Perceptions of Helpful and Unhelpful Responses to Disclosures of Suicidality in a Sample of Mobile App Users.

OBJECTIVE: Assessment and management of suicide risk is dependent on the individual at risk disclosing their suicidal thoughts. This study analyzed self-reported data collected via Youper, a mental-health app, to explore user experiences with suicide-related disclosure. METHOD: 2,952 international users who endorsed suicidal ideation reported on experiences with suicide-related disclosure. Differences in experiences were examined according to age, gender, and symptoms of psychopathology. RESULTS: Just over half of users (56.17%) shared their suicidal thoughts. The primary reason for not sharing was thinking others would not understand. Of those who had disclosed their suicidal thoughts, 56.31% perceived the listener's response to be helpful, with listening and expressing care identified as most helpful. More severe depression and generalized anxiety symptoms were associated with higher disclosure likelihood, whereas higher borderline-personality and social-anxiety symptoms were associated with lower disclosure likelihood. Perceptions of what users found helpful when they disclosed suicidality varied by gender. Lack of understanding was the most frequently reported unhelpful response universally. CONCLUSION: Findings suggest that listening and expressing care should be prioritized to maximize suicidal individuals' experiences of feeling supported. That said, gender and symptoms impact likelihoods of and experiences with disclosure, which should be considered when receiving suicide-related disclosure.HIGHLIGHTSNearly half of users shared suicidal thoughts and found listener responses helpful.Users most often endorsed listening as helpful and not understanding as unhelpful.Symptom severity and gender informed suicide-related disclosure experiences.

Randomized controlled experimental study of hydrocortisone and D-cycloserine effects on fear extinction in PTSD.

Fear extinction underlies prolonged exposure, one of the most well-studied treatments for posttraumatic stress disorder (PTSD). There has been increased interest in exploring pharmacological agents to enhance fear extinction learning in humans and their potential as adjuncts to PE. The objective of such adjuncts is to augment the clinical impact of PE on the durability and magnitude of symptom reduction. In this study, we examined whether hydrocortisone (HC), a corticosteroid, and D-Cycloserine (DCS), an N-methyl-D-aspartate receptor partial agonist, enhance fear extinction learning and consolidation in individuals with PTSD. In a double-blind placebo-controlled 3-group experimental design, 90 individuals with full or subsyndromal PTSD underwent fear conditioning with stimuli that were paired (CS+) or unpaired (CS-) with shock. Extinction learning occurred 72 h later and extinction retention was tested one week after extinction. HC 25 mg, DCS 50 mg or placebo was administered one hour prior to extinction learning. During extinction learning, the DCS and HC groups showed a reduced differential CS+/CS- skin conductance response (SCR) compared to placebo (b = -0.19, CI = -0.01 to -37, p = 0.042 and b = -0.25, CI = -08 to -0.43, p = 0.005, respectively). A nonsignificant trend for a lower differential CS+/CS- SCR in the DCS group, compared to placebo, (b = -0.25, CI = 0.04 to -0.55, p = 0.089) was observed at retention testing, one week later. A single dose of HC and DCS facilitated fear extinction learning in participants with PTSD symptoms. While clinical implications have yet to be determined, our findings suggest that glucocorticoids and NMDA agonists hold promise for facilitating extinction learning in PTSD.

Impact of the COVID-19 Pandemic on Mental Health among 157,213 Americans.

BACKGROUND: The coronavirus (COVID-19) pandemic presents an unprecedented crisis with potential negative mental health impacts. METHODS: This study used data collected via Youper, a mental health app, from February through July 2020. Youper users (N = 157,213) in the United States self-reported positive and negative emotions and anxiety and depression symptoms during the pandemic. We examined emotions and symptoms before (pre), during (acute), and after (sustained) COVID-related stay-at-home orders. RESULTS: For changes in frequency of reported acute emotions, from the pre to acute periods, anxiety increased while tiredness, calmness, happiness, and optimism decreased. From the acute to sustained periods, sadness, depression, and gratitude increased. Anxiety, stress, and tiredness decreased. Between the pre and sustained periods, sadness and depression increased, as did happiness and calmness. Anxiety and stress decreased. Among symptom measures, anxiety increased initially, from the pre to the acute periods, but later returned to baseline. LIMITATIONS: The study sample was primarily comprised of young people and women. The app does not collect racial or ethnicity data. These factors may limit generalizability. Sample size was also not consistent for all data collected. CONCLUSIONS: The present study suggests that although there were initial negative impacts on emotions and mental health symptoms in the first few weeks, many Americans demonstrated resilience over the following months. The impact of the pandemic on mental health may not be as severe as predicted, although future work is necessary to understand longitudinal effects as the pandemic continues.

