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Purpose To describe Lifestyle Coach perceptions of dyads (i.e., family members and/or friends) in the National Diabetes Prevention Program (NDPP). Design Qualitative evaluation of cross-sectional survey responses. Setting Online. Participants Lifestyle Coaches (n=253) with experience teaching at least one in-person year-long NDPP cohort at a CDC-recognized organization. Measures Survey included items on background and experience with dyadic approach, as well as open-ended items on the benefits and challenges observed when working with dyads in the NDPP. Analysis Lifestyle Coach background and experience were analyzed descriptively in SPSS. Open-ended responses were content coded in ATLAS.ti using qualitative description, and then grouped into categories. Results Most Lifestyle Coaches (n=210; 83.0%) reported experience delivering the NDPP to dyads. Benefits of a dyadic approach included having a partner in lifestyle change, superior outcomes and increased engagement, and positive “ripple effects.” Challenges included difficult relationship dynamics, differences between dyad members, negative “ripple effects,” and logistics. Conclusion Lifestyle Coaches described a number of benefits, as well as some challenges, with a dyadic approach to the NDPP. Given the concordance between close others in lifestyle and other risk factors for type 2 diabetes, utilizing a dyadic approach in the NDPP has the potential to increase engagement, improve outcomes, and extend the reach of the program.

The unified protocol (UP) is a promising transdisgnostic treatment for emotional disorders; limited data exists with trauma-exposed populations. This study compared effectiveness of the UP, presented centered therapy (PCT), and treatment as usual (TAU) in trauma-exposed veterans presenting to routine care.Trauma-exposed veterans with one or more emotional disorder diagnoses participated in a pilot hybrid-1 effectiveness/preimplementation study. Thirty-seven male and female veterans were randomized to one of three conditions.Multilevel growth curve modeling demonstrated improvement over time across conditions with large effect sizes (range: -2.15 to -3.32), with the UP demonstrating the greatest change. The between group effect sizes for reductions in number of comorbid diagnoses were medium to small and statistically significant (TAU and UP, d = 0.49, p = .056; TAU and PCT d = 0.18, p = .166, UP and PCT d = 0.31, p = .229). Only the UP led to a decrease in the number of comorbid diagnoses (d = -0.71). Psychosocial functioning varied by group, with slight increases in impairment in PCT and TAU, and medium effect size reduction in the UP. Only the UP exhibited significant decreases in self-reported anxiety and depression. Between group differences for UP and PCT were medium to large and statistically significant for depression across two measures (d = -0.72 to d = -1.40).This represents the first trial examining effectiveness of the UP, PCT, and TAU in trauma-exposed veterans. Despite a small sample, large effect size differences demonstrated promising advantages for the UP. Trial Registration Number: NCT02944994.

Individuals from socioeconomically disadvantaged groups have lesser participation and success in the National Diabetes Prevention Program (NDPP). Barriers to NDPP participation and lifestyle change were examined from the perspective of Lifestyle Coaches serving lower versus higher income participants. Lifestyle Coaches (n = 211) who serve lower income (n = 82) or higher income (n = 129) participants reported on observed barriers to NDPP participation and lifestyle change and ranked the three most significant barriers to (a) NDPP participation and (b) lifestyle change. Group differences in number/type of barriers were examined using t-tests and chi-square analyses, and ranking differences were examined using multilevel cumulative logit models. Lifestyle Coaches of lower income (versus higher income) participants reported two additional barriers on average. Ranked barriers to participation were similar between groups, and notably included physical/emotional barriers. However, for lifestyle change, those serving lower income groups were more likely to rank lack of access to healthy grocery stores, but less likely to rank low motivation and lack of family support. Lifestyle Coaches of lower income participants were less likely to rank long wait period prior to enrollment as the most significant barrier to participation, and to rank lack of time off from work as the most significant barrier to lifestyle change. Despite more barriers observed among lower versus higher income participants, overlap in the most significant barriers highlights the potential utility of widely addressing common barriers among NDPP participants. In particular, physical and emotional barriers have been overlooked, yet deserve greater attention in future research and practice.The National Diabetes Prevention Program (NDPP) has less successfully reached and changed the lifestyles of lower income (versus higher income) adults in the USA who are at high risk for type 2 diabetes. In a nationwide online survey, we asked Lifestyle Coaches who deliver the NDPP to identify up to 37 potential barriers to participation and success that they had observed among their participants. We then compared the number, type, and rankings of the most significant barriers to participation and success in the NDPP from the perspective of Lifestyle Coaches estimating the majority of their participants had lower versus higher incomes. Lifestyle Coaches delivering the NDPP to lower income participants reported an average of two additional barriers to participation and success than those delivering the program to higher income participants. The barriers ranked among the most significant to NDPP participation and lifestyle change were generally similar among Lifestyle Coaches working with lower versus higher income participants. Top-ranked barriers included physical/emotional symptoms (e.g., anxiety, depression) as well as barriers previously reported in studies focused on NDPP participants. It is critical that barriers be carefully evaluated and addressed to improve the nationwide impact of the NDPP.

