Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

Virtual Standardized Patients vs Academic Training for Learning Motivational Interviewing Skills in the US Department of Veterans Affairs and the US Military: A Randomized Trial.

Importance: Despite the need for effective and scalable training in motivational interviewing (MI) that includes posttraining coaching and feedback, limited evidence exists regarding the effectiveness of using virtual (computerized) standardized patients (VSPs) in such training. Objective: To evaluate the efficacy of training with a VSP on the acquisition and maintenance of MI skills compared with traditional academic study. Design, Setting, and Participants: This study was a 2-group, parallel-training randomized trial of 120 volunteer health care professionals recruited from a Department of Veterans Affairs and Department of Defense medical facility. Motivational interviewing skill was coded by external experts blinded to training group and skill assessment time points. Data were collected from October 17, 2016, to August 12, 2019. Interventions: After a computer course on MI, participants trained during two 45-minute sessions separated by 3 months. The 2 randomized training conditions included a branching storyline VSP, which provided MI skill rehearsal with immediate and summative feedback, and a control condition, which included academic study of content from the computerized MI course. Main Outcomes and Measures: Measurement of MI skill was based on recorded conversations with human standardized patients, assessed using the Motivational Interviewing Treatment Integrity 4.2.1 coding system, measured at baseline, after training, and after additional training in the randomized condition 3 months later. Results: A total of 120 volunteers (83 [69%] women), with a mean (SD) of 13.6 (10.3) years of health care experience, participated in the study; 61 were randomized to receive the intervention, and 59 were randomized to the control group. Those assigned to VSP training had significantly greater posttraining improvement in technical global scores (0.23; 95% CI, 0.03-0.44; P = .02), relational global scores (0.57; 95% CI, 0.33-0.81; P = .001), and the reflection-to-question ratio (0.23; 95% CI, 0.15-0.31; P = .001). Differences were maintained after the 3-month additional training session, with more improvements achieved after the 3-month training for the VSP trainees on the reflection-to- question ratio (0.15; 95% CI, 0.07-0.24; P = .001). Conclusions and Relevance: This randomized trial demonstrated a successful transfer of training from a VSP to human standardized patients. The VSP MI skill outcomes were better than those achieved with academic study and were maintained over time. Virtual standardized patients have the potential to facilitate dissemination of MI and may be useful for training in other evidence-based skills and treatments. Trial Registration: ClinicalTrials.gov Identifier: NCT04558060.

Randomized controlled trial of acceptance and commitment therapy for distress and impairment in OEF/OIF/OND veterans.

OBJECTIVE: Acceptance and commitment therapy (ACT) is a widely utilized psychotherapeutic approach, but randomized, controlled studies are lacking in veterans. This study evaluated the efficacy of ACT for emotional distress among veterans of the conflicts in Iraq and Afghanistan. METHOD: One hundred sixty veterans (80% male, Mage = 34 years) with anxiety or depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) were randomized to ACT or present-centered therapy (PCT) and assessed before, during, and after treatment and during 3- to 12-month follow-up. The primary outcome was general distress as measured by the Brief Symptom Inventory-18 Global Severity Index. Additional outcomes included symptomatology, disability, quality of life, acceptability, and satisfaction. RESULTS: There was improvement following treatment in the whole sample across a variety of measures, including general distress (d = 0.74, 95% confidence interval [CI: 0.52, 0.96]) and functioning (d = 0.71, 95% CI [0.50, 0.93]) and moderate to high levels of satisfaction with treatment. Response to the 2 interventions did not differ on the primary outcome or most secondary outcomes, although ACT led to greater improvement in insomnia than did PCT (ds = 0.63 and 0.08, respectively). Treatment dropout did not differ by condition but was high (41.9%). CONCLUSIONS: ACT's efficacy in this group was modest and generally did not differ from that for PCT. Additional work is needed to understand the reasons that ACT did not perform as well as predicted in this veteran sample. (PsycINFO Database Record

The efficacy of Focused Acceptance and Commitment Therapy in VA primary care.