Internet-based cognitive behavior therapy for depression, social anxiety disorder, and panic disorder: Effectiveness and predictors of response in a teaching clinic.

Though therapist-guided Internet-based cognitive behavior therapy (ICBT) appears to be efficacious for depression, social anxiety disorder, and panic disorder, relatively little is known about real-world settings and predictors of treatment effects derived from cognitive-behavioral theory. We examined treatment effectiveness and predictors of improvement in a prospective cohort study where patients took part in 10 weeks of ICBT for depression (n = 114), social anxiety disorder (n = 150), or panic disorder (n = 106) at a teaching clinic. Patients self-reported symptoms before, during, and after treatment. Effect sizes were large for improvement in the primary symptom domain of each treatment group: depression (d = 1.48), social anxiety disorder (d = 1.01), and panic disorder (d = 1.15). In ICBT for depression, having no previous experience of psychological treatment (r = 0.21), and more frequent baseline negative automatic thoughts (r = 0.20) predicted larger improvement. In ICBT for panic disorder, having more baseline safety behaviors (r = 0.25) predicted larger improvement. Predictors remained significant when baseline symptoms were included in the statistical models. We conclude that ICBT can be effective in a real-world teaching clinic, and that patients with greater deficits at baseline benefit the most.

Randomized Controlled Trial Testing Mobile-Based Attention-Bias Modification for Posttraumatic Stress Using Personalized Word Stimuli.

Although behavioral therapies are effective for posttraumatic stress disorder (PTSD), access for patients is limited. Attention-bias modification (ABM), a cognitive-training intervention designed to reduce attention bias for threat, can be broadly disseminated using technology. We remotely tested an ABM mobile app for PTSD. Participants (N = 689) were randomly assigned to personalized ABM, nonpersonalized ABM, or placebo training. ABM was a modified dot-probe paradigm delivered daily for 12 sessions. Personalized ABM included words selected using a recommender algorithm. Placebo included only neutral words. Primary outcomes (PTSD and anxiety) and secondary outcomes (depression and PTSD clusters) were collected at baseline, after training, and at 5-week-follow-up. Mechanisms assessed during treatment were attention bias and self-reported threat sensitivity. No group differences emerged on outcomes or attention bias. Nonpersonalized ABM showed greater declines in self-reported threat sensitivity than placebo (p = .044). This study constitutes the largest mobile-based trial of ABM to date. Findings do not support the effectiveness of mobile ABM for PTSD.

Temporal trends in attention disengagement from social threat as a function of social anxiety.

BACKGROUND AND OBJECTIVES: Difficulty disengaging attention from threat has been observed in some anxious samples, but the evidence to date is mixed. The current study examines temporal trends in attention disengagement and compares this construct across multiple forms of social threat. METHODS: Participants (85 adults with a principal diagnosis of social anxiety disorder) completed a spatial cueing task with four image categories (angry faces, disapproving faces, neutral faces, neutral objects). Attention disengagement was assessed via reaction time (RT) over 256 trials. RESULTS: Participants with greater social anxiety exhibited an initial delay in attention disengagement from disapproving faces that habituated over the course of the task. RTs to angry and neutral stimuli did not differ as a function of social anxiety. LIMITATIONS: The current task only allowed for examining speed of attention disengagement, and thus we were unable to compare our results to trajectories of speed at which participants orient towards threat. Additionally, disapproving facial images were created for this paradigm and may benefit from further validation. CONCLUSIONS: Findings suggest that social anxiety is associated with an initial delay in attention disengagement from social threat that resolves over the course of repeated exposures to such stimuli. Treatment implications are discussed.

Examining Positive and Negative Affect as Outcomes and Moderators of Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy for Social Anxiety Disorder.

