effects through NA, PA, anxiety symptoms, and diagnostic severity. METHOD: Data collected as a part of previous clinical trials at a clinic at a large university in the southwestern United States were used. Participants included 61 individuals from a mixed anxiety-disordered sample for whom pre- and post-treatment data were available. Mediation analyses were conducted using ordinary least squares regression in path-analytic form. RESULTS: The total effect of the model was significant (F(10, 50) = 8.40, p < .001). When controlling for potential mediators, the direct effect of treatment was not significant (B = -1.01, t = -0.40, p = .688). Analysis of indirect effects revealed significant effects of NA (B = 0.50, SE = 0.17, p = .005, 95%CI [0.02, 0.83]) and IU (B = 0.13, SE = 0.05, p = .010, 95%CI [0.03, 0.23]), but not diagnostic severity (B = 1.39, SE = 0.86, p = .114, 95%CI [-0.35, 3.12]), anxiety symptoms (B = 0.19, SE = 0.12, p = .136, 95%CI [-0.06, 0.44]), or PA (B = -0.25, SE = 0.13, p = .051, 95%CI [-0.51, 0.01] on depression symptoms when modeled with TGCBT). CONCLUSION: These results suggest IU contributes uniquely to the improvement of comorbid depression in TGCBT above negative affect, an established change process. Implications for treatment and theory are discussed.

Secondary depression in transdiagnostic group cognitive behavioral therapy among individuals diagnosed with anxiety disorders.

Anxiety and depression co-occur at high rates, and their comorbidity typically creates a more severe clinical presentation then either alone. The effect of comorbid depression appears to vary across anxiety and related disorders. Transdiagnostic treatments present a promising option to improve comorbid conditions by targeting shared factors (e.g., information processing biases). The purpose of this study was to examine the reciprocal effects of secondary depression in transdiagnostic group cognitive behavioral therapy for anxiety (TGCBT). 120 individuals diagnosed with a primary anxiety disorder, 42 of whom had a depressive diagnosis, were enrolled in 12 weeks of TGCBT. Depressed individuals were compared to those without a depressive diagnosis on both clinician-rated and self-reported anxiety and depression following TGCBT. Although depressed individuals scored higher on most indices of anxiety at pre-treatment, both groups improved similarly with some evidence of greater improvement among those with comorbid depression. All individuals improved in self-reported depressive symptoms and comorbid depression improved to subclinical levels. These results posit TGCBT as an effective, efficient option for treating patients with anxiety and comorbid depression.

Intolerance of uncertainty and transdiagnostic group cognitive behavioral therapy for anxiety.

BACKGROUND: Recent evidence suggests intolerance of uncertainty (IU) is a transdiagnostic variable elevated across anxiety disorders. No studies have investigated IU's response to transdiagnostic group CBT for anxiety (TGCBT). This study evaluated IU outcomes following TGCBT across anxiety disorders. METHODS: 151 treatment-seekers with primary diagnoses of social anxiety disorder, panic disorder, or GAD were evaluated before and after 12 weeks of TGCBT and completed self-report questionnaires at pre-, mid-, and post-treatment. RESULTS: IU decreased significantly following treatment. Decreases in IU predicted improvements in clinical presentation across diagnoses. IU interacted with time to predict improvement in clinical presentation irrespective of primary diagnosis. IU also interacted with time to predict improvement in clinical presentation although interactions of time with diagnosis-specific measures did not. IUS interacted with time to predict reduction in anxiety and fear symptoms, and inhibitory IU interacted with time to predicted reductions in anxiety symptoms but prospective IU did not. CONCLUSION: IU appears to be an important transdiagnostic variable in CBT implicated in both initial presentation and treatment change. Further implications are discussed.

Smoking-Specific Experiential Avoidance is Indirectly Associated with Trait Worry and Smoking Processes among Treatment-Seeking Smokers.

Limited work has examined worry, or apprehensive anticipation about future negative events, in terms of smoking. One potential explanatory factor is the tendency to respond inflexibly and with avoidance in the presence of smoking-related distress (smoking-specific experiential avoidance). Participants (n = 465) were treatment-seeking daily smokers. Cross-sectional (pre-treatment) self-report data were utilized to assess trait worry, smoking-specific experiential avoidance, and four smoking criterion variables: nicotine dependence, motivational aspects of quitting, perceived barriers to smoking cessation, and severity of problematic symptoms reported in past quit attempts. Trait worry was significantly associated with greater levels of nicotine dependence, motivation to quit smoking, perceived barriers for smoking cessation, and more severe problems while quitting in the past; associations occurred indirectly through higher levels of smoking-specific experiential avoidance. Findings provide initial support for the potential role of smoking-specific experiential avoidance in explaining the association between trait worry and a variety of smoking processes.

The Mood and Anxiety Symptom Questionnaire across four ethnoracial groups in an undergraduate sample.