Focused Acceptance & Commitment Therapy (FACT) is a brief intervention based on traditional Acceptance and Commitment Therapy (ACT). Although there is a growing body of research on the efficacy of ACT for a variety of populations and disorders, there is little research to date on the use of FACT in group settings. This project is 1 of the first of its kind, as it examines data on psychological flexibility, health and mental health status, and symptom reduction from a 4-week FACT group. Participants in this study were 51 patients who attended this group as part of routine clinical care in a VA integrated primary care and mental health setting. They completed pre- and posttreatment measures of well-being, depression, anxiety, stress, psychological flexibility, and perceptions of physical and mental health functioning. Pre- to posttreatment analyses of variance demonstrated large effects for quality of life, F(1, 51) = 21.29, p < .001, η2 = 0.30, moderate effects for depressive symptoms, F(1, 51) = 11.47, p < .001, η2 = 0.08, and perceptions of mental health functioning (MCS scale), F(1, 51) = 9.67, p = .003, η2 = 0.11, and small effects for perceptions of perceived stress, F(1, 51) = 4.08, p = .04, η2 = 0.03, and physical health functioning (PCS scale), F(1, 51) = 6.60, p = .01, η2 = 0.08. There was a statistical trend for reductions in anxiety, F(1, 51) = 3.29, p = .07, η2 = 0.01, and a nonsignificant effect for psychological flexibility, F(1, 51) = 2.05, p = .16, η2 = 0.04. These data provide initial support for the implementation of a group-based FACT protocol within a VA primary care setting and help to lay a foundation for further, more controlled studies on Group FACT in future research. (PsycINFO Database Record

Quetiapine for the treatment of cocaine use disorder.

BACKGROUND: Cocaine addiction continues to be a significant healthcare issue, yet there are no FDA approved medications for the treatment of cocaine use disorder within the United States. METHODS: This 12-week, prospective, double-blind, randomized, placebo-controlled study examined the effectiveness of quetiapine (Seroquel XR™) versus matched placebo for the treatment of DSM-IV cocaine dependence in non-psychotic individuals. Subjects randomized to quetiapine (N = 29) were titrated up to a target dose of 400mg/day of quetiapine, while those in the placebo arm (N = 31) were given a matched placebo. All subjects had weekly clinic visits and a cognitive-behavioral therapy group session. Outcome measures included self-report of cocaine use and money spent on cocaine as well as urine drug screens (UDS). RESULTS: The drop-out rate was substantial at 68%. Logistic regression analysis did not find significant differences between groups in predicting end-of trial abstinence, defined as three consecutive weekly negative UDS (13.7% in the quetiapine group versus 12.9% in the placebo group; p = .92). Based upon a repeated measures analysis of variance, subjects in this study, as a whole, demonstrated reductions in their self-reported use of cocaine, self-reported money spent on cocaine, and number of days per week using cocaine. However, the quetiapine group did not differ significantly from the placebo group. CONCLUSIONS: This study did not find group differences between the quetiapine and placebo arms, suggesting that quetiapine is not an efficacious treatment for DSM-IV cocaine dependence.

Psychopathic traits and preattentive threat processing in children: a novel test of the fearlessness hypothesis.

We tested the fearlessness hypothesis of psychopathy in an at-risk sample of 88 preadolescent children. Psychopathy was measured using combined child- and parent-reported scores on the Antisocial Process Screening Device (APSD). Using a continuous-flash-suppression paradigm, we evaluated threat processing at the preattentive level for the first time in a study of psychopathy. Scores for the APSD Callous/Unemotional factor, which assesses the core affective deficits of psychopathy, predicted preattentive face-recognition deficits for fearful faces and, to a lesser extent, for disgusted faces. This finding contradicts recent suggestions that the fearlessness associated with psychopathy is solely a consequence of overt attentional artifacts. Future research should focus on preattentive processing of fear in individuals with callous-unemotional traits, and on the implications of preattentive-processing deficits for treatment and theory development.

Heavy episodic drinking in college students: associations with features of psychopathy and antisocial personality disorder.