Uptake of Evidence-Based Psychotherapies (EBPs) by mental health (MH) clinicians, especially in community settings, remains highly variable. This formative pilot study aimed to understand the attitudes and practices of Veterans Health Administration community-based MH clinicians regarding EBPs and to identify multi-level factors that enable and hinder EBP implementation in this unique context.Semi-structured interviews were conducted with MH clinicians (N = 40) working in community-based outpatient clinics (CBOCs) in metro/urban (n = 20) and non-metro/rural (n = 20) locations. Interviews were guided by the Consolidated Framework for Implementation Research and were analyzed using rapid content analysis. Results were organized by system-, clinician-, patient-, and innovation-levels.EBPs were consistently perceived as important to delivering quality MH care, with most clinicians having received training in at least one VHA EBP. However, limited EBP training and consultation opportunities, inadequate autonomy to schedule EBP sessions, high and complex caseloads, and feelings of isolation at CBOCs decreased EPB use. Social workers perceived disparities in EBP training access relative to psychologists. Some barriers were more salient in non-metro/rural settings (e.g., patient-level privacy concerns).Increased EBP training opportunities- particularly for social workers-, greater flexibility over schedules and caseloads, and more mechanisms for consultation and professional development may increase EBP uptake in community-based clinics.

PURPOSE OF REVIEW: This review synthesizes literature on transdiagnostic treatments for PTSD and trauma-related psychopathology over the last three years and discusses their across diverse contexts. RECENT FINDINGS: Global and domestic studies suggest that a transdiagnostic approach has the potential to address many challenges providers encounter when treating traumatized populations. Existing research shows that transdiagnostic approaches (including the Unified Protocol, Common Elements Treatment Approach, and Modular Approach to Therapy for Children) are effective across low and high resourced settings, populations, and with comorbid mental health symptoms. Moreover, transdiagnostic approaches offer flexibility in treatment delivery, adaptability across contexts, and parsimonious training to treatment providers. They also provide a standalone alternative for unable or unwilling individuals to engage in traditional single diagnosis trauma-focused treatment, or those presenting with complex presentations that might otherwise require sequential courses of targeted interventions. SUMMARY: The promise of transdiagnostic treatment for trauma-populations is strong. Research is needed to examine patient and therapist perceptions of these approaches for optimally addressing PTSD and related symptoms, the extent to which they offer comparable, or perhaps better, outcomes than existing single diagnosis PTSD treatments, and their sustainability overtime. Considerations of adaptations to transdiagnostic treatment manuals across settings are also needed.