Increasing awareness of cross-cultural issues in psychology has led many to question the validity and utility of instruments in nonmajority ethnic and racial groups. The Mood and Anxiety Symptom Questionnaire (MASQ; Clark & Watson, 1991) is a widely used measure of anxious and depressive symptoms. However, some of the most-cited investigations into the psychometric properties of the MASQ have failed to report the demographics of their samples. The purpose of this study was to examine and compare the psychometric properties of the MASQ across ethnoracial groups. Results suggest that the internal consistency and convergent and divergent validity of the MASQ are similar across ethnoracial groups. Multigroup confirmatory factor analysis indicated cross-racial invariance of loadings on the General Distress and Anxious Arousal factors, although noninvariance was observed for the Anhedonic Depression. Implications for assessment and clinical research are discussed.

Beyond Negative Affectivity: A Hierarchical Model of Global and Transdiagnostic Vulnerabilities for Emotional Disorders.

BACKGROUND: Negative affectivity (NA) has been linked to anxiety and depression (DEP). Identifying the common factors between anxiety and DEP is important when explaining their overlap and comorbidity. However, general factors such as NA tend to have differential relationships with different disorders, suggesting the need to identify mediators in order to explicate these relationships. METHODS: The current study tests a theoretically and empirically derived hierarchical model of emotional disorders including both a general factor (NA) and transdiagnostic risk factors [anxiety sensitivity (AS) and intolerance of uncertainty (IoU)] using structural equation modeling. AS was tested as a mid-level factor between NA and panic disorder/agoraphobia, while IoU was tested as a mid-level factor between NA and social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and DEP. Data from 642 clinical outpatients with a heterogeneous presentation of emotional disorders were available for analysis. RESULTS: The hierarchical model fits the data adequately. Moreover, while a simplified model removing AS and IoU fits the data well, it resulted in a significant loss of information for all latent disorder constructs. LIMITATIONS: Data were unavailable to estimate post-traumatic stress disorder or specific phobias. Future work will need to extend to other emotional disorders. CONCLUSIONS: This study demonstrates the importance of both general factors that link disorders together and semi-specific transdiagnostic factors partially explaining their heterogeneity. Including these mid-level factors in hierarchical models of psychopathology can help account for additional variance and help to clarify the relationship between disorder constructs and NA.

The Indirect Effect of Anxiety Sensitivity in the Relationship Between Panic Symptoms and Panic Severity.

The cognitive model of panic (Clark, 1988) suggests that panic attacks result from the catastrophic misinterpretation of bodily sensations rather than the sensations themselves. Anxiety sensitivity (AS) is fear of anxious bodily sensations (Reiss, 1991) and has implications in panic development, maintenance, and severity. Although previous work has demonstrated that AS amplifies symptoms in response to provocations, few have analyzed the role of AS in the relationship between panic symptoms and panic disorder severity. The purpose of this investigation was to determine if AS, a cognitive risk for panic, has an indirect effect on the association between self-reported panic symptoms and panic severity, both self-reported and clinician-assessed, among 67 treatment-seeking individuals with a primary diagnosis of panic disorder with or without agoraphobia. Data were analyzed using the bootstrapped conditional process indirect effects model. Results indicated that the overall total mediational effect on Panic Disorder Severity Scale (PDSS) was significant with evidence of partial mediation. The direct effect of Beck Anxiety Inventory (BAI) on PDSS remained significant although there was also a significant indirect effect of BAI via AS. Results showed a similar relationship when Clinician Severity Rating was the outcome. Moderation analyses were not significant. Therefore, AS was a significant partial mediator of the relationship between symptom intensity and panic severity, whether clinician-rated or self-reported. This investigation provides support for the importance of AS in panic, highlighting its importance but suggesting that it is not sufficient to explain panic disorder.

Anxiety sensitivity across four ethnoracial groups in an undergraduate sample.

Anxiety sensitivity (AS), the fear of anxious cognitive and physiological experiences, is multidimensional and adds incrementally to the prediction of relationships of panic and relevant phenomenology. Many agree upon the content of the dimensions, but there is less agreement about the factor structure of the anxiety sensitivity index (ASI), a widely used measure of AS, across cultural groups. Anxiety disorders vary in their epidemiology and phenomenology across ethnoracial groups. This investigation adds clarity to research in the psychometric properties of the ASI across four cultural groups. Results from a confirmatory factor analysis support invariance across groups with the exception of three psychometrically questionable items assessing fear of gastrointestinal symptoms. The convergent and divergent validity are consistent with cross-group invariance as well. Clinical implications are discussed.

Mediators of transdiagnostic group cognitive behavior therapy.

The efficacy of cognitive-behavioral therapy (CBT) for anxiety is well established. Investigations into the mechanisms of change in CBT report changes in cognitive vulnerabilities mediating improvements over the course of treatment. As anxiety disorders share certain risk factors, there is a trend toward CBT emphasizing these vulnerabilities, including negative affectivity (NA) and also more specific constructs such as anxiety sensitivity (AS) and intolerance of uncertainty (IU). The purpose of this investigation was to analyze potential mediators of anxiety reduction over the course of transdiagnostic group CBT. NA, AS, and IU all decreased over the course of treatment. Among the potential mediators, change in NA had a significant relationship with change in anxiety but change in AS and change in IU did not. Neither the main effect of primary diagnosis nor the interactions between potential mediators and primary diagnoses were significant, indicating that there were no differential changes in anxiety or the potential mediators across primary diagnoses. Results strongly point toward NA as an overarching mediator of anxiety reduction during transdiagnostic group CBT.