OBJECTIVE: This study extends the college heavy episodic drinking literature by examining the associations between features of psychopathy and antisocial personality disorder (ASPD), on the one hand, and heavy episodic drinking and associated problem behaviors, on the other. PARTICIPANTS: Participants were 159 (85 male, 74 female) undergraduates from a private university. METHODS: Participants completed self-report measures assessing alcohol use, frequency, and consequences of heavy episodic drinking, and personality pathology. RESULTS: It was found that psychopathy, independent of ASPD, was related to the prediction of heavy episodic drinking frequency and problems associated with alcohol use. It was also found that the relation between traits of psychopathy and heavy episodic drinking are limited largely to the impulsive and antisocial aspects of this condition. CONCLUSION: These findings point to the need for further investigation of the association between psychopathy and ASPD traits and heavy episodic drinking behaviors in college students.

Interactions between the COMT Val108/158Met polymorphism and maternal prenatal smoking predict aggressive behavior outcomes.

The purpose of the current study is to examine the moderating influence of the catechol O methyltransferase gene (COMT) on the maternal prenatal smoking/offspring externalizing disorder relationship. The sample consisted of 430 young adults born between 1981 and 1984 at the Mater Misericordiae Mother's Hospital in Brisbane, Australia, as well as their mothers and peers. Mothers reported their prenatal smoking status during pregnancy, and genetic data was obtained from the youth at a later follow-up in adulthood. The outcome measures in this study were mother and teacher reports of youth attention problems and aggression at age 15, and youth, mother and peer reports of youth attention problems and aggression at age 20 (combined to create latent factors of attention problems and aggression at each age). The COMT Val108/158Met polymorphism (rs4680) significantly interacted with maternal cigarette smoking during pregnancy to predict youth aggressive behavior at ages 15 and 20. This gene-environment interaction was not significant for youth attention problems.

Differences between trait fear and trait anxiety: implications for psychopathology.

Fear and anxiety are poorly delineated in much of the clinical and research literatures. Although some theorists and researchers have posited explanations for how trait fear and trait anxiety differ, many others conceptualize the constructs as largely or entirely interchangeable. The primary goals of this review are to examine clinical conceptualizations and neurobiological studies of fear and anxiety, examine the animal and human literatures on the correlates of fear and anxiety, provide clearer definitions of these two constructs, and discuss their implications for psychopathology. A secondary goal is to evaluate content of self-report measures of trait fear and anxiety, and meta-analyze the relations between self-reported trait fear and anxiety. We found that existing measures share significant content overlap across constructs. Despite this overlap, our meta-analysis revealed only a moderate (r=0.32) relationship between measures of trait fear and anxiety, with an even lower relationship (r=0.14) when we examined trait fear measures operationalized in terms of harm avoidance. These findings suggest that fear and anxiety are largely distinct emotions, and that psychological disorders of trait fear and trait anxiety warrant classification in separate higher-order categories. Moreover, they suggest that future research should focus on deriving more content valid measures of trait fear and trait anxiety from the neurobiological and diagnostic literatures.

Gender differences in autonomic indicators of antisocial personality disorder features.

We investigated the autonomic indicators of antisocial personality disorder (APD) features in a mixed gender student sample. One hundred college students (50 men, 50 women) were administered an interview of APD and self-report measures of aggression and psychopathy. Participants completed a passive coping task and viewed emotionally valenced slideshows while their electrodermal activity (EDA), pre-ejection period (PEP), and respiratory sinus arrhythmia (RSA) were measured. Associations between APD features and autonomic reactivity were examined, controlling for aggression and psychopathy. APD features were associated with EDA hyporeactivity in men, but not women, during passive coping. While viewing threatening slides, APD features were associated with RSA hyperreactivity in women and with PEP hyperreactivity in men. APD features were associated with RSA hyperreactivity in women, but not men, while viewing slides of others in distress. These findings suggest that APD features are characterized by parasympathetic nervous system dysfunction in women but sympathetic nervous system dysfunction in men.

Trait correlates of relational aggression in a nonclinical sample: DSM-IV personality disorders and psychopathy.

The implications of adult relational aggression in adults for personality pathology are poorly understood. We investigated the association between relational aggression and features of DSM-IV personality disorders and psychopathy in a sample of undergraduates (N = 220). In contrast to the childhood literature, we found no significant difference in relational aggression between men and women. Unlike overt aggression, which correlated about equally highly with features of all three personality disorder clusters, relational aggression correlated significantly more highly with features of Cluster B than Clusters A or C. In addition, even after controlling for overt aggression, relational aggression correlated significantly with features of psychopathy, although only with Factor 2 traits. With the exception of sadistic personality disorder features, gender did not moderate the relationship between relational aggression and personality pathology. Further research on the psycho-pathological implications of relational aggression in more severely affected samples is warranted.