Traditional cognitive-behavioral therapy (CBT) for anxiety disorders has been designed to target reductions in negative affect (NA) associated with defense-related processes. However, a subset of anxiety disorders, including social anxiety disorder (SAD), are also characterized by low positive affect (PA) resulting from separate deficits in appetitive-related processes. In contrast to CBT, "third-wave" approaches, such as acceptance and commitment therapy (ACT), align more consistently with motivational processes and, as a result, PA. However, the differential effect of CBT and ACT on PA and NA has yet to be investigated. Using secondary data from a randomized controlled trial, the present study sought to compare CBT's (n = 45) and ACT's (n = 35) effect on PA and NA in SAD. Findings were compared to a wait-list (WL) control condition (n = 31), as well as normative data from a general adult sample. Baseline PA and NA were also examined as moderators and predictors of theory-relevant treatment outcomes. NA decreased significantly in both CBT and ACT from pre to posttreatment. Although ACT outperformed WL in reducing NA, this effect was not observed for CBT. PA increased significantly in both CBT and ACT from pre to posttreatment, with neither ACT nor CBT outperforming WL in increasing PA. Neither PA nor NA were found to moderate theoretically relevant treatment outcomes. Findings suggest that ACT and CBT share common treatment mechanisms, making them more similar than distinct. Further efforts should be focused on optimizing CBT's and ACT's influence on threat and reward learning, and elucidating common processes of change.

Oxytocin increases eye gaze in schizophrenia.

Abnormal eye gaze is common in schizophrenia and linked to functional impairment. The hypothalamic neuropeptide oxytocin modulates visual attention to social stimuli, but its effects on eye gaze in schizophrenia are unknown. We examined visual scanning of faces in men with schizophrenia and neurotypical controls to quantify oxytocin effects on eye gaze. In a randomized, double-blind, crossover study, 33 men with schizophrenia and 39 matched controls received one dose of intranasal oxytocin (40 IU) and placebo on separate testing days. Participants viewed 20 color photographs of faces while their gaze patterns were recorded. We tested for differences in fixation time on the eyes between patients and controls as well as oxytocin effects using linear mixed-effects models. We also tested whether attachment style, symptom severity, and anti-dopaminergic medication dosage moderated oxytocin effects. In the placebo condition, patients showed reduced fixation time on the eyes compared to controls. Oxytocin was associated with an increase in fixation time among patients, but a decrease among controls. Higher attachment anxiety and greater symptom severity predicted increased fixation time on the eyes on oxytocin versus placebo. Anti-dopaminergic medication dosage and attachment avoidance did not impact response to oxytocin. Consistent with findings that oxytocin optimizes processing of social stimuli, intranasal oxytocin enhanced eye gaze in men with schizophrenia. Further work is needed to determine whether changes in eye gaze impact social cognition and functional outcomes. Both attachment anxiety and symptom severity predicted oxytocin response, highlighting the importance of examining potential moderators of oxytocin effects in future studies.

Self-referential processing during observation of a speech performance task in social anxiety disorder from pre- to post-treatment: Evidence of disrupted neural activation.

Self-referential processing is critical to understanding social anxiety disorder (SAD). This study examined neural differences in self-referential processing in healthy controls (HC) and participants with SAD at pre- and post-treatment. Participants (n = 64) underwent fMRI scanning while viewing a video of themselves ("Self") or another person ("Other"). SAD participants were randomized to cognitive behavior therapy (CBT), acceptance and commitment therapy (ACT), or waitlist, and were re-scanned at post-treatment. In SAD vs. HC, the fusiform face area (FFA) showed significantly more activation during Self vs. Other, and greater SAD severity was associated with significantly more activation during Self vs. Other in the right FFA and the left extrastriate body area (EBA). Greater reduction in SAD severity was associated with stronger connectivity between the amygdala and FFA during Self vs. Other at post-treatment, whereas the strength of connectivity during Self and Other was comparable at post-treatment for those with less SAD reduction. Thus, there were significant differences in activation and functional connectivity of brain regions implicated in self-referential processing in SAD. Change in connectivity between the amygdala and FFA were observed as a function of change in SAD severity, suggesting that improvements in SAD severity may correct this altered functional connectivity.