Background Implementation strategies are necessary to ensure that evidence-based practices are successfully incorporated into routine clinical practice. Such strategies, however, are frequently modified to fit local populations, settings, and contexts. While such modifications can be crucial to implementation success, the literature on documenting and evaluating them is virtually nonexistent. In this paper, we therefore describe the development of a new framework for documenting modifications to implementation strategies. Discussion We employed a multifaceted approach to developing the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS), incorporating multiple stakeholder perspectives. Development steps included presentations of initial versions of the FRAME-IS to solicit structured feedback from individual implementation scientists (“think-aloud” exercises) and larger, international groups of researchers. The FRAME-IS includes core and supplementary modules to document modifications to implementation strategies: what is modified, the nature of the modification (including the relationship to core elements or functions), the primary goal and rationale for the modification, timing of the modification, participants in the modification decision-making process, and how widespread the modification is. We provide an example of application of the FRAME-IS to an implementation project and provide guidance on how it may be used in future work. Conclusion Increasing attention is being given to modifications to evidence-based practices, but little work has investigated modifications to the implementation strategies used to implement such practices. To fill this gap, the FRAME-IS is meant to be a flexible, practical tool for documenting modifications to implementation strategies. Its use may help illuminate the pivotal processes and mechanisms by which implementation strategies exert their effects.

Fidelity monitoring is a critical indicator of psychotherapy quality and is central to successful implementation. A major barrier to fidelity in routine care is the lack of feasible, scalable, and valid measurement strategies. A reliable, low-burden fidelity assessment would promote sustained implementation of cognitive behavioral therapies (CBTs). The current study examined fidelity measurement for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) using clinical worksheets. External raters evaluated patient worksheets done as a part of treatment, both guided by the therapist and completed independently as homework. Results demonstrated that fidelity ratings from CPT session worksheets were feasible and efficient. Notably, they were strongly correlated with observer ratings of the fidelity of CPT strategies that were present on the worksheets. Agreement among ratings conducted by individuals with a range of experience with CPT was acceptable to high. There was not a main effect of therapist-guided, in-session worksheet ratings on PTSD symptom change. However, patient competence in completing worksheets independently was associated with greater PTSD symptom decline and in-session, therapist-guided worksheet completion was associated with larger symptom decreases among patients with high levels of competence. With further research and refinement, rating of worksheets may be an efficient way to examine therapist and patient skill in key CPT elements, and their interactions, compared to the gold standard of observer ratings of therapy video-recordings. Additional research is needed to determine if worksheets are an accurate and scalable alternative to gold standard observer ratings in settings in which time and resources are limited.

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.

Inclusion of consumer preferences to disseminate evidence-based psychosocial treatment (EBPT) is crucial to effectively bridge the science-to-practice quality chasm. We examined this treatment gap for insomnia, posttraumatic stress disorder (PTSD), depression, and comorbid symptoms in a sample of 622 young adult veterans through preference in symptom focus, treatment modality, and related gender differences among those screening positive for each problem. Data were collected from veteran drinkers recruited through targeted Facebook advertisements as part of a brief online alcohol intervention. Analyses demonstrated that veterans reported greater willingness to seek insomnia-focused treatment over PTSD- or depression-focused care. Notably, even when participants screened negative for insomnia, they preferred sleep-focused care to PTSD- or depression-focused care. Although one in five veterans with a positive screen would not consider care, veterans screening for both insomnia and PTSD who would consider care had a preference for in-person counseling, and those screening for both insomnia and depression had similar preferences for in-person and mobile app-based/computer self-help treatment. Marginal gender differences were found. Incorporating direct-to-consumer methods into research can help educate stakeholders about methods to expand EBPT access. Though traditional in-person counseling was often preferred, openness to app-based/computer interventions offers alternative methods to provide veterans with EBPTs.

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

The article "The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial", written by Iris Sijercic, Jeanine E. M. Lane, Cassidy A. Gutner, Candice M. Monson and Shannon Wiltsey Stirman, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 28 August 2019 with open access. With the author(s)' decision to step back from Open Choice, the copyright of the article changed on 30 August 2019 to © Springer Science+Business Media, LLC, part of Springer Nature 2019 and the article is forthwith distributed under the terms of copyright.