Emotional responses to self-injury imagery among adults with borderline personality disorder.

Nonsuicidal self-injury (NSSI) and suicide attempts (SAs) are especially prevalent in borderline personality disorder. One proposed mechanism for the maintenance of NSSI and SAs is escape conditioning, whereby immediate reductions in aversive emotional states negatively reinforce the behaviors. Psychophysiological and subjective indicators of negative emotion associated with NSSI and SA imagery were examined in 42 individuals who met criteria for border personality disorder. Personally relevant imagery scripts that involved an NSSI and/or an SA incident were created, as were control scenes involving imagery of an accidental injury, an accidental death, or an emotionally neutral event. Results did not support the hypothesis that decreases in negative emotion would occur during NSSI imagery; however, decreases were found during imagery of the moments after NSSI, which suggests some support for escape conditioning. Support for the model was not found for SAs. Possible implications of patterns that demonstrate decreases in negative emotion during accidental death imagery are discussed.

Autonomic correlates of attention-deficit/hyperactivity disorder and oppositional defiant disorder in preschool children.

Numerous studies have revealed autonomic underarousal in conduct-disordered adolescents and antisocial adults. It is unknown, however, whether similar autonomic markers are present in at-risk preschoolers. In this study, the authors compared autonomic profiles of 4- to 6-year-old children with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD; n = 18) with those of age-matched controls (n = 20). Children with ADHD and ODD exhibited fewer electrodermal responses and lengthened cardiac preejection periods at baseline and during reward. Although group differences were not found in baseline respiratory sinus arrhythmia, heart rate changes among ADHD and ODD participants were mediated exclusively by parasympathetic withdrawal, with no independent sympathetic contribution. Heart rate changes among controls were mediated by both autonomic branches. These results suggest that at-risk preschoolers are autonomically similar to older externalizing children.

A comparison of psychophysiological and self-report measures of BAS and BIS activation.

The behavioral approach (BAS) and behavioral inhibition (BIS) systems are central to theories of both personality and psychopathology, yet agreement on methods of assessing BAS and BIS sensitivity has yet to emerge. We compare the Carver and White (1994) BIS/BAS scales with putative physiological markers of BAS (pre-ejection period [PEP], respiratory sinus arrhythmia [RSA]) and BIS (electrodermal responding) reactivity during reward and extinction among 50 undergraduates. PEP, RSA, and electrodermal activity each responded strongly to one or more task conditions, but correlations with BIS/BAS scores were stronger for measures of affectivity than for any physiological marker. Finally, PEP reactivity was the only autonomic index that responded only to reward. These findings suggest that (a) self-report and physiological measures of BAS and BIS reactivity are independent, and (b) PEP may be superior to RSA as an index of approach motivation.

Psychological, autonomic, and serotonergic correlates of parasuicide among adolescent girls.

Although parasuicidal behavior in adolescence is poorly understood, evidence suggests that it may be a developmental precursor of borderline personality disorder (BPD). Current theories of both parasuicide and BPD suggest that emotion dysregulation is the primary precipitant of self-injury, which serves to dampen overwhelmingly negative affect. To date, however, no studies have assessed endophenotypic markers of emotional responding among parasuicidal adolescents. In the present study, we compare parasuicidal adolescent girls (n=23) with age-matched controls (n=23) on both psychological and physiological measures of emotion regulation and psychopathology. Adolescents, parents, and teachers completed questionnaires assessing internalizing and externalizing psychopathology, substance use, trait affectivity, and histories of parasuicide. Psychophysiological measures including electrodermal responding (EDR), respiratory sinus arrhythmia, and cardiac pre-ejection period (PEP) were collected at baseline, during negative mood induction, and during recovery. Compared with controls, parasuicidal adolescents exhibited reduced respiratory sinus arrhythmia (RSA) at baseline, greater RSA reactivity during negative mood induction, and attenuated peripheral serotonin levels. No between-group differences on measures of PEP or EDR were found. These results lend further support to theories of emotion dysregulation and impulsivity in parasuicidal teenage girls.