Neural connectivity during affect labeling predicts treatment response to psychological therapies for social anxiety disorder.

BACKGROUND: Although psychological treatments for social anxiety disorder (SAD) can be highly effective, many individuals do not respond to treatment. Identifying factors associated with improved outcomes can facilitate individualized treatment choices. We investigated whether patterns of neural connectivity predicted treatment responses and whether treatment type, cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT), moderated this effect. METHODS: Participants with SAD (n = 34) underwent fMRI prior to treatment and completed implicit and explicit emotion regulation tasks. Neural connectivity measures were estimates of amygdala-prefrontal cortex connectivity. Treatment responder status was defined using the 'clinically significant change index' (Loerinc et al., 2015). RESULTS: Right amygdala-right ventrolateral prefrontal cortex connectivity during implicit emotion regulation was a significant predictor of treatment response (OR = 9.01, 95% CI = 1.77, 46.0, p = .008). Stronger inverse connectivity was associated with greater likelihood of treatment response. There were no significant neural moderators of treatment response to CBT versus ACT. LIMITATIONS: The primary limitation of this work was the small sample size which restricted the power to detect significant moderation effects, and results should be interpreted as preliminary. CONCLUSIONS: Amygdala-vlPFC connectivity during affect labeling predicted treatment responder status following CBT or ACT for social anxiety disorder. This suggests that the functioning of neural circuitry supporting emotion regulation capacities may be a 'gateway' to receiving benefit from psychological treatments. Future work should aim to replicate this effect in a larger sample and consider methods for enhancing functional connectivity within this circuitry as a potential treatment adjunct.

Comparing anxiety and depression to obesity and smoking as predictors of major medical illnesses and somatic symptoms.

OBJECTIVE: Anxiety and depression predict poor physical health longitudinally, but are neglected in primary care settings compared to other risk factors such as obesity and smoking. Further, anxiety has been less commonly studied than depression, and whether anxiety has unique predictive effects for physical health is unknown. We compared anxiety and depression to obesity and smoking as predictors of physical health indices and examined unique predictive effects of anxiety and depression. METHOD: Using data from the Health and Retirement study, a US population-based cohort study of older adults, we tested longitudinal associations of anxiety and depression symptoms with onset of self-reported physical health indices (N = 15,418; M age = 68). Medical illnesses (heart disease, stroke, arthritis, high blood pressure, diabetes, and cancer) and somatic symptoms (stomach problems, shortness of breath, dizziness, back pain, headache, pain, and eyesight difficulties) were assessed on two occasions over four years. Anxiety and depression were measured at the initial time point and tested as predictors of medical illness and somatic symptom onset. RESULTS: Anxiety and depression symptoms predicted greater incidence of nearly all medical illnesses and somatic symptoms. Effects were as strong as or stronger than those of obesity and smoking, and anxiety and depression independently increased risk for most physical health indices assessed. CONCLUSIONS: Findings suggest that anxiety and depression are as strongly predictive of poor future physical health as obesity and smoking and that anxiety is independently linked to poor physical health. Greater attention should be paid towards these conditions in primary care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effects of Threat Context, Trauma History, and Posttraumatic Stress Disorder Status on Physiological Startle Reactivity in Gulf War Veterans.

In the current study, we explored exaggerated physiological startle responses in posttraumatic stress disorder (PTSD) and examined startle reactivity as a biomarker of PTSD in a large veteran sample. We assessed heart rate (HR), skin conductance (SC), and electromyographic (EMG) startle responses to acoustic stimuli under low-, ambiguous-, and high-threat conditions in Gulf War veterans with current (n = 48), past (n = 42), and no history of PTSD (control group; n = 152). We evaluated PTSD status using the Clinician-Administered PTSD Scale and trauma exposure using the Trauma History Questionnaire. Participants with current PTSD had higher HR, ds = 0.28-0.53; SC, d = 0.37; and startle responses than those with past or no history of PTSD. The HR startle response under ambiguous threat best differentiated current PTSD; however, sensitivity and specificity analyses revealed it to be an imprecise indicator of PTSD status, ROC AUC = .66. Participants with high levels of trauma exposure only showed elevated HR and SC startle reactivity if they had current PTSD. Results indicate that startle is particularly elevated in PTSD when safety signals are available but a possibility of danger remains and when trauma exposure is high. However, startle reactivity alone is unlikely to be a sufficient biomarker of PTSD.