A common metric for determining implementation success is the measurement of clinician adherence to, and competence in, delivering a psychotherapy. The present study examined clinician and organizational factors as predictors of early adherence and competence among 78 clinicians delivering cognitive processing therapy (CPT), an evidence-based psychotherapy (EBP) for posttraumatic stress disorder, in a randomized controlled implementation trial. Results indicated that clinicians' willingness to adopt an EBP if required to do so was significantly associated with early adherence and competence in CPT delivery. Level of clinician education was significantly associated with early competence in delivering CPT. Organizational factors did not predict early adherence or competence. Implications of the findings are discussed.

OBJECTIVES: Screening women for intimate partner violence (IPV) is increasingly expected in primary care, consistent with clinical prevention guidelines (e.g., United States Preventive Services Task Force). Yet, little is known about real-world implementation of clinical practices or contextual factors impacting IPV screening program success. This study identified successful clinical practices, and barriers to and facilitators of IPV screening program implementation in the Veterans Health Administration (VHA). DESIGN: Descriptive, qualitative study of a purposeful sample of 11 Veterans Affairs Medical Centers (VAMCs) categorized as early and late adopters of IPV screening programs within women’s health primary care clinics. VAMCs were categorized based on performance measures collected by VHA operations partners. PARTICIPANTS: Thirty-two administrators and clinician key informants (e.g., Women’s Health Medical Directors, IPV Coordinators, and physicians) involved in IPV screening program implementation decisions from six early- and five late-adopting sites nationwide. MAIN MEASURES: Participants reported on IPV screening and response practices, and contextual factors impacting implementation, in individual 1-h semi-structured phone interviews. Transcripts were analyzed using rapid content analysis with key practices and issues synthesized in profile summaries. Themes were identified and iteratively revised, utilizing matrices to compare content across early- and late-adopting sites. KEY RESULTS: Five successful clinical practices were identified (use of two specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, co-location of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified. CONCLUSIONS: Findings advance national efforts by highlighting successful clinical practices for IPV screening programs and informing strategies useful for enhancing their implementation within and beyond the VHA, ultimately improving services and women’s health.

While modular and transdiagnostic approaches may address implementation challenges, there remains limited investigation into the fit within large healthcare systems. The current study examines qualitative interviews from patients, clinicians and administrative stakeholders in the Veterans Administration about experiences with, and views of, the Unified Protocol (UP; Barlow et al. in The unified protocol for transdiagnostic treatment of emotional disorders: therapist guide, Oxford University Press, New York, 2011) to understand potential for implementation. Qualitative interviews were conducted based on an established implementation framework and speak to implementation of transdiagnostic treatment in veterans, including insight into barriers, facilitators, intervention characteristics, patient characteristics, and system level variables. The UP demonstrated promise for improving efficiency, satisfaction and personalizing mental healthcare.

Research in psychopathology has identified psychological processes that are relevant across a range of Diagnostic and Statistical Manual (DSM) mental disorders, and these efforts have begun to produce treatment principles and protocols that can be applied transdiagnostically. However, review of recent work suggests that there has been great variability in conceptions of the term "transdiagnostic" in the treatment development literature. We believe that there is value in arriving at a common understanding of the term "transdiagnostic." The purpose of the current paper is to outline three principal ways in which the term "transdiagnostic" is currently used, to delineate treatment approaches that fall into these three categories, and to consider potential advantages and disadvantages of each approach.

Contains fulltext : 174490.pdf (Publisher’s version ) (Open Access) Importance: Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. Objective: To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. Data Sources: PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Study Selection: Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Data Extraction and Synthesis: Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Results: Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. Conclusions and Relevance: D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response. 10 p.

Contains fulltext : 209315.pdf (Publisher’s version ) (Closed access) The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/). 8 p.

Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current “gold standard” for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client’s ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions. To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity. Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes. ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.