Gender differences in longitudinal relationships between depression and anxiety symptoms and inflammation in the health and retirement study.

Depression and anxiety have been linked to elevated inflammation in cross-sectional and longitudinal studies. Yet, in terms of longitudinal studies, findings are inconsistent regarding whether depression predicts worsening inflammation or vice versa, and anxiety has been infrequently examined. Further, we know little about longitudinal relationships between inflammation and specific symptom profiles of depression and anxiety. The current study examined longitudinal associations between depression and anxiety symptoms and inflammation in 13,775 people (59% women, average age = 67) participating in the Health and Retirement Study - a population-based study focused on older adults. High sensitivity C-reactive protein and depression and anxiety symptoms were measured at two time-points separated by four years. We used cross-lagged panel models to examine bidirectional relationships, and tested interactions with gender. We found that depressive symptoms predicted increasing inflammation for men, but not for women, and inflammation predicted worsening depression for women, but not for men. These gender differences were driven by somatic symptoms. Specifically, somatic symptoms predicted increasing inflammation for men only and were predicted by inflammation for women only. Regardless of gender, inflammation predicted worsening dysphoric symptoms of depression, and lack of positive affect predicted increasing inflammation over time. Anxiety was not associated with inflammation longitudinally. These findings indicate bidirectional relationships between depressive symptoms and inflammation, but not between anxiety symptoms and inflammation, and that the direction of these effects may differ by gender and type of depressive symptom.

Who needs more than standard care? Treatment moderators in a randomized clinical trial comparing addiction treatment alone to addiction treatment plus anxiety disorder treatment for comorbid anxiety and substance use disorders.

INTRODUCTION: Understanding for whom treatments exert their greatest effects is crucial for prescriptive recommendations that can improve overall treatment efficacy. Anxiety and substance use disorder comorbidity is prevalent and a significant public health concern. Little is known about who should receive specialized, integrated treatments to address both problems. This study aimed to examine baseline patient characteristics that predict differential outcome between typical treatment for substance use disorders (UC) compared to that treatment combined with cognitive behavioral therapy for anxiety disorders (UC + CALM ARC). METHODS: We examined several putative treatment moderators in a dataset of community-based participants (N = 75) from a randomized clinical trial at an outpatient community substance use disorder (SUD) specialty clinic. Participants who met criteria for any anxiety disorder and any SUD were randomized to UC (the Intensive Outpatient Program at the clinic) or UC + CALM ARC. Outcome measures included anxiety symptoms, drug use, and alcohol use, and were assessed at pre-treatment, post-treatment, and a 6-month follow-up assessment. RESULTS: Older age and female gender were associated with greater improvement on anxiety outcomes in UC + CALM ARC compared to UC. The presence of an alcohol use disorder was associated with greater improvement in alcohol use in UC + CALM ARC compared to UC. Higher opiate-related withdrawal symptoms and the presence of more SUDs were associated with greater improvement in drug use outcomes in UC + CALM ARC compared to UC. CONCLUSIONS: Several pre-treatment characteristics are associated with a return of symptoms for those who receive only UC, whereas the addition of CALM ARC prevented the return of symptoms. Implications for future research and preliminary clinical recommendations are discussed.

Personalizing Affective Stimuli Using a Recommender Algorithm: An Example with Threatening Words for Trauma Exposed Populations.

Experimental paradigms used in affective and clinical science often use stimuli such as images, scenarios, videos, or words to elicit emotional responses in study participants. Choosing appropriate stimuli that are highly evocative is essential to the study of emotional processes in both healthy and clinical populations. Selecting one set of stimuli that will be relevant for all subjects can be challenging because not every person responds the same way to a given stimulus. Machine learning can facilitate the personalization of such stimuli. The current study applied a novel statistical approach called a recommender algorithm to the selection of highly threatening words for a trauma-exposed population (N = 837). Participants rated 513 threatening words, and we trained a user-user collaborative filtering recommender algorithm. The algorithm uses similarities between individuals to predict ratings for unrated words. We compared threat ratings for algorithm-based word selection to a random word set, a word set previously used in research, and trauma-specific word sets. Algorithm-selected personalized words were more threatening compared to non-personalized words with large effects (ds = 2.10-2.92). Recommender algorithms can automate the personalization of stimuli from a large pool of possible stimuli to maximize emotional reactivity in research paradigms. These methods also hold potential for the personalization of behavioral treatments administered remotely where a provider is not available to tailor an intervention to the individual. The word personalization algorithm is available for use online (https://threat-word-predictor.herokuapp.com/).

Effects of trauma and PTSD on self-reported physical functioning in sexual minority women.

OBJECTIVE: Sexual minority women (lesbians, bisexual women, and women who partner with women) experience high rates of trauma exposure, are more likely to develop posttraumatic stress disorder (PTSD), and have high rates of physical health problems compared with heterosexual women. The present study tested whether PTSD may be the mechanism through which trauma exposure affects self-reported physical functioning in this population. METHOD: In a sample of 857 sexual minority women, we examined the association between trauma exposure and worsening physical functioning (measured using the 12-item Short Form Health Survey) 2 years later, whether PTSD mediated this relationship, and if so, which PTSD symptom clusters best accounted for this mediation. RESULTS: Results showed that more Criterion A traumatic events experienced (based on DSM-IV) predicted greater decline in physical functioning 2 years later, and PTSD symptoms mediated this relationship, explaining 73% of the total effect. The arousal/reactivity symptom cluster was the only significant mediator, explaining 68% of the total effect. CONCLUSIONS: Results show that PTSD, and arousal/reactivity symptoms in particular, may be the mechanism through which traumatic events negatively impact self-reported physical functioning. These findings provide further evidence that, for this at risk population, treating PTSD as soon as possible after onset may improve long term physical functioning. (PsycINFO Database Record

Advancing Personalized Medicine: Application of a Novel Statistical Method to Identify Treatment Moderators in the Coordinated Anxiety Learning and Management Study.

There has been increasing recognition of the value of personalized medicine where the most effective treatment is selected based on individual characteristics. This study used a new method to identify a composite moderator of response to evidence-based anxiety treatment (CALM) compared to Usual Care. Eight hundred seventy-six patients diagnosed with one or multiple anxiety disorders were assigned to CALM or Usual Care. Using the method proposed by Kraemer (2013), 35 possible moderators were examined for individual effect sizes then entered into a forward-stepwise regression model predicting differential treatment response. K-fold cross validation was used to identify the number of variables to include in the final moderator. Ten variables were selected for a final composite moderator. The composite moderator effect size (r = .20) was twice as large as the strongest individual moderator effect size (r = .10). Although on average patients benefitted more from CALM, 19% of patients had equal or greater treatment response in Usual Care. The effect size for the CALM intervention increased from d = .34 to d = .54 when accounting for the moderator. Findings support the utility of composite moderators. Results were used to develop a program that allows mental health professionals to prescribe treatment for anxiety based on baseline characteristics (http://anxiety.psych.ucla.edu/treatmatch.html).

Applying a novel statistical method to advance the personalized treatment of anxiety disorders: A composite moderator of comparative drop-out from CBT and ACT.

BACKGROUND: No prior studies have examined moderators of dropout between distinct treatments for anxiety disorders. This study applied a novel statistical approach for examining moderators of dropout from traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). METHOD: We combined data from two randomized controlled trials (N = 208) comparing CBT and ACT for patients with DSM-IV anxiety disorders. Adapting Kraemer's method for constructing and evaluating composite moderators (2013), 26 variables were examined for individual effect sizes. Forward-stepwise regression combined with k-fold cross validation was used to identify a model to predict treatment dropout. RESULTS: Four baseline variables comprised the final composite moderator: self-reported degree of control over internal anxiety, current psychiatric medication use, religiosity, and endurance in a voluntary hyperventilation stressor. This composite moderator predicted differential dropout from ACT vs. CBT with a medium effect size (r = 0.28), and had a significantly larger effect size than any individual moderator. CONCLUSIONS: Findings reveal that specific patient profiles predict differential dropout from ACT vs. CBT for anxiety disorders. In the first investigation of a composite moderator with a dichotomous outcome, findings also support the superiority of composite over individual moderators.