International audience; To improve health outcomes in people living with HIV, adoption of evidence-based interventions (EBIs) using effective and transferable implementation strategies to optimise the delivery of healthcare is needed. ViiV Healthcare's Positive Pathways initiative was established to support the UNAIDS 90-90-90 goals. A compendium of EBIs was developed to address gaps within the HIV care continuum, yet it was unknown whether efforts existed to adapt and implement these EBIs across diverse clinical contexts. Therefore, this review sought to report on the use of implementation science in adapting HIV continuum of care EBIs. A systematic literature review was undertaken to summarise the evaluation of implementation and effectiveness outcomes, and report on the use of implementation science in HIV care. Ten databases were reviewed to identify studies (time-period: 2013-2018; geographic scope: United States, United Kingdom, France, Germany, Italy, Spain, Canada, Australia and Europe; English only publications). Studies were included if they reported on people living with HIV or those at risk of acquiring HIV and used interventions consistent with the EBIs. A broad range of study designs and methods were searched, including hybrid designs. Overall, 118 publications covering 225 interventions consistent with the EBIs were identified. These interventions were evaluated on implementation (N = 183), effectiveness (N = 81), or both outcomes (N = 39). High variability in the methodological approaches was observed. Implementation outcomes were frequently evaluated but use of theoretical frameworks was limited (N = 13). Evaluations undertaken to assess effectiveness were inconsistent, resulting in a range of measures. This review revealed extensive reporting on implementation science as defined using evaluation outcomes. However, high variability was observed in how implementation outcomes and effectiveness were defined, quantified, and reported. A more specific and consistent approach to conducting and reporting on implementation science in HIV could facilitate achievement of UNAIDS 90-90-90 targets.

Traditional treatments for anxiety disorders include cognitive-behavioral therapy and anxiolytic medications. Although these treatments are more effective than placebo, there is still considerable room for further improvement. Unfortunately, combining these different modalities is generally not substantially better than monotherapies. Recently, researchers have turned their attention toward translating preclinical research on the neural circuitry underlying fear extinction to clinical applications for the treatment of anxiety disorders with the goal to augment the learning process during exposure-based procedures with cognitive enhancers. This review examines d-cycloserine, cortisol, catecholamines, yohimbine, oxytocin, modafinil, as well as nutrients and botanicals as agents to augment treatment for anxiety disorders. D-cycloserine shows the most empirical support. Other promising agents include cortisol, catecholamines, yohimbine, and possibly oxytocin. Less support comes from studies that examined nutrients and botanicals, such as caffeine, nicotine, and omega-3 fatty acid. Limitations of the exiting literature and future research directions are discussed.

Sleep disturbance is a core component in posttraumatic stress disorder (PTSD). Although cognitive-behavioral treatments for PTSD reduce the severity of sleep symptoms, they do not lead to complete remission. The present study examines the impact of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) on subjective measures of sleep disturbance from treatment randomization through long-term follow-up (LTFU). Participants were 171 female rape victims with PTSD who were randomly assigned to CPT, PE, or Minimal Attention (MA). After 6-weeks, the MA group was randomized to CPT or PE. Sleep symptoms were assessed at baseline, post-MA, post-treatment, 3-months, 9-months and LTFU using the Pittsburgh Sleep Quality Index (PSQI) and nightmare and insomnia items from the Clinician Administered PTSD Scale. Change in sleep during MA, from pre- to post-treatment for CPT and PE, and from post-treatment through LTFU was assessed using piecewise hierarchical linear modeling with the intent-to-treat sample. Controlling for medication, sleep improved during CPT and PE compared to MA, and treatment gains were maintained through LTFU. CPT and PE were equally efficacious and improvements persist over LTFU, yet, neither produced remission of sleep disturbance. Overall, sleep symptoms do not remit and may warrant sleep-specific treatments.

Both theoretical and empirical findings have demonstrated similarities across diagnoses, leading to a growing interest in transdiagnostic interventions. Most of the evidence supporting transdiagnostic treatment has accumulated for depression, anxiety, and eating disorders, with minimal attention given to posttraumatic stress disorder and other reactions to traumatic stressors. Although single-diagnosis protocols are effective for posttraumatic stress disorder (PTSD) and other trauma-related disorders, in principle, transdiagnostic approaches may have beneficial applications within a traumatized population. This paper defines different types of transdiagnostic treatments, reviews transdiagnostic approaches used in related disorders, and discusses their applicability to PTSD. Examples are drawn from existing transdiagnostic treatments in order to provide a framework for the application of such interventions to the field of traumatic stress. Implications for implementation and dissemination are also discussed.

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

OBJECTIVE First-line treatments for posttraumatic stress disorder (PTSD) are often implemented twice per week in efficacy trials. However, there is considerable variability in the frequency of treatment sessions (e.g., once per week or twice per week) in clinical practice. Moreover, clients often cancel or reschedule treatment sessions, leading to even greater variability in treatment session timing. The goal of the current study is to investigate the impact of PTSD treatment session frequency on treatment outcome. METHOD One hundred thirty-six women (Mage = 32.16 [SD = 9.90]) with PTSD were randomized to receive cognitive processing therapy or prolonged exposure. PTSD symptom outcome was measured using the Clinician-Administered PTSD Scale, and session frequency and consistency were measured using dates of treatment session attendance. Session frequency was operationalized using average days between session, and consistency was defined by the standard deviation of the number of days between treatment sessions. RESULTS Piecewise growth curve modeling revealed that higher average days between sessions was associated with significantly smaller PTSD symptom reduction, with more frequent sessions yielding greater PTSD symptom reduction (p < .001, d = .82). Higher consistency was also associated with significantly greater PTSD symptom reduction (p < .01, d = .48). The substantially larger effect size for frequency suggests that average days between treatment sessions impacts treatment outcome more than consistency. Follow-up analyses revealed a longer time interval between Sessions 4 and 5 was associated with smaller reductions in PTSD treatment outcome. CONCLUSIONS More frequent scheduling of sessions may maximize PTSD treatment outcomes. (PsycINFO Database Record

Research on d-cycloserine (DCS) has demonstrated a significant effect on symptom reduction in human studies that utilized conventional exposure-based approaches. Recent studies have offered promising results for targeting fears through subliminal paradigms. In this double-blind, randomized placebo controlled study, 45 spider fearful individuals received DCS or placebo pills prior to completing a subliminal cue exposure task to images of spiders. Participants completed self-report questionnaires and a behavioral approach task to a live caged tarantula. After repeated exposure to subliminal spider cues, participants in the DCS group reported a greater reduction in disgust than individuals in the placebo group. No difference was observed in fear ratings. These findings suggest that DCS augments the reduction in disgust in spider fearful subjects after subliminal exposure to spider cues.

The goal of this study was to examine the role of rejection sensitivity in the relationship between social anxiety and body dysmorphic concerns. To test our hypothesis that rejection sensitivity mediates the link between social anxiety and body dysmorphic concerns, we administered self-report questionnaires to 209 student volunteers. Consistent with our prediction, rejection sensitivity partially mediated the relationship between social anxiety symptoms and body dysmorphic concerns. The implications of the overlap between these constructs are discussed.

Item does not contain fulltext Cognitive-behavioral therapy is an effective intervention for anxiety disorders. However, a significant number of people do not respond or only show partial response even after an adequate course of the treatment. Recent research has shown that the efficacy of the intervention can be improved by the use of cognitive enhancers that augment the core learning processes of cognitive-behavior therapy. This manuscript provides a review of the current state of cognitive enhancers for the treatment of anxiety disorders. 10 p.

Studies have assessed relationships between posttraumatic stress disorder (PTSD) symptoms and physiological reactivity concurrently; fewer have assessed these relationships longitudinally. This study tests concurrent and prospective relationships between physiological reactivity (heart rate and skin conductance) to a monologue procedure and PTSD symptoms in female assault survivors, tested within 1 and 3 months posttrauma. After controlling for initial PTSD and peritraumatic dissociation, 3 measures of increased physiological reactivity to the trauma monologue at 1 month predicted 3-month PTSD reexperiencing severity. Additionally, increased heart rate following trauma and neutral monologues at 1 month was predictive of 3-month numbing symptoms. Implications for the prospective relationship between physiological reactivity to trauma cues and PTSD over time are discussed.

A substantial minority of people drop out of cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD). There has been considerable research investigating who drops out of PTSD treatment; however, the question of when dropout occurs has received far less attention. The purpose of the current study was to examine when individuals drop out of CBT for PTSD. Women participants (N = 321) were randomized to 1 of several PTSD treatment conditions. The conditions included prolonged exposure (PE), cognitive processing therapy (CPT), CPT-cognitive only (CPT-C), and written accounts (WA). Survival analysis was used to examine temporal pattern of treatment dropout. Thirty-nine percent of participants dropped out of treatment, and those who dropped out tended to do so by midtreatment. Moreover, the pattern of treatment dropout was consistent across CBT conditions. Additional research is needed to examine if treatment dropout patterns are consistent across treatment modalities and settings.

Background Clinicians often modify evidence-based psychotherapies (EBPs) when delivering them in routine care settings. There has been little study of factors associated with or implications of modifications to EBP protocols. This paper differentiates between fidelity-consistent and fidelity-inconsistent modifications and it examines the potential influence of two clinician characteristics, training outcomes, and attitudes toward EBPs on fidelity-consistent and fidelity-inconsistent modifications of cognitive behavioral therapy in a sample of clinicians who had been trained to deliver these treatments for children or adults. Methods Survey and coded interview data collected 2 years after completion of training programs in cognitive behavioral therapy were used to examine associations between successful or unsuccessful completion of training, clinician attitudes, and modifications. Modifications endorsed by clinicians were categorized as fidelity-consistent or fidelity-inconsistent and entered as outcomes into separate regression models, with training success and attitudes entered as independent variables. Results Successful completion of a training program was associated with subsequent fidelity-inconsistent modifications but not fidelity-consistent modifications. Therapists who reported greater openness to using EBPs prior to training reported more fidelity-consistent modifications at follow-up, and those who reported greater willingness to adopt EBPs if they found them appealing were more likely to make fidelity-inconsistent modifications. Conclusions Implications of these findings for training, implementation, EBP sustainment, and future studies are discussed. Research on contextual and protocol-related factors that may impact decisions to modify EBPs will be an important future direction of study to complement to this research.

This study examined the relationship between changes in coping and posttraumatic stress disorder (PTSD) symptomatology among recent female rape and physical assault victims as a function of assault type and perpetrator status. Participants were assessed within 1 month after trauma and again at 3 months after trauma. Results indicate that changes in coping strategies over time are associated with the severity of the PTSD symptoms. Assault type was not a significant factor in the association between changes in coping and PTSD, but perpetrator status was. Victims with known perpetrators, who coped more by social withdrawal, had more severe PTSD symptoms over time. The importance of examining the dynamic nature of coping in the development of PTSD is discussed.

Comorbidity between alcohol use and posttraumatic stress disorder (PTSD) has been well documented. However, there are few longitudinal studies with acute trauma samples. The present study examined symptoms of alcohol use disorders (AUDs) and PTSD longitudinally after assault. Female sexual (n = 69) and physical assault victims (n = 39) were assessed 2 to 4 weeks and 3 months post trauma. Women who had lifetime AUD had higher intrusive and avoidance symptoms than those who did not have AUD. Women who had any alcohol problems had higher PTSD symptoms. Participants who had alcohol problems had the same pattern of symptom recovery as those who did not have alcohol problems but remained more symptomatic over the 3 months. These findings suggest that early intervention strategies for women who have previous histories of alcohol problems and seek medical attention early post trauma may be indicated.

OBJECTIVE There is a large body of literature documenting the relationship between traumatic stress and deleterious physical health outcomes. Although posttraumatic stress disorder (PTSD) symptoms have been proposed to explain this relationship, previous research has produced inconsistent results when moderating variables such as gender or type of traumatic stressor are considered. Within a large sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, the current study examined if deployment stressors (i.e., combat stress, harassment stress) contributed unique variance to the prediction of physical health symptoms (i.e., pain, nonpain) beyond the effects of PTSD symptoms. METHODS A total of 2,332 OEF/OIF Veterans, with equal representation of women and men, completed a series of self-report measures assessing deployment stressors, PTSD symptoms, and physical health symptoms. RESULTS RESULTS revealed that harassment, but not combat stress, added unique variance in the prediction of pain and nonpain symptoms after accounting for PTSD symptoms. CONCLUSIONS This study extends the existing literature by demonstrating the unique influence of harassment stress on physical health outcomes. Specifically, the relationship between combat stress and physical health symptoms appears to be explained mainly by an individual's experience of PTSD symptoms, whereas the relationship between harassment stress and physical health symptoms is not fully explained by PTSD symptoms, suggesting that other variables may be involved in the pathway from harassment stress to physical health symptoms.

Anxiety sensitivity (AS) has been conceptualized as trait-like vulnerability and maintenance factor for PTSD. Although recent literature has demonstrated its malleability during treatment, few have examined its influence on and effect from PTSD treatment. Using multilevel regression analyses we examined: (a) changes in AS during treatment and (b) whether pre-treatment AS predicted PTSD treatment response, in sample of female victims of interpersonal trauma receiving one of three treatments (cognitive processing therapy, cognitive processing therapy-cognitive, and written accounts). Participants exhibited reductions in total ASI scores from pre- to post-treatment. Growth curve modeling revealed slightly different trajectories of PTSD symptoms as a function of pre-treatment AS, and overall decreases in PTSD symptoms during treatment were not associated with pretreatment AS. Pretreatment AS dimensions impacted PTSD total scores and symptoms clusters differentially. Clinical and theoretical implications for these results are discussed.

Body dysmorphic disorder falls under the category of obsessive-compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive-compulsive disorder (OCD; n=22), social anxiety disorder (SAD; n=25), and panic disorder (PD; n=21). Participants filled out self-report measures of body image disturbance, attitudes toward one's appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.

Although exposure-based therapies have demonstrated effectiveness in the treatment of anxiety and related disorders, there remain a significant number of individuals who do not respond or only show partial response even after an adequate course of the treatment. Recent research suggests that augmentation agents can enhance the core learning processes of exposure-based therapy, thus potentially improving treatment response and maintenance of gains in the long-term. This chapter provides an overview of the current state of cognitive enhancers for the treatment of psychological disorders, particularly in the realm of anxiety.

The goal of this study was to examine the linguistic correlates of social anxiety disorder (SAD). Twenty-four individuals with SAD (8 of them with a generalised subtype) and 21 non-anxious controls were asked to give speeches in front of an audience. The transcribed speeches were examined for the frequency of negations, I-statements, we-statements, negative emotion words, and positive emotion words. During their speech, individuals with either SAD subtype used positive emotion words more often than controls. No significant differences were observed in the other linguistic categories. These results are discussed in the context of evolutionary and cognitive perspectives of SAD.

This study examines peritraumatic (and posttrauma) responses in a sample of female crime victims who had been sexually or physically assaulted within the previous 2 months. Women were interviewed about their emotional and behavioral responses during the trauma and assessed for posttraumatic stress disorder and depression symptomatology. Results indicate that women experience a wide range of behavioral and emotional responses during a traumatic event and that these responses have implications for posttrauma adjustment. Women who experienced behaviors typical of a freeze response are more likely to have a greater degree of symptomatology after the assault. Peritraumatic emotions, other than fear, such as sadness, humiliation, and anger, also appear to be related to posttrauma depression symptoms. These findings highlight the necessity of exploring the full range of possible reactions during a trauma.

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation. To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics’ capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS. It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs. NCT02449421 . Registered 02/09/2015